Achsi Equip Core 2

The ACHS EQuIP6 GUIDE
BOOK 2
Accreditation, Standards and Guidelines
Support and Corporate Functions
Safety
Quality
Performance
The ACHS EQuIP6 Guide:
Part 2 - Accreditation, standards, guidelines
Published by The Australian Council on Healthcare Standards (ACHS)
Copies available from the ACHS Publications Service
Phone: + 61 2 9281 9955
Fax: + 61 2 9211 9633
Copyright © The Australian Council on Healthcare Standards (ACHS)
This work is copyright. Apart from any use as permitted under the Copyright Act 1968,
no part may be reproduced by any process without prior written permission from
The Australian Council on Healthcare Standards. Requests and enquiries concerning
reproduction and rights should be addressed to the Chief Executive, The Australian
Council on Healthcare Standards, 5 Macarthur Street, ULTIMO NSW 2007 Australia.
Recommended citation: The Australian Council on Healthcare Standards (ACHS),
The ACHS EQuIP6 Guide, Part 2 - Accreditation, standards, guidelines.
2016, Sydney, Australia.
The EQuIP Guide:
First published 1996
Second edition 1998
Second edition revised 1999
Third edition 2002
Fourth edition 2006
Fifth edition 2010
Sixth edition 2016
6th Edition
ISBN-13: 978-1-921806-68-1 (paperback)
ISBN-13: 978-1-921806-69-8 (web)
212 The ACHS EQuIP6 Guide | Book 2 | Accreditation, Standards and Guidelines | Support Function
CONTENTS
Book 1 Book 2
Foreword 3 Section 7
Introduction 6 The Standards (Support Function) 215
Section 1 The Standards (Corporate Function) 319
ACHS and Accreditation 7 Section 8

1.1 The Australian Council on Healthcare Standards 7 Glossary 400
1.2 What is accreditation? 7
Section 9
1.3 The EQuIP principles 8
1.4 What is EQuIP? 8 Acknowledgements 414
1.5 The review of EQuIP 9
Section 2
Overview of EQuIP 10
2.1 The EQuIP framework 10
2.2 The EQuIP criterion ratings 14
2.3 Mandatory criteria 14
2.4 Not Applicable (NA) criteria 15
2.5 Expectations for ratings 15
2.6 The EQuIP accreditation cycle 18
Section 3
The EQuIP6 Guide 19
3.1 Terminology and definitions 19
Section 4
Further Information 20
4.1 Healthcare regulators 20
4.2 Policies, procedures, protocols, guidelines and
codes of practice 20
4.3 Vulnerable / At-risk populations and individuals 20
Section 5
The Standards (Clinical Function) 23
Section 6
Glossary 194
March 2016 213

SECTION 7 Standards, criteria,
elements and guidelines
2.1 Quality Improvement and Risk There are four criteria in this standard. They are:
Management Standard The organisation’s continuous quality
2.1.1
The standard is: improvement system demonstrates its
The governing body leads the organisation in commitment to improving the outcomes of care
its commitment to improving performance and and service delivery.
ensures the effective management of corporate The integrated organisation-wide risk
2.1.2
and clinical risks. management framework ensures that
The intent of this standard is to ensure that corporate and clinical risks are identified,
the organisation: minimised and managed.
ffectively manages all corporate and clinical risks in

e Healthcare incidents are managed to ensure
2.1.3
an integrated way improvements to the systems of care.
ontinuously improves all aspects of the organisation

c Healthcare feedback, including complaints,
2.1.4
and the services that the organisation provides. is managed to ensure improvements to the
systems of care.
Risk management is intended to reduce the threat
of activities and processes going wrong, Quality
improvement is the action taken throughout the
organisation to increase the effectiveness of activities
and processes to provide added benefits to the
organisation and consumers / patients.
While risk management and quality management are
distinct functions, a quality and risk management
continuum exists. Quality and risk management
programs must work together to achieve organisational
goals and quality outcomes. Incident and feedback
management is one strategy available to healthcare
organisations for identifying, analysing and treating risks.
March 2016 215

Standards, criteria, elements and guidelines
SECTION 7 Standard 2.1: The governing body leads the organisation in its
commitment to improving performance and ensures the effective
management of corporate and clinical risks.
Implementation
Criterion LA Awareness SA LA plus the following
Criterion 2.1.1 a) Policy / guidelines addressing a) Quality improvement is planned

continuous quality improvement and continuous, and responsive to
The organisation’s continuous quality
are consistent with relevant the risk management system and
improvement system demonstrates
legislation, standards, guidelines the strategic plan.
its commitment to improving the
and/or codes of practice, support
outcomes of care and service delivery. b) Annual planning includes
the organisation’s vision, values
identification of key quality
This is a mandatory criterion and strategic direction, and are
improvement objectives both
readily available to staff.
organisation-wide and at the unit /
b) An integrated, organisation-wide department level.
quality improvement framework
c) The organisation supports health
is developed, documented
professionals and other staff in
and implemented.
identifying and responding to
c) Health professionals and other opportunities to improve the
staff are provided with orientation quality of care and service delivery.
and ongoing education about
d) Leaders in quality improvement
the organisation-wide quality
are identified and developed
improvement framework
across the organisation to drive
and their responsibilities for
ongoing improvement.
quality improvement.
d) The governing body demonstrates
its commitment to continuous
quality improvement.
Overview Relationships of 2.1.1 with other criteria

This criterion is designed to ensure that all healthcare This guideline should be read in conjunction with all
organisations understand the importance of the other criteria.
development of an improvement culture and system,
and are able to demonstrate their commitment to This criterion requires healthcare
continuous quality improvement in all aspects of care organisations to:
and service delivery.
ave an effective, integrated organisation-wide quality
H
improvement framework.
Be committed to continuous quality improvement.
upport quality improvement leadership and
S
participation of health professionals and other staff.
rovide orientation and ongoing education about the
P
quality improvement system.
Evaluation Distinction Leadership
MA SA plus the following EA MA plus the following OA EA plus the following
a) T
he effectiveness of the quality a) The organisation shows distinction a) The organisation demonstrates
improvement framework and its in continuous quality improvement. it is a leader in continuous
component activities is evaluated, quality improvement.
and improvements are made
as required.
b) Q
ualitative and quantitative data
are collected, analysed and used
to plan and drive improvement.
c) Improvement strategies are
evaluated, communicated, and
where appropriate implemented
across the organisation to
ensure safe practice and a
safe environment.
d) Health professionals, other
staff and relevant stakeholders
including consumers are involved
in the evaluation of the quality
improvement system.
e) Outcomes of quality and safety
initiatives are reported to staff,
consumers, the community, and
the governing body.
Integrated quality improvement framework There are some essentials that characterise a quality
improvement program irrespective of the QI framework
Implementing processes that assist an organisation to
used by the organisation, its size, type or complexity. It
become a safe and accountable healthcare environment
would be expected that:
for consumers / patients and healthcare providers
requires attention to systems and the analysis of s taff members accountable for taking action are
collected data. identified and informed
Quality improvement and the management of risks r isk management and consumer / patient safety are
in health care should be part of both strategic and considered in all decision making
operational planning in every area and service of improvement teams are multidisciplinary
healthcare delivery. Risk management and quality
improvement should be considered when determining uality activities are informed by appropriate
q
clinical practice, equipment design and procurement, data collection
personnel management and financial planning. s taff are familiar with quality objectives and processes,
ideally through formal training, but in the absence of
this, through orientation and mentoring
March 2016 217

Criterion 2.1.1 identify the strengths and weaknesses of the

The organisation’s continuous quality organisation’s approach to quality improvement.
improvement system demonstrates its Has the organisation’s framework been compared
to systems and processes used by other
commitment to improving the outcomes of similar organisations?
care and service delivery. (continued)
EQuIP has been developed as a framework for
there are channels through which concerns about assessing organisational performance against wide-
quality of care and/or processes can be directed reaching standards and criteria. Member organisations
may choose to structure their QI activities around
identified goals for the healthcare system are the same framework. However, although the EQuIP
considered and integrated into planning. elements reflect the maturation of QI processes
Organisations will be expected to demonstrate that (awareness  implementation  evaluation and
they have developed and implemented structures and further improvement  excellence  outstanding
processes within a framework of: achievement), this alone will not provide the tools to
undertake a QI project in an area of concern.
good governance
ACHS has developed the Risk Management and
risk management Quality Improvement Handbook to support members in
ongoing monitoring implementing quality improvement and risk management
within their organisation. The handbook is available to
improvements emanating from review. members on the ACHS website and will introduce the
The integrated quality improvement framework should: many tools, skills, principles and frameworks available to
conduct effective quality improvement projects.
rovide a structure for identification, analysis,
p
action, monitoring, review for risks, problems and/or
opportunities and communication and consultation Prompt points
with stakeholders
escribe how quality improvement
D
e used to tackle performance questions. If not,
b activities are initiated, organised and
potential reasons may arise from organisational coordinated? Is there a central framework or
culture. Changing culture may be essential, but this committee to coordinate this activity? If so,
is likely to be a long-term issue for senior managers. what roles are played by the component parts?
In the meantime, actions taken by the quality team
might reduce the impact of identifiable factors escribe the links between QI activity and the
D
such as inadequate leadership, inadequate time or strategic plan? What links tie QI activity to risk
resources, failure to gain multidisciplinary attendance management? When QI activity suggests the
at meetings, or to achieve outcomes from meetings need for education, are there any links that
would facilitate the provision of training?
ork effectively across different types of quality
w
issues. If not, organisations should consider the hat processes / measures are used to
W
circumstances and reasons why the framework has monitor the quality of service provision?
not been effective. Have any changes been made ow is the QI system itself evaluated
H
in process, personnel or resources to refine the and improved?
improvement framework and its operations?
onitor that actions taken as part of a QI project
m
are followed-up, measured, further refined, and the
outcomes communicated to management. Where
positive outcomes have been achieved, has the
organisation initiated the same changes more broadly,
or reported the outcome to similar organisations
through a presentation, conference or journal?
Organisational commitment to continuous
quality improvement Prompt points
To be effective, quality improvement must be ow does the governing body
H
fundamental to the way the organisation thinks about demonstrate its commitment to continuous
what it does and embedded within the organisation’s quality improvement within the organisation?
philosophy, practices and business processes, rather ow does the governing body monitor and
H
than viewed or practised as an independent activity. motivate quality improvement efforts and
It is important that every staff member is engaged in actions within the organisation?
improvement efforts that are relevant and important for
their work. Organisations should build in time for staff to
participate in quality improvement as part of their daily Quality improvement leadership,
work, and provide the necessary training, resources,
participation and support
flexibility and authority for staff to test processes and
make improvements. Leaders are not always ‘titled’ personnel filling prominent
roles. Quality may be the responsibility of a person with
Clinical leadership, arising from the governing body, is
the title, ‘Quality Manager’, but achieving consumer /
needed if quality management is to operate effectively
patient care that is safe and excellent is the responsibility
amid the complexities of a healthcare environment.
of all clinical personnel, irrespective of their position in
An organisation can demonstrate commitment by: an organisational hierarchy. Guiding genuine change
in consumer / patient care will require support and
the use of key quality indicators by the governing
commitment from people working at an operational level.
body within their regular meeting structure
Organisational support may be overt or built into a
inclusion of quality improvement in the strategic plan
supportive culture. Organisations and managers can
key staff appointments support identified leaders by:
budgetary decisions formally providing time for the management /
coordination of QI teams / projects that have been
ays that the organisation uses an accreditation
w
formally recognised by management
framework in planning (EQuIP or other)
roviding space (on websites, noticeboards, etc.)
p
the governing body’s response to ACHS surveyors’ or
and leadership support for any notices or project
other external consultants’ recommendations
recruitment efforts associated with quality projects
interactions with organisational councils,
recognising QI activity and outcomes in staff
committees or commissions responsible for
performance reviews
monitoring and ensuring the effectiveness of quality
improvement efforts s upporting further education in quality and leadership
through conference attendance, local workshops or
articipation by members of the governing body and
p
funding to support further education
support for organisational staff involvement in external
quality activities, such as training programs, EQuIP s upporting promotion of successful projects at
surveying, voluntary reporting of performance data conferences and awards
to external organisations, training programs with a
formally acknowledging teams and their leaders in
quality focus, presentations of QI project outcomes at
newsletters, staff meetings and other ways.
conferences, etc.
sing any (public) performance reports as
u
opportunities to identify deficiencies and improve care,
health outcomes, and consumer / patient satisfaction.
Performance reports include coroner’s reports,
a Royal / Special Commission, indicator reports,
consumer / patient survey or focus group reports.
March 2016 219

Criterion 2.1.1
The organisation’s continuous quality trategic and operational plans, budgets that
S
include quality improvement
improvement system demonstrates its
commitment to improving the outcomes of overning body endorsement of framework for
G
care and service delivery. (continued) quality improvement
ontinuous quality improvement plans,
C
The governing body and senior management are frameworks such as philosophy, policy,
responsible for providing support for clinical staff improvement processes, performance
to make and execute good decisions and improve targets, links to incidents, complaints, risks,
healthcare performance. This can be supported by: education, planning
s taff, consumers and other stakeholders being trategies for supporting staff to be leaders /
S
informed about, and actively involved in, the participants in improvement activities
organisation’s safety and quality issues and
improvement initiatives y-laws, appointment criteria, position
B
descriptions that include quality
uality systems being in place that encourage learning
q improvement responsibilities
driven by information and ensure that staff are trained
and supported to gain competency in their assigned ystem for prioritising improvements to address
S
governance responsibilities high-risk, high-volume issues
review of the quality improvement system that includes eports of quantitative and qualitative
R
health professionals from the range of clinical areas. performance data, clinical and non-clinical, and
communication and distribution channels
Minutes of meetings that discuss and action data
Prompt points
A list of improvements, clinical and non-clinical
ow does the organisation develop
H
health professionals who will understand and valuation of the improvement activities -
E
lead in quality improvement? impact on the consumer / patient, organisation
performance targets, cost versus benefit
ow does the organisation support its staff to
H
participate in continuous quality improvement? valuation of governing body, management and
E
staff participation such as membership of project
hat role do health professionals, particularly
W teams, number of activities
medical staff, play in quality improvement
within the organisation? How are the outcomes valuation of the continuous quality
E
of quality improvement reported back to the improvement framework such as understanding
health professionals? and knowledge of the philosophy, policy,
improvement processes, performance targets;
improvements addressing high-risk, high-volume
services; costs versus benefits
The following evidence may help to enchmarking activities, improved practices and
B
address criterion 2.1.1 systems assessment of organisational culture for
quality improvement
uality council / QI committee / improvement
Q
team membership that includes governing body
leadership and participation
overning body agenda and minutes
G
with reports of improvements, clinical and
non-clinical performance, sponsoring of key
improvement activities
Suggested reading
Arya, Dr D K. So, You Want to Lead a Transformational
Change! Asia Pacific Journal of Health Management 2012; 7:
2. Available from: www.achsm.org.au/DownloadDocument.
ashx?DocumentID=1427 Viewed 3 March 2016.
The Deming Institute. Theories and Teachings. Available from:
https://www.deming.org/theman/theories Viewed 3 March 2016.
Balding, C. Create a Great Quality System in Six Months. A
blueprint for building the foundations of a great consumer
experience. 2013. Available from: www.achsm.org.au/
DownloadDocument.ashx?DocumentID=1665 Viewed 3
March 2016.
Agency for Healthcare Research and Quality. Quality Measure
Tools and Resources. Available from: http://www.ahrq.gov/
professionals/quality-patient-safety/quality-resources/index.
html Viewed 3 March 2016.
Institute for Healthcare Improvement. Tools. Available from:
http://www.ihi.org/resources/Pages/Tools/default.aspx Viewed
3 March 2016.
Balding C. From quality assurance to clinical governance. Aust
Health Rev 2008; 32(3): 382-391. Available from: http://www.
publish.csiro.au/?act=view_file&file_id=AH080383.pdf Viewed
3 March 2016.
March 2016 221

Implementation
Criterion 2.1.2 a) Policy / guidelines addressing a) There is integration between quality

corporate and clinical risk are improvement, risk management
The integrated organisation-wide risk
consistent with relevant legislation, and strategic planning.
management framework ensures
standards, guidelines and/or
that corporate and clinical risks are b) Annual planning includes the
codes of practice, identify specific
identified, minimised and managed. identification of key organisational
strategies for managing risk, and
risks, and controls to mitigate risk.
This is a mandatory criterion are readily available to staff.
c) A risk management approach
b) An integrated, organisation-wide
is used when considering
risk management framework
and developing new and
addressing corporate and clinical
modified services.
risk is developed, documented
and implemented. d) Risk identification and risk
analysis are undertaken using
c) Health professionals and other
qualitative and quantitative data
staff are provided with orientation
and strategies are developed and
and ongoing education about the
implemented to mitigate risk.
risk management framework and
their responsibilities for identifying e) The organisation supports health
and managing risk. professionals and other staff in
identifying and responding to
d) The governing body demonstrates
opportunities to mitigate risk.
its commitment to managing risk
within the organisation. f) There are processes to ensure
that timely action is taken to
mitigate risks identified by
health professionals, other staff,
consumers / patients, carers and
other visitors.

All activities of all organisations involve risk that must This guideline should be read in conjunction with all
be managed. This is particularly true of healthcare other criteria.
organisations, where in addition to the degree of risk
inherent to the provision of care there is community This criterion requires healthcare
expectation of safety. This criterion is to ensure that organisations to:
the organisation identifies, minimises and manages
its corporate and clinical risks via an integrated, ave an effective, integrated organisation-wide risk
H
organisation-wide risk management framework. management framework.
Be committed to managing risk within the organisation.
upport health professionals and other staff to be
S
involved in risk management.
rovide orientation and ongoing education about the
P
risk management system.
a) T
he corporate and clinical risk a) The organisation shows distinction a) The organisation demonstrates it
management framework is in risk management. is a leader in corporate and clinical
evaluated, and improvements are risk management.
made as required.
b) R
isk mitigation strategies are
evaluated, and improvements are
made as required.
c) Health professionals, managers
and other staff use data from risk
management processes to plan
and implement improvements to
care and services.
d) Outcomes of risk analysis and
management are reported to the
governing body.
Integrated risk management framework system, or risk management framework. This framework
in turn ensures that information about risk derived from
Risk is defined as the effect of uncertainty on objectives.
the risk management process is satisfactorily reported
A healthcare organisation’s objectives have different
and used as the basis for future decision making and
aspects, such as clinical, financial, health and safety
accountability. The risk management framework should
or environmental, and they apply at the strategic,
link to strategic and business planning and support
organisation-wide, unit, project and process levels.
assessment of new and/or altered services.
Risk management is a coordinated activity that directs
Successful risk management:
and controls the organisation with regard to risk,
while a risk management framework is the systematic nhances consumer / patient outcomes, while
e
application of management policies, procedures and reducing the probability of negative events for
practices to the activities of communicating, consulting, consumers / patients, staff and visitors, and provides
establishing the context, and identifying, analysing, assurance that the organisation’s objectives will be
evaluating, treating, monitoring and reviewing risk. achieved within an acceptable degree of residual risk
By associating the management of risk with all facilitates legislative compliance
objectives, of all kinds and at all organisational levels,
it becomes fully integrated as an organisation-wide
March 2016 223

Criterion 2.1.2 implementation of financial management systems

The integrated organisation-wide risk fraud minimisation schemes
management framework ensures that
workplace health and safety strategies
corporate and clinical risks are identified,
minimised and managed. (continued) ffective use of feedback from consumers / patients
e
and staff
reates an environment in which quality
c staff education and training programs
improvement occurs as the natural consequence
of the identification, assessment and elimination or recruitment and retention strategies
minimisation of risk staff performance review and development.
an be considered as an aspect of the organisation’s
c
Clinical risk management strategies may include (but are
ongoing continuous quality improvement program.
not limited to):
For risk management to be effective it should: clinical audit processes
reate and protect value by contributing to the
c superior review, peer review and peer supervision
demonstrable achievement of objectives, and
redentialing and defining the scope of clinical
c
improvement of performance
practice for all health professionals (discussed within
be an integral part of all organisational processes criterion 3.1.3)
be a part of decision making implementation of an incident management system
explicitly address uncertainty that includes management of adverse and sentinel
events (discussed within criterion 2.1.3)
be systematic, structured and timely
retrospective consumer / patient health record reviews
be based on the best available information
effective use of clinical indicators
be tailored to the organisation
mortality and morbidity reviews
take human and cultural factors into account
performance review and professional development.
be transparent and inclusive
facilitate continual improvement of the organisation. Organisations should establish policy / guidelines and a
system that:
Organisational commitment to identifies
managing risk analyses
Within the health system, an integrated strategy will evaluates
include the management of both corporate and clinical
risk; not only consumer / patient- and staff-related treats
clinical risk, but also financial, human resources, continuously monitors and reviews
workplace health and safety, environmental and
asset-related risk. All such risks must be identified communicates
and integrated with the quality improvement system. ...all corporate and clinical risks that occur, or that have
The management of risk associated with information the potential to occur, in a healthcare organisation, as
technology is discussed within criterion 2.3.4. well as delineating the specific strategies for managing
Corporate risk management strategies may include (but these risks.
are not limited to):
audit processes
human resources planning
political risk management
The organisation’s commitment to the management of part of further education
risk can be demonstrated by:
…according to the role of each staff member within
governing body-endorsed policy / guideline that
a the organisation as to their specific responsibility for
confirms its risk management framework, describes identifying, evaluating and/or mitigating risk, and the
its principles, processes and specific strategies for steps by which any individual can initiate action in order
achieving its objectives and the responsibility of all to prevent and/or reduce the impact of risks.
staff for their implementation
It should be emphasised that staff responsibility extends
onsultation with stakeholders, achieved via
c to all categories of risk, not clinical risk alone.
departmental meetings, use of the committee
structure and/or focus groups Health professional engagement:
r isk issues discussed and actioned during meetings of is critical to the effective management of clinical risk
the organisation’s governing body, and documentation
s hould be considered during credentialing and defining
to reflect this, such as meeting agendas and minutes
the scope of clinical practice and at other forums for
a comprehensive risk register that: health professional participation, according to the
• facilitates consistency in the identification, analysis size and scope of the organisation, such as Medical
and documentation of risks Advisory Committees (MAC) or specialist groups.
• is a dynamic tool that is regularly reviewed and The organisation should also seek to remove barriers to
amended to support decision making about health professional involvement, including time restraints. In
risk management larger organisations, the employment of project officers to
facilitate health professional participation via actions such
• supports the evaluation and improvement of the risk as prompt distribution of data and the implementation of
management framework. time management programs may be worthwhile.
Prompt points
Prompt points
ow does the organisation inform and
H
ow often is the organisation’s risk
H educate its staff about their responsibilities
management framework evaluated and, in risk management? How does it determine
if necessary, improved? What prompts whether these processes are effective?
this re-evaluation?
hat does the organisation do to encourage
W
hat processes does the organisation use
W staff to participate in risk management?
to consult with its stakeholders about the
management of risk? hat resources does the organisation provide
W
to facilitate health professional engagement in
ow is the organisation’s risk management
H clinical risk management?
policy / guideline made available to staff?
ow does the organisation distribute the data
H
gathered from risk management processes?
How does it determine to whom the data
Health professional and staff involvement
should be provided?
in risk management
ow does the organisation ensure that
H
All staff at all levels have a role to play in the necessary changes identified during the risk
organisation’s management of risk. This accountability management process are implemented?
should be:
made explicit within position descriptions
discussed during performance reviews
art of orientation, with an overview of the
p
organisation’s processes for risk management
March 2016 225

Criterion 2.1.2 Standards

The integrated organisation-wide risk AS/NZS ISO 31000:2009 Risk management — Principles
management framework ensures that and guidelines.
corporate and clinical risks are identified, HB 254-2005 Governance, risk management and
minimised and managed. (continued) control assurance.
Suggested reading
The following evidence may help to
Blackerby Associates. Learn More About Strategic Planning
address criterion 2.1.2 in the Not-for-Profit and Government Sector. Available from:
rganisation-wide risk management policy /
O http://www.blackerbyassoc.com/SPDefine.html Viewed 3
guideline and procedures, endorsed by March 2016.
the governing body, that guide staff in the Dahms T. Part 1: Risk management and corporate
management and prevention of corporate governance: are they the same? Risk Management Magazine.
and clinical risks, and that link with the quality Available from: http://www.plumcon.com.au/PDF/Risk_Gov_1.
improvement system pdf Viewed 3 March 2016.
trategic, operational and business plans that

S Dahms, T. Part 2: Risk management and corporate governance:
consider risks are they the same? Risk Management Magazine. Available from:
http://www.plumcon.com.au/PDF/Risk_Gov_2.pdf Viewed 3
inutes of governing body, Medical Advisory
M March 2016.
Committee, medical staff council and staff
Dückers M, et al. Safety and risk management in hospitals.
meetings where risk issues were reported The Health Foundation. December 2009. Available
and actioned from: http://www.health.org.uk/sites/default/files/
Budget allocation for risk management SafetyAndRiskManagementInHospitals.pdf
Viewed 3 March 2016.
Tools for identifying and analysing risks
uantitative and qualitative data on identified
Q
risks such as incidents, Root Cause Analysis
findings, clinical outcomes, staff injury and
budget variances
eports of the data on risks and on the
R
communication and distribution channels used
to reach relevant staff
Improvements resulting from the analyses of risks
y-laws, appointment criteria and
B
position descriptions that include risk
management responsibilities
ealth professional engagement in clinical risk
H
management as an aspect of credentialing and
defining the scope of clinical practice
valuation of health professional,
E
management and staff understanding
of the risk management system
valuation of the risk management system -
E
policy, risk identification, system for managing
and preventing risks, communication of data on
risks, use of data, high-risk, high-volume activities
identified and improved, cost versus benefit
March 2016 227
Implementation
Criterion 2.1.3 a) Policy / guidelines addressing a) There is an integrated incident

incident management and open management system,
Healthcare incidents are managed to
disclosure are consistent with which includes:
ensure improvements to the systems
relevant legislation, standards,
of care. (i) d
ocumented delineation
guidelines and/or codes of
of responsibilities
This is a mandatory criterion practice, and are readily available
to staff. (ii) d
ocumented lines
of communication
b) Consumers / patients are provided
with information about incident (iii) identification, risk rating and
management processes, including review of incidents, including
open disclosure and how to near misses
access advocacy support.
(iv) in-depth investigation of
c) Health professionals and other serious incidents / sentinel
staff are provided with orientation events, including Root Cause
and ongoing education about Analysis where necessary
incident management, their
(v) appropriate corrective action
responsibilities in incident
reporting, and open disclosure. (vi) support for consumers /
patients, carers and staff
d) The organisation supports and
involved in incidents
promotes the principles of
open disclosure. (vii) dissemination of outcomes of
investigations and action taken.
b) There are processes to guide the
immediate response to an incident.
c) T
he principles of open disclosure
are evident in the system to
manage incidents.
d) Relevant health professionals,
managers and staff are trained
in incident management and
open disclosure.
e) T
he organisation supports the
identification and reporting of
near misses by staff, consumers /
patients and carers.
a) The incident management system a) The organisation shows distinction a) The organisation demonstrates it
is evaluated in consultation with in incident management. is a leader in incident management
health professionals, other staff systems and processes.
and relevant stakeholders including
consumers, and improvements are
made as required.
b) Incidents are trended, risks are
identified, and improvements are
made as required.
c) The support provided for
consumers / patients, carers
and staff involved in incidents is
made as required.
d) Outcomes of incidents and the
organisation’s response are
reported to the governing body.
March 2016 229

Criterion 2.1.3 Supporting the identification and reporting

Healthcare incidents are managed to ensure of incidents
improvements to the systems of care. The process of incident reporting will vary according to
(continued) the size of the organisation. Large facilities commonly
use a software-based system, which is capable of
Overview collecting the data, alerting the relevant parties, issuing
updates and generating reports, where small facilities
The intent of this criterion is to ensure that organisations
may use a paper-based system.
have in place effective systems for the management of
healthcare incidents and near misses as and when they Regardless of the method used, it is important to
occur, so that their causes may be investigated and remember that the reporting of incidents is a means to
improvements made to processes and cultures in order an end, not an end in itself. The main object of reporting
to prevent recurrence. is to initiate, and prioritise, action and thereby to facilitate
the prevention of similar incidents. The organisation must
Relationships of 2.1.3 with other criteria be able to demonstrate not only that it has a system of
reporting, but that reporting is only the first step in its
Management of healthcare incidents is a vital integrated program of incident management.
component of the provision of safe care and services
(Standard 1.5) and of the organisation’s commitment to Identifying and reporting incidents:
quality improvement (Criterion 2.1.1). The organisation’s is a crucial aspect of incident management
risk management framework must include processes
for investigating and minimising the occurrence of s hould be viewed as a valuable contribution to
incidents (Criterion 2.1.2), which may employ an the process of continuous improvement of
information technology system by which incident data healthcare provision
can be recorded and analysed (Criterion 2.3.3). Failure s hould include incidents that occur over time rather
to manage incidents correctly may lead to complaints than instantaneously, such as the development
(Criterion 2.1.4). The management of incidents is an of pressure ulcers or deep vein thrombosis with
aspect of the rights of the consumer / patient (Criterion prolonged hospitalisation, or a failure to detect signs
1.6.2), which include the right to provide feedback of the deterioration of a consumer / patient. These are
and/or to lodge a formal complaint, and to have the often underreported because staff do not recognise
issues raised thereby investigated and resolved; and these episodes as being ‘incidents’
the right to privacy and confidentiality throughout the
management of incidents. requires a workplace culture that actively promotes
the reporting of incidents, which is essential to the
process. It is vital that the organisation supports and
This criterion requires healthcare encourages its staff in this respect
organisations to:
s hould be part of the orientation process for new staff,
upport health professionals, other staff and
S and all staff should be educated in how to recognise
consumers / patients in the identification and reporting an incident and the correct process for reporting it.
of incidents.
However, recognising potential dangers before anyone
Have an integrated incident management system. is harmed is as important, if not more so, than changing
Support and promote the principles of open disclosure. systems after a serious incident has already occurred.
rovide orientation and ongoing education about
P
identification and reporting of incidents, and about
open disclosure principles.
An integrated incident investigation by the designated internal and, where
management system appropriate, external authorities
A degree of risk is an inherent component of the lassification, which is defined as the process of
c
provision of health care, and organisations must capturing relevant information to ensure that the
recognise and admit this while striving at all times to nature of the incident is completely documented
reduce that risk. The right of the consumer / patient and understood
to safe, high quality health care is fundamental, and nalysis and action, to understand how and why the
a
a vital aspect of the provision of safe services is the incident occurred, and to identify ways of preventing
management of incidents. a recurrence
Incidents, including near misses, must be: feedback, which should include the changes made,
identified and the improvements achieved as a result of
the changes.
reported
investigated The organisation must:
…and all appropriate steps taken in order to prevent have a system for the investigation of incidents
their recurrence. learly document the processes for investigating
c
An incident is an event or circumstance that results in, or incidents of all kinds, and the authority of those
could have resulted in, unintended or unnecessary harm designated to do so
to a person and/or a complaint, loss or damage. nsure investigators are invested with all
e
A near miss is an incident that did not cause harm, loss proper authority
or damage, but had the potential to do so. s pecify the timeframes within which investigation will
An adverse event is any incident that results in harm to be completed
an individual receiving health care, whether or not the isseminate the results of incident investigation, and
d
individual is aware that the incident has occurred, and particularly the details of changes made as a result of
regardless of the degree of harm. the investigation.
A sentinel event is a rare adverse event leading to
serious harm or death, which is specifically caused by The incident management system should have two
the healthcare process rather than by the consumer / completely separate investigative processes:
patient’s underlying condition or illness. n objective review of system issues that may have
a
Open disclosure is the admission and discussion of an contributed to the incident
incident that results in harm to a consumer / patient etermination of the role played by any healthcare
d
while receiving health care, a process that involves an providers involved.
expression of regret, an explanation, the outlining of
any consequences or potential consequences, and an Organisational policy should identify the circumstances
account of the steps being taken to prevent recurrence. under which each type of investigation, or both, should
take place.
An integrated incident management system must have
the capacity to record, examine and respond to a Feedback as to the results of incident investigation and
diverse range of real and potential outcomes. Incident the actions taken should be provided in a timely manner.
management itself is a multistep process, involving: All aspects of incident investigation and any actions
identification of incidents, including near misses taken as a consequence must be thoroughly
documented. Regular reports on trended aggregated
otification of identified incidents via the organisation’s
n data should be supplied to those responsible for the
reporting system management of incidents and other relevant staff.
rioritisation, to ensure that a standardised, objective
p
measure of severity is allocated to each incident
March 2016 231

Criterion 2.1.3 Supporting the principles of

Healthcare incidents are managed to ensure open disclosure
improvements to the systems of care. Open disclosure is the frank and transparent discussion
(continued) of incidents that result in harm to a consumer / patient
while receiving health care. The principles of open
Any staff directly involved in an incident should be disclosure are:
informed of any recommendations arising from it. Under
1. Openness and timeliness of communication
some circumstances, feedback must also be given to a
consumer / patient involved in an incident. 2. Acknowledgement of the event
3. An expression of regret
Prompt points 4. Recognition of the reasonable expectations of
consumers / patients and their support persons
hat legislation and policies did the
W
organisation draw upon in shaping its incident 5. Staff support
management policy?
6. Integrated risk management and systems improvement
hat system of incident reporting does the
W
7. Good governance
organisation use?
8. Confidentiality.
ow does the organisation actively promote
H
incident reporting by staff? How is feedback
At the facility level:
provided to staff?
the principles of open disclosure should be evident in
ithin the organisation, who is responsible for
W
the incident management system
incident investigation?
there should be policy / guidelines to direct the
hat changes have been made to the
W
processes of open disclosure
organisation’s systems and processes as a
result of incident investigation? ealthcare providers and managers should be
h
educated in its principles and trained in its practice,
ho is responsible for evaluating the
W
with the training shaped to the roles of individuals
organisation’s system of incident management?
within the organisation.
How often does this happen? Have any
changes been made to the system as a result of Those discussing an adverse event with a consumer /
this evaluation? patient should be at all times mindful of the consumer /
patient’s perspective: an incident that might be
ow does the organisation communicate the
H
considered ‘minor’ in healthcare terms may be
outcomes of incident investigation to staff?
emotionally and/or psychologically traumatic for the
How does it ensure that this communication
consumer / patient and his or her family.
is effective?
Consumers / patients should be:
informed about the organisation’s incident
management processes, as well as notified about how
to contact support personnel such as advocates or
translators
rovided with timely feedback if involved in an
p
incident, and updates should be given throughout
the investigation, rather than a final ‘report’ at the
conclusion of what may be a lengthy process
reassured that their right to privacy and the
confidentiality of the health record will be respected
throughout the investigative process
involved in the development of any new plans or
changes to the care plan as a result of an adverse The following evidence may help to
event, in consultation with, where appropriate, address criterion 2.1.3
their carers.
Incident management systems
The organisation’s management of open disclosure must Policies and procedures, including:
also include:
• incidents
the provision of all necessary staff support, including
• open disclosure
professional counselling
• how incident management is addressed
on-punitive outcomes, where the goal is not the
n
during orientation
assignment of blame, but the improvement of processes
articipation in programs such as the Australian
P
eetings between the consumer / patient and his
m
Incident Monitoring System (AIMS) or the
or her family with the relevant staff, and access to
Incident Information Management System (IIMS)
translators, advocates or counsellors.
vidence of the integration of complaints and
E
feedback in the incident management system
Prompt points
vidence of staff education and training in
E
ow are the principles of open disclosure
H incident management and incident reporting
evident in the organisation’s system of
vidence of staff training in the principles and
E
incident management?
practice of open disclosure
ow does the organisation educate and
H
vidence of feedback sought from consumers /
E
train staff in the principles and practices of
patients and staff regarding open disclosure
open disclosure? How often are these
support services
programs evaluated?
ow are adverse events investigated
H
within the organisation? Who is involved in
the investigation?
ow are consumers / patients provided
H
with information about incident management
and complaints?
hat support services does the organisation
W
provide for staff involved in an adverse event?
ow does the organisation ensure that the
H
support services it provides for consumers /
patients and staff involved in an adverse
event are appropriate? Who is responsible for
evaluating these services? What improvements
have been made to these services as a result of
their evaluation? - and if none, why not?
March 2016 233

Suggested reading
The Australian Commission on Safety and Quality in Health
Care. Australian Open Disclosure Framework. Available
from: http://www.safetyandquality.gov.au/wp-content/
uploads/2013/03/Australian-Open-Disclosure-Framework-
Feb-2014.pdf Viewed 3 March 2016.
Finlay A, Stewart C, Parker M. Open disclosure: ethical,
professional and legal obligations, and the way forward for
regulation. Med J Aust 2013; 198 (8): 445-448. Available from:
https://www.mja.com.au/journal/2013/198/8/open-disclosure-
ethical-professional-and-legal-obligations-and-way-forward
The Royal Australasian College of Medical Administrators.
The Quarterly. Open Disclosure and its Usefulness
for Medical Executives. 2015. Available from: http://
www.racma.edu.au/index.php?option=com_
content&task=view&id=156&Itemid=444 Viewed 3 March 2016.
Byrth J, Aromataris E, Health professionals’ perceptions
and experiences of Open Disclosure: A systematic review
of qualitative evidence. Vol 12, No 5 (2014), Joanna Briggs
Library. Available from: http://joannabriggslibrary.org/index.
php/jbisrir/article/view/1552 Viewed 3 March 2016.
Department of Health / Victorian Government. Incident
reporting instructions. Available from: http://www.dhs.vic.gov.
au/__data/assets/pdf_file/0010/680662/incident-reporting-
instruction-updated-may-2013.pdf Viewed 20 April 2016.
Department of Health, Government of Western Australia.
Clinical Incident Management Toolkit. Available from: http://
ww2.health.wa.gov.au/~/media/Files/Corporate/general%20
documents/Quality/PDF/150616_Final_CIM_TOOLKIT.ashx
Viewed 20 April 2016.
Clinical Excellence Commission. Clinical Incident Management
in the NSW public health system. Available from: http://www.
cec.health.nsw.gov.au/clinical-incident-management Viewed
20 April 2016.
March 2016 235
Implementation
Criterion 2.1.4 a) Policy / guidelines addressing a) T

here is a system for the
feedback and complaints management of complaints,
Healthcare feedback, including
management are consistent with which includes:
complaints, is managed to ensure
improvements to the systems of care. (i) registration of the complaint
guidelines and/or codes of practice,
and are readily available to staff. (ii) review, including formal review
of serious complaints
b) The organisation has a process
for receiving and managing (iii) response in a timely manner
complaints, including assessing
(iv) support and/or advocacy for
the severity of a complaint, which
consumers / patients, carers
is communicated to staff.
and staff involved in complaints
c) Consumers / patients and carers
(v) communication of outcomes
are informed of the process for
to the complainant and
giving feedback or making a
others involved.
complaint, including the process
for escalating complaints and how b) Relevant staff are trained in
to access advocacy services. methods of conflict and
complaint resolution.
d) Health professionals and other
staff are provided with orientation c) There is a system to implement the
and ongoing education regarding: recommendations from the review
of feedback and complaints.
(i) complaints management
d) Feedback is sought from
(ii) consumer / patient and
consumers / patients and carers
carer feedback
regarding the organisation’s
(iii) the use of feedback management of complaints.
and complaints to
e) F
eedback received about care
drive improvement.
and services is made available to
staff, consumers / patients
and management.

Feedback, including complaints, from consumers / Effective management of healthcare feedback, including
patients provides vital data, both positive and negative, complaints, is an important aspect of the organisation’s
about the organisation’s systems and processes and its provision of safe care and services (Standard 1.5) and of
provision of services. This criterion is to ensure that the its commitment to quality improvement (Criterion 2.1.1).
organisation has in place effective systems for managing Consumers / patients are encouraged to participate
consumer / patient feedback and complaints, so that the actively in the planning, delivery and evaluation of
information provided will drive meaningful and necessary health care (Criterion 1.6.1), and an aspect of this is
quality improvement, while also identifying what the the consumer / patient’s right to provide feedback or to
organisation and its staff does well. lodge a complaint about their health care, and to have
appropriate action taken, along with the right to advocacy
services and/or other support if desired (1.6.2).
a) T
he complaints management a) The organisation shows distinction a) The organisation demonstrates it
system is evaluated with consumer / in the management of feedback is a leader in the management of
patient and carer participation, and complaints. feedback and complaints.
as required.
b) C
omplaints are trended, risks are
identified, and improvements are
made as required.
c) The support and access to
advocacy provided for consumers /
patients, carers and staff involved
in complaints are evaluated, and
improvements are made
as required.
d) Outcomes of feedback and
complaints management are
The process of consumer / patient complaints lodging This criterion requires healthcare
and investigation should be tied into the system of organisations to:
incident management (Criterion 2.1.3) within the
organisation’s integrated risk management framework ave a process for receiving feedback, including
H
(Criterion 2.1.2). A complaint involving an adverse event compliments and complaints.
should be managed according to the organisation’s Have a system for the management of complaints.
policy / guidelines on open disclosure (Criterion 2.1.3),
while a complaint lodged by either a consumer / patient rovide support to health professionals, other staff
P
or another staff member against a health professional and consumers / patients involved in a complaint.
may require formal investigation by the relevant
rovide orientation and ongoing education about
P
professional body (Criterion 2.2.3), and impact upon
complaints management and conflict resolution.
credentialing and scope of practice (Criterion 3.1.3).
The organisation will have policy and procedures for
managing staff grievances (Criterion 2.2.5).
March 2016 237

Criterion 2.1.4 nsure complaints are actioned and all participants

e
Healthcare feedback, including complaints, are kept advised throughout the complaint
is managed to ensure improvements to the management process
systems of care. (continued) ave a process for entering as much detail as possible
h
into the organisation’s incident reporting system
Processes for receiving feedback, including nsure the complainant is informed that the incident
e
compliments and complaints has been logged and given a timeline for follow-up
The provision of feedback by consumers / patients, their rovide a variety of ways by which complaints may be
p
families and/or carers can offer a unique perspective lodged, to ensure that consumers are not discouraged
on consumer and community needs, and draw from complaining by language or cultural barriers, or
attention to both successes and flaws in the systems, by degrees of literacy, including technological literacy
processes and services operating within organisations.
onsider feedback offered to the organisation via
c
Valid complaints, properly managed, should lead to
surveys or through contact with consumer groups, as
the consumer-driven improvement of those systems,
this may also take the form of a complaint, and should
processes and services; while positive feedback and
be treated as such.
compliments provide an opportunity to highlight the
achievements of the organisation’s operation and, in
particular, its staff.
Prompt Points
Very often, feedback to an organisation is in the form of
ithin the organisation, who is
W
a compliment directed at the services or the staff, which
responsible for receiving complaints?
should be passed on to all relevant parties, as well as
- entering complaints into the incident
being communicated to management. Compliments
management system? - investigating
from those accessing a health service serve to identify
complaints?
the successes of the facility and its staff, and should be
advertised throughout and, where appropriate, externally ow are compliments from consumers /
H
to the organisation. patients disseminated within the organisation?
Many complaints are received by staff in a spontaneous, ow are consumers / patients informed of their
H
verbal manner, and the appropriate response may include: right to provide feedback? When and where
does this happen?
acknowledgement of the complainant’s concern
y what different means may a complaint be
B
an explanation if the staff member(s) can give it
lodged within the organisation by consumers /
note of the complaint made in the health record of
a patients or their representatives?
the consumer / patient concerned
facilitation of a discussion between the complainant
Systems for the management of complaints
and the relevant health professional(s)
Effective complaints management should be a part
an apology if warranted
of the organisation’s integrated risk management
the provision of information as to how the complaint framework. The data collected by the complaints
can be formally lodged, should the complainant wish management system should be collated and trended,
to proceed. to allow any ‘hot-spots’ for consumer complaints
to be identified and all necessary changes made.
The organisation should: Complaints data are a valuable source of information
llocate a single, publicly recognisable point of
a for organisations, particularly inasmuch as they can
contact within the organisation for the receipt and draw attention to problem areas that are not being
management of compliments and complaints reported as ‘incidents’. Trending of data over time will
allow organisations to judge the effectiveness of existing
nsure compliments are celebrated, and the recipient
e systems, and of any changes made as a consequence
of the compliment is advised about it of complaints management.
Complaints management is a multistep process.
A complaint is: Prompt points
received from a complainant either verbally, in writing hat legislation and policies did the
W
or online organisation draw upon in shaping its
registered and acknowledged, a formal process complaint management policy?
that includes the complaint being entered into the ow often is feedback provided to the
H
organisation’s incident management system, and the complainant during the complaints investigation
complainant being informed that this has been done process? How is the complainant informed that
ssessed, an initial judgement of the severity of
a a complaint has been resolved?
the incident ow is the complaints management system
H
investigated by the relevant internal and/or tied into the organisation’s process for incident
external authorities management? How are the principles of open
disclosure evident within the system?
nalysed and reviewed to determine the appropriate
a
course of action ow does the organisation ensure that
H
recommendations from the investigation of a
responded to, with the recommendations of the complaint are implemented?
investigators being acted upon
hat changes have been made to the
W
resolved, in which, in the event of a valid complaint, organisation’s systems and processes as a
formal acknowledgement is made to the complainant, result of complaints investigation?
and all documentation finalised.
ho is responsible for evaluating the
W
Organisations should: organisation’s system of complaints
management? How often does this happen?
have processes in place for the lodging of a complaint Have any changes been made to the system as
ather as much information about the complaint
g a result of this evaluation?
as possible ow does the organisation communicate the
H
assess the validity and severity of a complaint outcomes of complaints investigation to staff?
How does the organisation communicate
ssess and investigate the complaint, ensuring all
a to staff any changes made as a result of a
information is thoroughly documented complaint investigation? How does it ensure
rovide and/or facilitate consumer / patient support
p that this communication is effective?
if required
respect the complainant’s right to privacy
Information, education and support
and confidentiality
Feedback from consumers / patients can shine a light
rovide a formal explanation to the complainant of the
p
on a wide variety of issues, both positive and negative,
circumstances that led to the complaint
within the organisation. All participants in the healthcare
implement any recommendations resulting from the system benefit from processes that encourage feedback
analysis and review of the data about the services received by consumers / patients,
and organisations should ensure that any concerns are
offer an apology to the complainant if warranted
resolved in an open, fair and timely manner. Consumer /
nsure all relevant parties are included in any
e patient feedback is a vital resource, as those accessing
communications related to the investigation of health services will evaluate them from an entirely
the complaint. different perspective from those delivering the services
and, in addition to offering a unique perspective, may
highlight flaws in existing systems or processes that
escaped the attention of those designing them.
March 2016 239

Criterion 2.1.4
Healthcare feedback, including complaints, Prompt points
is managed to ensure improvements to the ow are consumers / patients informed
H
systems of care. (continued) of their right to provide feedback? When and
where does this happen?
Organisations should:
oes the organisation provide Patient
D
rovide information about giving feedback to
p Representatives or Consumer Advocates to
consumers / patients prior to or at admission, and support consumers / patients and/or their
ensure staff offer periodic reminders carers through the complaints process? If not,
what advocacy groups does the organisation
isplay information in appropriate areas such as
d
provide contact details for?
waiting-rooms and at reception, as well as upon the
organisation’s website ow does the organisation ensure that its
H
provision of support services to consumers /
ake consumers / patients aware that external
m
patients and staff is appropriate and effective?
advocacy services exist, what they do, and that they
have a right to access these services if they wish hat information about complaints management
W
is provided to staff during orientation?
ake staff aware of the organisation’s processes
m
for complaints management at orientation, and ow often are ‘refresher’ sessions in this
H
subsequently at regular education sessions information provided?
nsure frontline staff, who are in direct contact with
e hat training does the organisation provide
W
consumers / patients, their families and/or their or facilitate to assist staff in the handling
carers, receive formal training not only in the correct of complaints? For what staff is this
procedure for reporting a complaint, but in conflict training offered?
and complaint resolution
ow does the organisation provide feedback
H
ducate and train staff in the appropriate behaviour
e to staff concerning the outcomes of
and responses to complaints complaints investigation?
rovide training in communication skills, particularly
p hat support services are available to staff
W
listening skills affected by a complaint?
inform staff about access to support services such as
counselling, if these services are needed.
Standards
The following evidence may help to AS/NZS 10002: 2014 Guidelines for complaints handling
address criterion 2.1.4 in organizations.
Complaints management system
Policies and procedures, including: Suggested reading
Reader T, Gillespie A, Roberts J. Patient complaints in healthcare
• complaints
systems: a systematic review and coding taxonomy. BMJ
• open disclosure Qual Saf doi:10.1136/bmjqs-2013-002437. 2013. Available
from: http://qualitysafety.bmj.com/content/early/2014/05/29/
• how complaints management is addressed bmjqs-2013-002437.full Viewed 3 March 2016.
during orientation
Hong Kong Hospital Authority. Complaints System.
Integration of incident and complaints Available from: https://www.ha.org.hk/haho/ho/qns/v3/doc/
management systems complaintsys_eng_cs1.pdf Viewed 3 March 2016.
Information available to consumers / patients on Health Services Review Council. Guide to Complaint Handling
how to provide feedback or lodge a complaint in Health Care Services. (Revised 2011) Available from: http://
www.health.vic.gov.au/hsc/resources/guide.htm Viewed 6
vidence of staff training in complaints handling,
E April 2016.
conflict resolution and open disclosure
Levin CM and Hopkins J. Creating a patient complaint
vidence that the organisation facilitates the
E capture and resolution process to incorporate best practices
access of consumers / patients to support for patient-centered representation. Jt Comm J Qual Patient
personnel including translators and advocates Saf 40(11): 484-492, 2014. Available from: http://www.
mc.vanderbilt.edu/documents/cppa/files/JCJ%20Stanford%20
Health%20Care%20Article.pdf Viewed 6 April 2016.
March 2016 241

2.2 Human Resources The standard for human resources management

Management Standard contains five criteria. These are:
The standard is: Workforce planning supports the organisation’s

2.2.1
Human resources management supports quality current and future ability to deliver safe, high
health care, a competent workforce and a quality care and services.
satisfying working environment for staff. The recruitment, selection and appointment
2.2.2
The intent of this standard is to ensure that the system ensures that the skill mix and
organisation’s workforce is recruited and managed in a competence of staff, and mix of volunteers,
manner that supports the provision of safe, high quality meets the needs of the organisation.
care and services. Human resources management The performance management system
2.2.3
practices should also support the organisation’s goals ensures the competence of staff and volunteers.
and objectives.
The learning and development system ensures
2.2.4
the skill and competence of staff and volunteers.
Support systems promote staff wellbeing and a
2.2.5
positive work environment.
Human resources management is the policies,
practices and systems that influence staff members’
behaviours, attitudes and performance.
March 2016 243

SECTION 7 Standard 2.2: Human resources management supports quality
health care, a competent workforce and a satisfying working
environment for staff.
Implementation
Criterion 2.2.1 a) Policy / guidelines / tools a) The workforce strategic plan is

addressing workforce planning clearly linked to the organisation’s
Workforce planning supports the
and management are readily strategic direction and goals.
organisation’s current and future
available to staff.
ability to deliver safe, high quality care b) Workforce management functions
and services. b) The organisation’s workforce and responsibilities are clearly
planning ensures the skill mix of identified and documented.
clinical and support staff, and
c) There are contingency plans to
reflects current and future needs
manage long- and short-term
of consumers / patients and staff.
workforce shortages, including
c) Strategies are in place to ensure unplanned shortages.
safe, high quality treatment and
d) Fatigue prevention and
care if prescribed levels of skill
management strategies
mix of clinical and support staff are
are implemented.
not available.
d) Policy / guidelines addressing
safe working hours support the
management of shift work and
fatigue, and are readily available
to staff.

This criterion requires the organisation to have plans to Workforce planning provides a vision for, and responds
meet its current and future needs within each segment to, all aspects of workforce management (Standard 2.2).
of its workforce, which will include both clinical and Workforce planning should reflect the organisation’s
non-clinical staff, and will range from workers with no strategic and operational goals (Criterion 3.1.1).
formal qualifications providing support services through
The availability, quality and fallibility of staff presents a
to highly qualified specialists working in technology-
risk factor for all organisations, but even more so for
intensive positions. It is acknowledged that the
service organisations with a responsibility to ensure the
workforce is supported by volunteers and carers.
safety of the public, such as healthcare organisations.
The control of safety factors associated with workforce
planning is an aspect of the organisation’s integrated
risk management framework (Criterion 2.1.2), and failure
in this area may lead to incidents (Criterion 2.1.3) and
complaints (Criterion 2.1.4).
a) T
he workforce policy, plan, a) The organisation shows distinction a) The organisation demonstrates it is
goals and strategic direction are in workforce planning. a leader in planning for current and
evaluated, and improvements are future workforce requirements.
made as required.
b) U
nit / department workforce plans
are evaluated, and improvements
are made as required.
c) Strategies for fatigue prevention
and management are evaluated,
as required.
This criterion requires healthcare It should recognise and respond to the changing
organisations to: environment, and address both the long-term needs
of the organisation and the appropriate response to an
Implement workforce plans that are based upon the immediate staffing shortfall.
defined skill mix required to deliver care and services.
Workforce planning should:
anage the workforce at both the unit / department
M
level and organisation-wide. over all key elements of workforce needs, including
c
assessment, recruitment, retention, development
evelop contingency plans to address potential
D and contingency
staff shortages.
e linked to the organisation’s strategic
b
nsure the safety of consumers / patients and staff by
E planning process
effective management of shift work and fatigue.
recognise and respond to changes in the healthcare
environment, and other factors which may influence
Comprehensive workforce planning
staffing levels
Workforce planning is the systematic and ongoing
include forecasts of workforce demand and supply
process of analysing the organisation’s workforce needs
and determining what actions are necessary to ensure involve organisational managers with experience of
that the right people with the right skills are available existing workforce arrangements
when needed, at the present time and into the future.
include the regular review and evaluation of workforce
The workforce strategic plan should be proportional plans, polices, strategies and goals.
to the role, function and size of the organisation, and
cover all key elements of workforce needs at both
an organisation-wide and unit / department level.
March 2016 245

Criterion 2.2.1
Workforce planning supports the organisation’s Prompt points
current and future ability to deliver safe, high ow are staff made aware of workforce
H
quality care and services. (continued) policies and procedures?
ow do these policies and procedures assist
H
staff with understanding the system and
Prompt points support them to perform well?
ow does the workforce plan address
H
ow does the organisation know that the
H
the goals and objectives outlined in the
workforce policies and procedures are current
organisation’s strategic plan?
and relevant?
hat are the key factors affecting the
W
organisation’s workforce supply?
Workforce management
hat characteristics of the workforce and
W
labour supply have been considered when The organisation’s workforce planning should strive for
developing the workforce plan? the creation of an effective managerial hierarchy, with
properly qualified personnel providing leadership at all
ho is responsible for preparing and
W
levels of the organisation, in a framework of defined
implementing the workforce plan?
accountability. All managers should be aware of their
ow is the effectiveness of the organisation’s
H specific responsibilities as a supervisor of their staff.
workforce planning evaluated?
Workforce management should:
e distinct from human resources management, to
b
Policies and procedures avoid either duplication or omission of any recruitment
and staff support processes
Workplace policies and procedures should, at a minimum,
communicate to staff and management the performance perate at both the organisation-wide and unit /
o
levels required of them and the legal aspects of workforce department level
management, so that the workforce is aware of its
y supported by policy and procedures in which
b
responsibilities and can contribute to meeting the goals
workforce management functions and responsibilities
and objectives of the organisation.
are clearly defined
Policies and procedures should address those aspects
include delineation of each individual manager’s own
of workforce management most relevant to the
responsibilities and key performance indicators, which
organisation, including (but not limited to):
should be included in the position description
legal and ethical aspects such as agreements, awards
onsider the size and structure of the organisation
c
and contracts
when defining the responsibilities of managers, which
recruitment, selection and appointment may include (but are not limited to):
orientation and integration • induction and training
code of conduct • staff development
performance management • team building
pay, leave and conditions • conflict resolution
learning and development • oversight of expenditure
staff wellbeing. • workplace health and safety
• creation and maintenance of organisational culture.
Prompt points Prompt points
H ow does the organisation ensure that
H
individual managers are aware of staff with the correct skills are available
their responsibilities? when and where they are needed on a day-to-
day basis?
ow is the effectiveness of workforce
H
management both organisation-wide and at the hat patterns of skill shortages exist for
W
unit / department level evaluated? this organisation? What strategies has the
organisation used to address these shortages?
ow is the organisation using strategic
H
Contingency planning planning to minimise short-term and day-to-day
Workforce planning should recognise and address both workforce shortages?
long-term environmental factors and immediate, short-
ow is the existing skill mix at the unit /
H
term-factors that may result in shortages in the number
department level monitored? How does the
of qualified staff and/or the correct skill mix of staff. The
organisation respond if a skill-mix shortfall is
organisation should adopt flexible contingency planning
identified? How does the organisation ensure
processes that can respond either to a potentially long-
that standards of care are maintained in the
term staff shortage, or to an immediate staff shortage
absence of the correct skill mix?
that may be organisation-wide or confined to a single
unit / department (for example, higher-than-normal ow does the organisation ensure that the
H
absenteeism due to illness). correct skill mix is maintained when there
are changes to service requirements or case-
Contingency planning for workforce and skill-mix
mix, or when new interventions or treatments
shortages should:
are introduced?
ssess the changing demographics of the
a
organisation’s community and of the health workforce
in order to determine potential demand and supply Shift work, fatigue and safe working hours
recognise the importance of an organisational culture It is essential that the organisation recognise that fatigue
that strives to retain staff and to develop their skills caused by shift work and/or long working hours can
impair judgement and competence, and represents
incorporate methods by which the correct skill mix may
a risk to both the quality of care and the wellbeing of
be maintained both in the long-term and on a day-by-
the individual. Rostering based around the principles
day or shift-by-shift basis, such as the ‘up-skilling’ and
of safe working hours is an important aspect of fatigue
‘re-skilling’ of existing staff, role substitution and the
risk management, which should strive to minimise
expansion of health professionals’ scope of practice
the hazards associated with shift work and extended
e supported by staff learning and development
b working hours.
programs that encourage the acquisition of new skills
Management of shift work, fatigue and safe working
and facilitate flexible workforce management
hours should:
include strategies to ensure safe, high quality care in
e supported by policy and procedures developed
b
the event that the prescribed skill mix is not available.
with staff input, and which are made readily available
to the entire workforce including any visiting medical
officers and students
include rostering developed using the principles
of safe working hours and drawing upon fatigue
management tools
nsure that shifts include opportunities for regular meal
e
and drink breaks, and for sleep where appropriate
March 2016 247

Criterion 2.2.1
Workforce planning supports the organisation’s The following evidence may help to
current and future ability to deliver safe, high address criterion 2.2.1
quality care and services. (continued) ocumented linkages between workforce
D
planning and the organisation’s strategic
ddress identified high-risk operational areas including
a direction and goals
emergency departments, obstetric departments and
Evaluation of the achievement of workforce plans
operating theatres
Evaluation of the workforce planning process
ddress high-risk practices including staff working at
a
two different facilities, and health professionals with Evaluation of skill mix against service requirements
both public and private workloads.
olicies and procedures describing the
P
responsibilities of workforce managers
Prompt points osition descriptions including individual
P
workforce management responsibilities and key
hat strategies / practices are used to
W
performance indicators
minimise errors and incidents when someone
is fatigued? How effective are these strategies? inutes of meetings relating to workforce
M
planning, skills shortages and/or fatigue
ow is fatigue risk systematically identified?
H
management, and actions implemented
Which staff groups are at most risk? What
controls are in place to manage risk? Fatigue risk policy
hat aspects of the organisation’s culture
W osters developed using recognised fatigue
R
may lead staff working long hours even risk tools
when fatigued?
hat longer-term planning is being conducted
W
by the organisation to minimise risks associated
with fatigue?
ow is fatigue, or the potential for fatigue,
H
managed in staff who may be engaged in
other employment?
Suggested reading Lopes MA, Almeida AS and Almada-Lobo, B. Handling
healthcare workforce planning with care: where do we stand?
World Health Organization (WHO). Health workforce: Tools Human Resources for Health (24 May 2015) Available from:
and guidelines for human resources for health. Geneva CH; http://www.human-resources-health.com/content/13/1/38
WHO; 2016. Available from: http://www.who.int/hrh/tools/en/ Viewed 11 January 2016.
Viewed 12 January 2016.
McCarty MV and Fenech BJ. Towards best practice in national
Addicott R, Maguire D, Honeyman M and Jabbal J. Workforce health workforce planning. MJA Open 2012; 1 Suppl 3:
planning in the NHS. London UK; The King’s Fund; 2015. 10–13. Available from: https://www.mja.com.au/system/files/
Available from: http://www.kingsfund.org.uk/sites/files/kf/field/ issues/001_03_230712/mcc10309_fm.pdf
field_publication_file/Workforce-planning-NHS-Kings-Fund- Viewed 11 January 2016.
Apr-15.pdf Viewed 11 January 2016.
Masnick K and McDonnell G. A model linking clinical workforce
Community Services & Health Industries Skills Council skill mix planning to health and health care dynamics. Human
(CS&HISC). Workforce Planning Toolkit. Sydney NSW; Resources for Health (30 April 2010) Available from: http://
CS&HISC; 2015. Available from: http://www.cshisc.com.au/ www.human-resources-health.com/content/pdf/1478-4491-8-
media/359203/interactive_wf_planning_toolkit.pdf Viewed 12 11.pdf Viewed 11 January 2016.
January 2016.
American Hospital Association (AHA). Developing an
effective health care workforce planning model. Chicago and
Washington DC USA; AHA; 2013. Available from: http://www.
aha.org/content/13/13wpmwhitepaperfinal.pdf Viewed 12
January 2016.
Safe Work Australia (SWA). Guide for managing the risk of fatigue
at work. Canberra ACT; Commonwealth of Australia; 2013.
Available from: http://www.safeworkaustralia.gov.au/sites/SWA/
about/Publications/Documents/825/Managing-the-risk-of-fatigue.
pdf Viewed 6 April 2016.
Health Workforce Australia (HWA). National Rural and Remote
Health Workforce Innovation and Reform Strategy. Adelaide
SA; HWA; 2013. Available from: http://www.hwa.gov.au/
sites/uploads/HWA13WIR013_Rural-and-Remote-Workforce-
Innovation-and-Reform-Strategy_v4-1.pdf
Health Workforce Australia (HWA). Health Workforce 2025 -
Doctors, Nurse, Midwives. Adelaide SA; HWA; 2012. Available
from: http://www.hwa.gov.au/our-work/health-workforce-
planning/health-workforce-2025-doctors-nurses-and-midwives
NSW Ministry of Health. Aboriginal Workforce Strategic
Framework 2011 - 2015 (revised). North Sydney NSW; NSW
Ministry of Health; 2013. Available from: http://www0.health.
nsw.gov.au/policies/pd/2011/pdf/PD2011_048.pdf Viewed 11
January 2016.
March 2016 249

Implementation
Criterion 2.2.2 a) Policy / guidelines addressing a) The recruitment, selection and

recruitment, selection and appointment system ensures that
The recruitment, selection and
appointment are consistent with the number and skill mix of staff is
appointment system ensures that
relevant legislation, standards, commensurate with organisational
the skill mix and competence of staff,
guidelines and/or codes of need and the provision of safe,
and mix of volunteers, meets the
practice, and are readily available high quality care.
needs of the organisation.
to staff.
b) The recruitment, selection and
b) Recruitment, selection and appointment system responds to
appointment processes ensure changing service requirements.
that staff and volunteers have the
c) All units / departments comply
necessary licences, registration,
with the organisation’s
qualifications, skills and experience
recruitment, selection and
to fill their defined roles.
appointment processes.
d) The volunteer recruitment system
supports an adequate number
and mix of volunteers to provide
appropriate services.
e) There is a system and program for
the orientation and integration of
all staff and volunteers.

This criterion requires the organisation to implement Comprehensive workforce planning (Criterion 2.2.1)
and monitor a system for the recruitment, selection identifies the staff needed to allow the organisation to
and appointment of staff and volunteers, which fulfils achieve the goals outlined in its strategic and operational
all legislative requirements and meets the needs of the plans (Criterion 3.1.1). If recruitment is subcontracted
organisation with respect to its ability to deliver safe, to external service providers, this arrangement must
high quality health care. be managed so as to ensure the quality of the service
delivery, assessed against the terms of agreement
(Criterion 3.1.4). Failures in the processes for recruiting
appropriately qualified staff may lead to incidents
(Criterion 2.1.3) and complaints (Criterion 2.1.4).
Organisational need will determine the recruitment
of health professionals, whose suitability for available
positions will be managed via the processes of
credentialing and defining the scope of clinical practice
(Criterion 3.1.3).
a) T
he effectiveness of the a) The organisation shows distinction a) The organisation demonstrates it is
recruitment, selection, and in recruitment, selection, a leader in recruitment, selection,
appointment system in appointment, orientation and appointment, orientation and
maintaining necessary staffing integration of staff and volunteers. integration systems.
and volunteer levels is evaluated,
as required.
b) P
erformance measures are used
to evaluate the recruitment,
selection and appointment
system, and improvements are
made as required.
c) The orientation and integration
system is regularly evaluated,
as required.
This criterion requires healthcare Recruitment, selection and appointment

organisations to: The organisation’s recruitment, selection and
ecruit and appoint staff and volunteers at a
R appointment of staff and volunteers should align with
level commensurate with consumer / patient and and support its broader strategic and operational
organisational need. planning. Workforce planning will identify both the level
of staffing required to meet consumer / patient and
Implement an organisation-wide system for organisational needs and the desired skill mix, as well
recruitment, selection and appointment of staff as outlining strategies for reaching and maintaining
and volunteers that is in accordance with all these goals in practice, where resource constraints,
legislative requirements. shortages of appropriately qualified applicants or other
onfirm that appointed staff and volunteers have the
C shortfalls may hinder full employment. The organisation’s
necessary licences, registration, qualifications, skills recruitment, selection and appointment practices should
and experience. be designed to ensure that both current and future
service provision needs are met.
Implement an orientation and integration program for
staff and volunteers. Recruitment, selection and appointment of staff and
volunteers should:
ssist the organisation to meet its strategic
a
and operational goals as identified through
workforce planning
result in staff numbers commensurate with consumer /
patient safety and organisational need
March 2016 251

Criterion 2.2.2
The recruitment, selection and appointment Prompt points
system ensures that the skill mix and ow does consumer / patient need
H
competence of staff, and mix of volunteers, affect the organisation’s management
meets the needs of the organisation. (continued) of staff recruitment?
ow is the skill mix within the relevant team
H
llow the organisation to maintain the skill mix defined
a reviewed before a new position or replacement
as being necessary for the delivery of safe, high quality is recruited? How are future service needs
care and services considered as part of this process?
e undertaken against updated position
b ow do the organisation’s recruitment
H
descriptions that reflect current organisational processes ensure that the best person is
needs and resource constraints. recruited to a position? How are these
The organisation should have a system for the recruitment, process evaluated?
selection and appointment of staff that ensures that each ow does the organisation ensure that it
H
position is filled with the best qualified applicant, while complies with relevant legislation and regulations
simultaneously ensuring that the organisation’s legislative when recruiting, selecting and appointing staff?
obligations are met. The system for recruitment, selection How is non-compliance managed?
and appointment should be implemented in a consistent
manner organisation-wide, and evaluation of the system If the recruitment process is outsourced,
should be undertaken at the local level, to ensure what documentation from the external
compliance with all relevant processes. If the organisation provider indicates that it meets legislative
uses external recruitment services, it must likewise ensure and regulatory requirements?
that these services are conducted in accordance with its
own legislative and policy requirements.
Volunteers
Processes for recruitment, selection and
appointment should: Organisations choosing to undertake a volunteer
program should have a clear rationale, including a clear
meet all legislative requirements explanation of the reasons for using volunteers instead of
e implemented organisation-wide in a
b employing staff in particular roles. The use of volunteers
consistent manner carries some costs and risks for an organisation. Issues
for consideration include availability of staff to coordinate
e thoroughly documented, and made readily
b the program, funding for volunteer activities, including
available to all staff furniture and equipment, insurance for volunteers, and
nsure that all appointments are made following a
e the privacy and confidentiality of consumers / patients.
defined and consistent series of steps Considerable planning, management, feedback and
review are required to achieve an effective management
include the signing of an employment contract which program for volunteers.
describes the conditions of employment, such as:
Volunteer appointments should:
• hours of employment and full-time, part-time or
casual nature of employment status (permanent or e undertaken with due consideration of the
b
stated temporary duration) associated risk
• salary and benefits ccur only where adequate training and supervision
o
are available
• start date and probation period
support the work of the paid workforce, not replace it
• any other conditions of employment
recognise and manage the different reasons for
here recruitment is conducted by an external
w volunteering and the different skills of volunteers.
agency, be governed by a contract that includes
defined performance measures, which are
regularly reviewed.
Orientation and integration
Prompt points Generally, an orientation program should introduce staff
hat organisational structures and/or
W and volunteers to the organisation, while an integration
processes are in place to support program introduces them to their specific role and duties.
volunteer appointments? However, the content of each program will vary according
to nature of the organisation, the care and services
ow does the organisation use volunteers to
H provided, and the identity and qualifications of the
support the paid workforce? participants. Orientation may highlight the organisation’s
ow does the organisation monitor satisfaction
H vision and values, and universal responsibilities such
of volunteers in their role? as security, workplace health and safety and infection
control; integration should take into account the
background and previous experiences of the individual,
Checking of qualifications / credentials and ensure that they understand the environment in which
they will be working and the expectations upon them.
Pre-employment screening is an essential risk
Volunteers should also receive appropriate orientation and
management process. It is essential that the
integration, which can help to maximise their contribution
organisation has robust processes for checking the
while reducing risks to the organisation.
claimed qualifications, credentials and experience of all
potential appointees, whether local or local or foreign- Orientation and integration programs for new staff and
based. Where casual staff are sourced from agencies, volunteers should:
it is important to confirm that all agency staff have
e developed to meet the specific needs of the
b
themselves been screened and have met the standards
organisation and in response to characteristics or the
of the contracting organisation.
identity of the participants
Formal checking of applicants should include:
e structured to ensure that participants receive all
b
references necessary information
all claimed qualifications, skills and experience introduce new staff and volunteers to the the
organisation, its vision and values and the
all necessary licences and registrations
organisational culture
here appropriate, criminal history and working with
w
rovide participants with information about key staff
p
children clearance.
members and the unit / department in which the they
will be based
Prompt points nsure that staff and volunteers understand the role(s)
e
to which they have been appointed and all associated
H
duties and expectations
appointees have the necessary licences,
registrations, qualifications, skills and experience? llow for the easy transition of staff and volunteers into
a
their new roles.
escribe the pre-employment screening
D
process undertaken for a managerial staff
member? How does the process change when
the staff member will occupy a clinical role?
ow does the organisation confirm the
H
credentials of applicants who are based in
and/or who trained in a different country?
March 2016 253

Criterion 2.2.2 Suggested reading

The recruitment, selection and appointment World Health Organization (WHO). Health workforce: Tools
system ensures that the skill mix and and guidelines for human resources for health. Geneva CH;
WHO; 2016. Available from: http://www.who.int/hrh/tools/en/
competence of staff, and mix of volunteers, Viewed 12 January 2016.
meets the needs of the organisation. (continued)
Australian Human Rights Commission. Factsheet: Best
practice guidelines for recruitment and selection. Sydney
NSW; Australian Human Rights Commission. Available from:
Prompt points https://www.humanrights.gov.au/sites/default/files/content/
hat skills / knowledge / values are
W info_for_employers/pdf/11_guidelines_recruitment_selection.
given to new appointees during orientation pdf Viewed 13 January 2016.
and integration? Australian Health Practitioner Regulation Agency (AHPRA).
Registration. Melbourne VIC; AHPRA; 2016. Available from:
ow are the orientation and integration
H http://www.ahpra.gov.au/Registration.aspx Viewed 13
programs adapted for different groups of January 2016.
personnel, including permanent, casual and
contracted staff, and volunteers? Community Toolbox. Hiring and training key staff for
community organizations. Lawrence USA; Work Group for
ow has feedback from staff and volunteers
H Community Health and Development, University of Kansas;
been used to improve the orientation and 2015. Available from: http://ctb.ku.edu/en/table-of-contents/
integration programs? structure/hiring-and-training Viewed 13 January 2016.
The Postgraduate Medical Council of Victoria Inc. (PMVC) An
orientation manual for overseas medical graduates. Fitzroy
VIC; PMCV; 2015. Available from: http://www.pmcv.com.au/
The following evidence may help to computer-matching-service/resources/132-img-orientation-
manual/file Viewed 13 January 2016.
address criterion 2.2.2
NSW Ministry of Health. Framework for engaging, supporting
valuation of recruitment and selection policies,
E
and managing volunteers. North Sydney NSW; NSW Ministry of
procedures and processes Health; 2011. Available from: http://www0.health.nsw.gov.au/
valuation of compliance with legislation /
E policies/pd/2011/pdf/PD2011_033.pdf Viewed 13 January 2016.
regulations for recruitment, selection Masnick K and McDonnell G. A model linking clinical workforce
and appointment skill mix planning to health and health care dynamics. Human
Resources for Health (30 April 2010) Available from: http://
ecords of manager training in recruitment
R www.human-resources-health.com/content/pdf/1478-4491-8-
and selection in line with organisational policies 11.pdf Viewed 11 January 2016.
and procedures
National Health and Medical Research Council (NHMRC).
udits of appointments made against the
A Working with volunteers and managing volunteer programs in
requirements of position descriptions health care settings. Melbourne VIC; NHMRC; 2003. Available
from: https://www.nhmrc.gov.au/_files_nhmrc/publications/
Audits of licence / registration / reference checks attachments/nh48_working_with_volunteers.pdf Viewed 13
eview of agreement with external recruitment
R January 2016.
agencies, including any performance indicators
and performance evaluation and feedback
ecords of orientation / integration program
R
completion by new staff and volunteers
March 2016 255
Implementation
Criterion 2.2.3 a) Accurate and complete personnel a) The performance management

records, including qualifications and review system ensures that:
The performance management
and completed mandatory and
system ensures the competence of (i) h
ealth professionals, other staff
non-mandatory training, are
staff and volunteers. and volunteers are competent
maintained and kept confidential.
and accountable for their work
b) Health professionals, other staff
(ii) there is active participation
and volunteers are provided with
of both the manager and the
a written description outlining
individual in performance review
their position or volunteer role,
responsibilities and accountabilities. (iii) a
reas for improvement and
additional education needs
c) Staff comply with published codes
are identified
of professional practice relevant
to their professional role, and the (iv) opportunities for professional
organisation’s Code of Conduct. development are identified.
d) There is a process to identify b) T
here are processes to ensure
mandatory training for health effective management of staff and
professionals, other staff and, volunteers at unit / department level.
where appropriate, volunteers.
c) There is a process to ensure that
e) There is an organisation-wide professional and other licensed
process for the performance review staff provide verified documentary
of all staff, including volunteers. evidence to demonstrate their
continuing registration with the
f) Policy / guidelines address the
relevant regulatory body.
process for managing a complaint or
concern about a health professional, d) Position descriptions
including ensuring the immediate including accountabilities and
safety of consumers / patients. responsibilities are regularly
reviewed.
g) Policy / guidelines address the
process for managing a
complaint or concern about
non-clinical staff, including
contractors and volunteers.

This criterion requires the organisation to implement Management of a staff member’s performance follows
and monitor a system for the management of staff on from their appointment, orientation and integration
and volunteers which ensures that all staff, including (Criterion 2.2.2). With respect to health professionals,
contracted, visiting and casual staff, and all volunteers this will further involve credentialing and delineation of
understand the requirements of their position, the scope of clinical practice (Criterion 3.1.3).
their accountabilities and responsibilities, and the
The organisation’s management of its staff and volunteers
organisation’s expectations with respect to personal and
should be supported by a learning and development
professional conduct.
system that will further develop the skills of staff and
volunteers and improve performance (Criterion 2.2.4).
a) T
he performance management and a) The organisation shows distinction a) The organisation demonstrates
review system is regularly evaluated in performance management. it is a leader in performance
with staff participation, and management systems.
improvements are made as required.
b) E
valuation is undertaken to ensure
that staff, including contracted staff
and, when appropriate, volunteers
have participated in performance
review, and improvements are made
as required.
c) T
he performance review process is
evaluated to ensure that it addresses
the competency and accountability
of staff and volunteers, and
d) T
he management of staff and
volunteers at unit / department level
is evaluated, and improvements are
made as required.
e) T
he process for managing a
complaint or concern about a health
professional, including the steps
taken to ensure the immediate
safety of consumers / patients, is
made as required.
f) The process for managing a
complaint or concern about non-
clinical staff, including contractors
and volunteers, is evaluated, and
Effective implementation and management of appropriate This criterion requires healthcare

support systems should facilitate long-term employment organisations to:
and increase staff wellbeing (Criterion 2.2.5).
rovide all staff and volunteers with an up-to-date
P
position description.
aintain and keep confidential accurate
M
personnel records.
nsure that staff and volunteers comply with the
E
organisation’s Code of Conduct, and any relevant
codes of professional practice.
March 2016 257

Criterion 2.2.3
The performance management system ensures Prompt points
the competence of staff and volunteers. ho is responsible for ensuring that all
W
(continued) current organisational positions have an
associated position description?
Implement a system through which staff and volunteer
ow is the position description used in the
H
performance is managed at the unit / department level.
performance review process?
Implement an organisation-wide performance
ow does the organisation ensure that the
H
review system.
position description is updated following
ave in place a system for the management of a
H performance review?
complaint against a health professional, or against any
ow does the organisation use position
H
other staff member or volunteer.
descriptions to assist volunteers to understand
what is expected of them?
Position descriptions
Accurate, up-to-date position descriptions with well-
defined roles and responsibilities will assist staff Personnel and training records
members and volunteers to understand their duties and The organisation should implement a comprehensive
the lines of authority impacting their position. Position system for the collection and storage of relevant
descriptions should be ‘living documents’, reviewed information about its staff, within a framework of records
and updated in response to changes to individual management that ensures the organisation meets
responsibilities and/or service provision. Preparing its legal responsibilities with regard to privacy and
position descriptions for volunteers helps to formalise confidentiality, and records retention and destruction.
their relationship with the organisation, and clarifies the Access of an individual staff member to their own
rights and responsibilities of both parties. personnel record should also be according to relevant
Position descriptions should: legislation and organisational policy. An effective
personnel records system should have the capacity to
be maintained in a centralised file alert appropriate staff to an individual’s non-completion
s pecify responsibilities, accountabilities, job functions of professional competencies, mandatory training and
and activities (including scope of clinical practice for any other training and/or education required for
health professionals) and the frequency and process their position.
of performance review Personnel records should:
e kept current, and reflect any changes in duties and
b e created, stored and accessed according to the
b
responsibilities over time organisation’s legal obligations, including all relevant
e updated following any significant changes to
b privacy statutes
employment structures, duties or service provision be complete and accurate
e jointly reviewed by the staff member and their
b be kept confidential
manager during the performance review, and changes
in duties and responsibilities discussed ave an alert system for non-completion of training,
h
competencies and ongoing education
here appropriate, be developed for volunteer
w
positions to provide guidance and focus. include documented outcomes of the annual
performance review, including an updated position
description and any agreed training
e managed according to policy and procedures,
b
which should: Prompt points
• specify who has limited and unlimited access to ow does this organisation store its
H
personnel records personnel records?
• define the limits of acceptable physical movement hat systems ensure that confidential
W
of personnel records and/or electronic access information recorded on personnel records
to records is restricted so that it is reviewed only under
• define the circumstances in which specified relevant circumstances by authorised staff?
information from the records may be disclosed ow does the organisation ensure that personnel
H
• describe the circumstances under which staff records are complete and up-to-date?
may access their own personnel records, and the ow is the organisation alerted to any non-
H
process to be followed completion of mandatory training or professional
• specify the conditions under which the records competencies? What action is taken in
must be stored, and the schedule and means of response to an identified non-completion?
their destruction
ontain all relevant information about the staff
c Managing performance
member, including (but not limited to) records of:
While the organisation will have an overall staff
• personal details, including a designated management plan, effective management on a day-
financial authority to-day basis, at the level of the unit / department, is
• all qualifications, registrations, referee and other necessary for consumer / patient safety and quality
validation checks service provision. Appropriate supervision and an
effective management structure are important factors
• completed orientation, and attendance at required in ensuring that each member of staff, volunteer and
ongoing education student is aware of policy and procedures relevant
• all completed training, including mandatory training to their position, understands what is expected of
and all required professional competencies them, and is able to carry out their duties safely
and effectively. Managers should be focused upon
• vaccinations, and any relevant health information facilitation of their area’s performance, and ensure that
• leave taken each individual for whom they are responsible is given
appropriate supervision and training, and that they in
• annual performance reviews turn demonstrate the required level of compliance with
• any formal disciplinary action. policies and codes of conduct / practice while carrying
out their tasks.
Work management and supervision should:
operate at the unit / department level
e appropriately provided for all those working within
b
a unit / department, including volunteers and students
perate within defined responsibilities
o
and accountabilities
create a framework of defined duties and expectations
involve other qualified / specialist personnel
when required
March 2016 259

Criterion 2.2.3 promote staff retention. While it may not be necessary or

The performance management system ensures feasible to hold performance reviews for all volunteers,
an interview process concentrating upon mutual
the competence of staff and volunteers. feedback may be beneficial for both parties.
(continued)
Performance review should:
include the ongoing monitoring of general competency e conducted annually for all staff and volunteers
b
and day-to-day performance, with provision for organisation-wide, including all health professionals
intervention in staff / volunteer / student performance
when required have a consistent framework and clear outcomes
onitor compliance with organisational policy and

m include personnel responsible for the work
procedures, and with relevant codes of conduct and management of the staff member / volunteer
professional practice be conducted in a positive and non-punitive manner
e able to facilitate access to remedial training
b ctively involve both the staff member / volunteer and
a
when necessary their manager
nsure that consumer / patient safety is at the
e include a review of the position description
forefront of all organisational activities.
identify any areas in performance which may need to
be addressed through education or training
Prompt points identify opportunities for professional development
ow does the organisation ensure
H highlight performance strengths
that unit / department managers have the
necessary skills to create and maintain an for volunteers, focus upon a review of goals and
effective working environment? objectives and the gaining of feedback.
ow are staff and volunteers made aware of the

H
lines of management and authority in their Prompt points
unit / department?
H
ow are managers supported to take action
H performance reviews are conducted in an
in the event of an identified shortcoming in objective, constructive manner?
the performance of a staff member, volunteer
or student? ow are areas for improvement or for further
H
professional development identified during
ow does the organisation ensure the safety
H performance review followed-up?
of consumers / patients when it undertakes
student training? ow does the organisation ensure that all
H
necessary performance reviews are conducted?
ow does the organisation manage
H
Performance review performance review of its contracted staff? If
An organisation-wide system should ensure the annual the organisation uses agency staff, how does it
performance review of all staff, including all health ensure that they have undergone a satisfactory
professionals. The review should actively involve both performance review?
the manager and the staff member, and be conducted in ow does the performance review of volunteers
H
a positive manner. A well-structured performance review differ from that of staff?
should acknowledge strengths, allow for agreed-upon
remedial measures for any performance shortcomings,
and identify opportunities for further development and
education. Aligning individual goals with the goals of the
unit / department and organisation whenever possible
will help to build positive working relationships and
Managing complaints against health involve a formal investigation of the allegation, and
professionals, or against any other staff notification of appropriate bodies (governance /
member or volunteer medical / other authorities)
It is vital that the organisation implement a well- include provisions to protect those making a
structured, responsive system for the management of complaint, to ensure that they are not subject to
complaints against health professionals, other members recrimination, reprisal or intimidation
of staff, and volunteers. Where a health professional here a health professional is involved, fulfil all
w
is the subject of a complaint, consumer / patient legal requirements and those of the relevant
safety should be the organisation’s immediate priority. medical authorities
The process for investigation and management of a
complaint against a health professional must fulfil the include a regular assessment of the effectiveness of
organisation’s legal obligations in this area, while the the management process, the resolution of complaints
organisation may also be required to notify various and the satisfaction of complainants with the process.
relevant authorities.
Any expressed concern against any member of Prompt points
staff or volunteer, whatever the source, should be
oes the organisation’s process for
D
investigated. However, the organisation should ensure
managing a complaint or concern about
that where the complainant is another member of staff,
a health professional differ from that used to
there are processes in place to prevent any negative
manage a complaint about a non-clinical staff
repercussions. In particular, ‘whistleblowers’ who
member? - in what way(s)?
draw attention to inappropriate behaviour, professional
misconduct or failures in systems or processes may ow does the process for managing a
H
run the risk of being bullied or otherwise intimidated complaint about a health professional fulfil the
into silence. The organisation’s system for managing organisation’s legal requirements in this area?
complaints against a staff member should include
ho is responsible for managing complaints
W
processes for the protection of the complainant.
and concerns about members of staff and
Complaints management should: volunteers? What training is offered to
these individuals?
e supported by policy / guidelines that define the
b
processes to be followed and identify those with ow does the organisation protect those
H
designated responsibilities, and which are readily individuals who make a complaint or voice
available to staff a concern?
respond promptly to any expressed concern, which ow does the organisation ensure that the
H
may address: process for making a complaint or voicing a
concern is understood?
• substandard performance
ho is responsible for ensuring that all relevant
W
• unethical conduct
parties are notified when a complaint is made?
• physical or mental impairment
• non-compliance with policy, or codes of conduct or
professional practice
• inappropriate conduct, including disruptive
behaviour, bullying or harassment
include processes for ensuring the immediate safety
of consumers / patients
be conducted by individuals with appropriate training
March 2016 261


The performance management system ensures AS ISO 15489.1-2002 (R2013)
the competence of staff and volunteers. Records management - General.
(continued) AS ISO 15489.2-2002 (R2013)
Records management - Guidelines.
The following evidence may help to AS/NZS ISO 30300-2012
address criterion 2.2.3 Management systems for recordkeeping - Fundamentals
and vocabulary.
entral file of position descriptions, with
C
evidence that they are current AS/NZS 30301-2012
Management systems for recordkeeping - Requirements.
ystem of alerts for non-completion of training /
S
professional competencies AS/NZS 10002:2014
Guidelines for complaint management in organizations.
olicy describing content / storage / access /
P
destruction of personnel files AS ISO 10002-2006/Amdt 1-2011
Customer satisfaction - Guidelines for complaints
osition descriptions including managerial /
P handling in organizations.
supervisory responsibilities and key
performance indicators
Suggested reading
Audits of completed performance reviews Department of Health. NHS staff management and health
raining offered in response to areas of
T service quality. London UK; Department of Health. Available
improvement / further professional development from: https://www.gov.uk/government/publications/nhs-staff-
management-and-health-service-quality
identified during performance review
Viewed 2 February 2016.
ecords of resolved complaints / concerns
R Health Resources and Services Administration. Performance
about health professionals, other members or management & measurement. Washington DC USA;
staff and/or volunteers Department of Health and Human Services. Available
from: http://www.hrsa.gov/quality/toolbox/methodology/
performancemanagement/index.html Viewed 2 February 2016.
Department of Health & Human Services. Performance
appraisal and support for senior medical practitioners in
Victorian public hospitals. Melbourne VIC; Department of
Health & Human Services. Available from: https://www2.
health.vic.gov.au/about/publications/researchandreports/dla-
fox-phillips Viewed 2 February 2016.
Medical Board of Australia. Good medical practice: A code
of conduct for doctors in Australia. Melbourne VIC; Medical
Board of Australia; 2014. Available from: http://www.
medicalboard.gov.au/Codes-Guidelines-Policies/Code-of-
conduct.aspx Viewed 2 February 2016.
Royal Australasian College of Surgeons (RACS). Guidelines
to bullying and harassment: Recognition, avoidance and
management. East Melbourne VIC; RACS; 2014. Available
from: https://www.surgeons.org/media/21379791/art_2015-
02-17_racs_028_-_bullying_and_harassment.pdf Viewed 2
February 2016.
Choudhary GB and Puranik S. A study on employee
performance appraisal in health care. Asian Journal of
Management Sciences 02 (03 Special Issue): 59-64, 2014.
Available from: http://www.literatipublishers.com/Journals/
index. Viewed 2 February 2016.
Safe Work Australia. Guide for preventing and responding to
workplace bullying. Acton ACT; Safe Work Australia; 2013.
Available from: http://www.safeworkaustralia.gov.au/sites/
SWA/about/Publications/Documents/827/Guide-preventing-
responding-workplace-bullying.pdf Viewed 10 March 2016.
State Records Authority of NSW. Managing personnel records.
Sydney NSW; NSW Government; 2013. Available from:
https://www.records.nsw.gov.au/recordkeeping/resources/
personnel-and%20e-recuitment%20records/Managing%20
personnel%20records Viewed 29 January 2016.
Kumar R, Anjum B and Sinha A. Employee performance
appraisal in health care. International Journal of Management
and Strategy 11 (3): July-Dec, 2011. Available from: http://
facultyjournal.com/webmaster/upload/__rakesh%203%20
EMPLOYEE%20PERFORMANCE%20APPRAISAL%20IN%20
HEALTH%20CARE.pdf Viewed 2 February 2016.
Commonwealth Ombudsman. Better practice guide to
complaint handling. Canberra ACT; Commonwealth of
Australia; 2009. Available from: http://www.ombudsman.gov.
au/docs/better-practice-guides/onlineBetterPracticeGuide.pdf
March 2016 263

Implementation
Criterion 2.2.4 a) There is a planned and a) There is an evidence-based

documented learning and learning and development system
The learning and development
development program that available to staff, including
system ensures the skill and
addresses organisational and volunteers, that:
competence of staff and volunteers.
staff needs.
(i) identifies the needs of both the
b) Staff and volunteers are consulted organisation and staff
about their learning and
(ii) e
nsures staff remain competent
development needs.
to perform their work
c) The organisation provides
(iii) m
eets new and changing staff
mandatory training in
needs in a timely manner
accordance with legislative and
policy requirements. (iv) responds to changes in the
organisation’s environment.
d) The organisation provides
adequate resources for learning b) The organisation ensures
and development. that education and training
are delivered by appropriately
e) Staff and volunteers and, where
qualified individuals and/or to an
relevant, students are provided
appropriate standard.
with appropriate supervision by
experienced, trained and c) Where relevant, the organisation
qualified staff. ensures that student requirements
for training are met.
f) There is a system to
record and check staff d) Staff meet their requirements
completion of professional for self-directed professional
development requirements. development.
Overview
This criterion requires the organisation to implement
a learning and development system for its staff
and volunteers that is structured, planned and
comprehensive, and to provide all training necessary to
fulfil its legislative requirements and develop the skills
and competency of staff, volunteers and students.
a) T
he learning and development a) The organisation shows a) The organisation demonstrates
system is regularly evaluated with distinction in staff and volunteer it is a leader in learning and
staff participation to ensure that learning and development. development systems.
it meets organisational and staff
needs, and improvements are
made as required.
b) T
he education and training
delivered by the organisation are
made as required.
c) The supervision of staff, volunteers
and students is evaluated,
as required.
d) The system to record and check
completion of mandatory training
and professional development is
made as required.
Relationships of 2.2.4 with other criteria This criterion requires healthcare

Learning and development is an important aspect organisations to:
of the creation of a skilled and competent workforce Implement and support a learning and
that performs within a satisfying working environment development program.
(Standard 2.2). Some aspects of learning and
development will be voluntary, while others will be onsult with staff about their learning and
C
mandated by legislation or policy, for example, fire development needs.
and disaster safety training (Criterion 3.2.4) and health rovide all mandatory training, and all other training
P
records management (Criterion 2.3.1). For clinical identified as necessary in organisational policy.
staff, learning and development may be necessary to
fulfil the requirements of credentialing and maintaining nsure that those individuals supervising staff,
E
or expanding the scope of clinical practice (Criterion volunteers and students are appropriately skilled
3.1.3). It is also vital for those health professional who and experienced.
recruit consumers / patients for research projects, and onfirm and record the completion of all professional
C
associated staff involved in such projects (Criterion 2.5.1). development requirements by staff.
March 2016 265

Criterion 2.2.4 • training in management skills, for example,

The learning and development system conflict resolution
ensures the skill and competence of staff and • any training initiated in response to an identified
volunteers. (continued) performance gap
• any other training identified as developing staff skills
Learning and development in consultation and competency
with staff e adequately resourced; where budget limitations
b
An effective learning and development system will serve are a concern, the organisation may consider various
the dual purpose of ensuring that the organisation alternatives to traditional training methods, such as:
employs properly trained and competent staff, while • on-the-job teaching / training
providing opportunities for staff to develop their careers
and acquire new skills. While it will not always be • teleconferencing, webinars and other technological
possible to fully align organisational and staff needs in approaches
this respect, those responsible for planning learning • support for self-directed study
and development programs should strive to meet
both aims, and consultation with staff should be a • support for staff undertaking external studies
fundamental principle. Furthermore, planning should include a system for monitoring and recording
take into account not only existing needs, but expected the completion of all mandatory training,
and potential changes to organisational service delivery professional development requirements,
and the associated skill mix required. The overall goal and any self-directed education or training.
should be to create a flexible learning and development
program that is able to respond in a timely manner to
organisational and environmental changes. Prompt points
The organisation’s learning and development hat staff consultation occurs when
W
program should: the organisation is planning, implementing
e developed with staff consultation, and reflect goals
b and/or changing its learning and development
identified during performance review program? How are staff learning and
development needs identified during
im to develop and extend the competency of staff
a performance review used during this process?
and volunteers
ow does the organisation ensure that its
H
respond to changing organisational or staff needs in a learning and development program is able
timely manner to respond in a timely manner to changing
im to match staff learning and development goals
a service requirements or a changing
to organisational goals and/or expanded or changing healthcare environment?
service plans ow does the learning and development
H
ddress both organisational and staff requirements
a program assist the organisation to meet its
and needs, which may include (but are not limited to): strategic goals? How does it increase the
competency of staff and volunteers?
• all mandatory training identified as such
by legislation hat different approaches does the
W
organisation use within its learning and
• all professional development required to maintain development program? How does the
competency and credentialing organisation support staff members who
• training for specialised positions or functions, for wish to extend their learning / skills?
example, health records management
• training in organisational systems, structures
and processes
Providing and recording training
In addition to broader learning programs, the Prompt points
organisation will need to plan and deliver specific staff hat training is designated as
W
training in order to fulfil the requirements of legislation ‘mandatory’ within this organisation? How
and policy. Various levels of training may also be does the organisation ensure the completion of
required, for example, while all staff will undergo all mandatory training by staff, volunteers and
emergency response training, those individual appointed students? How are any shortfalls in
as fire officers will require further training in the duties of completion addressed?
their positions. Specific training should also be provided
to staff, volunteers and students, as required to ensure or what specialised or position-based
F
that they acquire the skills necessary to perform their areas of management does the organisation
various functions in a safe and competent manner. provide training?
Planning in this area should define the expected ow does the organisation ensure that its
H
outcomes of training, and the organisation should be staff completes all self-directed professional
confident that the qualifications and/or experience of development requirements?
those delivering the training will ensure that outcome
If the organisation has students, how does it
goals are met.
ensure that it meets the requirements for their
The training of staff, volunteers and students should: training and supervision?
fulfil all requirements of legislation
eet the needs of the organisation, as described
m
in policy The following evidence may help to
e evidence-based, and draw upon principles of
b address criterion 2.2.4
current best practice earning and development plan / staff
L
here self-directed, be completed in a timely
w development plan
manner and this completion formally demonstrated ngoing education programs / training linked to
O
and recorded performance review
here provided by the organisation, be delivered
w andatory training schedule, attendance register
M
by appropriately qualified individuals and/or to an and follow-up of non-attendees
appropriate standard
chedule for specialised or
S
include the use of experienced supervisors to develop position-based training
the skills and competency of staff and volunteers
vidence of qualifications of trainers and/or of
E
nsure that all requirements for the training and
e evidence based training
supervision of any students are met, within a
framework that: vidence of support for self-directed staff
E
learning and development
• adheres to all relevant guidelines for clinical supervision
• provides all essential skills and experiences
• controls impositions on consumers / patients
• minimises the risk of errors.
March 2016 267

Suggested reading
Australian Health Practitioner Regulation Agency (AHPRA).
Approved programs of study. Melbourne VIC; AHPRA; 2016.
Available from: http://www.ahpra.gov.au/About-AHPRA/
Contact-Us.aspx Viewed 11 February 2016.
Primary Health Care Research & Information Service (PHCRIS).
Introduction to mentoring. Bedford Park SA; PHCRIS; 2016.
Available from: http://www.phcris.org.au/guides/mentoring_
matters.php Viewed 11 February 2016.
The HR Council for the Nonprofit Sector. Learning, training &
development: Getting your organization ready for employee
training & development. Ottawa CA; Community Foundations
of Canada; 2016. Available from: http://hrcouncil.ca/hr-toolkit/
learning-ready.cfm Viewed 11 February 2016.
Department of Health. Delivering high quality, effective,
compassionate care: Developing the right people with the right
skills and the right values. A mandate from the Government to
Health Education England: April 2013 to March 2015. London
UK; Department of Health; 2013. Available from: https://www.
gov.uk/government/uploads/system/uploads/attachment_
data/file/203332/29257_2900971_Delivering_Accessible.pdf
Australian Public Service Commission (APSC). Building
capability: A framework for managing learning and
development in the APS. Phillip ACT; APSC; 2013. Available
from: http://www.apsc.gov.au/publications-and-media/current-
publications/building-capability Viewed 11 February 2016.
Care Quality Commission (CQC). Supporting information and
guidance: Supporting effective clinical supervision. London
UK; CQC; 2013. Available from: https://www.cqc.org.uk/
sites/default/files/documents/20130625_800734_v1_00_
supporting_information-effective_clinical_supervision_for_
publication.pdf Viewed 11 February 2016.
Health Workforce Australia (HWA). National clinical supervision
framework. Adelaide SA; HWA; 2011. Available from:
http://www.hwa.gov.au/sites/uploads/hwa-national-clinical-
supervision-support-framework-201110.pdf Viewed 11
February 2016.
Gesme DH, Towle EL and Wiseman M. Essentials of staff
development and why you should care. Journal of Oncology
Practice 6 (2): 104-106, 2010. Available from: http://jop.
ascopubs.org/content/6/2/104.full.pdf+html Viewed 11
February 2016.
March 2016 269
Implementation
Criterion 2.2.5 a) The workplace rights and a) The organisation supports flexible
responsibilities of management work practices.
Support systems promote
and staff are clearly defined,
staff wellbeing and a positive b) There is a system that
communicated and respected.
work environment. motivates staff and identifies
b) Staff know about, and can access, the value of staff through
support systems that promote appropriate acknowledgement.
staff wellbeing and a positive
c) Managers facilitate staff access
work environment.
to support services and
c) Staff are consulted about workplace relations.
workplace support services and
d) Management and staff work
workplace relations.
cooperatively and, where
d) There is a process for identifying appropriate, in consultation with
and managing staff or volunteer relevant external bodies to achieve
behaviour that is inappropriate or effective workplace relations.
creates risk.
e) There is a transparent system
e) Information about grievance to identify, manage and resolve
processes is readily available to workplace issues, which includes
management and staff. a consultation process.

This criterion requires the organisation to implement The provision of staff support systems and the
and/or facilitate access to staff support systems and to facilitation of workplace relations are vital components
support workplace relations, in order to create a positive of the organisation’s management of human resources
working environment and promote staff wellbeing. (Standard 2.2), and will support the recruitment,
appointment and retention of staff (Criterion 2.2.2),
performance management (Criterion 2.2.3), and learning
and professional development (Criterion (2.2.4). A secure,
motivated workforce is essential for the provision of
safe, high quality care and services (Criterion 3.1.1). The
organisation’s management of its workforce is an aspect
of its integrated risk management framework (Criterion
2.1.2), and failure to implement proper support systems
and to facilitate workplace relations may lead to incidents
(Criterion 2.1.3) and complaints (Criterion 2.1.4).
a) P
erformance measures are used a) The organisation shows distinction a) The organisation demonstrates it
regularly to assess staff access in staff support systems. is a leader in systems to promote
to assistance programs and to staff wellbeing and a positive
evaluate the staff support services, working environment.
as required.
b) S
taff are involved in the
evaluation of support systems,
as required.
c) The management and resolution
of workplace issues, including
grievances, is evaluated,
as required.
This criterion requires healthcare Workplace rights and responsibilities

organisations to: Workplace rights and responsibilities will be defined
efine, communicate and respect the rights and
D by both legislation and organisational policy, while
responsibilities of management and staff. further expectations may be placed upon health
professionals via Boards, colleges or other authorities.
Implement and/or facilitate access to staff support The organisation should strive to create a workplace
systems, and ensure that staff are aware of how to culture where rights are respected, and responsibilities
access these services. understood and enacted. Legislation will often
onsult with staff about workplace relations including,
C address rights and responsibilities in the area of
where appropriate, industrial relations. employment conditions, while the organisation itself
and relevant external bodies may define further rights
ave processes for the identification and
H and responsibilities with respect to individual conduct
management of inappropriate staff or and inter-personal behaviour in the workplace. It is the
volunteer behaviour. organisation’s own responsibility to ensure that staff are
ave processes for the management and resolution
H free to associate with relevant external bodies, including
of grievances. in the area of industrial relations.
Workplace rights and responsibilities should:
e in accordance with legislative requirements and
b
organisational policy
reflect the organisation’s vision and values
March 2016 271

Criterion 2.2.5 Staff support systems should:

Support systems promote staff wellbeing and a be developed with staff consultation
positive work environment. (continued) be available to all staff
s upport the creation and maintenance of a safe and include an organisation-wide communication
equitable working environment, free from bullying, component to ensure that staff are aware of all aspects
harassment, and discrimination on any basis of the support system(s), and how to access them
e communicated to all staff, including (but not limited
b ave processes to ensure that staff access to
h
to) via employment contacts and during orientation assistance programs remains confidential
e actively supported and enforced by management,
b include components for motivating staff and
with monitoring of compliance and appropriate acknowledging high performance / outstanding
disciplinary action when a breach occurs contributions by staff
include processes that ensure that staff interaction encourage staff health and wellbeing
with relevant external bodies, including (but not limited
where practicable, encourage staff work-life balance.
to) professional associations and industrial relations
representatives, is facilitated.
Prompt points
Prompt points ow does the organisation ensure that
H
staff are informed about its support systems
H
and how to access them?
all staff are informed of their rights
and responsibilities? ho does the organisation consult with when
W
developing aspects of its support systems?
hat rights and responsibilities are outlined
W
in employment agreements for the different ow does the organisation use its support
H
categories of staff employed by or contracted to systems to ensure that staff feel appreciated?
the organisation?
hat action is taken when a breach of rights or
W Workplace grievance and
a failure to meet responsibilities is identified?
behavioural management
ow does the organisation respond to incidents
H
of bullying or discrimination? In addition to the management of staff with respect to
their defined positions, the organisation will have broader
responsibilities for managing and resolving workplace
Staff support systems issues, staff grievances, and instances of inappropriate
staff and volunteer behaviour. The organisation
Appropriate support systems that promote staff should strive to create a working environment free of
wellbeing will assist the organisation to create a positive discrimination, harassment and bullying, and ensure that
working environment. Support systems need be staff are aware of how to proceed if they are the target
neither elaborate nor expensive, but should focus upon of such inappropriate behaviour, and that all instances
motivating staff and acknowledging their contributions of such behaviour are investigated and resolved, with
to the organisation. It is to the benefit of both the disciplinary action taken if necessary.
organisation and its staff if the support systems offered
have specific components promoting good health and
wellbeing, for example, exercise programs. In addition,
many organisations provide their staff with access to
an Employee Assistance Program, which will offer free,
confidential assistance with a variety of work-related and
personal issues.
Where broader workplace issues are identified,
consultation with relevant staff should be an aspect of the Prompt points
management process, and there should be transparency
with respect to the process itself and the resolution of the hat staff does the organisation consult
W
issue. The organisation should ensure that individuals with when resolving workplace issues? How
with responsibilities in the investigation, management are relevant parties informed of the outcomes of
and/or resolution of grievances / disputes / incidents have this process?
the appropriate skills, and that the overall management ow does the organisation disseminate
H
system reflects the principles of natural justice. information to staff about its processes
The system for managing workplace grievances and for lodging a grievance or reporting
behavioural issues should: disruptive behaviour?
nsure that the safety and security of consumers /

e hat are the organisation’s processes
W
patients is a priority at all times for managing instances of discrimination,
harassment and/or bullying?
e based upon the principles of natural justice,
b
including an absence of bias, a guarantee of a fair ow does the organisation ensure that
H
hearing, and transparent management processes individuals with responsibility for investigating,
managing and resolving grievances, disputes
include staff consultation where appropriate or instances of disruptive behaviour are
nsure that all staff know how to lodge a grievance
e appropriately trained?
or report inappropriate behaviour, including
discrimination, harassment or bullying
include processes whereby disruptive, risky or The following evidence may help to
otherwise inappropriate staff or volunteer behaviour address criterion 2.2.5
can be reported by consumers / patients, external
contractors or visitors to the organisation Staff education on rights and responsibilities
nsure appropriate training for those individuals
e e-identified data on staff access to an
D
responsible for investigating, managing and/or Employee Assistance Program
resolving grievances or behavioural issues raining programs for relevant staff in grievance
T
nsure that appropriate action is taken in response
e resolution and/or behavioural management
to any incident of disruptive, risky or otherwise Reporting system for inappropriate behaviour
inappropriate behaviour by a staff member or
volunteer, including reporting to relevant external ocumented organisational responses to
D
bodies where required incidents of bullying or harassment
nsure that remedial or disciplinary action is taken

e vents / rewards that acknowledge high
E
in response to any identified incident of bullying, performing staff / staff contributions
harassment or discrimination on any grounds. rograms to encourage and support
P
staff wellbeing
March 2016 273

Criterion 2.2.5
Support systems promote staff wellbeing and a
positive work environment. (continued)
Suggested reading
Fair Work Ombudsman. Effective dispute resolution. Sydney
NSW; Australian Government; 2016. Available from: https://
www.fairwork.gov.au/how-we-will-help/templates-and-guides/
best-practice-guides/effective-dispute-resolution Viewed 16
February 2016.
Lozina L and Hadley J. Lessons from the healthcare industry
on workplace bullying and harassment risks. Sydney
NSW; DibbsBarker; 2015. Available from: http://www.
dibbsbarker.com/publication/Lessons_from_the_healthcare_
industry_on_workplace_bullying_and_harassment_risks.
aspx?utm_source=Mondaq&utm_medium=syndication&utm_
campaign=View-Original Viewed 16 February 2016.
Farouque K and Burgio E. The impact of bullying in
health care. Malvern VIC; The Royal Australian College
of Medical Administrators; 2013. Available from:
http://www.racma.edu.au/index.php?option=com_
content&view=article&id=634&Itemid=362 Viewed 16
February 2016.
NSW Health. Grievance - effective workplace resolution.
North Sydney NSW; NSW Ministry of Health; 2010. Available
from: http://www0.health.nsw.gov.au/policies/pd/2010/pdf/
PD2010_007.pdf Viewed 16 February 2016.
Comcare. Effective health and wellbeing programs. Canberra
ACT; Australian Government; 2010. Available from: https://
www.comcare.gov.au/__data/assets/pdf_file/0011/70220/
Effective_Health_and_Wellbeing_Programs_Pub_82_PDF,3.63_
MB.pdf Viewed 15 February 2016.
PricewaterhouseCoopers. Workplace wellness in Australia.
Aligning action with aims: Optimising the benefits of
workplace wellness. Sydney NSW; PricewaterhouseCoopers;
2010. Available from: http://www.usc.edu.au/media/3121/
WorkplaceWellnessinAustralia.pdf Viewed 16 February 2016.
2.3 Information Management Standard There are four criteria in this standard. They are:
The standard is: 1.3.1 H
ealth records management systems support
Information management systems enable the the collection of information and meet the
organisation’s goals to be met. consumer / patient and organisation’s needs.
The intent of this standard is to ensure that data and Corporate records management systems
1.3.2
information meet the organisation’s needs and support support the collection of information and meet
the delivery of quality care and services. the organisation’s needs.
The principles of good information management are the Data and information are collected, stored
1.3.3
same regardless of the size and type of organisation and and used for strategic, operational and service
the complexity of the information technology. There are improvement purposes.
increasing requirements for information management 1.3.4 The organisation has an integrated approach to the
to support organisational performance and planning, use and management of information
healthcare delivery. and communication technology (ICT).
March 2016 275

SECTION 7 Standards, criteria, elements and guidelines
Standard 2.3: Information management systems enable the
organisation’s goals to be met.
Implementation
Criterion 2.3.1 a) Policy / guidelines addressing a) There is a health records

health records management are management system that ensures:
Health records management systems
consistent with relevant legislation,
support the collection of information (i) the secure, safe and systematic
and meet consumer / patient and storage of data and records
codes of practice, and are readily
organisational needs.
available to staff. (ii) the allocation and maintenance
of the unique identifier
b) Organisation-wide policy /
guidelines describe the allocation (iii) timely and accurate retrieval
of a unique identifier for each and transport of records stored
consumer / patient. on or off-site
c) A central index of identifiers (iv) consumer / patient privacy when
is maintained. information is communicated
d) Where multiple records for the (v) retention and destruction
consumer / patient exist they are
according to all relevant legislation,
cross-referenced.
e) Clinical classification is undertaken codes of practice.
for all inpatient admissions
b) A
ll components of the health
in accordance with relevant
record are accounted for at a
legislation, standards, guidelines
central point, and are monitored.
and/or codes of practice.
c) The health record is linked to other
f) Guidelines describing how
health information systems using
consumers / patients can access
the unique identifier.
their health records are readily
available and staff are advised of their d) Relevant staff are trained in
responsibility to facilitate the process. health record keeping and
records management.
e) Coding and reporting time-
frames meet internal and
external requirements.
f) Health professionals participate
in the analysis of data including
clinical classification information.
g) Requests by consumers / patients
for access to health records
are met within a set period
in accordance with relevant
legislation, standards, guidelines
and/or codes of practice.
a) T
he health records management a) The organisation shows distinction a) The organisation demonstrates
system is evaluated, and in health records management. it is a leader in health records
improvements are made management systems.
as required.
b) C
ompliance with health record
keeping and records management
is monitored and evaluated, and
improvements are made to training
programs as required.
c) Checks for consumers / patients
with multiple identifiers are
regularly made on the central
index, and improvements / links
d) The tracking and monitoring of
health records is evaluated, and
as required.
e) Coding and reporting processes
f) Compliance with policy and
timeliness of response to consumer /
patient requests for health record
access are monitored, and
March 2016 277

Criterion 2.3.1 onduct clinical classification in accordance with

C
Health records management systems support legislation and organisational policy, and within
the collection of information and meet set timeframes.
consumer / patient and organisational needs. rovide appropriate training to relevant staff in health
P
(continued) records management.
Implement processes by which consumers / patients
Overview can access their own health records.
This criterion requires the organisation to implement
systems for health records management that will support Managing health records
the tracking of records and their components, the issuing An effective health records management system must
and use of the unique identifier, the timely retrieval of be capable of creating, maintaining and monitoring
records, and their secure transportation and storage, consumer / patient health and personal information in a
irrespective of the form of the health record (paper-based, manner consistent with the requirements of legislation,
electronic, combination). There must also be systems organisational policy, and all relevant standards and
for timely clinical classification and coding of heath data. guidelines. The organisation must ensure that whether
Consumers / patients have the right to access their own its consumer / patient records are paper-based,
health records, and staff must be aware of the process electronic or a combination of both, and whatever the
and their responsibilities in this area. nature of the health information entered in the record
(e.g. paper forms, scans, images, photographs), it has
Relationships of 2.3.1 with other criteria a system capable of creating, monitoring, retrieving,
transporting and storing records in a secure, accurate
Safe, high quality care depends upon the timely and
and timely manner. Relevant staff should receive training
accurate gathering of data into the health record
in health records management appropriate to their
(Criterion 1.1.8), which must then be kept secure
positions and responsibilities.
yet accessible to relevant health professionals by
an effective health records management system, The health records management system should:
and which may be wholly or partly operated through
fulfil the requirements of legislation governing the
the organisation’s information and communication
creation, storage and destruction of the health record,
technology framework (Criterion 2.3.4). The issuing
and consumer / patient privacy
of the unique identifier requires the correct and formal
identification of the consumer / patient (Criterion 1.5.6). e managed in accordance with organisational policy,
b
with respect to matters including (but not limited to):
Efficient health record management supports effective
ongoing care (Criterion 1.1.6) and the processes of • the unique identifier
clinical handover (Criterion 1.1.5). It is an aspect of the
• privacy and confidentiality
organisation’s integrated risk management framework
(Criterion 2.1.2), and failure to implement a fully effective • updating of information
system may lead to incidents (Criterion 2.1.3) and • consumer / patient access
complaints (Criterion 2.1.4). Access to his or her own
health record is a fundamental right of the consumer / • security
patient (Criterion 1.6.2). • storage
This criterion requires healthcare • damage

organisations to: • retrieval
ollate, manage, monitor, track and store health
C • transportation
records in a manner consistent with legislation, • retention
organisational policy and relevant standards.
• destruction
Implement a system for issuing and maintaining
unique consumer / patient identifiers.
include a central point at which all components of of the record are stored in different places, or in different
individual health records are monitored and formats. Where relevant, the system should have the
accounted for capacity to issue an anonymous identifier.
track all records out of / removed from storage, and The unique identifier system should:
the departments / individuals responsible require the formal identification of the consumer /
ave processes to ensure that records are retrieved
h patient, on a basis which will be defined by legislation
and transported in an accurate and timely manner, and/or organisational policy
whether they are stored on or off-site include a central index of all issued identifiers
ave processes to monitor and track health records
h ave processes to prevent the issuing of a second
h
when in transit identifier to the same consumer / patient, for instance
aintain privacy and confidentiality when
m if the consumer / patient presents at a different site
consumer / patient health and personal link the current consumer / patient health record to any
information is communicated other existing records for the same consumer / patient,
nsure that records are stored in a safe and
e to any other parts / components of the same record,
systematic manner and to other relevant health information systems
retain and destroy records according to legislation and aintain its integrity via processes to check /
m
organisational policy search for:
e supported by general education for staff in the health
b • consumers / patients with multiple identifiers
records management system, and by training for staff • different consumers / patients with the same name
involved in records creation, maintenance and handling.
• names that are phonetically alike but spelled differently
• the use of aliases
Prompt points
here allowable by legislation and policy, include the
w
oes the organisation use paper-based
D capacity to issue an anonymous identifier, and to
or electronic records? How does it ensure the correctly link the identifier to all components of the
completeness of its health records? anonymous consumer / patient’s health record.
ow does the organisation ensure the security
H
of health records during transportation?
Prompt points
hat education / training does the organisation
W
provide with respect to health records ow many forms of identification does the
H
management? How does the organisation organisation require before issuing a
ensure that casual / agency staff are aware of unique identifier?
their responsibilities in this area? hat system-based precautions prevent
W
hat are the organisation’s destruction
W different sites / departments issuing a second
processes for health records? identifier to the same person?
ow are multiple identifiers checked? What
H
process is followed when multiple identifiers
The unique identifier are discovered?
The organisation should have a system for issuing a oes this organisation issue anonymous
D
unique identifier for each consumer / patient, which identifiers? How does the organisation ensure
will require the formal identification of the consumer / that the correct health record is linked to the
patient according to legislation and policy. The aim of the anonymous individual?
identifier is to ensure continuity of care, prevent incidents
due to misidentification, avoid duplication, and maintain
the integrity of the consumer / patient health record if it
must be divided due to size, or if different components
March 2016 279

Criterion 2.3.1 Health record access

Health records management systems support The organisation should have a process for facilitating
the collection of information and meet the access of consumers / patients to their own health
consumer / patient and organisational needs. record, which will be described in policy, and should
(continued) operate within a timeframe which may be subject to
legislation. Staff should be educated with respect to
their responsibilities in this area, including providing
Clinical classification consumers / patients with the necessary information,
Clinical classification is the process of translating and responding to requests in a timely manner.
healthcare data, such as that relating to diseases,
Consumer / patient health record access should:
conditions, injuries and interventions, from a consumer /
patient record into a coded format using a relevant be recognised as a consumer / patient right
classification system. The coded data will be used
ccur within the timeframe defined by legislation
o
internally for clinical and non-clinical decision making,
and/or organisational policy
quality improvement activities and benchmarking,
while the organisation will also be required to fulfil e supported by guidelines describing the process
b
external reporting and funding-mechanism obligations. and the expectations upon staff in responding to
Accuracy and timeliness of coding are essential, and consumer / patient requests for access
the organisation should ensure that relevant staff are e managed so as to ensure that consumer / patient
b
appropriately trained and resourced. privacy and confidentiality are maintained.
Clinical classification should:
e completed within timeframes defined
b Prompt points
by organisational policy and external
reporting requirements ow does the organisation ensure that
H
staff understand their responsibilities when
e conducted by appropriately trained and qualified
b consumers / patients request access to their
staff, who are supported by access to relevant health records?
standards and guidelines
ow does the organisation ensure that there
H
e subject to regular auditing of data accuracy and
b is a timely response to consumer / patient
timeliness, with provision of remedial education / requests? What action is taken in the event
retraining where necessary that requests are not fulfilled within the required
ave health professional support and involvement, to
h timeframe?
ensure correct interpretation and coding.
Prompt points
hat external reporting requirements
W
does the organisation have with respect to
its coded data?
hat resources does the organisation
W
provide to support those involved in
clinical classification?
hat role do the organisation’s health
W
professionals play in clinical classification
and coding?
AS ISO 18308-2005
The following evidence may help to Health Informatics - Requirements for an electronic
address criterion 2.3.1 health record architecture (ISO/TS 18308:2004, MOD).
vidence of monitoring / tracking of health

E AS 4846:2014
records and health record components Person and provider identification in healthcare.
etention / destruction schedule for health

R
Suggested reading
records, including means of destruction for
different material formats Office of the Australian Information Commissioner. Health.
Sydney NSW; Australian Government; 2016. Available from:
Central index of unique identifiers https://www.oaic.gov.au/individuals/faqs-for-individuals/health/
ducation / training programs for staff involved in
E
health records management Office of the Australian Information Commissioner. Healthcare
identifiers. Sydney NSW; Australian Government; 2016.
udits of clinical classification / coding accuracy
A Available from: https://www.oaic.gov.au/privacy-law/other-
and timeliness legislation/healthcare-identifiers Viewed 17 February 2016.
udits of timely compliance with consumer /
A Office of the Australian Information Commissioner. Australian
patient requests for health record access Privacy Principles. Sydney NSW; Australian Government; 2016.
Available from: https://www.oaic.gov.au/privacy-law/privacy-act/
australian-privacy-principles Viewed 17 February 2016.
Standards National Casemix and Classification Centre (NCCC).
AS ISO 15489.1-2002 (R2013) Homepage. Wollongong NSW; University of Wollongong;
Records management - General. 2016. Available from: https://nccc.uow.edu.au/index.html
AS ISO 15489.2-2002 (R2013)
Australian National Audit Office. Records management
Records management - Guidelines. in health. Barton ACT; Commonwealth of Australia;
AS/NZS ISO 30300-2012 2015. Available from: http://www.anao.gov.au/~/
Management systems for recordkeeping - Fundamentals media/Files/Audit%20Reports/2015-2016/10/ANAO_
Report_2015-2016_10.pdf Viewed 17 February 2016.
and vocabulary.
AS/NZS 30301-2012
Management systems for recordkeeping
- Requirements.
AS/NZS ISO 15801:2014
Document management - Information stored
electronically - Recommendations for trustworthiness
and reliability.
AS/NZS ISO 13028:2012
Information and documentation - Implementation
guidelines for digitization of records.
AS 2828.1-2012
Health records - Paper-based health records.
AS 2828.2(Int)-2012
Health records - Digitized (scanned) health record
system requirements.
March 2016 281

Implementation
Criterion 2.3.2 a) Policy / guidelines for corporate a) There is a corporate records

records management are management system that ensures:
Corporate records management
systems support the collection (i) the secure, safe and systematic
of information and meet storage of data and records
codes of practice, and are readily
organisational needs.
available to staff. (ii) timely and accurate retrieval
and transport of records stored
b) Policy / guidelines define the
on or off-site
governance and accountability for
corporate records management. (iii) a
ppropriate retention and
destruction of records
c) Policy / guidelines specify the
requirements for standardised according to all relevant legislation,
record creation and tracking. standards, guidelines and/or
codes of practice.
b) The security of corporate records is
assured through restricted access.
c) Corporate records created by the
organisation are supported by
appropriate record systems.
d) Relevant staff are trained in
corporate record keeping and
records management.

This criterion requires the organisation to implement Establishing and maintaining an effective records
systems for corporate records management that will management framework represents a significant
ensure appropriate access, facilitate timely retrieval business challenge for many organisations, requiring the
and tracking, and maintain the integrity and security of organisation to be responsive to changing legislative and
organisational records. other requirements, and to ongoing developments in
information technology.
The management of corporate records has some
commonalities with the management of health records
(Criterion 2.3.1); both will be impacted by systems
a) T
he corporate records a) The organisation shows distinction a) The organisation demonstrates it
management system is evaluated, in corporate records management. is a leader in corporate records
and improvements are made management systems.
as required.
b) C
ompliance with corporate record
keeping and records management
improvements are made to training
programs as required.
c) Corporate records creation
and tracking is evaluated, and
as required.
for the collection, use and storage of data (Criterion This criterion requires healthcare
2.3.3) and by the management of information and organisations to:
communication technology (Criterion 2.3.4). Corporate
records systems will in turn play a significant role in ollate, manage, monitor, track and store corporate
C
many aspects of the organisation’s governance and records in a manner consistent with legislation,
management (Criteria 3.1.1 and 3.1.2), human resources organisational policy and relevant standards.
management (Standard 2.2), in particular workforce efine the governance and accountability for
D
planning (Criterion 2.2.1), orientation (Criterion 2.2.2) and corporate records management.
training (Criterion 2.2.3). Corporate records management
is a vital component of the organisation’s integrated risk ave a system that appropriately restricts access to
H
management framework (Criterion 2.1.2). corporate records.
rovide training to relevant staff in corporate
P
records management.
March 2016 283

Criterion 2.3.2 • employment contracts

Corporate records management systems • business contracts
support the collection of information and meet • minutes of meetings
organisational needs. (continued)
include processes for the handling and
storage of non-conventional record formats, for
Managing corporate records
example, information received via email or other
Corporate records are an organisation’s ‘memory’. electronic format
They provide evidence of actions and decisions and
nsure that records are stored in a safe and
e
represent a vital asset to support daily functions and
systematic manner
operations. Records support policy formation and
managerial decision making, protecting the interests retain and destroy records according to legislation and
of the organisation as well as the rights of staff and organisational policy
consumers / patients, and help in the delivery of services
e supported by general education for staff in
b
in a consistent and equitable way. They also support
the corporate records management system, and
consistency, continuity, efficiency and productivity in
by training for staff involved in records creation,
program delivery, management and administration.
maintenance and handling.
Effective corporate records management will be
maintained via a consistent, organisation-wide records Corporate records should be managed in accordance
creation and storage system that is in accordance with with organisational policy, with respect to matters
the requirements of legislation, organisational policy, and including (but not limited to):
all relevant standards and guidelines. The system should
information privacy
also ensure that access to records is appropriately
restricted, and that records are created, monitored, anagement of updating information, such as
m
retrieved, transported and stored in a secure, accurate personnel information
and timely manner. Relevant staff should receive training storage
in corporate records management appropriate to their
positions and responsibilities. risk minimisation
The corporate records management system should: retrieval
fulfil the requirements of legislation governing the retention
creation, storage and destruction of the destruction
corporate record
version control for draft documents.
perate within a defined framework of governance
o
and accountability
ave processes to ensure that changes to relevant
h
legislation are known and acted upon
nsure the consistent creation of each form of
e
corporate record, including (but not limited to):
• annual reports
• policies and procedures
• personnel records
• financial records
• asset records
maintain an auditable trail of records transactions
Prompt points include the disposition or transfer to any authorised
ow are corporate records distinguished
H external organisation, including an archives authority,
from health records in organisational policies within their tracking system
and procedures? nsure that only those users with appropriate
e
hat are the organisation’s retention policies /
W clearance or permission receive records for which they
procedures for tax records? Asset records such have been authorised.
as contracts and title deeds? Financial records?
Is there delineated responsibility for the
Prompt points
management of corporate records?
hat system does the organisation use
W
ow does the organisation ensure that it is
H
to monitor and track corporate records? How
aware of changes to legislation which may
was this system decided upon?
affect corporate records management?
ow is the system evaluated? What changes
H
hat checks are done to ensure staff are aware
W
have been made following evaluation of
of their responsibilities when creating, handling,
the system?
and storing records?
ow does the organisation ensure compliance
H
with records management policy? Which, if Restricting access to corporate records
any, corporate records are audited regularly to Creation, storage and retention of legal records, for
monitor adherence to policy and processes? example, minutes of meetings of Boards, may be
subject to specific processes such as storage in a
tamper-proof journal, and policy should address how
Tracking the movement of these records are created, stored and accessed, and by
corporate records whom. In the case of electronic records, security levels,
Records that leave the central control should be tracked file paths and access should be considered.
and monitored, so that the organisation is aware of Organisations should:
who holds the record, especially if it is a single copy of
a paper-based record or if circulation of the information nsure the security of corporate records via restriction
e
could have legal ramifications. of access
Tracking mechanisms should record the track all records out of / removed from storage, and
following information: the departments / individuals responsible.
the item reference number or identifier
a description of the item (for example, the file title) Prompt points
the person, position or operational area having ow does the organisation know who
H
possession of the item should have access to certain records?
the date of movement. ow does staff know what records they cannot
H
have free access to?
ow does the organisation restrict access to
H
ave processes to ensure that records are retrieved
h sensitive records?
and transported in an accurate and timely manner,
whether they are stored on or off-site ow are access restrictions enforced? Are
H
access levels set on computer log-ins? Are keys
track the issue, transfer between persons, and return to locked storage rooms protected?
of records to their ‘home’ location or storage
ave processes to monitor and track corporate
h
records when in transit
March 2016 285


Corporate records management systems Office of the Australian Information Commissioner. Australian
support the collection of information and meet Privacy Principles. Sydney NSW; Australian Government; 2016.
organisational needs. (continued) australian-privacy-principles Viewed 17 February 2016.
National Archives of Australia. What is records management?
The following evidence may help to Canberra ACT; National Archives of Australia; 2016. Available
from: http://www.naa.gov.au/records-management/getting-
started/records-management/index.aspx
vidence of monitoring / tracking of
E Viewed 17 February 2016.
corporate records National Archives of Australia. Authorities covering common
etention / destruction schedule for corporate
R business activities. Canberra ACT; National Archives of
records, including means of destruction for Australia; 2016. Available from: http://www.naa.gov.au/
records-management/agency/keep-destroy-transfer/general-
different material formats
records-authorities/index.aspx Viewed 17 February 2016.
ocumented governance / accountability for
D
corporate records management
ducation / training programs for staff involved in
E
corporate records management
udits of compliance with policy in
A
records creation
Audits of timeliness of corporate records retrieval
Standards
AS ISO 15489.1-2002 (R2013)
Records management - General.
AS ISO 15489.2-2002 (R2013)
Records management - Guidelines.
AS/NZS ISO 30300-2012
Management systems for recordkeeping - Fundamentals
and vocabulary.
AS/NZS 30301-2012
Management systems for recordkeeping
- Requirements.
AS/NZS ISO 15801:2014
and reliability.
AS/NZS ISO 13028:2012
Information and documentation - Implementation
guidelines for digitization of records.
March 2016 287
Implementation
Criterion 2.3.3 a) Policy / guidelines addressing a) An implemented information

the collection, validation, management plan identifies
Data and information are collected,
protection, storage and use of the needs of the organisation at
stored and used for strategic,
data and information comply all levels.
operational and service
with professional and statutory
improvement purposes. b) A system is implemented for the
requirements, and are readily
validation and protection of data
available to staff.
and information.
b) Data are available for:
c) Data storage and retrieval are
(i) research facilitated through effective
classification and indexing.
(ii) development
d) Responsibility and accountability
(iii) improvement activities
for action on data and information
(iv) education are clearly delineated.
(v) corporate and clinical e) Databases are linked to provide
decision making. access within and across units
and departments.
c) Adequate resources are provided
for the collection, analysis and use f) Staff are informed of the data
of data. collected that are relevant to
their position and have access
d) The organisation contributes to
to training on data and
external databases and registers.
information management.
e) There are systems to provide
g) Reference and resource materials
information to authorised
are available for use by staff.
stakeholders that are consistent
with relevant privacy legislation. h) Liaison with external bodies
improves the quality of information
f) The needs of staff for reference and
supplied and received.
resource materials are identified,
analysed and prioritised.

This criterion requires the organisation to implement Effective management systems for information and
systems for the collection of data and information, and communication technology (Criterion 2.3.4) will assist
to ensure that data and information are made available organisations to collect, access, store and use data and
for use in a timely manner and are stored safely and information. The organisation must ensure the security of all
used effectively. records, both paper-based and electronic (Criterion 3.2.5).
Within healthcare organisations, the collection, storage
and usage of data are most conspicuous in the creation
and maintenance of consumer / patient health records
(Criterion 1.1.8) and the implementation of systems
for health record management (Criterion 2.3.1).
However, data systems also impact significantly upon
the management of other important records, including
a) S
ystems used for the validation a) The organisation shows distinction a) The organisation demonstrates
and protection of data and in the collection, storage and use it is a leader in systems for the
information are evaluated, of data and information. collection, use and storage of data
and improvements are made and information.
as required.
b) M
onitoring and analysis of
clinical and non-clinical data and
information occur to ensure:
(i) accuracy, integrity and
completeness of data
(ii) timeliness of information
and reports
(iii) the needs of the organisation
are met
as required.
c) D
ata use and reporting processes
d) T
he organisation reviews results
from external databases and
registers and improves care and
services as indicated.
e) Reference management and
resource material systems are
made as required.
personnel information (Standard 2.2), corporate records This criterion requires healthcare
(Criterion 2.3.2) and all research documentation (Criterion organisations to:
2.5.1). In addition, collection of data from incidents
(Criterion 2.1.3) and complaints (Criterion 2.1.4) should be ollect, validate, protect, retrieve, store and use data
C
recorded and analysed to minimise recurrence. and information according to organisational policy and
relevant professional and statutory requirements.
nsure that adequate resources are provided for the
E
collection, analysis and use of data and information,
including relevant reference and other material.
reate and link databases to ensure the availability of
C
data for organisational purposes.
March 2016 289

Criterion 2.3.3 nsure that corporate data and information are

e
Data and information are collected, stored available to support planning and decision making
and used for strategic, operational and service link and combine different types of data and
improvement purposes. (continued) information within and outside the organisation
include internal databases that make data and
ontribute to relevant external databases
C information available both in individual units /
and registers. departments and organisation-wide, as appropriate
nsure that staff are trained in data and information
E include processes to monitor the quality of data and
management as relevant to their positions. information, including data reliability, accuracy and
validity, from both internal and external sources
Data and information management
include information sources to support the
Organisations produce an overwhelming volume of data organisation’s clinical, educational, administrative,
and information, which need to be collected, validated, research and technical information needs.
managed, analysed, communicated and stored in a safe
and effective manner. When developing an information
management plan, the organisation should keep in mind Prompt points
each of the three main categories of information, namely:
ow does the organisation validate its
H
key corporate information data? When does this happen? How does
information shared within an organisation the organisation respond when inaccuracies
are discovered?
information communicated externally.
ow does the organisation use classification
H
File formats, the storage media chosen, how the system and indexing to support data and
is backed up, access restrictions and other factors will information management?
be influenced by legislation governing retention and ow are staff notified of lines of responsibility for
H
confidentiality issues, and whether the information will data and information management?
be shared with other departments, organisations and
data systems. ow does the organisation ensure compliance
H
with regulatory and professional standards with
Information management systems should: regard to data and information management?
identify and plan for the organisation’s current and
future information needs
Collection and use of data
e governed by policy and procedures which
b
define responsibility and accountability for data and Detailed and accurate data collection will be the basis
information management of planning and resource allocation for the organisation,
and should itself be properly resourced as an investment
efine and capture data and information from
d in quality improvement. When defining what data to
various sources and in compliance with all collect, the organisation should consider the various
statutory requirements available sources of data and the different purposes for
rotect and securely store all data and information,
p which information extracted from those data needs to
and include regular security checks be generated for the benefit of the organisation itself,
to fulfil the organisation’s obligations with respect to
onvert data into information in an accurate and
c
external bodies such as database and registers,
timely manner
and to be communicated to relevant external
se classification and indexing to support timely
u authorities / stakeholders.
retrieval of data and information
nsure that clinical data and information are available
e
at point-of-care
Data should: e made available when appropriate to relevant
b
e made available for a wide variety of organisational
b external bodies, including (but not limited to):
purposes, including (but not limited to): • Departments / Ministries of Health, or
• research similar authorities
• development • healthcare funders
• improvement activities • insurers
• education • accreditation and certification agencies
• corporate and clinical decision making • stakeholders

• legislators
e obtained from and/or compared to a variety of
b
sources, according to organisational need, including • coroners
(but not limited to): • courts of law
• clinical indicator programs • benchmarking groups
• benchmarking groups • the local community.
• service utilisation rates
• demographic data Prompt points
• complication rates or variance data ow does the organisation ensure that
H
data and information are available where they
• incident and complaints data
are needed throughout the organisation?
• infection surveillance outcomes
o what external databases does the
T
• Diagnosis-Related Groups organisation contribute data?
e collected within defined timeframes and in defined

b hat external sources does the organisation
W
formats, in order to fulfil the organisation’s mandatory draw upon when collecting data, or
external data collection and reporting requirements determining the significance of its own
including (but not limited to): data and information?
• inpatient statistics ow are health professionals involved in data

H
collection and analysis?
• infectious disease notification
• jurisdictional data collections
Staff training and resourcing in data and
• cancer notifications information management
• midwives data collection The organisation should ensure that all staff are aware of
• suspected child abuse / domestic violence / the data and information that are available to them, and
other crimes are relevant to their positions. Staff with responsibilities
for data collection, validation, analysis and reporting
• deaths / coroner’s cases should receive all necessary training, and be supported
• clinical registries by appropriate reference material and other resources.
• taxation information Staff training and resourcing should:
• payroll information s upport the organisation’s data and information
management system
include education on the availability of data and
information and their appropriate use
March 2016 291

Criterion 2.3.3
Data and information are collected, stored The following evidence may help to
and used for strategic, operational and service address criterion 2.3.3
improvement purposes. (continued) Data and information management plan
se of data and information in quality
U
e developed and delivered to help ensure the quality,
b
improvement activities
accuracy and timeliness of data collection, validation,
analysis and reporting Evidence of data security checks
nsure the availability of relevant and up-to-date
e Outcomes of data validation
reference material and other resources at the point-of-
vidence of contribution of data to external
E
need, and in appropriate formats
databases within defined timeframe(s)
include processes for managing reference, research
ecords of completed training in data and
R
and other resource materials which are based on
information management for different categories
current and future organisational and staff needs
of staff
tilise links with relevant external databases,
u
vailability of current reference and resource
A
information networks, bodies of expert help and
materials / tools
administrative or research knowledge.
Standards
Prompt points
HB 231:2004
ow are the needs of staff for reference
H Information security risk management guidelines.
and resource materials / tools identified? How
does the organisation monitor usage rates for ISO/IEC 27005:2011
the materials / tools provided? Information technology - Security techniques -
Information security risk management.
hat training in data and information
W
management is provided to different categories AS ISO/IEC 27001:2015
of staff? Information technology - Security techniques
- Information security management systems
ow does the organisation ensure that staff are
H - Requirements.
aware of the data and information available to
them, relevant to their positions? AS ISO/IEC 27002:2015
Information technology - Security techniques - Code of
y what processes does the organisation
B practice for information security controls.
monitor the accuracy of its data?
AS ISO 27799-2011
Information security management in health using ISO/
IEC 27002.
AS/NZS ISO/IEC 9798.6:2006
Information technology - Security techniques - Entity
authentication - Mechanisms using manual data transfer.
AS/NZS ISO 15801:2014
and reliability.
Suggested reading
Office of the Australian Information Commissioner. Australian
Privacy Principles. Sydney NSW; Australian Government; 2016.
National Archives of Australia. Information governance.
Canberra ACT; National Archives of Australia; 2016. Available
from: http://www.naa.gov.au/records-management/strategic-
information/information-governance/index.aspx Viewed 22
February 2016.
Australian Government. Information security management
guidelines: Risk management of outsourced ICT
arrangements (including Cloud). Barton ACT; Commonwealth
of Australia; 2015. Available from: https://www.
protectivesecurity.gov.au/informationsecurity/Documents/
stralianGovernmentInformationSecurityManagementGuidelines.
pdf Viewed 22 February 2016.
Australian Prudential Regulation Authority (APRA). Prudential
Practice Guide: CPG 235 - Managing data risk. Sydney
NSW; APRA; 2013. Available from: http://www.apra.gov.au/
CrossIndustry/Documents/Prudential-Practice-Guide-CPG-
235-Managing-Data-Risk.pdf Viewed 11 March 2016.
March 2016 293

Implementation
Criterion 2.3.4 a) There is effective governance of a) The organisation’s ICT planning

ICT that is supported by policy addresses current and future
The organisation has an integrated
and procedure. ICT needs.
approach to the planning, use and
management of information and b) Licences are purchased b) Strategies for:
communication technology (ICT). as required.
(i) backup
c) There is a system to manage the
(ii) security
use of mobile devices used in the
course of healthcare delivery. (iii) protection of privacy
d) There is a system of ICT (iv) virus detection
operational support.
are implemented and used.
e) There is a documented plan for
c) There is a planned system for
managing ICT risks and crises.
preventive maintenance of ICT.
f) Staff are trained in the correct use
d) A strategy and plan for disaster
of ICT relevant to the organisation
recovery / business continuity is
and their roles.
implemented and tested.
g) Staff are provided with orientation
e) The integrated ICT system
and ongoing education in the
supports the collection,
appropriate use of personal mobile
aggregation and analysis of data.
devices in healthcare delivery.
f) Relevant staff have access to
h) The organisation ensures that staff
decision support software and/or
education and training in ICT is
tools and are trained in their use.
adequately resourced.

This criterion requires the organisation to employ Information and communication technology (ICT) within
an integrated approach to the planning, use and healthcare organisations supports many areas of service
management of information and communication delivery, including health record content (Criterion 1.1.8),
technology (ICT), in order to create a secure, reliable and the management of health records (Criterion 2.3.1),
framework for the organisation’s data, information and corporate records (Criterion 2.3.2) and human resources
corporate and clinical records. records (Standard 2.2). All data collected, stored and
used within the organisation (Criterion 2.3.3) must be
managed. Many medical devices and other clinical
equipment also rely upon software and technology
(Criterion 3.2.2).
Correct and responsible use of ICT should be addressed
during staff orientation (Criterion 2.2.2), including the
appropriate use of personal mobile devices, and the
need for informed consent for the use of devices
in consumer / patient care (Criterion 1.1.3). Where
organisations rely upon external service providers
and operators of sections of their ICT strategic
a) T
he ICT system is evaluated, a) The organisation shows distinction a) The organisation demonstrates it
and improvements are made in the planning, use and is a leader in the planning, use and
as required. management of ICT. management of ICT.
b) C
ompliance with ICT policy and
procedures is monitored and
made as required.
c) The security and protection of
the ICT system are evaluated,
as required.
d) The preventive maintenance and
repair system for ICT is regularly
made as required.
e) The risk and crisis management
system for ICT is regularly
made as required.
f) Staff education and training in
the use of ICT are evaluated,
as required.
development and service delivery, appropriate and This criterion requires healthcare
detailed service agreements will be required (Criterion organisations to:
3.1.4). The organisation’s approach to planning, use
and management of ICT is an aspect of its integrated Implement an integrated information and
risk management framework (Criterion 2.1.2) and of communication technology (ICT) management
organisational security (Criterion 3.2.5). system as part of an ICT plan which supports the
organisation’s collection, aggregation and analysis
of data, and in which both current and future
organisational needs are addressed.
nsure that all necessary ICT security measures are
E
taken, and are supported by a tested plan for disaster
recovery / business continuity.
ffectively manage the use of mobile devices in
E
healthcare delivery, including the appropriate use of
personal devices.
rovide staff with training in ICT appropriate to
P
their positions.
March 2016 295

Criterion 2.3.4 include the implementation of organisation-wide

The organisation has an integrated approach ICT infrastructure and support, including (but not
to the planning, use and management of limited to):
information and communication technology • management of all ICT licensing
(ICT). (continued) • development, testing and maintenance of all
necessary security systems / processes
ICT planning and management • a preventive ICT maintenance system
An ICT management plan that addresses both current
• a disaster recovery / business continuity plan for ICT,
and future ICT needs should be the basis of an
which is regularly tested
integrated, organisation-wide ICT management system
proportionate to the size, role and complexity of the • staff support and assistance
organisation, and capable of supporting its care and
nsure that the organisation is able to meet its
e
service delivery and related business operations. The
obligations and goals with respect to the collection,
planning and execution of the ICT management system
analysis, use, reporting and storage of data, while
should reflect the organisation’s information needs
maintaining security and confidentiality
and available resources, and build towards identified
strategic goals. e addressed during staff orientation and ongoing
b
education, to ensure that staff understand the
ICT management should:
organisation’s ICT system and their legal and
reflect the provisions of an ICT plan that defines policy obligations
the organisation’s needs with respect to ICT
nsure that staff receive ICT training appropriate to
e
implementation and management, including (but not
their positions, and are aware of how to access ICT
limited to):
support and assistance
• communication technologies
e resourced to a level that will maintain ICT
b
• applications and services functionality and security, and meet organisational and
staff needs.
• integration with the current infrastructure
• management of data, information and knowledge
Prompt points
• change management and workflow redesign
ho is consulted when the organisation is
W
• ongoing maintenance, updating and development developing its ICT plan? How often does the
of ICT organisation review and revise its plan?
• organisational strategic and investment plans ow does the organisation decide licence
H
• consultation with staff and relevant stakeholders requirements for software? How are allocated
regarding current and future needs licences registered / documented? What
procedures are followed if additional licences
• planned outcomes from future investment in ICT are needed?
• requirements to fulfil legislated obligations, ow does the organisation respond to any
H
participate in national health strategies, etc. breach in ICT security?
e supported by policy and procedures that define
b hat backup systems does the organisation
W
responsibility and accountability for ICT and ensure employ to ensure the integrity and accessibility
effective governance of its data?
hat checks are made to determine
W
whether the organisation’s ICT system meets
requirements for both appropriate access and
privacy of different classes of records and data?
Disaster recovery and business continuity
As organisations increasingly depend on ICT, a business Prompt points
continuity plan becomes more important in case of ow often is the organisation’s ICT
H
any interruption to services. This may be caused by disaster recovery / business continuity plan
external factors such as electrical or communications tested? How does the organisation ensure that
interruptions or internal factors related to malfunctions of ICT functionality and security will be maintained
hardware or software. in the event of a challenge to the system?
Organisations should: here is the risk and crisis management
W
identify threats to the system and to uninterrupted plan stored? How often is it reviewed? Who
provision of services, and reduce the contributed to the plan?
organisation’s vulnerability hat protective actions help to protect ICT
W
nsure that there is an uninterruptible power supply to
e security for the organisation?
maintain essential services and that this is subject to
regular preventive maintenance
Software, portable electronic equipment
se protective technologies such as virus detection
u
and firewalls to reduce risks to systems
and mobile devices
Decision support software / tools are any device that
nsure backup is adequate, regular and maintained,
e
analyses data to help healthcare providers make clinical
and simultaneously protected from damage at the
decisions. They can provide health professionals and
organisation’s site, while being accessible in a crisis
consumers / patients with individualised application of
test the backup to ensure systems become medical knowledge.
operational when needed, and make improvements
Decision support software / tools include:
if required
omputerised alerts (drug–drug interactions and
c
repare staff and/or consultants to respond to
p
allergy warnings)
different types of interruptions to the service, to
ensure staff awareness and competence in downtime consumer / patient data reports
procedures, as well as staff familiarity with procedures
means to calculate an algorithm, for example EGFR /
a
for maintaining services in the face of a computer
calculating parameter of renal function.
system failure
documentation forms
nderstand priorities for recovery and restoration of
u
services following an interruption diagnosis advice from integrated reference information
aintain the integrity of information, so that it cannot
m …and other workflow / administrative tools to enhance
be modified without proper authorisation. accurate and timely diagnoses.
March 2016 297

Criterion 2.3.4 Many healthcare professionals regularly take clinical

The organisation has an integrated approach photos with personal mobile devices. Most do not
consider any legal ramifications of such a commonplace
to the planning, use and management of practice, universally seen as benefiting consumer /
information and communication technology patient outcomes. However, unsecured clinical usage
(ICT). (continued) of mobile devices may contravene consumer / patient
privacy laws.
Increasingly, healthcare delivery involves the use of
mobile devices, and these must be included when Management of personal mobile devices should:
the organisation is considering its ICT planning, e an aspect of the organisation’s overall ICT planning
b
management and security. ‘Mobile devices’ may include and management
portable electronic clinical equipment used directly in
e addressed via policy and procedures, which
b
the delivery of care, such as bedside monitors, or any
describe the appropriate use of such devices, and
device used to contain or enable access to consumer /
define the limits of their use within the organisation
patient information, including (but not limited to) health
and medical applications (‘apps’), laptop computers, onsider installing ‘protocols’ on mobile devices, for
c
tablet devices, USB flash drives, removable hard drives, example a smart ‘app’ that restricts storage of photos
mobile phones and personal digital assistants, as well on mobile devices, and instead stores images on a
as any media used for backing up such information. separate platform
The organisation must have effective governance for the
rovide orientation and ongoing education to staff on
p
use of mobile devices in care delivery and information
related issues, including (but not limited to):
storage / transfer, and ensure that its staff are trained in
the correct use of mobile devices and educated in the • the appropriate use of personal mobile devices
appropriate use of personal mobile devices.
• privacy and confidentiality with mobile device use
Management of portable electronic clinical
• informed consent in mobile device use.
equipment should:
e an aspect of the organisation’s overall ICT planning
b
and management Prompt points
e addressed via policy and procedures which
b hat mobile devices does the organisation
W
describe their appropriate use, and the limits of their use in its care delivery? How does the
use within the organisation organisation ensure the security of these devices
and any information they may contain?
include processes for the physical security of
mobile devices ow does the organisation ensure that staff
H
have access as needed to decision support
rovide all necessary staff training in the correct use of
p
software and/or tools?
mobile devices in care delivery
H
nsure access of relevant staff to decision support
e
consumer / patient privacy and confidentiality
software and/or tools, to support care delivery
are maintained when mobile devices are used in
rovide orientation and ongoing education to staff on
p care delivery?
the use of portable electronic clinical equipment.
hat education does the organisation
W
provide in the appropriate use of personal
mobile devices? How does the organisation
respond to any instance of non-compliance or
inappropriate use?
Suggested reading
The following evidence may help to Office of the Australian Information Commissioner. Health.
address criterion 2.3.4 Sydney NSW; Australian Government; 2016. Available from:
https://www.oaic.gov.au/individuals/faqs-for-individuals/health/
ICT plan
ICT preventive maintenance records Office of the Australian Information Commissioner. Australian
onitoring of compliance with ICT policy and
M Privacy Principles. Sydney NSW; Australian Government; 2016.
procedures Available from: https://www.oaic.gov.au/privacy-law/privacy-act/
Licensing records and renewal schedule
Australian Medical Association (AMA). Clinical images and
Evidence of system security checks the use of personal mobile devices. Barton ACT; AMA; 2014.
Available from: https://ama.com.au/article/clinical-images-and-
vidence of testing of disaster recovery /
E use-personal-mobile-devices Viewed 23 February 2016.
business continuity plan
Therapeutic Goods Administration (TGA). Regulation of medical
ecords of completed staff education in ICT,
R software and mobile medical ‘apps’. Symonston ACT; TGA;
including appropriate use of personal devices 2013. Available from: https://www.tga.gov.au/regulation-medical-
software-and-mobile-medical-apps Viewed 7 March 2016.
Australian Medical Association (AMA). Medical practitioner
Standards responsibilities with electronic communication of clinical
HB 231:2004 information - 2013. Barton ACT; AMA; 2013. Available from:
Information security risk management guidelines. https://ama.com.au/position-statement/medical-practitioner-
responsibilities-electronic-communication-clinical Viewed 23
ISO/IEC 27000:2014 February 2016.
Information technology - Security techniques - The Royal Australian College of General Practitioners (RACGP).
Information security management systems - Overview Computer and information security standards. (2nd ed.)
and vocabulary. East Melbourne VIC; RACGP; 2013. Available from: http://
www.racgp.org.au/your-practice/standards/computer-and-
ISO/IEC 27005:2011
information-security-standards/ Viewed 23 February 2016.
Information technology - Security techniques -
Information security risk management. Kirk M, Hunter-Smith SR, Smith K and Hunter-Smith, DJ.
The role of smartphones in the recording and dissemination
AS ISO/IEC 27001:2015 of medical images. Journal of Mobile Technology in Medicine
Information technology - Security techniques 3(2): 40-45, 2014. Available from: http://www.journalmtm.
- Information security management systems com/2014/the-role-of-smartphones-in-the-recording-and-
- Requirements. dissemination-of-medical-images/ Viewed February 23 2016.
AS ISO/IEC 27002:2015 Orel A and Bernik I. Implementing healthcare information

Information technology - Security techniques - Code of security: standards can help. Studies in Health Technology and
Informatics 186: 195-199, 2013. Available from: http://ebooks.
practice for information security controls.
iospress.nl/publication/32792 Viewed 23 February 2016.
AS ISO 27799-2011
Information security management in health using ISO/
IEC 27002.
AS 5552-2013
E-health secure message delivery.
ISO/TR 17522:2015
Health informatics - Provisions for health applications on
mobile/smart devices.
March 2016 299

2.4 Population Health Standard A great deal of progress has been made in improving the
health of the population over the past 20 years through
The standard is:
a combination of improving social and environmental
The organisation promotes the health of
conditions, providing a wider range of prevention
the population.
services and public education. Healthcare organisations,
The intent of this standard is to ensure that all healthcare the community, government and public and private
organisations take responsibility in some way for promoting institutions cannot however become complacent.
the health and wellness of the general population. The
During this time, the burden has shifted from
extent of this responsibility is dependent on the size and
communicable diseases to non-communicable
type of organisation and on the location of the service.
diseases such as heart disease, chronic respiratory
There is one criterion in this standard. This is: disease, diabetes type 2 and mental health problems.
New diseases, new threats to health and new health
2.4.1 The organisation conducts health promotion
challenges constantly emerge and need to be managed
and consumers / patients, carers, staff and the
in effective and innovative ways. Increasing health
community are educated about better health
inequalities will have a significant effect on population
and wellbeing.
health status in a range of ways. At the same time,
This standard and criterion focus on three main aspects population demographics continue to change, bringing
of population health: new resources, opportunities and issues. All healthcare
organisations have roles to play in the process of
health promotion
improving population health.
health protection
surveillance.
March 2016 301

Standard 2.4: The organisation promotes the health of the population.
Implementation
Criterion 2.4.1 a) Policy / guidelines addressing a) The organisation optimises the

health promotion are consistent delivery of health promotion and
The organisation conducts health
with government / authority interventions to consumers /
promotion and consumers / patients,
priorities and relevant education patients and carers.
carers, staff and the community are
programs, and are readily available
educated about better health b) Opportunistic health promotion
to staff.
and wellbeing. strategies are undertaken in
b) Staff and other key stakeholders partnership with consumers /
are informed of population health patients, carers, staff and
principles and participate in the community.
evidence-based health
c) Health surveillance data
promotion strategies.
appropriate to the organisation
c) The organisation is aware of are collected.
current and emerging health
d) Where appropriate, the
priority areas.
organisation provides health
d) The organisation understands education to consumers /
its statutory requirements for patients, carers, staff and the
reporting on public health matters. community via its healthcare and
community collaborations.
e) Training and resources are
available for staff to support the
development of evidence-based
health promotion and education
for consumers / patients, carers
and the community.
f) The organisation works in
collaboration with relevant
healthcare and community bodies
to utilise resources effectively and
support health promotion activities.

This criterion requires the organisation to take action to The organisation has an obligation to provide safe, high
promote the health and wellbeing of its community, via quality care (Standard 1.5). Many of the programs by
education programs, collaborations, internal services which the organisation regulates and improves aspects
and other activities appropriate to the organisation’s of its care, including those addressing medication
consumer / patient cohort and its size, services safety (Criterion 1.5.1), infection control (Criterion 1.5.2),
and location. falls prevention (Criterion 1.5.4) and nutrition (Criterion
1.5.7), can be adapted for inclusion in preventive health
programs for the broader community. Population health
initiatives are more likely to be effective if the community
is involved in their planning, delivery and evaluation
(Criterion 1.6.1). Organisations should also consider the
diverse needs and diverse backgrounds of those within
the community (Criterion 1.6.3).
a) The outcomes of health promotion a) The organisation shows distinction a) The organisation demonstrates it
are evaluated for their effectiveness in health promotion and education. is a leader in health promotion
in improving the health and and education.
wellbeing of consumers / patients,
staff, carers and the community,
as required.
b) P
erformance measures are
developed, and quantitative
or qualitative data collected,
to evaluate the effectiveness /
outcomes of health promotion
strategies implemented by
the organisation.
c) The organisation evaluates the
effectiveness of its collaborations
in supporting its health education
programs, and improvements are
made as required.
The organisation also has a responsibility for the health This criterion requires healthcare
and wellbeing of its staff, and health promotion within organisations to:
the organisation should be integrated with other staff
support services (Criterion 2.2.5). evelop and implement evidence-based health
D
promotion strategies appropriate to their community,
As with all programs implemented, the organisation’s and ensure that staff and other relevant stakeholders
health promotion strategies should be evaluated for their are informed of them.
appropriateness (Criterion 1.3.1) and effectiveness (1.4.1).
ollect health surveillance data in order to evaluate
C
the effectiveness of their health promotion programs
and fulfil their obligations for reporting on public
health matters.
xtend their health promotion activities by collaborating
E
with relevant healthcare and community bodies.
March 2016 303

Criterion 2.4.1 and wellbeing via education and other activities, the
The organisation conducts health promotion organisation will make a contribution to the overall
betterment of health.
and consumers / patients, carers, staff and the
community are educated about better health The health promotion program should:
and wellbeing. (continued) reflect jurisdictional and other health authority priorities
e included in orientation and ongoing education
b
nsure that relevant staff are trained and resourced to
E
for staff, and other communications with
support their health promotion program.
relevant stakeholders
Health promotion e appropriate to the organisation’s consumer /
b
patient cohort, staff need, and organisational resources
Health promotion is the process of enabling individuals
and groups to better understand, control and improve xtend the organisation’s own health promotion
e
their health, via the use of activities designed to address resources via collaboration with relevant bodies /
identified risk factors and encourage behavioural and groups (e.g. immigrant services, childhood health,
lifestyle improvements. Health promotion is concerned cancer support groups) within the general community
not only with strengthening the skills and capabilities se a variety of strategies to reach its target audience,
u
of individuals but also with actions directed towards including (but not limited to):
changing social, environmental and economic conditions
in order to improve individual and population health. • opportunistic health promotion during consumer /
The aim is to promote healthier lifestyles, to prevent patient admission or appointment
and control common risk factors, and to encourage • discussion of health strategies / lifestyle factors
individuals to ‘take ownership’ of their health. The during discharge planning, and referrals to relevant
development of a set of underlying health promotion allied health services
principles and goals may assist the organisation in the
development of its program. • different forms / venues of information presentation,
for example, on the organisation’s website, printed
Behavioural change is usually the result of a range flyers, newspaper advertisements
of strategies, rather than a single approach, and the
organisation should consider this in developing its • advertising / promotion of activities by the
approach to health promotion. Education is an important organisation’s collaborating bodies / groups, relevant
aspect of health promotion, and should be included allied health services, and community GPs
amongst the organisation’s strategies, whether it be ddress the needs of individuals or groups within
a
delivered directly by the organisation or via relevant the organisation’s community identified as being
community bodies / groups. However, education vulnerable or at increased risk, for example, the frail
should be supported by appropriate activities; for aged, particular ethnic groups, those with a disability,
example, diabetes education delivered to consumers the socioeconomically disadvantaged, returned
/ patients or carers may be offered in conjunction with service people
exercise classes, dietary counselling, smoking cessation
programs, or other relevant activities designed to s appropriate, address risk factors for major
a
encourage healthy lifestyle choices. These activities may communicable (e.g. sexually transmitted diseases)
be offered by the organisation itself, or facilitated by the and chronic / non-communicable (e.g. cardiovascular
organisation via its community collaborations. disease, diabetes) diseases
The organisation’s health promotion activities should

be appropriate for its community. In this context, the
organisation’s ‘community’ consists of those people
accessing or collaborating with the organisation: its
consumers / patients and carers, its staff, and relevant
bodies or groups with which the organisation interacts.
(For more detail about the organisation’s ‘community’,
see criteria 1.2.1 and 1.6.1). By promoting health
romote healthy lifestyle choices, and address
p
preventable health risk factors such as: Prompt points
• smoking hat jurisdictional and national priorities
W
• poor nutrition for health promotion are reflected in the
organisation’s planning?
• harmful use of alcohol
hat local demographics influenced the
W
• lack of physical activity organisation’s selection of health
• social and economic exclusion promotion measures?
• harm from UV exposure ow does the organisation ensure that

H
consumers / patients and carers are aware of
s upport staff health and wellbeing, via activities support and education bodies / groups relevant
developed with staff consultation, such as: to their needs, e.g. cancer support groups,
• vaccination programs (work-related and other) breastfeeding and baby care clinics, seniors
exercise programs?
• healthy eating programs
hat vulnerable / at-risk groups does the
W
• exercise programs organisation try to reach through its health
• smoking cessation programs promotion program?
e designed at a level appropriate to the health

b hat different strategies does the organisation
W
literacy of the community, which should take into use to alert its community to its health
account factors including (but not limited to): promotion activities?
• socioeconomic factors ow were staff consulted in the development of

H
the organisation’s health promotion program?
• language factors
H
• cultural factors health promotion activities are delivered at
• age. an appropriate level of health literacy for
its community?
Health reporting and surveillance

The organisation will have a variety of legislated and
jurisdictional requirements for reporting on public
health matters, and must ensure that it meets all
obligations in this respect. Infection reporting is
addressed in criterion 1.5.2. In addition, according to
the organisation’s location, size and function, it may
have further obligations for public health reporting, and
must ensure that staff are appropriately educated and
trained in data collection, analysis and reporting, as
addressed in criterion 2.3.3. By accessing appropriate
public health data, and by using measures such as
clinical indicators, the organisation will be able to gauge
its own performance in certain areas of public health and
disease prevention, and may implement or review its
health promotion strategies on this basis.
March 2016 305

Criterion 2.4.1 e factored into the evaluation of all organisational

b
The organisation conducts health promotion health promotion strategies, which should be
and consumers / patients, carers, staff and the assessed from three different perspectives:
community are educated about better health • process evaluation: an evaluation of all aspects of
and wellbeing. (continued) program delivery by measuring the reach and quality
of the systems used to promote health action (e.g.
In addition, the organisation’s health promotion program number of flyers distributed, number of inquiries
should be supported by appropriate surveillance, about a health activity, attendance numbers at
to determine the effectiveness of the implemented education programs, etc.)
strategies. When implementing any health promotion • impact evaluation: an evaluation of the immediate
strategy, the organisation should carefully consider what effect of a health activity, often measured through
measures are appropriate for determining the success behavioural change (e.g. decreased cigarettes per
or otherwise of a particular program. Feedback from day, increased exercise, dietary changes, etc.)
participants will be important, but should be supported
wherever possible by empirical data, such as decreased • outcome evaluation: an evaluation of the endpoint
disease incidence in the target population, smoking of health interventions, often in terms of quality of life
cessation, lowered blood pressure or cholesterol, weight (e.g. decrease in fillings amongst attendants at an
loss, increased vaccination rates, etc. Both individual oral health program, decrease in disease incidence
and target group outcomes should be assessed. The amongst targets of pro-vaccination program, etc.)
organisation should not implement any health promotion inform the organisation’s health promotion planning,
strategy without being clear about the desired outcome, review and resource allocation.
and how that outcome is to be measured.
Health reporting and surveillance should:
Prompt points
fulfil the organisation’s legislated and
jurisdictional obligations ow are the organisation’s health
H
surveillance data captured, collated and
s upport the organisation’s evaluation of its reported? In addition to meeting statutory
systems and processes, and form the basis of obligations, how are the data used by the
improvement activities organisation in promoting public health?
llow data to be gathered in various ways, as
a hat different performance measures does the
W
appropriate to support and inform health promotion organisation use to assess the success of its
activities, including (but not limited to): health promotion strategies?
• attendance numbers ive an example of one of the organisation’s
G
• consumer / patient and carer feedback successful health promotion activities, and how
this positive outcome was measured? How did
• disease incidence the organisation inform consumers / patients
• clinical indicator data and the community of this activity, in order to
gain participants?
• health test outcomes (e.g. weight loss, lowered
cholesterol, improved blood pressure) hat changes were made to the organisation’s
W
health promotion program as a result of its
• altered behaviour (e.g. regular attendance last evaluation?
at exercise classes, allied health checks,
education sessions)
• long-term / group outcomes (e.g. increased
vaccination rates, decreased disease incidence,
decreased emergency presentations amongst
target group)
Collaborative health promotion im to increase opportunities for consumer / patient and
a
carer education and support according to disease /
Although the organisation is expected to be active
physical impairment / lifestyle risk factors incidence
in health promotion, it is not expected to take full
within the organisation’s community.
responsibility for the delivery of health promotion
strategies. Rather, the organisation should develop
collaborative relationships with bodies / groups that
are already delivering health education and/or health-
Prompt points
promotion activities relevant to the organisation’s hat national / jurisdictional health
W
community, and work to ensure that its consumers / promotion and support groups does the
patients and carers are aware of, and have access organisation interact with?
to, the bodies / groups appropriate to their needs.
hat specific health needs are prevalent within
W
Partnerships of this nature will allow the organisation
the organisation’s community? - for example,
to extend its own resources and services, in order to
early childhood support, smoking cessation,
support the health of its community and better meet the
risk reduction for stroke, cardiovascular disease
needs of its consumers / patients.
and or diabetes?
In order to develop the most appropriate collaborations,
ow does the organisation use its collaborations
H
the organisation must ensure that it understands the
to increase health services for at-risk / vulnerable
demographics of its community, that is, the consumers /
groups within its community, for example, for the
patients, carers, staff, other allied health professionals
socioeconomically disadvantaged, those with a
and other individuals and groups that access the
disability, particular immigrant groups?
organisation’s services and/or assist the organisation to
deliver those services. The concept of ‘the community’ hat challenges does the collaboration present
W
is discussed in more detail in criteria 1.2.1 and 1.6.1. for the organisation? Has the collaboration
facilitated more effective, timely and cost-
Collaborative health promotion should:
effective delivery of programs?
e based upon the organisation’s understanding of its
b
community’s needs
e designed to extend the organisation’s resources,
b
and eliminate duplication of services
include relationships with established nationwide and
jurisdictional health promotion organisations providing
support and education for major communicable and
non-communicable diseases
im to increase access to health services for
a
individuals and groups considered vulnerable or at
increased risk of disease
ccess bodies / groups with expertise in specific
a
consumer / patient care and support relevant within
the organisation’s community, including (but not
limited to) services for:
• immigrants / particular cultural groups
• those with disabilities
• specific age groups, for example, early childhood,
the frail aged
• women and children
• returned service people
March 2016 307

Criterion 2.4.1 include support for staff who wish to undertake further
The organisation conducts health promotion education, training or involvement in public health
and consumers / patients, carers, staff and the and/or general health promotion, such as:
community are educated about better health • financial support
and wellbeing. (continued) • permission / support for conference attendance
• leave of absence or altered rostering
Staff education and training
• access to online resources and/or distance learning.
In addition to promoting the health and wellbeing of its
staff through programs and activities developed with staff
consultation, the organisation should ensure that staff are
in turn aware of their own responsibilities in promoting the Prompt points
health and wellbeing of consumers / patients. hat education and training in health
W
Any health interaction may be an opportunity to promotion does the organisation provide for
encourage new or altered behaviours that can positively its staff?
impact consumer / patient health and wellbeing. The ow does the organisation address the issue of
H
organisation should ensure that staff receive appropriate health literacy? How does it ensure that its staff
education, and understand when and how to approach understand the impact of health literacy upon
consumers / patients about broader health issues. At consumer / patient and carer access to services
the same time, staff should be made aware that, due to and understanding of care?
differing levels of health literacy within the community,
the same communication strategy cannot be used ow does the organisation support those
H
in all situations. The organisation should ensure that members of staff who wish to undertake further
health literacy is addressed within the context of health training in public health and/or become involved
promotion education. Training may be offered to in broader health promotion activities?
increase organisational capacity in this respect.
Staff should be encouraged to be active in health
promotion both within the organisation and in the The following evidence may help to
broader community. By supporting staff who wish address criterion 2.4.1
to be involved in wider health promotion activities,
or to undertake additional training in public health Health promotion plan
and/or health promotion, the organisation will increase Staff vaccination records
its own internal capacity and its range of involvement in
community programs. Resourcing in this area should be pportunistic health promotion noted in the
O
regarded as an investment. consumer / patient health record
Staff education and training should: Relevant referrals in discharge plans
ssist the organisation to increase its capacity to

a ecords of consumer / patient and carer
R
deliver health promotion attendance at education classes
nsure that staff understand their responsibilities in

e onsumer / patient and carer feedback on
C
opportunistic health promotion education programs
ddress health literacy, and ensure that staff are aware

a vidence of collaborations with public health
E
of different approaches appropriate for consumer / bodies / community groups
patient and carer understanding Staff attendance at relevant meetings / conferences
Suggested reading
World Health Organization (WHO). Health promotion. Geneva
CH; WHO; 2016. Available from: http://www.who.int/topics/
health_promotion/en/ Viewed 5 March 2016.
World Health Organization (WHO). The Ottawa Charter for
Health Promotion. Geneva CH; WHO; 2016. Available from:
http://www.who.int/healthpromotion/conferences/previous/
ottawa/en/ Viewed 5 March 2016.
Australian Health Promotion Association (AHPA). Homepage.
Camperdown NSW; AHPA; 2016. Available from: http://www.
healthpromotion.org.au/ Viewed 5 March 2016.
Australian Government. Health promotion. Canberra ACT;
Australian Government; 2016. Available from: http://www.
australia.gov.au/information-and-services/health/health-
promotion Viewed 5 March 2016.
The Department of Health. Programs & initiatives. Canberra
ACT; Australian Government; 2016. Available from: http://
www.health.gov.au/internet/main/publishing.nsf/content/
programs-initiatives-all Viewed 5 March 2016.
The Western Australian Centre for Health Promotion Research.
Checklist for planning and evaluating health promotion
programs. Bentley WA; Curtin University; 2015. Available from:
http://www.kemh.health.wa.gov.au/services/amssu/docs/
Planning_Evaluating_HP_Checklist.pdf Viewed 5 March 2016.
Australian Indigenous HealthInfoNet. Homepage. Mt Lawley
WA; Edith Cowan University; 2016. Available from: http://
www.healthinfonet.ecu.edu.au/ Viewed 5 March 2016.
The Department of Health. Health topic quickview: Health
promotion. Canberra ACT; Australian Government; 2015.
Available from: http://www.health.gov.au/internet/main/
publishing.nsf/content/portal-Health%20promotion Viewed 5
March 2016.
Russell LM. Hospitals should be exemplars of healthy
workplaces. Medical Journal of Australia 202(8): 424-
426, 2015. Available from: https://www.mja.com.au/
journal/2015/202/8/hospitals-should-be-exemplars-healthy-
workplaces Viewed 5 March 2016.
Australian Institute of Health and Welfare. Australia’s health
2014. Canberra ACT; Australian Government; 2014. Available
from: http://www.aihw.gov.au/australias-health/2014/ Viewed
5 March 2016.
The Prevention and Population Health Branch. Evaluation
framework for health promotion and disease prevention
programs. Melbourne VIC; State of Victoria Department of
Health; 2015. Available from: https://www2.health.vic.gov.
au/Api/downloadmedia/%7BCD822DEB-053E-435C-B3AB-
2EC7DCF4FB92%7D Viewed 5 March 2016.
March 2016 309

2.5 Research Standard There is one criterion in this standard. This is:
The standard is: 2.5.1 The organisation’s research program develops
The organisation encourages and adequately the body of knowledge, protects staff and
governs the conduct of research to improve consumers / patients and has processes to
the safety and quality of health care appropriately manage the organisational risk
within organisations. associated with research.
The intent of the Research standard is two-fold: Organisations should understand their responsibilities
for the governance of research, and this responsibility
to encourage organisations to participate in research
should not rest with a Human Research Ethics Committee.
to further the evidence available to healthcare
organisations for providing high quality care
to ensure that if healthcare organisations engage in
clinical or health services research, the research is
governed effectively, in accordance with acceptable
guidelines and standards.
March 2016 311

SECTION 7 Standard 2.5 The organisation encourages and adequately governs the
conduct of research to improve the safety and quality of health care
within organisations.
Implementation
Criterion 2.5.1 a) The organisation fosters and a) The organisation’s research

encourages clinical and health program and/or its involvement in
The organisation’s research program
services research aimed clinical trials are managed so as to
develops the body of knowledge,
at improving outcomes for ensure the safety and wellbeing of
protects staff and consumers /
consumers / patients. relevant consumers / patients.
patients and has processes
to appropriately manage the b) Policy / guidelines addressing b) The respective responsibilities of
organisational risk associated research governance are all parties involved in research are
with research. consistent with relevant legislation, identified and documented.
guidelines, standards, statements
c) Research ethics approval
and/or codes of conduct.
processes are transparent and
c) Policy / guidelines define which consistent with relevant guidelines
research requires ethics approval and scientific review standards.
and under what conditions ethics
d) Where relevant, the organisation’s
approval will apply.
research ethics committee is
d) Research policy / guidelines adequately resourced.
are readily available to staff
e) The organisation’s research
and consumers.
ethics oversight processes are
e) Formal agreements with clearly defined.
collaborating and funding
f) Consumers and researchers work
agencies are in place.
in partnership with the organisation
f) The governing body demonstrates to make decisions about research
its responsibility for the governance priorities, policy and practices.
of research.

Research, whether medical, scientific or informational, The proper conduct of research requires organisational
is undertaken in order to increase knowledge and, oversight and governance (Criterion 3.1.1), and that
ultimately, to improve the care given to the consumer / participating consumers / patients are informed of
patient and to have a positive impact on the community their rights and responsibilities (Criterion 1.6.2) and are
as a whole. While all organisations are encouraged able to give informed consent (Criterion 1.1.3). The
to undertake research appropriate to their size organisation must manage any risks involved in the
and function, this criterion requires that, in those research (Criterion 2.1.2), and failure to do so may lead
organisations that do so, there is appropriate oversight to incidents and complaints (Criteria 2.1.3 and 2.1.4).
and that the participating consumers / patients and staff External organisations that manage research, and
are protected. Human Research Ethics Committees and Animal Ethics
Committees from other bodies, are external service
providers (Criterion 3.1.4).
a) T
he system for ensuring effective a) The organisation shows distinction a) The organisation demonstrates
research governance is evaluated, in research governance. that it is a leader in research
and improvements are made governance and the management
as required. of associated risk.
b) T
he organisation’s research
program and/or its involvement
in clinical trials are evaluated with
respect to the safety and wellbeing
of relevant consumers / patients,
and results are reported to the
governing body.
c) The organisation’s:
(i) research-related reporting
(ii) internal ethics processes
(iii) management of clinical trials,
where relevant, including any
specimens or medications
d) Research outcomes are reported
to the governing body, and
made readily available to
staff and consumers.
This criterion requires healthcare Health research

organisations to: Research involves a systematic and rigorous inquiry
nsure that all organisational research is conducted
E or investigation, to discover or confirm facts or
according to national and jurisdictional standards and principles. Health research is fundamental to the
guidelines, and relevant codes of conduct, and that ongoing improvement of human health, health care and
there is governing body oversight. consumer / patient services. Any research undertaken
by the organisation should add to the health sciences
ake all necessary steps to protect the safety of
T knowledge pool, and should advance health care or
consumers / patients involved in research, including the health and wellbeing of the community. Healthcare
in clinical trials, and to ensure that their rights and organisations should foster and encourage research
responsibilities are respected. programs, and facilitate the development of skills
nsure that all research is conducted ethically, and
E and expertise to investigate questions of interest and
with appropriate ethical oversight. communicate the findings.
onduct their research in a transparent manner,
C Organisations are encouraged to conduct or participate
with their research policy / guidelines and research in research appropriate to their scope and resources,
outcomes readily available to consumers and staff, to facilitate the development of the necessary skills and
and consumer involvement in research oversight. expertise, and to communicate their findings.
March 2016 313

Criterion 2.5.1 it was coordinated by an external health authority,

The organisation’s research program develops such as a Ministry / Department of Health
the body of knowledge, protects staff and there was an intention to publish the outcomes in a
consumers / patients and has processes to peer-reviewed journal
appropriately manage the organisational risk the conduct of the project impacted non-participating
associated with research. (continued) staff and/or consumers / patients.
Healthcare research may take a variety of forms: Research governance

rganisations may have dedicated research facilities
o Health research carries an associated risk to any
where much of the primary work may not involve consumers / patients and staff involved and to the
human subjects researchers conducting the research, and hence to
rganisations may trial new procedures as part of a
o the organisation itself. It is imperative that this risk be
project coordinated by their owners, a collaborating managed via a research governance framework that sets
agency or a government body out the guiding principles for organisational research,
including its conduct, ethics and reporting.
ealth professionals at an organisation may recruit and
h
monitor consumers / patients as part of a clinical trial The governing body has ultimate responsibility for the
managed for a pharmaceutical company or university safe and ethical conduct of the organisation’s research,
including that conducted by health professionals
rganisations may have researching health
o contracted to the organisation. However, it is expected
professionals who undertake and publish primary that appropriate delegations will assist the governing
research within their own specialty area body with respect to oversight of the organisation’s
rganisations may undertake investigations to compare
o research program, its outcomes, all associated
different approaches to providing clinical care; many reporting and any requirements for ethical approval of
quality improvement projects are of this type. the research. The nominated individual / committee
with day-to-day responsibility for the research program
It is important that organisations understand the should report regularly to the governing body.
difference between research and the continuous quality
improvement that should support all organisational While there is risk associated with all research, in certain
systems and processes. Research is, in general, a forms of research this risk is significantly increased
far more substantive and formally conducted activity, and the organisation must ensure that its governance
often involving formal, external collaborations, and structures are adequate to manage it. Such projects
requiring effective governance due to the associated include (but are not limited to):
risk. However, some quality improvement projects are clinical trials
sufficiently substantial to be regarded as ‘research’
within the context of this criterion. pharmaceutical testing
In general, an organisation would be considered to be any project requiring blood sampling.

conducting research if a project met two or more of the
following criteria: The three key components of research governance are:
the project was funded by a body outside the protection of consumers / patients, carers and
the organisation staff involved in research: this includes such matters
as consent, the provision of appropriate and safe
it required approval by a Human Research Ethics facilities in which clinical research may be undertaken,
Committee or an Animal Research Ethics Committee and the monitoring of consumer / patient wellbeing
its objective was to develop a marketable product the protection of researchers: this includes training,
that might be adopted by other organisations (e.g. a facilities, processes for the proper conduct of
wound care solution, alternative bandaging technique, research, and appropriate employment arrangements
software tool)
the protection of the organisation: this includes
matters that might pose a risk to the organisation or Prompt points
bring the organisation into disrepute, for example, the
ow does the organisation demonstrate
H
risk to the reputation of that organisation posed by
its commitment to fostering and
dishonest research, financial risk, intellectual property
encouraging research?
risk, commercial arrangements, and liability with
regard to consumer / patient harm. hat legislation, standards, guidelines and/or
W
codes of conduct are referenced in the
The governance of research should: organisation’s research policy and procedures?
nsure that all research conducted within the
e hat is an example of a research project
W
organisation, or in collaboration with other undertaken within this organisation?
organisations / bodies, is in accordance with relevant
legislation, guidelines, standards, statements and/or hat individual or committee is responsible for
W
codes of conduct oversight of the organisation’s research? How
often does the governing body receive reports
e supported by policy and procedures that define
b on the organisation’s research?
responsibility and accountability for research, and
which address at a minimum: ow does the organisation ensure that its
H
research is conducted in an ethical and
• the responsibilities of all parties transparent manner? How are consumers
• participant indemnity involved in the organisation’s management of its
research program?
• participant consent processes
• the protection and support of researchers and
assisting staff Research ethics
• management of inquiries and complaints Research that has any risk of causing harm physically,
psychologically or spiritually, or that potentially could
nsure that research is planned and conducted in a
e breach confidentiality or privacy, must always be
transparent manner, including (but not limited to): submitted to a properly constituted Human Research
• making the organisation’s research policy / Ethics Committee. This includes research where
guidelines publicly available members of the organisation’s staff are the participants.
• reporting the organisation’s research outcomes An organisation may have a formal Human Research
Ethics Committee and/or an Animal Research Ethics
• supporting consumer involvement in the Committee. These bodies must be formally registered,
organisation’s research planning and constituted and conducted according to relevant
e assisted by appropriate delegations, which ensure
b legislation and standards. Where the organisation has
oversight of all aspects of the organisation’s research its own committee(s), the governing body should ensure
program and all decisions relating to ethics approval that it is adequately resourced to conduct its business in
of research a timely and efficient manner.
include processes which ensure that all research- More commonly, the organisation will make use of
related reporting is completed in a timely manner ethics committees established within other bodies,
and that all relevant documents / submissions are such as universities. In this situation, the organisation
securely stored should appoint an appropriately qualified individual or
a committee to oversee the organisation’s research
nsure that formal agreements are in place for
e
program, with authority to make decisions regarding the
all research collaborations and funding
need for ethical approval by an external committee, and
arrangements, including those involving
the responsibility to ensure that researchers fulfil their
intellectual property agreements
obligations with respect to applying for ethical approval
here appropriate, ensure that the organisation’s
w and reporting to the external committee.
Research Ethics Committee(s) is adequately
resourced and properly conducted.
March 2016 315

Criterion 2.5.1 e overseen by a nominated individual or committee,

b
The organisation’s research program develops with responsibility for making decisions regarding the
the body of knowledge, protects staff and need for formal ethical approval and overseeing the
conduct of research within the organisation
consumers / patients and has processes to
appropriately manage the organisational risk e an aspect of the formal reporting required
b
with respect to all research conducted within the
associated with research. (continued) organisation, by the organisation in collaboration, or
by health professionals contracted to the organisation
Where research has human or animal subjects, the prior
need for ethical approval is self-evident. However, in e the subject of regular reporting to the governing
b
certain research projects the risk to participants may be body, as an aspect of the governing body’s
low or non-existent and the need for approval uncertain, responsibility for research conducted by
for example, in certain quality improvement projects or the organisation.
where consumer / patient involvement extends only to
answering questionnaires. Conversely, projects which
will not cause physical harm but may involve consumer / Prompt points
patient privacy and confidentiality, such as projects
oes the organisation have its own
D
based upon a review of health records, may require
Human Research Ethics Committee?
ethical approval. All proposed research projects should
How does the organisation ensure that this
be submitted in advance to the organisation’s appointed
Committee is properly constituted
individual / committee, where a decision will be made as
and conducted?
to the necessity or otherwise of formal ethical approval
by an external Human Research Ethics Committee. If the organisation does not have its own
Human Research Ethics Committee, where
It is important that the organisation understands the
are human research proposals submitted
difference between the general ethical conduct of the
for review?
care and service delivery, and ethical approval that relates
solely to the conduct of research. The organisation will ho is responsible for ethics review / decision
W
have a nominated body to oversee ethical decision making within the organisation? How does
making with regard to its health care, for example, with the organisation ensure that those with
respect to end-of-life care or the management of the responsibilities in this area are appropriately
refusal of consent. This is an aspect of the organisation’s qualified / have the necessary knowledge?
governance, and is addressed within criterion 3.1.1. The oes the organisation conduct animal-
D
current criterion applies only to the ethical conduct of based health research? To what Animal
research, and the processes for acquiring ethical approval Ethics Committee does it submit its research
of human or animal-based research. proposals? Where does it display its project
Research ethics should: approval numbers?
here the organisation has its own Human Research
w
Ethics Committee and/or Animal Research Ethics
Committee, be the responsibility of a body adequately
resourced, and constituted and conducted according
to relevant legislation, standards and/or guidelines
here the organisation applies to an external Human
w
Research Ethics Committee and/or Animal Research
Ethics Committee, be subject to formal application
by the organisation’s researchers, according to the
relevant guidelines and processes
e a consideration in the planning of all research
b
projects involving human or animal subjects in
any capacity
Suggested reading
The following evidence may help to World Health Organization (WHO). Ethical standards and
address criterion 2.5.1 procedures for research with human beings. Geneva CH;
WHO; 2016. Available from: http://www.who.int/ethics/
Research plan
research/en/ Viewed 5 March 2016.
Research in reports to the governing body Primary Health Care Research & Information Service (PHCRIS).
esearch as a standing agenda item for
R Introduction to: Consumer involvement in research. Bedford
committee meetings Park SA; PHCRIS; 2016. Available from: http://www.phcris.org.
au/guides/consumer_participation.php Viewed 5 March 2016.
ocumented ethical approval of all relevant
D
research projects Ethical issues and further resources. Canberra ACT; NHMRC;
Public reporting of research outcomes 2016. Available from: https://www.nhmrc.gov.au/health-
ethics/ethical-issues-and-further-resources Viewed 5 March
Publication of research in peer-reviewed journals / 2016.
conference presentations
vidence of consumer involvement in
E Human Research Ethics Committees (HRECs). Canberra
research planning ACT; NHMRC; 2016. Available from: https://www.nhmrc.gov.
au/health-ethics/human-research-ethics-committees-hrecs
Public availability of research policy / guidelines Viewed 5 March 2016.
Australian Research Council (ARC). Codes and guidelines.
Canberra ACT; ARC; 2015. Available from: http://www.arc.
gov.au/codes-and-guidelines Viewed 5 March 2016.
National Statement on Ethical Conduct in Human Research
(2007). Canberra ACT; NHMRC; 2015. Available from: https://
www.nhmrc.gov.au/guidelines-publications/e72 Viewed 5
March 2016.
Statement on Consumer and Community Participation in
Health and Medical Research (the Statement of Participation).
Canberra ACT; NHMRC; 2015. Available from: https://www.
nhmrc.gov.au/guidelines-publications/r22-r23-r33-r34 Viewed
5 March 2016.
Australian Code for the Care and Use of Animals for
Scientific Purposes (8th edition). Canberra ACT; NHMRC;
2013. Available from: https://www.nhmrc.gov.au/guidelines-
publications/ea28 Viewed 5 March 2016.
Australian Code for the Responsible Conduct of Research.
Canberra ACT; NHMRC; 2007 (under review). Available from:
https://www.nhmrc.gov.au/guidelines-publications/r39 Viewed
5 March 2016.
March 2016 317

3.1 Leadership and Management Standard There are five criteria in this standard. They are:
The standard is: Governance is assisted by formal structures and
3.1.1
The governing body leads the organisation’s delegation arrangements within the organisation.
strategic direction to ensure the provision of 3.1.2 S
trategic and operational planning and
quality, safe services. development support the organisation’s delivery
The intent of this standard is to ensure that an of safe, high quality care and services.
organisation is aware of and manages all the key Processes for credentialing and defining the
3.1.3
components of governance of a healthcare organisation. scope of clinical practice support safe, high
The standards and criteria contained in this functional quality health care.
area provide guidance on how healthcare organisations
can achieve effective corporate and clinical governance. External service providers are managed to
3.1.4
maximise safe, high quality care and services.
3.1.5 D
ocumented corporate and clinical policies
and procedures assist the organisation to
provide safe, high quality care and services.
These standards and criteria emphasise the need for
strong leadership, governance and direction.
March 2016 319

Standard 3.1: The governing body leads the organisation’s strategic
direction to ensure the provision of quality, safe services.
Implementation
Criterion 3.1.1 a) The organisation’s culture reflects a) Leaders and managers actively
its vision and values. promote the organisation’s values
Governance is assisted by
and respectful behaviours.
formal structures and delegation b) The governing body’s duties
arrangements within and responsibilities comply with b) Members of the governing body
the organisation. relevant legislation, and are receive formal orientation and
defined and documented. ongoing education regarding
their role.
c) Allocation of resources is based on
the service requirements identified c) A formal delegation system has
in the strategic and operational been implemented.
planning processes.
d) Minutes of committee and
d) Terms of reference, membership governing body meetings are
and procedures are in place for recorded and confirmed, and
meetings of the governing body. decisions and actions are
implemented and communicated.
e) The system for the recruitment and
appointment of senior managers e) The governing body regularly
defines the accountability of shares information about its
managers for the provision of activities and decisions with
safe services. relevant stakeholders.
f) A system has been implemented f) The governing body or its
to govern decision making with delegated authority monitors,
ethical implications. assesses and records issues
referred for ethical consideration.
g) The organisation has a budget
development and review process. g) The organisation has sound
financial management practices,
h) Financial processes are
including an independent
consistent with legislative and
audit process.
government requirements.
h) Useful, timely and accurate
financial reports are provided to
the governing body and those with
delegated financial authority.

This criterion requires that essential structures and The delivery of care that is high quality (Standard 1.1)
processes are in place for effectively managing the and safe (Standard 1.5) relies on robust governance
organisation, that individual roles and responsibilities structures and delegations.
are understood, and that there are clear channels of
Formal governance structures, leadership and delegation
communication and accountability.
practices are necessary to action strategic and
operational plans (Criterion 3.1.2), to support and drive
organisational commitment to improving performance
and the management of corporate and clinical risk
(Standard 2.1), and to successfully manage and support
320 The ACHS EQuIP6 Guide | Book 2 | Accreditation, Standards and Guidelines | Corporate Function
a) T
he vision and values of the a) The organisation shows distinction a) The organisation demonstrates it
organisation are evaluated, and in its governance. is a leader in governance systems.
changes are made as required.
b) T
he governing body assesses its
performance, and the performance
of its members, and improvements
c) The governing body receives,
evaluates and responds to reports
on the quality of care and services
and risk management.
d) The effectiveness of formally
constituted committees is
monitored and regularly evaluated,
as required.
e) Organisational structures and
processes are reviewed to ensure
effective service delivery.
f) Compliance with delegations is
monitored and evaluated,
as required.
g) The system to manage issues of
ethical consideration is evaluated,
as required.
a skilled and competent workforce (Standard 2.2). This criterion requires healthcare
Structures must also be in place to govern research and organisations to:
research ethics (Criterion 2.5.1), which is distinct from
general decision making with ethical implications. ave governance structures that support the delivery
H
of safe, high quality care and services.
nsure the governing body has the relevant
E
qualifications and experience to provide oversight to
the organisation.
nsure leadership practices and organisational culture
E
are aligned.
March 2016 321

Criterion 3.1.1 effective clinical governance that:

Governance is assisted by formal structures • provides an environment that fosters quality
and delegation arrangements within the
• monitors the quality of care
organisation. (continued)
• provides a regular report to the governing body on
Implement sound financial management practices that the quality of care
support strategic and operational plans. • identifies and minimises the risk of deficiencies in the
mploy ethical oversight in all operations of
E quality of care
the organisation. • effectively addresses and overcomes
these deficiencies
Governance structures
reporting mechanisms to the governing body,
Governance is the system by which organisations are internally within the organisation and to stakeholders.
directed and controlled. In health care, it is a leadership
responsibility to set organisational agendas for, and The governing body:
monitor, both corporate and clinical governance. The
governing body and senior managers need to ensure is responsible for both corporate and clinical governance
that the organisation is performing effectively, that akes certain that accountability is clear and creates
m
services are being delivered according to predefined a ‘just’ culture that is able to embrace reporting and
standards and that mechanisms are in place to take support improvement
remedial action when problems are encountered.
is responsible for ensuring that the organisation is run
Having adequate reporting mechanisms and reviewing efficiently, within legal constraints
clinical and organisational performance through
is responsible for discharging fiscal responsibilities,
accurate interpretation of data on a regular basis are
which may include creating returns on investment,
preconditions to effective governing body and
providing direction and using effective decision making
executive leadership.
processes to achieve corporate objectives
In addressing this criterion, the organisation should
anages and monitors fiscal responsibilities through
m
define which body carries legal accountability and/or
the use of delegation practices, performance
scope of organisational responsibility for the
indicators, committee activities and appropriate levels
functions covered.
of reporting
Formal organisational structures include:
s hould be fundamentally concerned with fairness,
larity regarding composition, such as appointments
c transparency and ethical business practices
of senior managers and health professionals,
ust work with, and through, the chief executive
m
representation of disciplines, professional bodies and
officer, however named
committee structures
s hould operate within clearly defined and documented
elegation of authority appropriate to individual roles
d
duties and responsibilities
and responsibilities within the organisation for the
operation of clinical and non-clinical services informs relevant stakeholders of activities and
decisions to facilitate healthy partnership relations and
linkages with stakeholders and facilities
encourage information flow in all directions and at
numerous levels
penly and willingly reports on relevant safety and
o
quality issues and improvements to all stakeholders,
including action taken to address problems
emonstrates practical commitment to
d
continuous improvement Prompt points
is assisted in meeting its responsibilities by hich body carries legal accountability
W
committees and appropriate delegations. and/or scope of organisational responsibility
for the governance functions? If this is shared,
The governing body should: how are accountability and the various
learly articulate organisational and individual
c responsibilities delineated?
accountabilities for safety and quality throughout ow does the organisation ensure that roles,
H
the organisation duties and responsibilities of the governing body
implement planning and review of integrated are clearly defined and effective?
governance systems for consumer / patient safety ow does the organisation ensure that the
H
and quality governing body members remain up-to-date
implement and maintain systems, materials, education and comply with relevant legislation?
and training, which ensures that safe, effective and oes the organisation produce reports of
D
reliable health care is delivered reviews of governing body compliance
facilitate compliance and manage performance across with legislation?
the organisation and within individual areas hat methods does the governing body utilise
W
of responsibility to regularly and transparently communicate with
odel behaviours which optimise safety and high
m stakeholders regarding non-confidential matters?
quality care as part of the implementation of a safety ow does the organisation evaluate the
H
culture within the organisation performance of the governing body and
onsider safety and quality implications in decision
c its members?
making processes hat is in place to guide the governing body’s
W
s upport consumers / patients to exercise their structure, roles and responsibilities, terms of
healthcare rights. reference, subcommittees, minutes of meetings
and use of attendance registers?
Organisations should regularly review their governance
and assurance arrangements to assess if all the threads hat Key Performance Indicators are in place
W
of quality, performance and governance are aligned and documented for the governing body,
and integrated. Consideration should be given to executive team, subcommittees, working
whether committee structures, their terms of reference, groups, meetings and advisory boards,
relationships and their ‘supports’ (staff, advisors, systems etc.? How are progress measured and
and processes) are all fit for the purpose and flexible deficiencies addressed?
enough to cope with changing priorities and risks. ow are committee structures, terms of
H
reference and reporting lines determined and
clearly defined? How are meeting minutes
shared and with whom?
H
governing body and committee meeting
minutes are of high quality and comprehensively
reflect discussions and decisions made?
In what ways do the organisation’s annual
reports reflect the organisation’s direction
and activities?
March 2016 323

Criterion 3.1.1
Governance is assisted by formal structures Prompt points
and delegation arrangements within the hat specific expertise in quality
W
organisation. (continued) improvement and consumer / patient safety in
health care or another industry is incorporated
Orientation and education for the into membership of the governing body?
governing body If this capacity is lacking, what steps are
being taken to attract and appoint
The organisation is responsible for enabling members members with such expertise?
of the governing body to develop and maintain a clear
understanding of their overall purpose, role and function in ow does the organisation build and nurture
H
relation to the core business. To fulfil their responsibilities, effective relationships between the governing
governing body members need to exercise care, diligence body, clinical staff and senior leadership?
and skill, through actions such as: ow does the organisation ensure that
H
taking reasonable steps to guide and monitor the governing body receives meaningful
the management of the organisation including its information, including trended and/or
approach to risk management benchmarked performance reporting, on quality
and consumer / patient safety?
ecoming familiar with the business of the
b
organisation and how it is operated ow does the organisation ensure that
H
appropriate orientation and education is
pplying their minds to the overall position of
a provided to governing body members?
the organisation.
ow are the requirements for ongoing
H
Members should also be oriented regarding education determined? Is a training needs
appropriate governance dynamics and relations analysis undertaken to identify gaps? How often
that support constructive interaction. This includes does this occur?
governance relations:
ow does the content of orientation and
H
amongst governing body members education programs assist governing body
etween the governing body, management and
b members to undertake their role?
senior health professionals
etween the governing body and members of external
b Delegation and accountability
governing bodies or networks to facilitate coordinated
planning or service delivery. Appropriate delegation to senior executives and
managers for the operation of clinical and non-
clinical services assists them to fulfil their duties
and meet expectations regarding their roles and
the implementation of governing body decisions.
Expectations regarding accountability for safety and
quality within specified areas of responsibility should be
clearly outlined and linked to performance measures.
A formal delegation system ensures that clear lines
of accountability exist, particularly where temporary
delegations are enacted.
As the governing body is accountable for clinical and
corporate standards of governance, it has a key role in Prompt points
establishing and maintaining a climate of high standards,
and for holding others accountable for the performance Is there a formal delegation system in
of the organisation and services, as well as for being operation? How are clear areas and scope
held accountable itself. This can include: of responsibility defined and documented,
particularly for temporary delegations?
s etting clear targets and standards for performance
and behaviours hen was the delegation system last reviewed,
W
and what recommendations were implemented?
nsuring processes are in place to support individuals
e Has this resulted in improvements?
in achieving these standards
ow is accountability monitored and
H
reating a climate of support and accountability, rather
c addressed if standards are not being upheld?
than a climate of blame Is this undertaken within a climate of support
olding people to account for what they have agreed
h and accountability?
to deliver ow does the governing body monitor
H
being prepared to be held to account by others implementation of its decisions?
insisting upon improved performance if standards If there are delays in executing long-term
are slipping. governing body decisions, how does the
organisation demonstrate that planning
Delegation policies may include as a minimum: is underway?
the limits of delegation

the instrument of delegation Leadership and organisational culture
how the policy was formulated Organisational culture refers to the prevailing pattern
of beliefs, attitudes, values and behaviours within
implementation and compliance monitoring. an organisation, which is often built upon
Regular review of the delegation structure, including underlying assumptions.
whenever there is a significant change such as an Culture incorporates a set of structures, routines, rules
alteration to a role, the organisation or its services, will and norms which guide and constrain behaviour. It is
ensure that delegations remain appropriate. shaped by relations between the governing body and
management, as well as broader leadership behaviour,
and is constantly created and enacted through
human interactions.
In health care, a positive organisational culture
values safe, high quality consumer / patient care,
responsible use of resources, community service,
and ethical behaviour.
Strong cultures are built on:
consistent, visible role modelling and leadership
onsistent feedback on both positive and
c
negative performance
onstant communication and sharing of experiences
c
around what is important to the organisation.
March 2016 325

Criterion 3.1.1 Financial management practices

Governance is assisted by formal structures The organisation’s financial management process will
and delegation arrangements within the usually include:
organisation. (continued) ppropriate delegation of responsibility for the
a
management of financial affairs
A positive organisational culture:
lanning and budget preparation with the participation
p
s hould be demonstrated throughout the organisation of senior management and staff
in everyday practice and interactions - that is, there
should be consistency between what is said and what risk management and insurance program that
a
is done includes appropriate insurance cover
ncourages individuals to report mistakes so that the
e monitoring of financial and productivity measures
precursors to errors can be better understood in order reporting the relationship between budget and
to fix the system issues actual experience
olds organisations accountable for the systems they
h omprehensive reporting to the governing body and
c
design and for how they respond to staff behaviours in senior managers
fair and just ways.
analysing the results of financial reports
internal control
Prompt points
reparation of accounts that meet
p
ow does the governing body set the
H statutory requirements
tone of the organisational culture?
independent audit if required by statute
hat development opportunities are provided
W
for leaders and managers and how do these anagement follow-up on recommendations, reports
m
support their role in promulgating organisational and related feedback.
culture? Are cultural surveys administered While the allocation of resources may not be determined
regularly? How are results utilised to improve at the organisational level in all cases, the governing body
organisational culture? has responsibility to utilise all resources, including funding,
ow is organisational culture measured and
H staff, facilities and available equipment to ensure the
improvements made? delivery of safe, high quality care according to identified
service requirements and in line with strategic and
ow is application of the organisational culture
H operational plans. Clinical and resourcing decisions are
by committees or other groups monitored? interlinked and should be made with consideration of all
What documentation is audited? factors, including ethical issues, and potential impacts.
ow are complaints from staff or consumers /
H Evaluation of financial management can be undertaken
patients regarding episodes that do not reflect through the ongoing receipt and monitoring of
organisation values managed? accurate and detailed reports by the governing body,
re ‘whistleblower’ and respectful behaviour
A measurement and trending against key financial
policies in place? How are staff protected? indicators and regular auditing. Identified improvements
should be made to facilitate financial viability.
ave a mechanism to address ethical issues in care
h
Prompt points delivery, including the everyday ethical challenges
encountered by individual staff
ow are finances managed to facilitate
H
the achievement of organisational goals, record decisions made regarding ethical issues, and
including the ability to provide quality care? give consideration to implementing improvements in
practice that may have been identified.
hat organisational values shape behaviour
W
regarding financial management?
ow does the budget development and review
H Prompt points
process ensure the most equitable / just,
hat ethical decision-making mechanism(s)
W
efficient and effective use of resources?
is available to both clinical and non-clinical staff,
particularly for everyday ethical challenges? How
is this made known and promoted?
Ethical oversight
ow does the governing body receive,
H
Ethical decision making refers to the way in which an
monitor and assess issues referred for
organisation’s ideals, values and ethos - the sum of
ethical consideration?
ideals which define an overall culture - are translated into
everyday practice through the actions and behaviour of hat arrangements are in place to address
W
people. This is relevant to both clinical and non-clinical unanticipated ethical challenges, should
areas. The organisation’s statement of values, its policies they arise?
and procedures regarding consumer / patient rights and ow are the outcomes of clinical ethical issues
H
responsibilities, as well as professional codes of ethics, reviewed and improvements made?
provide a basis for addressing many ethical issues. The
organisation should also have a framework in place
that aims to protect consumer rights and to guide care
and accountability.
Ethical issues that may need to be addressed include:
equity of access to services
marketing of services
recognition of cultural or religious beliefs that affect the
provision of care
allocation of scarce resources
billing and charging policies
organ donation
withdrawal / continuation of life support
trialling of new drugs or procedures
conflicts of interest.
The organisation should:

romote a consistent approach to ethical decision
p
making throughout the organisation
provide staff with appropriate support
March 2016 327


Governance is assisted by formal structures 5 Million Lives Campaign. Getting Started Kit: Governance
and delegation arrangements within the Leadership “Boards on Board” How-to Guide. Cambridge,
MA: Institute for Healthcare Improvement; 2008. Available
organisation. (continued) from: www.ihi.org Viewed 8 March 2016.
Testa M, Sipe L. The Organizational Culture Audit: Countering
The following evidence may help to Cultural Ambiguity in the Service Context. Open Journal of
Leadership 2013. Vol.2, No.2, 36-44. Available from: http://
dx.doi.org/10.4236/ojl.2013.22005 Viewed 8 March 2016.
easurement of and improvements to
M World Health Organization. Human Factors in Patient Safety.
organisational culture Review of Topics and Tools. 2009. Available from: http://www.
rientation and education program content and
O who.int/patientsafety/research/methods_measures/human_
attendance by members of the governing body factors/human_factors_review.pdf Viewed 8 March 2016.
Health Workforce Australia. Leadership for the sustainability of
he structure of the governing body, its roles and
T
the Health System. 2012. Available from: http://www.hwa.gov.
responsibilities, terms of reference, minutes of au/sites/uploads/leadership-for-sustainability-of-health-sector-
meetings, attendance registers literature-review-012012.pdf Viewed 8 March 2016.
Organisational structure or chart Organisation for Economic Co-operation and Development.
G20/OECD Principles of Corporate Governance. 2015.
tructures of committees, terms of reference,
S
Available from: http://www.oecd.org/daf/ca/Corporate-
reporting lines, minutes of meetings Governance-Principles-ENG.pdf Viewed 8 March 2016.
Annual reports The International Finance Corporation. Who’s running
eports of reviews of governing body
R the Company: A guide to reporting on corporate
governance. 2012. Global Corporate Governance
compliance with legislation in its responsibilities
Forum and the International Centre for Journalists.
Delegation documents or instruments Available from: http://www.ifc.org/wps/wcm/
connect/aa93d6804d394d5eabc8eff81ee631cc/
Reports of reviews of the delegation documents Whos+Running+the+Company+Rev+-+Lo+Res.
Position descriptions pdf?MOD=AJPERES Viewed 8 March 2016.
Quality and Patient Safety Directorate. Quality and Patient
olicies and procedures for budget
P
Safety Clinical Governance Development…an assurance check
development reviews for health service providers. Available from: http://www.hse.ie/
Policies and procedures for financial management eng/about/Who/qualityandpatientsafety/Clinical_Governance/
CG_docs/clingovassurancecheckFeb2012.pdf Viewed 8
eports of reviews of the financial system’s
R March 2016.
compliance with legislation
Independent audit / sign-off of financial records,
particularly matters that may be considered
commercial-in-confidence
Easy availability of ethical facts and information
forum where staff can discuss ethical issues,
A
or a referral process for issues to be considered
by the governing body
March 2016 329
Implementation
Criterion 3.1.2 a) A strategic plan has been a) Organisational and service planning
developed which reflects the reflects strategic objectives.
Strategic and operational planning
organisation’s vision and values.
and development support the b) Clinical and non-clinical service
organisation’s delivery of safe, high b) Operational plans reflect the planning addresses projected
quality care and services. organisation’s objectives and service demands.
guide day-to-day activities.
c) Planning identifies priority areas for
c) Strategic and operational care / service development and
planning is supported by the most efficient use of resources
documented change and risk including physical assets.
management strategies.
d) Planned changes are
d) There is a planned approach to clearly communicated to
the development of facilities and relevant stakeholders.
services.
e) Relationships with relevant
e) Service delivery needs of the external organisations are formally
organisation’s community recognised in the planning process.
are analysed and considered
f) Stakeholders and, where
when developing strategic and
appropriate, consumers / patients
operational plans.
and carers are involved in the
f) The organisation’s activities development and implementation
comply with relevant by-laws, of plans.
articles of association and/or
policies and procedures.

This criterion requires healthcare organisations to The organisation’s strategic and operational planning
have an integrated planning process that begins at should articulate its commitment to the delivery of safe,
the strategic level and guides everyday work through high quality care (Standard 1.1), continuous quality
operational planning. A well-articulated strategic plan improvement (Criterion 2.1.1), the management of risk
that is supported by a detailed operational plan(s) allows (Criterion 2.1.2) and consumer participation (Criterion
everyone to work towards the same vision and values, 1.6.1). The planning will consider all operational
while providing clear direction regarding each unit, team aspects of the organisation, including human resources
or individual’s role in the achievement of the organisation’s (Standard 2.2), information technology (Criterion
strategic objectives and service development. 2.3.4), governance (Criterion 3.1.1) and the safety of
consumers / patients, visitors and staff (Standard 3.2).
a) T
he governing body evaluates a) The organisation shows distinction a) The organisation demonstrates
progress towards achieving in strategic and operational it is a leader in strategic
the vision and objectives of the planning and development. and operational planning
strategic plan, and takes remedial and development.
action as required.
b) S
trategic and operational plans
are evaluated to ensure they
continue to meet the needs of the
organisation, the community and
other stakeholders where relevant.
c) Changes driven by the strategic
plan are evaluated in consultation
with relevant stakeholders.
This criterion requires healthcare Strategic and operational plans

organisations to: Strategic planning is a process which articulates the
evelop and implement strategic and
D organisation’s vision and values, and planned objectives;
operational plans. that is, what it intends to achieve for its community.
The process of strategic planning is a function of the
Perform a strategic / needs analysis. governing body but ideally involves staff, stakeholders
uild relationships both internal and external to the
B and consumers as well.
organisation and collaborate in the planning process. Health systems are complex and dynamic, characterised
Implement change management strategies. by constant change and innovation in the organisation,
funding and delivery of health services, and operate in
a context of changing social, economic and political
environments. Responsiveness to change is therefore
essential and driven by the emergence of new health
needs and priorities within the population, better
understanding of those needs, and the adoption of new
clinical practice and technologies in the prevention,
diagnosis and treatment of illness. There is a need to
March 2016 331

Criterion 3.1.2 Therefore, the strategic plan:

Strategic and operational planning and stablishes an organisation’s overall
e
development support the organisation’s strategic objectives
delivery of safe, high quality care and services. is organisation-wide
(continued) is responsive to the organisation’s risks
ensure that this occurs in alignment with overall strategic identifies the organisation’s long-term direction
objectives, such as equitable service provision and value
identifies how resources are to be allocated
for money services, both in terms of clinical effectiveness
and cost-efficiency. identifies what services are available and what
is needed.
Organisational strategy defines what an organisation
seeks to do and how it plans to do it.
The governing body approves the plan that is
Major strategic planning activities include: implemented and revised as necessary.
strategic analysis The operational plan:
‘seizing the future’, and being responsive to the is a short-term plan that details the methods
environment in which the organisation operates or strategies by which the strategic plan will be
accomplished
setting strategic direction
an be developed for specific sites / areas /
c
being clear about the organisation’s objectives
programs / services
being aware of the organisation’s resources
identifies responsibilities and timeframes in a format
action planning. that can be easily understood.
The strategic plan and operational plans can be
In setting strategic directions organisations should:
aligned using performance indicators. Performance
etermine what needs to be done in relation to
d improvement, change management and risk
meeting the objectives and addressing the major management processes should also be included to
issues and opportunities identified in the strategic ensure the achievement of outcomes identified in the
analysis process strategic plan.
onsider the overall accomplishments the organisation
c
In summary, the organisation’s strategic and operational
should achieve, and the overall methods, or
plans should be:
strategies, required to achieve these
integrated
‘seize the future’ meaning acting now to shape
the future responsive to the needs of the community
ake the most of current opportunities to bring about
m eveloped cooperatively by management, staff and
d
improvements that are of benefit to staff, consumers / the community, along with other relevant health
patients and carers. service providers and stakeholders.
Operational plans should be aligned with the strategic
Long- and short-term objectives are essential for
plan and performance indicators used to facilitate
effective management of the organisation. Action
monitoring and progress towards achievement of
planning is carefully laying out how the strategic
strategic objectives.
objectives will be accomplished using the identified
methods or strategies. This often includes declaring
specific results for each objective. Reaching a strategic
objective typically involves accomplishing a set of
results, or milestones, along the way.
Strategic / needs analysis
Prompt points To be successful, healthcare organisations must be able
hat are the organisation’s vision,
W to deal effectively and creatively with their increasingly
strategic objectives and values and how do uncertain operational scenario. The ability to anticipate
these guide planning? and respond to significant shifts within the environment
is critical to the success of the organisation. A key
How are these made known to all stakeholders? element of organisational strategy is a thorough analysis
hat framework and processes does the
W of the environment within which the organisation is
organisation use to develop strategic and operating. It is critical that this analysis includes the
operational plans? major features of the external environment as well as
the important attributes of its internal environment. This
hat role do stakeholders play in strategic and
W
allows the establishment of appropriate assumptions on
operational planning?
which to build the strategic plan.
hat evidence of identified needs, priorities,
W
Strategic or needs analysis includes:
appropriateness and effectiveness is used to
guide planning? onducting a scan, or review, of the organisation’s
c
environment, for example, of the political, social,
ow are areas for care / service
H
economic and technical environment
development prioritised?
arefully considering various driving forces in the
c
How is action planning undertaken?
environment, such as increasing competition, change
hat strategies are in place to achieve the
W in policy direction, changing demographics, etc.
organisation’s objectives?
s taying aware of best clinical and
hat change or risk management strategies
W management practice
are documented?
nderstanding how services are being delivered to
u
ow do operational plans achieve the
H consumers / patients, to pick up early warning signs
organisation’s objectives and guide of difficulty, and to seize opportunities to improve the
day-to-day activity? consumer / patient experience
H eing aware of practice elsewhere, enabling
b
operational plans guide performance replication or improvement upon it in the organisation
improvement and the management of change and across the health community
and risk?
nderstanding of the organisation’s capacity,
u
ow is progress monitored against objectives
H resources and capabilities and how these contribute
outlined in the strategic and operational plans, to the development of organisational strengths
and corrective action taken if necessary? and weaknesses
reviewing the organisation’s various strengths,
weaknesses, opportunities and threats
(a SWOT analysis)
identifying and planning for possible internal and
external challenges to assist the organisation to
be prepared.
March 2016 333

Criterion 3.1.2 Building relationships and collaborating

Strategic and operational planning and in planning
development support the organisation’s Systems theory emphasises continuous reflection on
delivery of safe, high quality care and services. the bigger picture and consideration of the numerous
(continued) interconnections and interrelationships between parts,
individuals and groups within systems. To ensure a
An external challenge could be described as a challenge comprehensive approach to planning, it is crucial
imposed on an organisation by external forces, or the for strategic and operational planning processes to
‘rules of success’. These could include: incorporate formal consideration and recognition of
the relationships that exist, or need to be developed,
changes in legislation or regulation
between the healthcare organisation and other bodies,
technological advances such as other health services, community organisations,
health funds and government bodies. Broad consultation
government department restructures
will help to identify and address the needs and
governing organisation restructures or takeover expectations of the organisation’s internal and external
customers. The involvement of managers, staff and the
national workforce shortages
community in strategic and operational planning, as well
xternal disasters such as earthquakes, transport
e as the implementation of those plans, will ensure that
accidents or bushfires needs, expectations and opportunities are determined
outside competition and considered.
hange in government policy that may impact on

c The organisation should:
the organisation.
e committed to working and engaging constructively
b
An internal challenge may be described as a challenge with internal and external stakeholders
within the organisation, and could include: s trive to create the conditions for successful partnership
recruitment issues work to ensure that the strategy for health improvement,
and the planning, development and provision of health
technological crises services, are cohesive and ‘joined up’
the emergency department being full to capacity emonstrate understanding and sensitivity to
d
an unavailability of beds in the organisation diverse viewpoints, as collaborative working is
critical in delivering measurable and radical health
a continuing adverse financial trend. improvements in a complex and changing health and
social care environment
Prompt points efine who its community, or the population it serves,

d
is, as discussed within criterion 1.2.1, in order to meet
hat processes are used to determine
W its needs
and analyse key factors in the
external environment? nalyse the influence of various stakeholders
a
associated with the organisation, and the impact such
ow does the organisation anticipate and
H influence may have on planning.
ensure adaptability to changing circumstances?
ow are internal and external
H Strategies should be in place to ensure:
challenges addressed? onsumers participate in planning, improvement and
c
ow is projected demand for clinical and
H monitoring organisational processes
non-clinical services incorporated into there is clear, open and respectful communication
planning processes? between consumers and the organisation at all levels,
hat evidence is used to support provision
W including strategically
(or non-provision) of particular services?
s ervices respond with humanity to the diverse needs s etting the organisational climate that people
of consumers / patients and the community experience, whether the context is a hospital, a
community setting or a network, through strong
s ervices learn from consumer / patient feedback on
leadership, which is critical in inspiring people to make
clinical care and service delivery.
changes and in getting diverse stakeholders to work
effectively together
Prompt points providing clarity about individual and team roles.
ow are the views of diverse stakeholders
H
While changing organisational structure is a popular
incorporated into planning processes?
thing to do, much research suggests that this often
ow is consumer participation encouraged and
H results in poor outcomes, with the benefits sought
supported in planning activities? by those who initiate restructuring only rarely being
achieved. Instead, there are strong arguments for
ow is stakeholder influence acknowledged,
H
making improvements to systems and cultures. This
balanced and managed?
means striving to influence and shape how people tackle
ow does the organisation actively create
H change, their behaviours and practices, attitudes and
conditions for successful partnership work? values, which are the fundamental building blocks of
ow are partnerships utilised to support
H successful and sustainable change.
planning for ‘joined up’ or integrated care? Organisations should:
hat communication and distribution channels
W establish a change agenda and improvement program
are utilised for informing management, staff and
nticipate change and be responsive in a
a
the community of plans and any changes?
planned manner
communicate their vision and rationale for change
Change management strategies
engage and facilitate others to work collaboratively
Improvement - which is productive change - is achieved
prioritise effort to get the best outcomes
if the people involved in the workplace design it, own it,
are involved in the transition, and experience the results. focus on making improvements to systems and
cultures, rather than structure alone
Few organisations these days are not embracing
change. Shifts in the external environment, and the involve relevant staff and consumers throughout the
rapid development of new improvements and initiatives, design, implementation and evaluation phases
are major factors in changes within the healthcare
tilise an interactive, problem-solving approach, along
u
system. A critical question organisations face is how to
with a range of tools
prioritise effort to get the best outcomes, and not to run
into ‘change fatigue’. A key strategy is to establish an secure resources and support
agenda that positions the organisation to be in charge support staff through change processes
of its improvement program and able to strive to make
things happen according to plan, as productively and e open and transparent in communication
b
usefully as possible. with stakeholders:
Essential components when instituting change are: • internal stakeholders such as staff, visiting
medical officers, etc.
ommunicating the vision and rationale for change
c
and service improvement • the wider community
ngaging and facilitating others to work collaboratively
e • external service providers, such as local government
to achieve real improvement community services and general practitioners
• external stakeholders, such as government,
corporate office, etc.
March 2016 335

Criterion 3.1.2
Strategic and operational planning and The following evidence may help to
development support the organisation’s address criterion 3.1.2
delivery of safe, high quality care and services. ramework and process for developing strategic
F
(continued) and operational plans including categories
for participants
identify and measure the outcomes of any Vision, strategic objectives and value statements
significant change process; review and evaluation of
achievement against planned outcomes feeds back trategic and operational plans with objectives
S
into the planning process. and targets and links to other plans
egislative compliance activities - team
L
reviews, audits, mortality and morbidity review
Prompt points meetings, etc.
ow does the organisation strategically
H xamples of internal and external challenges that
E
anticipate and plan for change? have been addressed
ow are opportunities likely to achieve the
H xamples of issues where change management
E
greatest outcomes identified? strategies are used
re there examples of challenges that
A ommunication and distribution channels for
C
were overcome and change management informing management, staff and the community
strategies that were effectively used? Were of plans and any changes
these documented?
eports of progress to objectives and targets in
R
as the organisation able to direct efforts to
W the strategic and operational plans
improving systems or cultures?
eports of evaluation of changes to the
R
What approach was taken? organisation’s systems, culture, services,
ow was the vision and rationale for
H structures or practices
change communicated?
ow did the organisation ensure collaborative
H
stakeholder engagement throughout?
ow were risks identified, documented
H
and managed?
hat evaluation strategies were built in and
W
how are changes evaluated?
hat examples demonstrate that evaluation
W
findings have resulted in changes to clinical and
non-clinical areas?
ow have findings been utilised to further refine
H
the strategy, or inform other activities?
Suggested reading
Terzic-Supic Z, et al. Training hospital managers for strategic
planning and management: a prospective study. BMC Medical
Education. BioMed Central. 2015. Available from: http://
bmcmededuc.biomedcentral.com/articles/10.1186/s12909-
015-0310-9 Viewed 9 March 2016.
Balanced Scorecard Institute. Strategy Management Group.
Information about strategic planning. Available from: http://
balancedscorecard.org/Resources/Strategic-Planning-Basics
Reed S. 5 Intangible Benefits of Hospital Strategic Planning.
Becker’s Hospital Review. 2013. Available from: http://www.
beckershospitalreview.com/strategic-planning/5-intangible-
benefits-of-hospital-strategic-planning.html
Schneider S. Analysis of Management Practice Strategic
Planning: a comprehensive approach. Asia Pacific Journal of
Health Management 2015; 10: 3 Available from: http://www.
achsm.org.au/education/journal/ Viewed 9 March 2016.
Choudhuri D. Strategic Planning: A Comprehensive Approach.
2015. Available from: http://www.structuremag.org/?p=8943
March 2016 337

Implementation
Criterion 3.1.3 a) Organisation-wide policy / a) The appointment system for health

guidelines address the professionals includes a process
Processes for credentialing and
credentialing and, where relevant, for confirming the credentials of
defining the scope of clinical practice
registration of health professionals. applicants which is consistent with
support safe, high quality health care.
relevant standards and guidelines,
b) Organisation-wide policy /
This is a mandatory criterion and with organisational policy.
guidelines address defining and
reviewing the scope of clinical b) The process for defining and
practice of all health professionals. reviewing the scope of clinical
practice is organisation- or facility-
c) Organisation-wide policy /
specific and reflects the role and
guidelines address the safe
capabilities of the organisation.
introduction of new interventions
and treatments. c) The process for recommending
the scope of clinical practice
d) The governing body and/or
is consistent with relevant
its delegated authority
standards and guidelines, and with
demonstrate its responsibility for
organisational policy.
the governance of credentialing,
scope of practice, and the d) Outcomes of health professionals’
introduction of new interventions performance reviews are linked to
and treatments. the system for defining the scope
of clinical practice and, where
appropriate, communicated to
relevant external authorities.
e) The process for the safe
and treatments is consistent with
relevant standards and guidelines,
and with organisational policy.
f) The scope of practice of health
professionals is reviewed prior to
the introduction of new services,
procedures or other interventions.
g) Re-credentialing processes ensure
that all health professionals
have maintained or improved
their qualifications, skills
and competencies.
a) T
he system for the credentialing, a) The organisation shows distinction a) The organisation demonstrates
re-credentialing, registration where in credentialing and defining the it is a leader in systems for
relevant, and appointment of scope of clinical practice. credentialing and defining the
health professionals is evaluated, scope of clinical practice.
as required.
b) T
he system for defining and
reviewing the scope of clinical
practice for health professionals is
made as required.
c) The system for the safe introduction
of new interventions and treatments
is evaluated, and improvements are
made as required.
d) Outcomes of the management of
identified issues with credentialing,
defining the scope of clinical
practice and introducing new
interventions and treatments are
March 2016 339

Criterion 3.1.3 The credentialing system

Processes for credentialing and defining the Credentialing refers to the formal process used to
scope of clinical practice support safe, high verify the qualifications, experience, standing and
quality health care. (continued) other relevant attributes of health professionals for the
purpose of forming a view about their competence,
Overview performance and suitability to provide safe, high
quality healthcare services within specific
This criterion aims to ensure that the organisation’s organisational environments.
processes will reflect a growing understanding of the
role of credentialing in sound clinical governance and will For the purposes of the credentialing system, there
support safe, high quality health care. should be a clear definition of who is recognised as
a health professional within the organisation. The
The skills and competence of all health professionals term ‘health professional’ used in the context of this
should be correctly aligned with the competence of a guideline applies irrespective of legislated requirements
healthcare organisation, so that the right health for registration, and encompasses not only medical
professionals are providing the right care and services in practitioners, but all trained healthcare providers including
the right healthcare organisations. nurses, dentists, paramedics and all allied health services,
except for those required to work under supervision (i.e.
Relationships of 3.1.3 with other criteria junior medical officers and others in training).
The organisation’s processes for credentialing and The organisation should:
defining the scope of clinical practice are a major
ave comprehensive policies and procedures that
h
component of its commitment to improving performance
reference relevant standards and guidelines
(Criterion 2.1.1) and ensuring the effective management
of corporate and clinical risks (Criterion 2.1.2). These onvene a credentialing committee which is built
c
processes lie within the purview of the organisation’s around a core membership of health professionals
workforce planning (Criterion 2.2.1), its recruitment, from a range of disciplines, including, wherever
selection and appointment system (Criterion 2.2.2) possible, that of the individual being credentialed,
and its performance management and learning whose skills and experience qualify them to make the
and development systems, by which it ensures the necessary assessments
competence of staff (Criteria 2.2.3 and 2.2.4).
onfirm the pre-employment review, verifying claimed
c
work experience, additional training, references
This criterion requires healthcare and employment history before issuing a contract
organisations to: or commencing immigration processes for foreign-
nsure the competency of health professionals
E trained health professionals
through the credentialing system. nsure that there is a robust system in place to
e
efine the scope of clinical practice of all relevant
D investigate the credentials of foreign-trained
health professionals. health professionals
anage the introduction of new interventions

M nsure that all relevant registrations and memberships
e
and treatments. are in place
utline the responsibility for the governance of the

O stablish a credentialing appeals committee that is
e
credentialing system. independent of the original credentialing committee
whose decision is being appealed, to adjudicate on
any appealed decision(s)
ave a process for re-credentialing health
h
professionals that is as stringent as that followed for
the initial credentialing, and that:
• ensures that all relevant registrations and
memberships have been maintained
• reviews clinical outcomes, adverse events, and/or Defining the scope of clinical practice
complaints, a process which may form part of
The scope of practice of each health professional should
clinical / peer review meetings
be defined in the context of the organisation’s facilities
• considers any indications of underperformance such and clinical and non-clinical support services to be
as persistence with out-dated practices, clinical provided by the organisation, and the organisation’s
disinterest or poor procedural outcomes need and capability to enable health professionals to
• receives details of any further endorsements / provide safe, high quality healthcare services in the
accreditations achieved, any further education / specific organisational setting.
training undertaken, and all healthcare-related For any healthcare facility, organisational need and
activities since the previous credentialing capability will depend upon such factors as:
omprehensively document all decisions and actions
c the type of facility
by both the credentialing committee and the
its geographical location
appeals committee.
the needs of the community
the nature of the organisation’s role within the broader
Prompt points
healthcare system
hat credentials must a health
W
availability of services, equipment and support staff.
professional present to the credentialing
committee when being considered for
Defining the scope of clinical practice:
appointment? How does the committee confirm
those credentials? follows on from the credentialing of medical
practitioners and other health professionals
ow does the credentialing committee
H
determine the competence of health involves delineating the extent of, and the limits to,
professionals? an individual’s clinical practice within a particular
organisation based on that individual’s credentials,
oes the committee’s process for investigating
D
competence, performance and professional suitability,
the qualifications of foreign-trained health
and the needs and the capability of the organisation to
professionals differ from the usual process?
support the individual’s scope of clinical practice
If so, how?
is the outcome of matching a health professional’s
oes the organisation credential its junior
D
qualifications, skills, experience and competence with
medical officers? If not, how does the
the required services and the role and capabilities of
organisation ensure that its junior medical
the organisation
officers are appropriately supervised?
is context-specific, and the exact process may
nder the terms of the organisation’s policy /
U
therefore be unique to the organisation or facility
by-laws, how often is credentialing carried out?
must be conducted in a transparent manner
hat processes does the organisation use
W
to monitor the ongoing competence of health ust be outlined in position descriptions and/or
m
professionals? What steps are taken in the employment contracts / letters of appointment
event of an identified performance issue?
ay include applying limitations due to the level of
m
hat systems and processes would be
W training and experience of the health professional, the
followed if a decision of a credentialing review defined role or capability of the site or the extent of
was appealed? support staff expertise and technology available.
March 2016 341

Criterion 3.1.3 incorporate a definition of ‘new interventions and

Processes for credentialing and defining the treatments’ in the policy
scope of clinical practice support safe, high efine who may request assessments of new
d
quality health care. (continued) interventions or treatments, and the process by which
they may submit requests for those assessments
ave a process to assess the cost, risks, efficacy
h
Prompt points and cost-benefit of a proposed new intervention or
hat statutory requirements and guidelines
W treatment, including whether external benchmarking
did the organisation consult in developing its data should be considered
policy / by-laws governing defining the scope efine the organisation’s requirements for
d
of practice? consideration of the broader healthcare context
rior to writing a position description and
P within which the new interventions or treatments are
inviting applicants, how is organisational proposed to be introduced
need determined? identify the individuals or committees that are
ow does the organisation ensure health
H authorised to initiate an assessment of proposed new
professionals operate within their scope interventions and treatments
of practice? elineate the individuals or committees that are
d
ow does the organisation ensure that scope of
H responsible for overseeing the assessment of
practice information is disseminated on a ‘need proposed new interventions and treatments
to know’ basis only? efine the organisation’s requirement if a new
d
hat systems and processes would be
W intervention / treatment, which had not yet been
followed if a decision of a scope of clinical approved and therefore remains experimental, was
practice review was appealed? referred for consideration by a Human Research
Ethics Committee or a Clinical Ethics Committee
(as appropriate)
The introduction of new interventions formalise the approval and monitoring processes
and treatments of the new intervention and its outcomes against
A new intervention is a procedure, treatment or means predetermined goals for a specified period of time
of assessment not previously performed within the following its introduction.
organisation, or one where a significant variation to an Whilst the primary role of a credentialing committee is
existing procedure, treatment or means of assessment, the credentialing of individuals, in many organisations
such as new medication protocols, a new surgical the committee is also responsible for considering
technique or the use of a new medical device, applications and providing guidelines for the introduction
is introduced. of new interventions, which is seen as a natural
The introduction of new interventions and treatments extension of the committee’s function and an adjunct to
will assist organisations to provide quality, contemporary their defining of the clinical scope of practice.
care and services. However, the safety of new clinical The roll-out of a new service should be documented and
services, procedures or other interventions, and their monitored. Examination of the challenges, outcomes
potential to improve consumer / patient outcomes, are and any adverse events, consumer / patient feedback
the overriding considerations. and costs will allow decisions regarding the continuation
Organisations should: or refining of the new intervention or treatment to be
made in a timely and informed manner. However, the
ave a policy for the introduction of new interventions
h review process should not be used to limit appropriate
and treatments that operates within jurisdictional professional initiatives or to inappropriately restrict
legislation and is linked to the credentialing and scope measures available in an emergency situation.
of practice policy
that the circumstances under which an unplanned
Prompt points review of a health professional’s credentials and/
or scope of clinical practice may be initiated, the
hat role do health professionals play in
W
authorised persons and bodies within or outside the
the safe introduction of new interventions
organisation from whom a request for an unplanned
and treatments?
review will be accepted, and how the results of such a
ow does the organisation assess applications
H review will be implemented, are specified
for new interventions or treatments when new
there is an appeals committee and an
technology is involved?
appeals process
hat evidence is there of consumer / patient
W
that staff are aware of the mechanism through
involvement in the introduction and assessment
which an appeal may be made if responsibility for
of new interventions and treatments?
credentialing / scope of practice decisions lies outside
the organisation
Governance identification of the conditions, if any, under which
health professionals may administer necessary
The governing body of the organisation is responsible
treatment outside their authorised scope of clinical
for developing and implementing a policy or by-laws on
practice, for example in emergency situations where
credentialing and defining the scope of clinical practice
a consumer / patient may be at risk of serious harm if
for all health professionals.
treatment is not provided, and no health professional
Governance should ensure: with an appropriate authorised scope of clinical
practice is available
compliance with all relevant legal requirements
there is a process for credentialing and defining
llocation of responsibility to a defined organisational
a
the scope of clinical practice to be undertaken in
committee so that effective processes for credentialing
emergency situations where clinical expertise is
and for continually monitoring the clinical practice are
required on a temporary basis, and which clearly
in place
identifies who has delegated authority to undertake
identification of the maximum elapsed time following this process.
which the processes of credentialing and defining the
scope of clinical practice will be repeated
that health professionals who are required to be
Prompt points
registered are granted rights to practise within the hat statutory requirements and guidelines
W
organisation contingent at all times upon the health did the organisation consult in developing
professional maintaining appropriate registrations its policy / by-laws governing credentialing,
defining the scope of clinical practice and the
identification of the extent to which, and to whom,
introduction of new interventions?
the organisation will disseminate information about
each health professional’s authorised scope of hat oversight does the governing body have
W
clinical practice of the credentialing, scope of practice and
introduction of new interventions decisions?
that a health professional’s right to practise within
the organisation will be concluded, terminated or
suspended on conclusion, termination or
suspension of the health professional’s
appointment to the organisation
March 2016 343

Suggested reading
The following evidence may help to The Australian Commission on Safety and Quality in Health
address criterion 3.1.3 Care. Review by Peers - A guide for professional, clinical
and administrative processes. Available from: http://www.
vidence of compliance with policies on
E
safetyandquality.gov.au/wp-content/uploads/2012/01/37358-
credentialing processes, introduction of new Review-by-Peers1.pdf 2 Viewed 8 March 2016.
interventions, etc.
The Australian Commission on Safety and Quality in Health
ata on annual registration checks,
D Care. Standard for Credentialing and Defining the Scope of
including authentication and expiry date of Clinical Practice: a national standard for credentialing and
licences / registrations defining the scope of clinical practice of medical practitioners,
for use in public and private hospitals. Available from: http://
By-laws that include credentialing committees www.safetyandquality.gov.au/wp-content/uploads/2012/01/
inutes of medical advisory council
M credentl1.pdf Viewed 8 March 2016.
(MAC) meetings The Royal Australasian College of Medical Administrators.
RACMA Guide to Practical Credentialing and Scope of
redentialing policy and procedures, including
C Practice Processes. 2015. Available from: http://www.racma.
the credentialing application and the monitoring edu.au/ Viewed 8 March 2016.
and review process that comply with relevant
jurisdictional policies Australian Health Practitioner Regulation Agency. Registration.
Available from: http://www.ahpra.gov.au/Registration.aspx
taff lists matching the skills of health
S Viewed 7 April 2016.
professionals against the capabilities of The Australian Commission on Safety and Quality in Health
the organisation Care. National Guidelines for Credentials and Clinical
olicy and procedures for the introduction of
P Privileges. Available from: http://www.safetyandquality.
gov.au/internet/safety/publishing.nsf/Content/
new interventions and treatments that comply
F22384CCE74A9F01CA257483000D845E/$File/guide_cred_
with relevant jurisdictional policies clin_priv.pdf Viewed 9 March 2016.
eports of data (outcomes, adverse events,
R Eric S. Holmboe and Richard E. Hawkins. Practical Guide
incidents of non-compliance, feedback) used To The Evaluation Of Clinical Competence. Mosby Elsevier:
for monitoring the credentialing system and Philadelphia PA, 2008. Available from: http://emmilestones.
actions taken pbworks.com/w/file/fetch/61182046/Practical%20Guide%20
to%20Evaluation%20of%20Clinical%20Competence.pdf
eports of reviews of the introduction of new
R Viewed 9 March 2016.
interventions and treatments including data on
outcomes, adverse events, feedback, costs, etc.
March 2016 345
Implementation
Criterion 3.1.4 a) Policy / guidelines addressing the a) The organisation reviews its
management of external service arrangements with its external
External service providers are
providers are consistent with service providers according to a
managed to maximise safe, high
relevant legislation, standards, pre-determined schedule.
quality care and services.
guidelines and/or codes
b) External service providers can
of practice.
demonstrate compliance with
b) There are documented relevant regulatory requirements.
agreements with all external
c) The level of performance
service providers that include
demonstrated by external service
performance measures.
providers meets the standards
c) Arrangements with external service specified by the organisation.
providers include agreed dispute
d) External service providers supply
resolution mechanisms.
evidence of evaluation of the
services that they are providing to
the organisation either directly or
through a third party.
Overview This criterion requires healthcare

This criterion requires external service providers to organisations to:
be managed effectively, so that they provide care nsure selection and management of external service
E
and services that are safe and of the highest providers is in accordance with policy.
achievable quality.
ave documented agreements for the provision of
H
goods and services by external service providers.
Relationships of 3.1.4 with other criteria
nsure external service providers comply with relevant
E
The organisation may arrange for certain areas of
standards and regulatory legislation.
operation to be supplied or managed by external service
providers. Outsourcing of services is an aspect of the Evaluate the performance of external service providers.
organisation’s workforce planning (Criterion 2.2.1).
It is likely that many of the functions performed by Documented agreements
external service providers will fall within the scope of External service providers may supply regular, periodic
other criteria - for example, laundry services (Criterion or one-off services to both clinical and non-clinical areas
1.5.2), food preparation and delivery (Criterion 1.5.7), of the healthcare organisation. Outsourced services,
equipment installation and maintenance (Criterion including contracted services, may be governed by
3.2.2), waste management (Criterion 3.2.3) and security decisions and policy from a higher level, such as a head
(Criterion 3.2.5). It is the responsibility of the organisation office or jurisdictional authority.
to ensure both the standard of the services provided,
and that any contracted personnel are given all To ensure standards of quality and integrity, senior
necessary orientation and safety training (Criterion 3.2.4). managers must guarantee that probity requirements
The use of external service providers is a risk that must are met and understand the structures that support
be managed (Criterion 2.1.2) in order to avoid incidents decision making in relation to service provision to
(Criterion 2.1.3) and complaints (Criterion 2.1.4). facilitate compliance. For example, in most public and
private sector organisations there will be an identified
expenditure above which services will be tendered.
a) T
he organisation’s management a) The organisation shows distinction a) The organisation demonstrates it
of its external service providers is in its management of external is a leader in the management of
evaluated, and improvements are service providers. external service providers.
made as required.
b) A
greements with external
service providers are reviewed,
as required.
c) The organisation evaluates
the performance of external
service providers through agreed
performance measures, including
clinical outcomes and financial
performance where appropriate,
as required.
Organisations should: • include measures and timelines against expectations

of service provision, such as turnaround times,
implement procurement policies and guidelines on the
feedback survey information and counts of
management of external service providers
services provided
ave a delegation manual that nominates staff with
h
aintain lists of preferred suppliers for
m
the delegated authority to select suppliers of
specific projects
specific services
ocument the process for the selection of preferred
d
nsure policies reflect jurisdictional legislation and any
e
suppliers and a process to review the outcome of the
belief systems, structural frameworks, financial drivers
service provided.
or other goals that will guide service provision for
the business
gree upon a process to determine which contracts
a
need legal oversight during their preparation, due to
high value or risk
rovide templates for service agreements where
p
appropriate, including memoranda of understanding,
formal contracts and service agreements,
which should:
• abide by jurisdictional legislation
• ensure quality maintenance of the service
• include the level of service expected and the
evidence of compliance with that service’s regulatory
or industry standards required
March 2016 347

Criterion 3.1.4 Organisations should:

External service providers are managed to check and record details of subcontractor credentials
maximise safe, high quality care and services. e clear about the expectations upon staff operating
b
(continued) on the organisation’s premises, such as security
guards, cleaners and agency nurses
Prompt points learly define responsibilities regarding access to

c
organisational facilities and the provision of work-
Is there policy / by-laws covering the related equipment
appointment and management of external
service providers? larify the role of the contractor, for example with
c
respect to security guards, who may be asked to
ow does the organisation manage local
H restrain aggressive or mentally unstable patients. In
service suppliers appointed through centralised many jurisdictions, security guards are licensed, and
tendering processes? different classes of guard may require specific training
oes the organisation maintain a register of
D and expertise
external service providers? How is this retain details of evidence that their suppliers fulfill
cross-referenced with contracts or licensing and quality standards in the jurisdiction(s) in
service agreements? which the organisation operates, such as ‘Working
hat process determines KPIs for contracts?
W with Children’ and police checks. In the case of long-
How are they monitored by the governing body? term contracts, this evidence should be rechecked
according to a predetermined timeframe.
Is there a system to track agreements with
external service providers, including those
negotiated by head or regional offices or Prompt points
by networks? Does the system alert the
organisation to agreements / contracts that In what areas is compliance with
have reached term or time for review? standards or retention of accreditation a
condition for appointment or a performance
ow is performance of external service
H measure on service providers’ contracts?
suppliers managed?
Is performance against agreed performance
hat dispute resolution mechanisms are in
W measures reviewed before contracts for service
place for the organisation? Has the process and provision are renewed or at predetermined times
names of contact persons been communicated in long-term agreements? How is this information
to service suppliers in the terms of the communicated to the governing body?
agreement or in other correspondence?
hat action is taken when performance fails to
W
meet performance measures?
Standards and regulatory
legislation compliance
Evaluation of services provided
A number of legislated requirements regulate the
Evaluation and monitoring of supplier performance may
provision of certain services to protect public health
relate to price, service and/or quality, and the measures
and safety. When commissioning service providers,
organisations must ensure that they are approved to for evaluation should be decided in advance and
provide the commissioned service. recorded in the contracted agreement.
It is worthwhile to investigate how industries that Monitoring may include sending an appropriately
supply services are regulated. This will assist in asking qualified person to check the satisfactory completion of
key questions that may expose operators moving into a trades job, or regular audits for quality and accuracy of
areas of limited expertise, who may be overstating their services or timeliness, as may be more appropriate for
capabilities or competence. Many professions have ongoing suppliers of food, laundry or pathology services.
registration and certification processes.
Some contracted service providers may be expected to
supply details of their tasks and workloads, particularly The following evidence may help to
where fees vary with the volume of work. For example, address criterion 3.1.4
waste disposal services may report on volumes of
different classes of waste and any aberrant separation of olicies relating to external service providers,
P
classes of waste. Pathology services might list services including organisational information on service
by type, with cost and volume. provision by service providers contracted
through centralised processes
ontracts with external service providers
C
onitor the service received and have channels by
m that include detailed task information and
which staff can feed back any concerns performance measures
record feedback from staff, consumer / patients and dministrative systems (or spreadsheets /
A
visitors regarding service provision, and address databases) for coordinating the management of
issues individually as appropriate external service providers and staff who manage
retain feedback information for cumulative review these systems
against the agreed standards for supply of the service Tender documents and advertising of tender
se performance measures to monitor the service
u eview meetings with subcontracted services -
R
provided. These may be simple or complex, but meeting records or correspondence
should be specific, measurable, achievable and
relevant. Examples include: elevant questions on consumer / patient
R
feedback survey forms and outcomes of surveys
• turnaround times for recruitment advertising,
haematology samples or imaging udits of cleaning, or other specified
A
performance markers such as infection control
• feedback forms for education services or Employee
Assistance Programs ocuments demonstrating the handling of
D
complaints about subcontracted services
• staff survey and/or complaints for
security performance
• timeliness and numbers moved for transport services
Suggested reading
PricewaterhouseCoopers. Supplier Risk Management Study
• according to a specific standard for infection control 2013. Available from: http://www.pwc.com.au/assurance/
• consumer / patient surveys and complaints for food assets/supplier-risk-management-study-27nov13.pdf Viewed
and food service. 7 April 2016.
Deloite Access Economics Pty Ltd. Economic benefits of
better procurement practices. Available from: http://www.
Prompt points consultaustralia.com.au/docs/default-source/infrastructure/
better-procurement/dae---consult-australia-final-report-
ow is compliance with external standards
H 050215---96-pages.pdf Viewed 7 April 2016.
and any other performance measures stated
National Association of Testing Authorities, Australia. NATA
on contracts checked and maintained?
procedures for accreditation. Published December 2015.
ow are a supplier’s reported service levels and
H Available from: http://www.nata.com.au/nata/phocadownload/
costings cross-checked / audited? publications/Guidance_information/NATA-Procedures-for-
Accreditation.pdf Viewed 4 March 2016.
ow does the organisation use education,
H
Australian Institute of Family Studies / Australian Government.
incentives and/or hold providers to account, to
Pre-employment screening: Working with Children Checks
improve the quality / value of service received
and Police Checks. Available from: https://aifs.gov.au/cfca/
from external suppliers? publications/pre-employment-screening-working-children-
ow is performance measured and reported to
H checks-and-police-checks Viewed 7 April 2016.
the senior management team?
March 2016 349

Implementation
Criterion 3.1.5 a) Development of corporate and a) Policies and procedures for all key
clinical policies and procedures functions of the organisation are:
Documented corporate and clinical
references relevant:
policies and procedures assist the (i) documented
organisation to provide safe, high (i) legislation
(ii) risk-rated
quality care and services.
(ii) standards
(iii) authorised
This is a mandatory criterion
(iii) professional guidelines
(iv) implemented
(iv) codes of practice
(v) regularly reviewed.
(v) codes of ethics
b) A system is implemented that:
(vi) by-laws
(i) a
udits compliance with relevant
(vii) evidence legislation / regulations
(viii) current issues (ii) informs relevant staff of new or
amended legislation / regulations
(ix) operating and management
requirements. (iii) familiarises staff with relevant
legislation / regulations
b) There is an organisation-wide
applicable to their area
system for document control.
of responsibility.
c) There is a process to update policies
c) T
here is a process for the
and procedures when there are
rescinding of superseded
changes to practice and services in
policies and the distribution and
clinical and non-clinical areas.
implementation of reviewed
d) Relevant stakeholders including staff policies and procedures.
and consumers are involved in the
development of new and revised
local policy and procedures.

Policy, by-laws, guidelines and procedures represent the Corporate and clinical policies and procedures form
translation of legislation, relevant standards, and codes the infrastructure within which the organisation
of practice and ethics into a framework that allows the meets its obligation to provide safe, high quality
organisation to meet its obligations to the community care. Consequently, this guideline should be read in
it serves. conjunction with all other criteria.
This criterion ensures that the organisation is guided by
well-constructed and effective policy; that managers,
staff, volunteers, consumers / patients and other
stakeholders are informed of policy, by-laws and
guidelines relevant to their roles within the organisation;
and that the practical implementation of policy in the
form of appropriate, best evidence-based procedures
will result in safe, high quality health care.
a) The system for policy and procedure a) The organisation shows a) The organisation demonstrates it
development and implementation distinction in its development and is a leader in the development and
is evaluated, and improvements are management of corporate and management of corporate and
made as required. clinical policies and procedures. clinical policies and procedures.
b) C
ompliance with policies and
procedures is monitored and
made as required.
c) The system for ensuring
implementation of, and compliance
with, key or amended legislative
requirements is evaluated,
as required.
d) The system for the management
of revised policies and procedures
is evaluated, and improvements
This criterion requires healthcare Organisational policy and procedures

organisations to: Policy is a documented statement shaped by legislative
ave policies and procedures that address the range
H requirements that formalises the approach to tasks
of their operations. and concepts, and which is consistent with
organisational objectives.
Have a system to develop and review policies.
By-laws are rules, regulations and/or legislation adopted
nsure dissemination, implementation and compliance
E by the organisation for the regulation of both its internal
with policies. and external affairs.
Have a document control system. Guidelines are principles that guide or direct action.
Procedures are a set of documented instructions
conveying the approved and recommended steps for a
particular act or sequence of acts.
March 2016 351

Criterion 3.1.5 Clinical policies may include (but are not limited to):
Documented corporate and clinical policies admissions
and procedures assist the organisation to discharge of consumers / patients
provide safe, high quality care and services.
clinical handover
(continued)
infection control
Within the healthcare system, all organisations will
prevention and management of iatrogenic wounds
have policies to which they adhere, and which guide
operation at both the corporate and the clinical level. prevention and management of falls
Policies usually: blood and blood component / product management
arise from overriding legal obligations management of specific diseases
utline general courses of action designed to achieve
o medication management
a set of stated outcomes
orrect consumer / patient, correct procedure,
c
include specific references to their authority and a correct site
statement as to who is bound by them
consent
cover a significant aspect of the organisation’s operation.
end-of-life decision making
Corporate policies may include (but are not limited to): mortality management.
appointment of senior staff
delegation
onsider whether jurisdictional health department
c
credentialing / scope of practice issued policies are relevant to the size and nature of
the organisation and if these policies are integrated
into the framework of operation
committee structures
onsider the need to draft their own policies directly
c
reporting and outcomes from jurisdictional directives and according to the
requirements of their by-laws, operating requirements
disciplinary action
and/or management requirements, particularly for
recruitment and retention private hospitals and other independent organisations
advertising nsure the translation of jurisdictional policy to
e
secondary employment organisational policy complies with how stated
outcomes are to be achieved
information management
reference relevant standards, professional codes of
privacy and confidentiality practice, codes of ethics and other guidelines in
conflict of interest their policies
declaration of private interests demonstrate compliance through evaluation processes.
acceptance of gifts and benefits

Code of Conduct
workplace health and safety
security.
re shaped to the various areas in which they
a
Prompt points are intended for use (wards, operating theatres,
examination rooms, radiological services, sterilisation
or what aspects of the organisation’s
F
units, pharmacies, etc.)
operation do corporate policies exist? What
clinical policies exist? re intended for application specifically within the
a
geography of the individual organisation; although
hat non-legislative documents are referenced
W
their content will to an extent necessarily apply to all
within the organisation’s policies?
similar organisations.
hich of the organisation’s policies make
W
reference to evidence-based practice? Policies and procedures should be reviewed on a regular
basis. This process should also incorporate a review
of the framework via which policies are developed and
Development and review of policies implemented, and improvements made to the systems,
and procedures the delegation of responsibility and/or the management
of policy development as required. All active policies and
A framework for developing policies will ensure that they procedures should reflect current legislation, standards
are consistent across the organisation and that all of the and evidence; and all changes that are made to existing
essential elements are included, such as the aim, the policies and procedures and the reasons for them
expected outcome(s), the references and evidence used should be thoroughly documented.
to develop the policy, how and when the outcomes are
to be monitored, reviewed and updated. The organisation should be able to demonstrate:
The organisation must have: the system(s) by which it obtains the most current
information about legislation, standards and evidence
s ystems in place to incorporate legislation into all
everyday practices, to ensure that all aspects of those how it responds to this information
practices are up-to-date how this response is documented.
elegation and division of responsibility within an
d
overarching framework to make use of specialised
expertise and knowledge Prompt points
clearly defined authority for the finalising and/or
a ow does the organisation ensure that its
H
updating of policies, and the individual(s) responsible policies and procedures are based upon the
identified within documentation. most current information?
ow does the organisation involve staff in the
H
Relevant staff may assist in the writing of procedures, development of policies and procedures? What
as those individuals who must follow the procedures other stakeholders are involved?
issued have the most accurate knowledge of their
required scope, the means by which they may be ow often does the organisation review its
H
best implemented and knowledge of any practical policies and procedures?
issues affecting their implementation. At the least, staff
members should be consulted regarding the drafting
and updating of procedures, and their feedback
incorporated where appropriate.
Procedures:
represent the practical implementation of policy,
and may incorporate guidelines, pathways and/or
Standard Operating Procedures / Safe Work Practices
March 2016 353

Criterion 3.1.5
Documented corporate and clinical policies Prompt points
and procedures assist the organisation to ow does the organisation ensure that its
H
provide safe, high quality care and services. staff are aware of their legal responsibilities
(continued) with respect to policies and procedures?
ow are procedures implemented? How does
H
Dissemination, implementation the organisation monitor compliance with
and compliance procedures? How does the organisation deal
with identified instances of non-compliance?
It is essential that staff at all levels understand their
responsibilities with respect to implementation of, and
compliance with, policies and procedures. This can Document control
be assisted by an explanation of the framework under
which policies and procedures are developed and The organisation’s policies and procedures must
reviewed being included in orientation for new staff, as be managed via a system of document control -
well as regular education ‘refresher’ sessions targeted including policy and procedures for the preparation,
at particular staff, to facilitate understanding of the dissemination, implementation and rescinding of policy
relevant legislation and compliance on the part of those and procedures.
individuals operating within their scope. There are various ways in which this may be done,
Organisations should: and the form and the scope of the process will vary
according to the size and complexity of the facility. It
nsure that the organisation’s policies are read
e is imperative that the most current documentation is
by relevant staff and that a sufficient level of circulated and implemented and all superseded versions
understanding is attained, so that the reasoning are withdrawn and archived.
behind the development of procedures is clear and
correct implementation thus facilitated Document control systems require:
ave systems to disseminate information when new
h monitoring system for important documents as they
a
legislation is enacted or amendments made to existing evolve through a series of drafts
legislation / standards / codes / guidelines, to make v ersion control on documents emailed outside the
certain that staff are aware of their legal responsibilities organisation for comment or editing
and all active procedures are in accordance with the
most current information each document to have a unique identification
nsure that all changes made to procedures are

e documents to show dates of issue and review.
reflected in the altered conduct of staff
review the means by which material is disseminated, Prompt points
to ensure that all necessary information reaches all
relevant staff in a timely manner, and make changes hat system of document control does the
W
when required organisation employ? Who is in charge of it?
ave audit systems in place to monitor compliance

h ow does it ensure that the most current
H
with policies and procedures policies and procedures are available?
analyse the reasons for the non-compliance hat is the process for withdrawing earlier
W
versions of documents?
regularly review the means by which compliance
is audited, to make certain that the most effective In what format(s) are earlier versions of policies
processes for monitoring and improvement are and procedures stored?
in place.
The following evidence may help to
Framework for the development of policies
Corporate and clinical policies
Schedule for review of policies and procedures
ystems for identification and dissemination
S
of information on new or amended legislation,
standards, codes of practice, guidelines, etc.
rocesses for incorporating legislation,
P
standards, codes of practice, guidelines, etc.,
into policies
n example of the revision of existing policies /
A
procedures due to new information
valuation of compliance with policies
E
and procedures
ystems for retrieving superseded
S
policies / procedures
Standards
AS/NZS ISO 31000:2009 Risk management - principles
and guidelines.
ISO 19600:2014 Compliance management
systems - Guidelines.
Suggested reading
Australian Government. National Archives of Australia.
Information on policies, procedures and guidelines. Available
from: http://www.naa.gov.au/records-management/strategic-
information/linking/policies.aspx Viewed 4 March 2016.
Independent Commission on Corruption. Policy Development
Guide and Checklist. Available from: https://www.icac.nsw.gov.
au/documents/preventing-corruption/3158-policy-development-
guide-and-checklist/file Viewed on 4 March 2016.
Network of Alcohol and other Drugs Agencies (NADA). NADA
Policy Toolkit. Available from: http://www.nada.org.au/
resources/nadapublications/resourcestoolkits/nada-policy-
toolkit/ Viewed 4 March 2016.
March 2016 355

3.2 Safe Practice and Environment Standard There are five criteria in this standard. They are:
The standard is: Safety management systems ensure the
3.2.1
The organisation maintains a safe environment for safety and wellbeing of consumers / patients,
employees, consumers / patients and visitors. staff, visitors and contractors.
The intent of this standard is to ensure that the healthcare 3.2.2 A
ssets, goods and general services are
environment is safe and healthcare providers work in a managed safely and used efficiently and effectively.
safe manner. Safe Practice and Environment criteria all Waste and environmental management
3.2.3
require the systematic application of risk management supports safe practice and a safe and
principles to determine priorities and eliminate risks or sustainable environment.
implement controls.
Emergency and disaster management
3.2.4
supports safe practice and a safe environment.
Security management supports safe practice
3.2.5
and a safe environment.
March 2016 357

Standard 3.2: The organisation maintains a safe environment for
employees, consumers / patients and visitors.
Implementation
Criterion 3.2.1 a) P
olicy / guidelines addressing a) There is an organisation-wide system to identify,
safety management are consistent assess and document:
Safety
with relevant legislation, standards, (i) h ealth and safety risks / hazards
management
guidelines and/or codes of practice,
systems ensure (ii) r isks associated with manual tasks in both
and include:
the safety and clinical and non-clinical areas
wellbeing of (i) workplace health and safety (iii) s afe work practices / safety rules for all
consumers / (ii) workers compensation relevant procedures and tasks
patients, staff,
(iii) the suitability of the (iv) p rocesses to eliminate risks or
visitors and
physical environment implement controls.
contractors.
(iv) manual tasks b) Safe work practices / safety rules address the
This is a physical and environmental conditions under
mandatory (v) radiation and laser safety which work is carried out.
criterion (vi) management of dangerous goods c) Staff are involved in decisions that affect
and hazardous substances workplace health and safety and wellbeing.
(vii) other identified high-risk practices. d) Staff are trained in correct work practices to
b) Service planning includes health minimise the risk of injury.
and safety together with injury e) Staff with formal workplace health and safety
prevention strategies. responsibilities are appropriately trained.
c) S
taff are provided with orientation f) There is an injury prevention and management
and ongoing education in workplace program that reflects relevant legislation.
health and safety and their g) Procedures for the handling and use of dangerous
responsibilities. goods and hazardous substances address:
d) External service providers are (i) availability of Safety Data Sheets
supplied with relevant information and (ii) p ersonal protective equipment (PPE)
comply with the organisation’s health
(iii) the environment in which dangerous goods
and safety requirements.
and hazardous substances are to be stored
e) W
orkplace health and safety and used
requirements are communicated to (iv) the limits of occupational exposure.
carers and visitors as required.
h) There is a radiation safety management
f) There are processes for the plan which:
procurement, storage, management
(i) is coordinated with external authorities
and disposal of dangerous goods and
hazardous substances. (ii) includes a personal radiation monitoring
system and all relevant room monitoring
g) A register of all dangerous goods and
hazardous substances, and for the (iii) e nsures consumer / patient radiation is kept
disposal of all hazardous waste, to a minimum while maintaining good
is maintained. diagnostic quality
(iv) ensures staff exposure to radiation is kept as
h) A register of all radioactive
low as reasonably achievable (ALARA)
substances, and for the disposal of
all radioactive waste and radiation (v) e nsures a radiation safety report is provided to
equipment, is maintained. the ethics committee on any research project
involving irradiation of human subjects.
a) T
he safety management system is a) The organisation shows distinction a) The organisation demonstrates it
evaluated, and improvements are in safety management. is a leader in safety management
made as required. systems.
b) C
ompliance with policies
addressing safety management
as required.
c) The design and layout of the
organisation’s current or planned
physical environment are evaluated
to ensure that they are appropriate
for the tasks being conducted and
that all necessary safety measures
are developed and implemented.
d) The injury prevention and
management system is evaluated,
as required.
e) The ability of the workforce to
perform its functions safely is
evaluated in consultation with
relevant staff, and improvements
f) Education and training in
workplace health and safety are
evaluated with staff consultation,
as required.
March 2016 359

Criterion 3.2.1 nsure that safety management is addressed during

E
Safety management systems ensure the safety orientation and ongoing staff education, and that staff
and wellbeing of consumers / patients, staff, with specific responsibilities for safety management
receive appropriate training.
visitors and contractors. (continued)
ppropriately communicate safety requirements to
A
Overview contractors and visitors.
The organisation has an overriding responsibility to Safety management

create and maintain an environment that ensures
the safety of consumers / patients, staff, visitors and The organisation should implement a comprehensive
contractors, and facilitates the delivery of safe, high and integrated safety management system that
quality care and services. This criterion requires the mitigates and manages the risk associated with care
organisation to mitigate and manage the risk associated and service delivery and the healthcare environment.
with the healthcare environment via an organisation-wide The system should create a framework for the safe
safety management system, supported by appropriate conduct of work, both clinical and non-clinical, and
education and training. include processes to protect consumers / patients, staff,
contractors and other visitors to the organisation. The
Relationships of 3.2.1 with other criteria system should be developed with staff consultation, to
ensure the identification of risks associated with specific
Organisational systems and personal responsibilities tasks and develop safe work processes to prevent injury,
for workplace safety should be addressed during staff and supported by appropriate education and training.
orientation (Criterion 2.2.2) and training (Criterion 2.2.3). Effective safety management will consider specific
The design of the facility (Criterion 3.2.2) will impact organisational circumstances, and include strategies to
upon specific safety issues, such as falls risk (Criterion manage identified high-risk tasks.
1.5.4). To ensure safe management systems, staff
levels need to be commensurate with the workload Safety management systems should:
(Criterion 2.2.1). consider the organisation’s:
Safety management systems will operate within the • location and function
organisation’s risk management framework (Criterion
2.1.2), and should be integrated with the organisation’s • design and layout
security management (Criterion 3.2.5) and staff support • consumer / patient cohort
systems (Criterion 2.2.5). Failure to implement a
comprehensive system of safety management may • identified health and safety risks
lead to incidents (Criterion 2.1.3) and complaints reflect all relevant legislation, standards, guidelines,
(Criterion 2.1.4). and codes of practice
e supported by policy and procedures that
b
This criterion requires healthcare define responsibility and accountability for safety
organisations to: management, and which address high-risk tasks
Implement an organisation-wide safety management and associated safety measures, and other issues
system to create and maintain a safe environment impacting safety within the organisation, including (but
and mitigate and manage risk in both clinical and not limited to):
non-clinical areas, which is developed with • injury prevention and management strategies
staff consultation.
• manual tasks
itigate the risk associated with specific tasks and
M
actions, including through processes that include • dangerous goods and hazardous substances
injury prevention strategies. • radiation and laser safety
• needlestick injury and bodily fluid exposure
• provision of protective clothing and equipment
• violence and aggression Workplace health and safety
• falls risk ‘Workplace health and safety’ is an umbrella term
• electrical safety to refer to the day-to-day management of safety in
the work environment; ‘work health and safety’ or
• noise control ‘occupational health and safety’ are other terms which
• smoking may be used. Workplace health and safety requires
the management and monitoring of staff to ensure that
• ergonomics tasks are performed safely, with correct use of general
• staff immunisation equipment and personal protective equipment. It also
requires the identification of specific high-risk tasks
• off-site attendance to consumers / patients associated with health care, and the implementation of
e linked to the organisation’s risk management system
b processes to mitigate and manage those risks, including
and specifically the incident management system the provision of appropriate education and training.
Though all effort should be made to prevent injury in
be developed with staff consultation the workplace, the organisation’s workplace health and
nsure that service planning addresses health, safety
e safety management should include appropriate injury
and injury prevention management and return-to-work processes.
respond to risk assessment, and include processes to Workplace health and safety management should:
eliminate risks or implement controls e overseen by a committee or, in smaller
b
include orientation, education and relevant training organisations, an appropriately trained individual who
for staff reports to a relevant committee / governance body
se audits and ongoing education to ensure that staff
u include processes for injury prevention and
comply with organisational policy, procedures and management, and the return to work of injured staff
safe work practices. members, which are in accordance with relevant
legislation and/or jurisdictional guidelines
implement processes to mitigate the risk associated
Prompt points with tasks and behaviours required in the delivery of
hat legislation, standards, and guidelines
W care and services, including (but not limited to):
are referenced in the organisation’s safety • manual tasks
management policy and procedures?
• management of dangerous goods and
hat circumstances unique to the organisation
W hazardous substances
(location, size, consumer / patient cohort, etc.)
have been identified as impacting safety? • use of radiation and lasers
How have these been addressed in include processes for communication with staff regarding
safety management? workplace health and safety, and the gathering of
ow does the organisation consult with staff in
H feedback regarding health and safety issues.
developing its safety management system?
Injury prevention and management, and return to
oes the organisation employ staff specifically
D work should:
to manage safety? If not, who is responsible for
the practical implementation and monitoring of reflect the requirements of relevant legislation and
safety management? jurisdictional standards and guidelines
ow does the organisation monitor staff

H e an aspect of the organisation’s safety
b
compliance with policy, procedures and management, with respect to:
guidelines? What is the organisational response • risk identification and mitigation
to an identified instance of non-compliance?
• implementation of safe work practices
• staff training
March 2016 361

Criterion 3.2.1 include processes for the safe procurement, storage,

Safety management systems ensure the safety management and disposal of dangerous goods and
and wellbeing of consumers / patients, staff, hazardous substances
visitors and contractors. (continued) include the maintenance of registers of dangerous
goods and hazardous substances
facilitate access of injured staff to remedial health care ensure the installation of appropriate signage
include processes for return to work that address the nsure the provision of all necessary personal
e
physical capacity of the staff member protective equipment, and other relevant equipment
ensure that staff: nsure that staff have access to Safety Data Sheets
e
• are informed of aspects of the organisation’s and other relevant resources
injury prevention and management and return-to- include processes for managing a related emergency,
work processes such as a spill or an accidental exposure
• have access to all relevant resources / documents onitor compliance with safe practice requirements,
m
• understand what action to take in the event of and take remedial action where required.
an injury.
Radiation and laser management should:
Manual task management should: e subject to a radiation and laser safety plan, and
b
reflect relevant legislation, jurisdictional standards and reflect relevant legislation, jurisdictional standards and
guidelines and/or other relevant guidelines guidelines and/or other relevant guidelines
ddress the various actions that may pose a manual
a e overseen by a radiation safety officer or radiation
b
task risk, including (but not limited to): safety committee
• lifting, pushing, pulling, carrying, moving, holding or implement processes to mitigate and manage the
restraining any person, animal or object specific risks associated with radiation, including (but
not limited to) with respect to:
• performing repetitious tasks
• room shielding
• being subject to vibration
• exposure control
nsure that risk assessments are conducted for all
e
manual tasks, eliminating risks where possible, and • personal monitoring
mitigating any remaining risk via appropriate strategies • health surveillance, with records kept for the period
including (but not limited to): stated in any relevant legislation
• the use of appropriate equipment • licensing checks conducted by the
• staff education and training, to ensure safe practice appropriate authorities
• ergonomic redesign • evidence of appropriate professional qualifications or
industry approved training courses
• task sharing, or other approaches to reduce
individual risk • registration and compliance testing of x-ray
apparatus as required by the relevant authorities
onitor compliance with safe practice requirements,
m
and take remedial action where required. • storage and disposal of radioactive substances
• signage with relevant information, labelling and
Dangerous goods and hazardous substances
identification, including any information from
management should:
the provider
reflect relevant legislation, jurisdictional standards and
• safe handling and use of radioactive substances,
guidelines and/or other relevant guidelines
including emergency procedures in case of spillage
ensure the installation of appropriate signage Information, education and training
nsure the provision of all necessary personal
e The organisation has a wide-ranging responsibility
protective equipment, and other relevant equipment not only to manage safety, but to communicate
relevant health and safety information appropriate for
onitor compliance with safe practice requirements,
m
everyone accessing the organisation. This includes
and take remedial action where required.
communicating to carers and other visitors all relevant
workplace health and safety requirements, and ensuring
that contractors comply with both general safety
Prompt points
requirements and those applying to their specific reason
ho is responsible for overseeing the
W for access.
organisation’s workplace health and safety?
Safety management and personal responsibility should
hat high-risk tasks / activities are subject to
W be an aspect of orientation and ongoing staff education.
the organisation’s workplace health and safety Each member of staff should understand general
management? aspects of safety management, and those which apply
to their specific role(s). On a day-to-day basis, staff
ow does the organisation ensure that staff are
H
should have ready access to all relevant guidelines and
aware of the steps to take in the event of an
other resources to support safe practice and reduce
injury? How does the organisation manage the
risk, both to consumers / patients and themselves. The
return to work of an injured staff member?
content of staff education should be regularly reviewed
hat action has the organisation taken
W to ensure that it reflects current best-practice.
to reduce the risk associated with manual
Staff training should also be general and specific, as
tasks? How does the organisation ensure
required. For example, all staff should understand
that it provides a working environment that is
safe practice in respect to general risk such as that
ergonomically safe?
associated with manual tasks; while staff working with
oes the organisation use radiation and/or lasers?
D radiation and/or lasers will require specific safety training.
What legislation and standards are reflected in its Furthermore, the organisation must ensure that staff
relevant policy and procedures? Who oversees members with responsibility for managing or overseeing
the safe use of radiation and/or lasers? workplace health and safety are given all necessary
H training, and have access to appropriate resources.
dangerous goods and hazardous substances Visitors and contractors should:
are stored safely? How are Safety Data Sheets
e informed of all general health and safety issues
b
and other relevant resources made accessible
which may affect them due to their access of
to staff?
the organisation
H
be encouraged to ask questions, to assist understanding
contractors, including contracted health
professionals and external service providers, e informed of any specific issues relevant to their
b
are aware of aspects of workplace health and situation, for example:
safety that apply to their activities, and comply
• visitors may be required to practice hand hygiene, or
with organisational safety requirements?
be made aware of falls risks
• contractors are required to comply with all safe
practices associated with their activities within the
organisation, for example, collection of radioactive
waste should be compliant with legislation, policy
and/or guidelines, and according to the terms of the
external provider’s contract.
March 2016 363

Criterion 3.2.1
Safety management systems ensure the safety The following evidence may help to
and wellbeing of consumers / patients, staff, address criterion 3.2.1
visitors and contractors. (continued) Safety management plan
rganisational risk register, with rating of
O
Staff should:
environmental / practice risks and
e informed at orientation of the organisation’s safety
b mitigation strategies
management system and its processes for workplace
vidence of staff consultation in safety
E
health and safety
planning / management
receive ongoing education in safety management, the
Completed training records
content of which is regularly updated to reflect current
information and best-practice Radiation safety plan
ave ready access to all relevant guidelines and
h Appropriate personal protective equipment
related resources
Relevant signage
be trained in safe practices relevant to their role(s)
vailability of Safety Data Sheets and
A
hen responsible for management and/or oversight
w other resources
of safety management, or any aspect of workplace
ommittee meeting minutes addressing
C
health and safety, be given all necessary training and
safety issues
access to appropriate resources.
Standards
Prompt points
AS/NZS 4173:2004
H Guide to the safe use of lasers in health care.
visitors and contractors understand safety
requirements? How does the organisation AS/NZS 4801:2001
respond to identified non-compliance by Occupational health and safety management systems -
a contractor? Specification with guidance for use.
ow does the organisation ensure that staff

H AS/NZS 4804:2001
receive training in safe practices relevant to Occupational health and safety management systems
their role(s)? How does the organisation - General guidelines on principles, systems and
support staff with responsibility for safety supporting techniques.
management / oversight? AS 1885.1-1990
ow often does the organisation review and
H Measurement of occupational health and safety
update its safety education program? Who is performance - Describing and reporting occupational
responsible for ensuring the currency of the injuries and disease (known as the National Standard for
information provided? workplace injury and disease recording).
ow does the organisation use the outcomes

H
of investigation into workplace health and safety
incidents in its staff education?
Suggested reading
Safe Work Australia. Hazardous chemicals. Acton ACT;
Safe Work Australia; 2016. Available from: http://www.
safeworkaustralia.gov.au/sites/swa/whs-information/
hazardous-chemicals/pages/hazardous-chemicals-other-
substances Viewed 6 March 2016.
Australian Radiation Protection and Nuclear Safety Agency
(ARPANSA). Code of Practice for Radiation Protection in the
Medical Applications of Ionizing Radiation (2008) (Radiation
Protection Series No. 14). Yallambie VIC; Commonwealth of
Australia; 2015. Available from: http://www.arpansa.gov.au/
Publications/Codes/rps14.cfm Viewed 6 March 2016.
(ARPANSA). Code of Practice for the Exposure of Humans to
Ionizing Radiation for Research Purposes (Radiation Series No.
8). Yallambie VIC; Commonwealth of Australia; 2015. Available
from: http://www.arpansa.gov.au/Publications/Codes/rps8.cfm
Comcare. Managing risks in the workplace. Canberra ACT;
Comcare; 2014. Available from: https://www.comcare.gov.au/
preventing/managing_risks_in_the_workplace
Comcare. Hazardous manual tasks. Canberra ACT; Comcare;
2014. Available from: https://www.comcare.gov.au/
preventing/hazards/physical_hazards/hazardous_manual_tasks
(ARPANSA). Lasers. Yallambie VIC; Commonwealth of
Australia; 2013. Available from: http://www.arpansa.gov.au/
RadiationProtection/Basics/laser.cfm Viewed 6 March 2016.
Victorian Auditor-General’s Office (VAGO). Occupational
health and safety risk in public hospitals. Melbourne VIC;
VAGO; 2013. Available from: http://www.audit.vic.gov.au/
publications/20131128-OHS-in-Hospitals/20131128-OHS-in-
Hospitals.html Viewed 6 March 2016.
Safe Work Australia. Managing the work environment and
facilities: Code of practice. Acton ACT; Safe Work Australia;
2011. Available from: https://www.safework.sa.gov.au/
uploaded_files/CoPManagingWorkEnvironmentFacilities.pdf
Safe Work Australia. How to manage work health and safety
risks: Code of practice. Acton ACT; Safe Work Australia; 2011.
SWA/about/Publications/Documents/633/How_to_Manage_
Work_Health_and_Safety_Risks.pdf Viewed 10 March 2016.
European Agency for Safety and Health at Work. Occupational
health and safety risks in the healthcare sector: Guide
to prevention and good practice. Bilbao SP; EU-OSHA;
2016. Available from: https://osha.europa.eu/en/legislation/
guidelines/occupational-health-and-safety-risks-in-the-
healthcare-sector-guide-to-prevention-and-good-practice
March 2016 365

Implementation
Criterion 3.2.2 a) Policy / guidelines consistent with relevant a) T

here is a system to plan, manage
legislation, standards, guidelines and/or codes and operate / use:
Assets, goods and
of practice address health, safety and service
general services are requirements in the management of: (i) buildings / workplaces
managed safely and
(i) buildings / workplaces (ii) internal road systems
used efficiently
and walkways
and effectively. (ii) internal road systems and walkways
(iii) plant (iii) plant
(iv) medical devices, including loan / (iv) medical devices, including

trial equipment loan / trial equipment
(v) other equipment (v) other equipment
(vi) supplies (vi) supplies
(vii) consumables (vii) consumables.
(viii) workplace design
b) There is a documented, planned
(ix) fire safety. and coordinated preventive
b) Purchase and supply procedures ensure that maintenance system.
products are available or that appropriate c) Relevant staff are trained in the safe
alternatives are supplied. and appropriate use of medical
c) Plant and other equipment are installed devices and other equipment.
and operated in accordance with
manufacturer specifications. d) The organisation ensures the
cleanliness and hygiene of its
d) Plant logs are maintained and are in accordance facilities, including:
with manufacturer requirements.
(i) waiting rooms
e) Medical devices are:
(i) trialed (ii) food preparation areas
(ii) selected (iii) e
ating areas, including cafeterias
and staff lunchrooms
(iii) installed
(iv) operated (iv) toilets
(v) maintained (v) non-clinical waste storage areas.
(vi) repaired e) D
isability and cultural signage
(vii)calibrated when necessary by competent, includes the use of multilingual /
qualified people. international symbols and is
appropriate to the needs of the
f) The organisation provides adequate resources to community and the organisation.
support cleaning and hygiene requirements.
g) Clear, well-located internal and external signage f) The organisation supports staff,
meets the needs of consumers / patients, consumers / patients, carers and
visitors and staff. other visitors in identifying and
reporting incidents and near misses
h) Disability access and facilities meet relating to buildings, roads, walkways,
legislative requirements and/or are based on
plant, medical devices, equipment,
recognised guidelines.
consumables and supplies.
a) T
he safety and accessibility of a) The organisation shows distinction a) The organisation demonstrates it
the buildings / workplaces roads in its management of assets, is a leader in the management of
and walkways, and the safe and goods and general services. assets, goods and general services.
consistent operation of plant and
equipment, are evaluated, and
improvements are made to
reduce risk.
b) M
aintenance and/or replacement
of buildings, roads, walkways,
plant, medical devices and other
equipment is planned, prioritised
and budgeted for.
c) The acquisition, use, maintenance,
storage and appropriate recall
processes for medical devices
are monitored and evaluated,
as required.
d) The quality and reliability of
organisation-wide cleaning and
hygiene practices are evaluated,
as required.
e) The organisation regularly
evaluates whether its signage
meets community needs, and
as required.
March 2016 367

Criterion 3.2.2 This criterion requires healthcare

Assets, goods and general services are organisations to:
managed safely and used efficiently and Implement an organisation-wide system to create and
effectively. (continued) maintain a safe environment and mitigate and manage
risk with respect to:
Overview • buildings / workplaces
In addition to managing the safety of the healthcare • internal road systems and walkways
environment, the organisation is responsible for
managing its assets, goods and general services so • plant
as to create and maintain a safe environment for the • medical devices, including loan / trial equipment
delivery of care and services, and to ensure the safety
and wellbeing of consumers / patients and carers, • other equipment
staff, contractors and other visitors. This criterion • supplies
requires the organisation to implement a comprehensive
management system that supports the safety and • consumables
maintenance of: its buildings; their surrounds, including • workplace design
roads and walkways; plant and other equipment,
including medical devices; and supplies and • fire safety.
consumables; and which addresses workplace design, aintain plant and other equipment, including medical
M
signage and fire safety. devices, via an effective system of cleaning and
preventive maintenance.
Relationships of 3.2.2 with other criteria Ensure the cleanliness and hygiene of its facilities.
The organisation’s management of its assets, goods
nsure ready access of the organisation by all
E
and general services is an aspect of its responsibility to
consumers / patients, carers and other visitors via
ensure the safety of consumers / patients and carers,
appropriate design and signage.
staff, contractors and other visitors (Criterion 3.2.1)
and to manage risk (Criterion 2.1.2). It must reflect the acilitate the reporting of incidents and near misses
F
organisation’s commitment to safe practice and a safe associated with the physical environment by staff,
environment, as per its emergency (Criterion 3.2.4) consumers / patients, carers and other visitors.
and security management (Criterion 3.2.5), while also
providing for those consumers / patients and carers with Planning, design and safety
diverse needs and from diverse backgrounds (Criterion
A healthcare organisation may occupy a building or
1.6.3). The implementation of efficient cleaning practices
buildings that have been purpose-built, or that are
will align with the organisation’s responsibility for waste
refurbished facilities. In either of these circumstances,
and environmental management and providing a safe
planning and design must be compliant with relevant
and sustainable environment (Criterion 3.2.3) and should
legislation, and consider the safety of those accessing
be integrated with its infection control (Criterion 1.5.2).
the facilities for any reason. In many jurisdictions there
The organisation’s management of its medical devices
will be organisations or consortia that specialise in
may be integrated with its management of information
the planning, design, building and refurbishment of
and communication technology (ICT) (Criterion 2.3.4).
healthcare facilities, and in supporting organisations
A failure in the efficiency and/or effectiveness of the
via guidelines that reflect relevant legislation, standards
organisation’s management of its assets, goods and
and codes of practice. When undertaking new
general services may lead to incidents and complaints
construction or the refurbishment of healthcare facilities,
(Criteria 2.1.3 and 2.1.4).
the organisation should ensure that it meets its legal
obligations and its duty of care by planning and design
in which risk reduction and general safety are considered
in tandem with healthcare delivery. Fire safety should
also be addressed, in the placement of emergency exits,
fire doors, and fire equipment.
The organisation may also have responsibility for the • ensure that all plant and other permanent fixtures
design and/or maintenance of roads and walkways are chosen for safety and efficiency, and installed
within its grounds. Walkways should be free of hazards and maintained by qualified individuals and as per
and integrated with the organisation’s arrangements for the manufacturers’ instructions
disabled access, while management of roads should
• ensure that fire safety is addressed at all stages of
consider not only safe vehicular access and movement,
the planning and design process
but the safety of consumers / patients while being
transported and of visitors to the organisation while • consider the ease and effectiveness of
moving through the grounds. Smaller organisations may cleaning and maintenance of the completed and
not themselves be responsible for roads and walkways functioning facilities.
abutting their facilities, but should interact with relevant
local authorities to ensure the safety of their surroundings.
Prompt points
Plant and other permanent fixtures should be installed,
tested, commissioned and maintained in accordance with ere this organisation’s facilities
W
the manufacturers’ specifications, and by appropriately purpose-built? Who was consulted during
qualified individuals. The choice of fixtures should planning and design? How did the organisation
consider safety and ergonomics for both consumers / ensure that the completed facilities met the
patients and staff, as well as general function. requirements of relevant legislation, standards
and guidelines?
The planning and design of healthcare facilities should:
If an existing facility was adapted, what
here facilities are purpose-built, incorporate current
w
measures were taken to ensure that the
best-evidence and meet the requirements of
environment was appropriate to the intended
relevant legislation, standards, guidelines and
function? How was fire safety addressed during
codes of practice
the redesign?
here facilities are refurbished, ensure that the facilities
w
ow did considerations of ergonomics,
H
are fit for the intended purpose, and that the outcome
cleanliness and maintenance influence the
will meet the requirements of relevant legislation,
design and layout of the workplace?
standards, guidelines and codes of practice
H
here appropriate, include the planning and
w
walkways within and in front of its facilities are
management of internal roads, including with
well-maintained and free of hazards?
respect to:
ho is responsible for ensuring road safety
W
• movement of vehicles through the grounds
within the organisation’s grounds?
• speed
• parking
Plant, equipment, medical devices, supplies
• pedestrian safety and consumables
• consumer / patient transport, drop-off and collection The organisation should have processes for ensuring
• ambulance movement and access that its plant and equipment are chosen with
consideration of function, safety, cost and effectiveness,
here appropriate, include the planning and
w and installed, operated and maintained according to the
management of walkways, including with respect to: manufacturers’ instructions. In addition, the organisation
• width should support correct and effective use of equipment
via specialty training for staff where required, and ensure
• trip hazards that equipment, in particular medical devices, are
• disabled access cleaned, maintained and decommissioned by qualified
individuals. The management of mobile medical devices
• transport / movement of consumers / patients is addressed in criterion 2.3.4.
• safety of staff and visitors
March 2016 369

Criterion 3.2.2 Plant and equipment should:

Assets, goods and general services are e chosen according to an assessment process
b
managed safely and used efficiently and that considers:
effectively. (continued) • compliance with relevant legislation, standards,
guidelines and/or codes of practice
In certain circumstances, the organisation’s vehicles may
be considered ‘plant’, and should be subject to similar • intended use, and user and consumer / patient needs
processes for selection, purchase, use, maintenance • cost benefits
and replacement.
• safety, including manual task issues
The term ‘medical device’ applies to all equipment used
in treatment, diagnostic activities, monitoring, and direct • infection control, including waste management issues
consumer / patient care. This includes, but is not limited • energy efficiency and environmental sustainability
to, devices used for:
• training needs
life support: anaesthesia machines, ventilators, heart-
lung machines, etc. • storage and distribution
monitoring: bedside monitors, telemetry monitors, etc. installed, tested and commissioned in accordance
with the manufacturer’s instructions and by
treatment: lasers, electrosurgery, diathermy, etc. appropriately qualified individuals
iagnostics: pathology laboratory analysers, radiology
d aintained and cleaned according to a documented
m
equipment, endoscopes, etc. schedule, with the recording of a plant log
onsumer / patient support: hospital beds, fall injury
c where required
prevention, etc. onitored with respect to electrical shock, thermal,
m
radiant and mechanical hazards
While the health, wellbeing and safety of the consumer /
patient must be the overriding consideration, clinical e subject to documented processes for
b
efficacy and effectiveness, workplace health and safety procurement, upgrading and replacement
issues, infection control, clinical life and cost should also here vehicles are considered ‘plant’, be subject to
w
factor into selection of medical devices. processes for procurement, operation, maintenance
The choice of supplies and consumables may be subject and safety that consider:
to government contract or similar arrangements. Where • government contracts, where relevant
choice is the responsibility of the organisation, quality,
reliability, ease of use and fitness for purpose should be • vehicle operators’ (including volunteers) position
considered, as well as cost. Where appropriate, there descriptions that specify appropriate training
should be consultation with staff. Efficient inventory and licences
practices should ensure the ready availability of supplies • safe transport of consumers / patients
and consumables.
• secure transport of health records, medications,
equipment and/or supplies
• workplace health and safety issues associated with
vehicles, including appropriate seating, access,
storage, and manual task risk
• the reporting of any vehicular accident as
an incident.
Medical devices should:
support consumer / patient health and wellbeing Prompt points
e selected following consultation with relevant health
b hat plant / equipment / vehicles within
W
professionals and other staff the organisation require the operator(s) to be
licensed? How is correct licensing of operators,
e managed via a system that includes all medical
b including drivers of vehicles, monitored?
devices used by the organisation, its health
professionals and its consumers / patients, including or what plant / equipment / vehicles are logs
F
those devices: kept? Who is responsible for updating the logs?
• owned, leased or rented by the organisation hat staff did the organisation consult in
W
choosing its medical devices?
• on short-, medium- or long-term loan to
the organisation ow does the organisation ensure that its
H
medical devices are correctly installed and
• being trialed by the organisation maintained?
• prescribed by the organisation’s staff to ow are staff training needs for the correct use
H
consumers / patients of medical devices assessed?
here appropriate, be integrated with the
w oes the organisation reuse any single-use
D
organisation’s management of information and items? What policies / guidelines address this
communication technology (ICT) situation?
e installed, calibrated, maintained, repaired and
b In the event of the recall of a consumable, what
decommissioned and disposed of by registered is the organisation’s procedure?
and/or properly qualified, trained and
competent individuals
e operated by staff who have received all
b Preventive maintenance and cleaning
necessary training The organisation’s management of its assets, goods
e cleaned, sterilised and/or recommissioned
b and general services should be supported by a well-
separately from the organisation’s general planned and well-resourced system of preventive
cleaning processes. maintenance and cleaning. Maintenance of buildings,
plant and equipment should not be purely reactive:
Supplies and consumables should: the organisation should implement a planned and
coordinated system of preventive maintenance, in order
e managed according to policy and procedures
b to retain all assets in good working order, to extend
that address: the working life of critical and expensive equipment,
• contractual arrangements / procurement and to reduce the risk associated with poorly operating
equipment. All stages of preventive maintenance, from
• reuse of items planning to completion, should be documented.
• recall of items Cleaning is crucial in its own right, as well as a
be available for use via efficient processes for: vital component of the organisation’s infection
control and waste and environmental management
• ordering
systems. It should be staffed and resourced to
• delivery and distribution ensure the cleanliness and hygiene of all areas within
the organisation, non-clinical as well as clinical. A
• storage
documented schedule should describe the frequency of
• inventory control. cleaning and the areas / items to be cleaned; it should
also describe those areas / items not to be subject to
general cleaning (e.g. medical devices).
March 2016 371

Criterion 3.2.2 Access and signage

Assets, goods and general services are The organisation must ensure that its design and layout
managed safely and used efficiently and facilitate access by all consumers / patients and visitors,
effectively. (continued) including those with a disability. Designated routes of
access, facility location(s) and exits should be clearly
Preventive maintenance and cleaning should: indicated, via appropriate external and internal signage.
Word-based signage should use clear, simple and concise
e staffed and resourced to ensure that standards of
b
language, and font appropriate for the elderly or vision-
cleanliness and hygiene are maintained throughout the
impaired; if multiple languages are used, they should
organisation, and that plant and equipment operate
reflect the demographic of the organisation’s community.
safely and efficiently
Braille and/or tactile signs may be used, according to
e planned and carried out to optimise the physical
b jurisdictional building codes, along with symbols and
environment of the organisation colour-coding; however, the latter should consider the
needs of those with colour-vision impairment.
occur according to a documented schedule
Access and signage should:
include all relevant safety measures, for example,
correct storage of cleaning products, barriers in place e in accordance with relevant legislation,
b
while maintenance is carried out jurisdictional standards and guidelines, and other
standards / guidelines
include remedial planning for any occasion when
maintenance or cleaning cannot be carried out e appropriate for the organisation’s community, with
b
according to schedule, and documentation of respect to diverse needs and diverse backgrounds
the reason(s) and levels of literacy
nsure that cleaning and maintenance staff
e include external signage which addresses:
understand what areas / items must be cleaned
• directions to facilities
and/or maintained by trained, external contractors.
• appropriate routes of access
• hours of access
Prompt points
• after-hours access (where applicable)
ho is involved in the organisation’s
W
planning for preventive maintenance • telephone numbers
and cleaning? • details of other healthcare organisations in the area,
ow does the organisation ensure that all
H particularly the nearest accident / emergency facility
necessary safety measures are in place during • management issues, such as designated
cleaning and maintenance activities? parking / non-parking zones, ambulance bays,
ow does the organisation respond to an
H non-smoking areas
identified failure with respect to cleaning include internal signage which addresses:
or maintenance?
• directions to specific wards / departments / areas of
H the facility / organisation
cleaning and maintenance staff do not touch
items requiring specialist oversight, such as • exits, including emergency exits
medical devices? • health and safety information including non-smoking
areas, restricted mobile phone usage and the
presence of any hazards
• behavioural requirements, for example, hand hygiene
e regularly reviewed to ensure their effectiveness
b
and continued appropriateness for the
organisation’s community.
H ow does the organisation encourage
H
its access and signage arrangements are the reporting of incidents and near misses by
appropriate for its community? consumers / patients, carers and other visitors?
hat legislation, standards and/or guidelines
W ho is responsible for investigating incidents
W
govern the organisation’s disabled access? and near misses involving the organisation’s
buildings, roads, walkways, plant, equipment,
In what languages does the organisation
medical devices, consumables or supplies?
provide signage? How were these
languages chosen? hat remedial action has been taken within
W
this organisation in response to an incident
ow often are the organisation’s signage
H
or near miss involving its buildings, roads,
arrangements reassessed? On what basis are
walkways, plant, equipment, medical devices,
changes to the signage made?
consumables or supplies?
Incidents and near misses involving

the organisation’s surroundings and The following evidence may help to
physical assets address criterion 3.2.2
As an aspect of its risk management, the organisation esign / refurbishments plans referencing
D
should encourage the reporting of incidents and near relevant legislation / standards / guidelines
misses involving its assets, goods and general services.
Furthermore, it should facilitate incident and near miss Asset register
reporting by consumers / patients, carers and other Plant logs
visitors to the organisation. Reporting of this nature can
provide valuable insight into the suitability and safety of vidence of staff consultation in
E
the organisation’s arrangements. Any reported incidents equipment selection
and near misses should be investigated according to ontracts with external service providers for
C
the organisation’s usual processes, and remedial action specialised cleaning / maintenance
taken as required.
Cleaning schedule
Incident and near miss management should:
Preventive maintenance schedule
e an aspect of the organisation’s overall risk and
b
incident management ccess arrangements and signage appropriate
A
for the organisation’s community
respond to any incident or near miss involving
any aspect of the organisation’s buildings, roads, vidence of remedial action taken in response to
E
walkways, plant, equipment, medical devices, an incident or near miss
consumables and supplies
ncourage and facilitate incident and near miss
e
reporting by staff, consumers / patients, carers and
other visitors
include investigation of all reported incidents and
near misses
nsure that appropriate remedial action is taken, to
e
improve the safety of the organisation’s surroundings
and physical assets.
March 2016 373


Assets, goods and general services are Australasian Health Infrastructure Alliance (AHIA). Australasian
managed safely and used efficiently and Health Facility Guidelines. North Sydney NSW; AHIA; 2016.
Available from: https://healthfacilityguidelines.com.au/
effectively. (continued) australasian-health-facility-guidelines Viewed 7 March 2016.
Standards SA Health. Environmental hygiene in healthcare. Adelaide

SA; Government of South Australia; 2016. Available
CSA PLUS 317:2000 from: http://www.sahealth.sa.gov.au/wps/wcm/connect/
Guidelines For Elementary Assessment Of Building public+ content/ sa+health+internet/clinical+resources/
Systems In Health Care Facilities. clinical+topics/ healthcare+ associated+infections/
prevention+and+management+of+infections+in+healthcare
AS 4083-2010 +settings/environmental+hygiene+in+healthcare Viewed 8
Planning for emergencies - Health care facilities. March 2016.
AS ISO 13485-2003 Safe Work Australia. Workplace traffic management guidance
Medical devices - Quality management systems - material. Acton ACT; Safe Work Australia; 2014. Available
Requirements for regulatory purposes. from: http://www.safeworkaustralia.gov.au/sites/swa/about/
publications/pages/guidance-traffic-management Viewed 7
ISO 7001:2007 March 2016.
Graphical symbols - Public information symbols.
Safe Work Australia. Model Code of Practice - Managing
AS 2342-1992 (R2013) the Risks of Plant in the Workplace. Acton ACT; Safe Work
Development, testing and implementation of information Australia; 2013. Available from: http://www.safeworkaustralia.
and safety symbols and symbolic signs. gov.au/sites/swa/about/publications/pages/managing-the-
risks-of-plant-in-the-workplace Viewed 7 March 2016.
Therapeutic Goods Administration (TGA). Medical devices
regulation basics. Symonston ACT; TGA; 2016. Available from:
https://www.tga.gov.au/medical-devices-regulation-basics
Therapeutic Goods Administration. Australian regulatory
guidelines for medical devices (ARGMD). (Currently under
review) Symonston ACT; TGA; 2011. Available from: https://
www.tga.gov.au/publication/australian-regulatory-guidelines-
medical-devices-argmd Viewed 7 March 2016.
March 2016 375
Implementation
Criterion 3.2.3 a) Policy / guidelines addressing waste a) Controls are implemented to

and environmental management are direct the identification, handling,
Waste and environmental
consistent with relevant legislation, separation and segregation of
management supports safe
standards, guidelines and/or codes clinical, radioactive and hazardous
practice and a safe and
of practice. and non-hazardous waste.
sustainable environment.
b) Waste management streams are b) There is a system to assess,
identified and signage is displayed. separate, handle, transport and
dispose of all waste streams.
c) Staff are provided with orientation
and ongoing education in their c) Waste management systems
responsibilities in waste and are coordinated with
environmental management. external authorities.
d) External service providers comply d) Recycling, reducing and reusing
with any requirements for the processes support sustainability,
correct handling, transport and resource conservation, and waste
disposal of waste. and environmental management.
e) Guidelines direct the efficient and
sustainable use of energy, water
and other utilities.

Effective environmental management has the double Generation of waste is an unavoidable consequence
benefit of cost savings and increased sustainability. This of the delivery of health care, and one that must be
criterion requires the organisation to implement efficient carefully managed. Due to the nature of the waste
environmental management processes with respect produced within healthcare organisations, all waste
to its use of utilities and its generation of waste, as an management policies must be shaped with reference to
aspect of its creation and maintenance of a safe and considerations of infection control (Criterion 1.5.2) and
sustainable environment. the general cleanliness and hygiene of the organisation
(Criterion 3.2.2). The risks associated with each of
the various categories of waste generated must be
managed (Criterion 2.1.2), and failure to do so may
result in incidents and complaints (Criteria 2.1.3 and
2.1.4). The collection and disposal of waste may be
outsourced to external service providers (Criterion 3.1.4),
and this process must be managed by the organisation.
a) T
he waste and environmental a) The organisation shows a) The organisation demonstrates it is
management system is evaluated, distinction in waste and a leader in waste and environmental
and improvements are made environmental management. management systems.
as required.
b) T
he use of energy, water and
other utilities is evaluated annually,
and improvements are made to
enhance efficiency and improve
environmental sustainability.
This criterion requires healthcare Waste and environmental management

organisations to: Within a healthcare organisation, waste management
Implement an organisation-wide waste and requires not only the collection and disposal of waste,
environmental management system. but also the control of all associated risks, including
that of infection. Strictly maintained processes for waste
nsure that all waste generated by the organisation
E segregation, storage and handling will increase safety
is safely and securely handled and disposed of, and decrease costs: the correct disposal of hazardous
including by its external service providers. waste can cost up to twenty times more than the
upport sustainability and resource conservation via
S disposal of general waste, so it is in the organisation’s
efficient use of utilities and other resources. interest to ensure that waste disposal streams are
correctly maintained. Clear signage is required, and
rovide staff with orientation and ongoing
P staff education should address correct processes and
education in their responsibilities for waste and individual responsibilities.
environmental management.
Effective waste management will have multiple
goals including:
to protect the health and safety of consumers /
patients, staff and visitors
to maintain a safe working environment
to reduce waste handling and disposal volumes /
costs without compromising health care
to minimise the environmental impact of waste
generation / disposal.
March 2016 377

Criterion 3.2.3 • recyclable waste: paper and cardboard; glass, metal

Waste and environmental management and plastics, as appropriate
supports safe practice and a safe and • compostable waste
sustainable environment. (continued) • general waste
Utilities are the basic services that the organisation uses implement processes to ensure that all forms of waste
to function, including water, power, ventilation, medical are correctly and safely:
gases and suction systems, and communications • identified
systems. The management of utilities should aim to
be both effective and sustainable, underpinned by • separated
strategies to prevent waste and increase efficiency. Any • segregated
failure in the supply or function of a utility will severely
impact the organisation’s ability to delivery care and • stored
maintain a safe environment, and consequently the • disposed of
management of utilities should be integrated with the
organisation’s business continuity / resilience plan nsure that correct separation and segregation of
e
and its emergency management, as addressed within waste is assisted by appropriate signage
criterion 3.2.4. implement appropriate controls, including (but not
Efficient use of utilities and other resources, and the limited to):
effective management of waste including via reduction / • lockable bins, storage areas and freezers
reuse / recycle strategies, will simultaneously generate
cost savings for the organisation and assist it to meet its • ‘one-way’ waste collection vessels
responsibilities for a sustainable environment. • designated secure waste storage areas
Waste management should: include provision of appropriate personal protective

equipment to staff involved in waste handling
fulfil the requirements of relevant legislation and
jurisdictional standards, guidelines and/or codes of s far as is consistent with the organisation’s duty of
a
practice, and reflect jurisdictional priorities care to its consumers / patients, implement processes
to reduce waste generation and support sustainability
here appropriate, be coordinated with relevant
w via reducing, reusing and recycling
local authorities
nsure that external service providers responsible
e
e supported by policy and procedures that
b for the transportation and/or disposal of waste are
define responsibility and accountability for waste correctly licensed and operating according to all
management, and ensure effective governance relevant legislation and codes of practice
e integrated with the organisation’s management of
b include regular audits of correct waste segregation
workplace health and safety, infection control, and and handling, and the effectiveness of waste
general cleaning reduction strategies.
recognise and respond to the generation of different
categories of waste, including (but not limited to): Management of utilities should:
• clinical waste: blood, bodily fluids, tissues, or any e supported by policy and procedures that define
b
item stained with these; laboratory specimens or responsibility and accountability, and ensure effective
cultures; body parts; animal carcasses, body parts, governance
blood, bodily fluids, tissues, or any item stained e linked to the organisation’s risk management, and
b
with these an aspect of its business continuity / resilience and
• other hazardous waste: radioactive, chemical, emergency management
pharmaceutical or cytotoxic waste, or items stained e supported by contingency plans including back-up
b
with these; corrosive, organic or other liquid waste; strategies and redundancy systems, in the event of an
sharps, glass, or light bulbs / tubes; batteries, or interruption to supply
electrical waste; oil or grease
mploy conservation strategies including (but not
e of the individuals concerned in its handling. It is the
limited to): organisation’s responsibility to ensure that staff are made
aware of their obligations in this respect, to provide
• choosing high energy rated electrical equipment access to the appropriate training / licensing, and to
• labelling non-essential electrical items and supply all appropriate personal protective equipment.
promoting ‘switch-offs’ by staff The organisation must also ensure that untrained
and/or unlicensed individuals are not permitted to
• information / education to encourage waste
handle the waste in question.
reduction by staff
Staff should be encouraged to be active in waste
• where appropriate, installing solar panelling, water
reduction and conservation strategies; individuals
tanks, insulation, window tinting and other energy
may choose to ‘take the lead’ in recycling or water /
conservation measures.
electrical waste reduction campaigns, or to develop new
approaches to waste reduction and energy conservation.
Prompt points Staff should:
ow does the organisation’s waste
H e informed at orientation of the organisation’s waste
b
management system reflect the requirements and environmental management system, and their
of relevant legislation, standards and guidelines, responsibilities for waste management and reduction
and jurisdictional priorities?
receive ongoing education in waste management, the
hat different forms of waste are produced by
W content which is regularly updated to ensure currency
the organisation?
e trained in waste identification, separation and
b
ow does the organisation evaluate the
H segregation, according to their role(s)
effectiveness of its waste management and
here involved in waste handling, be trained and
w
reduction processes?
licensed as required, and given all necessary personal
hat is the organisation doing to minimise its
W protective equipment
waste production? What proportion of its waste
e encouraged to take an active role in waste
b
is recycled rather than discarded to landfill?
reduction and energy conservation within
ow does the organisation respond in the event
H the organisation.
of an electrical outage? An interruption to its
communication systems?
Prompt points
ow has the organisation improved the
H
efficiency of its energy and water usage? What ow does the organisation ensure that
H
conservation strategies has it implemented? staff understand their responsibilities for
waste management and reduction?
ow does the organisation monitor compliance
H
Education and training with its waste management processes? How
Waste management and waste reduction should be an does the organisation respond to any identified
aspect of orientation and addressed during ongoing staff instance of non-compliance?
education. All staff will generate waste of various kinds,
oes the organisation generate waste that
D
and must take responsibility for the correct identification,
requires those handling it to be licensed? Who
segregation and disposal of this waste. The organisation
is responsible for ensuring that staff involved are
should not assume that staff will be able to correctly
correctly trained and licensed?
classify any given form of waste, nor rely entirely upon
its signage, but should provide instruction as to the ow are staff encouraged to assist
H
correct procedures. with the organisation’s waste and
environmental management?
The collection, storage and disposal of certain kinds of
waste, such as radioactive, cytotoxic or pharmaceutical
waste, may require specific training and even licensing
March 2016 379


Waste and environmental management HB 292 Set-2006
supports safe practice and a safe and Business Continuity Management Handbooks Set.
sustainable environment. (continued) NZS 4304:2002
Management of Healthcare Waste.
The following evidence may help to HB 202-2000
address criterion 3.2.3 A management system for clinical and related
wastes - Guide to application of AS/NZS 3816-1998,
olicy and procedures reflecting legislation /
P Management of clinical and related wastes.
standards / guidelines, and jurisdictional priorities
AS/NZS 3816:1998
Education / training in waste stream management Management of clinical and related wastes.
ignage to direct waste separation, segregation
S (Under revision)
and storage AS/NZS 4261:1994/Amdt 1:1997
trategies for safe and secure waste
S Reusable containers for the collection of sharp items
collection / storage used in human and animal medical applications.
ecords of staff training / licensing for
R AS 4031-1992/Amdt 1-1996
waste handling Non-reusable containers for the collection of sharp
medical items used in health care areas.
C
specifying waste handling / removal / Suggested reading
disposal conditions Department of the Environment. Climate change. Canberra ACT;
usiness continuity / resilience plan including
B Commonwealth of Australia; 2016. Available from: http://www.
utilities management environment.gov.au/climate-change Viewed 8 March 2016.
Audits of waste handling / waste reduction SA Health. Environmental hygiene in healthcare. Adelaide SA;
Government of South Australia; 2016. Available from: http://
vidence of staff involvement in waste reduction
E www.sahealth.sa.gov.au/wps/wcm/connect/public+content/
and energy conservation sa+health+internet/clinical+resources/clinical+topics/
healthcare+associated+infections/prevention+and+
management+of+infections+in+healthcare+settings/
environmental+hygiene+in+healthcare Viewed 8 March 2016.
Department of Health & Human Services. Sustainability in
healthcare. Melbourne VIC; State of Victoria; 2015. Available
from: https://www2.health.vic.gov.au/hospitals-and-health-
services/planning-infrastructure/sustainability
World Health Organization (WHO). Safe management
of wastes from health-care activities. Geneva CH;
WHO; 2014, Available from: http://apps.who.int/iris/
bitstream/10665/85349/1/9789241548564_eng.pdf?ua=1
California Hospital Association (CHA). Hospital Utilities
Management: Preserving Critical Systems. Pre-Conference
Session from the 2013 Disaster Planning for California Hospitals
Conference. Sacramento CA; CHA; 2011. Available from: http://
www.calhospitalprepare.org/post/hospital-utilities-management-
preserving-critical-systems Viewed 8 March 2016.
March 2016 381
Implementation
Criterion 3.2.4 a) Policy / guidelines addressing a) There are systems for prevention,
the management of internal preparedness and response to
Emergency and disaster
and external emergencies are internal emergencies.
management supports safe practice
and a safe environment. b) There are systems for
preparedness and response to
This is a mandatory criterion codes of practice.
external emergencies, including
b) The organisation understands its triage and deployment of medical
role in responding to disasters. teams where appropriate.
c) Likely emergencies are identified, c) Internal and external emergency
and response and evacuation management plans are developed,
plans and instructions are reviewed and tested in consultation
prominently displayed. with relevant authorities.
d) Communication systems are in d) The organisation regularly
place to assist in the management tests its plan for business
of any emergencies or disasters. continuity / resilience.
e) A business continuity / resilience e) There is an appropriately trained
plan has been developed. fire officer / team.
f) Staff are provided with orientation f) Relevant staff have access to first
and ongoing education in aid equipment and supplies and
emergency management and the are trained in their use.
correct response to emergencies.
g) Where appropriate, disaster
g) Emergency practice / drill exercises response procedures and
including fire safety and evacuation preparations are coordinated with
are regularly conducted. the relevant external authorities and
other healthcare organisations.
h) External service providers
comply with the organisation’s h) There is a documented plan to
requirements for the prevention implement recommendations from
of emergencies. the fire report.
i) There is documented evidence that
an authorised external provider
undertakes a full fire report on the
premises at least once within each
EQuIP cycle or in accordance
with legislation.
a) T
he emergency management a) The organisation shows a) The organisation demonstrates it is
system is evaluated, and distinction in emergency and a leader in emergency and disaster
improvements are made disaster management. management systems.
as required.
b) The organisation’s disaster
response system is evaluated,
as required.
c) T
he organisation’s business
continuity / resilience plan is
made as required.
d) Staff training and competence in
managing emergency procedures,
including evacuation, is evaluated,
as required.
March 2016 383

Criterion 3.2.4 nsure business continuity / resilience by developing

E
Emergency and disaster management and incorporating contingencies into the emergency
supports safe practice and a safe environment. and disaster management plan.
(continued) ave strategies in place to manage a fire outbreak,
H
including an inspection for fire risks and a fire action
Overview plan as required.
This criterion requires organisations to identify and Emergency and disaster management
manage potential emergency situations that may arise
either internally or externally, in terms of consequence, systems and plans
exposure, probability and preventive actions, and to An emergency or a disaster is a serious disruption to
demonstrate its preparedness in terms of policies and a community that threatens or causes death, injury,
procedures, staff education and training, business damage to property, causes incidents that require
continuity planning and other contingency arrangements, responses beyond the day-to-day capacity of the
that will allow it to continue to meet its duty of care prescribed civilian statutory authorities, and requires
and maintain a safe environment in the event of an special mobilisation and organisation of resources other
emergency. Organisations should demonstrate the than those normally available to those authorities.
development and implementation of appropriate
The difference between an emergency and a disaster is
emergency response systems in consultation with
usually considered to be one of scale; a disaster is an
external emergency response organisations and other
emergency that overwhelms the immediate capabilities
relevant bodies.
of the authorities and services that must respond to it.
Relationships of 3.2.4 with other criteria An external emergency or disaster may necessitate
preparation for the reception of a significant number of
Successful emergency and disaster management victims and/or the allocation and transport of personnel
requires a multifaceted, organisation-wide program of and resources to an external site.
policies, procedures, education and training in which a
range of critical situations, both internal and external to An internal emergency or disaster can be caused
the organisation itself, are anticipated and planned for. by factors that may be internal or external to the
This also relates to the management and implementation organisation, may adversely affect consumers / patients,
of effective systems concerning medical emergencies visitors and staff, and requires an immediate response.
(Criterion 1.1.4). The development, implementation
and regular re-evaluation of such a program is a Planning for an external disaster
part of the organisation’s overall safety management
All organisations will have some role in external disaster
system (Criterion 3.2.1), including the design and safe
planning, although this role will vary according to the
management of its assets, goods and general services
size, location and capabilities of the organisation. For
and the approach to signage (Criterion 3.2.2). This
example, a large public hospital would have emergency
criterion also falls within the scope of the integrated
procedures in place for a number of specific external
risk management framework (Criterion 2.1.2) and
disasters, such as severe weather, bushfire, pandemic
management of security (Criterion 3.2.5).
and/or terrorist attack; while for some small rural
organisations, a traffic accident with multiple injuries may
This criterion requires healthcare also require activation of the disaster plan.
organisations to:
Private hospitals may be involved in a disaster response
ave internal and external emergency management
H as a result of agreements with the public hospital
plans and systems that are developed in consultation system, which may be formalised in a Memorandum
with relevant stakeholders. of Understanding.
nderstand their roles and responsibilities in the event
U In the event of a disaster, community health
of an emergency or disaster. organisations may also be required to provide support.
Organisations should consider: e proactive in the management of its emergency
b
types of disasters, and their possible extent (city-wide, procedures, and never allow its circumstances and its
area-wide) planning to be out of step.
vailability of adequate basic utilities and supplies:

a
gas, water, food, electricity, essential medical support Prompt points
and supplies
hat jurisdictional legislation, codes of
W
assignment of staff to specific tasks and responsibilities practice and standards do the organisation’s
an efficient system for notifying staff emergency policies and procedures refer to?
defined authority and control ow were the emergency response plans

H
developed? Who was involved in the process?
availability of an emergency control centre
nder what legislation, codes of practice and/
U
onversion of all appropriate space into clearly defined
c or standards were the plan(s) developed? What
areas for efficient triage, casualty observation and civil authorities were consulted?
immediate care
ow long are emergency and disaster plans
H
reparations for special categories of consumers /
p kept before they are reviewed?
patients, including those requiring decontamination
re any specific disasters or emergencies
A
transport arrangements for casualties highlighted in the organisation’s planning? Why?
rehearsal of strategies and the periodic review of hat emergency rehearsals does the
W
all plans. organisation use to ensure preparedness?
What staff take part in these rehearsals? How
Planning for an internal emergency does the organisation ensure that night shift
or disaster and contract staff are adequately trained in
emergency and evacuation procedures?
An internal emergency or disaster is one that occurs
upon the premises of the organisation, and that may
have adverse consequences for consumers / patients,
Developing plans in consultation with
staff and visitors, such as fire, failure of essential
services, structural damage or a bomb threat. relevant authorities
Organisations should: In developing management plans for internal and external
emergencies and disasters, organisations should consult
evelop evacuation plans for each facility within the
d with all relevant regional and local authorities. These
organisation and prominently display them, ideally as may vary between jurisdictions but would include the
a diagram(s) showing exit paths local government, the police, ambulance, and fire and
nsure staff are aware of the significance of the various
e emergency services. If planning committees exist on
alarms used by their organisation, and are trained in the a regional basis, those healthcare organisations that
correct reactions and their assembly points are invited to participate should actively attend any
meetings to ensure that there is a realistic sense of their
onduct evacuation drills so that all staff, from all
c organisation’s capability and operating procedures and to
facilities and through all shifts, are familiar with the establish lines of communication.
proper course of action
Where appropriate, community partners should also be
include provision for regular updating and posting of
consulted; communities that are actively engaged in the
consumer / patient lists, senior staff, and other staff on
process of emergency planning and management show
duty, to facilitate a rapid response
greater resilience and better recovery in the event of an
regularly review and update emergency and disaster actual emergency.
management systems in light of current best-
practice evidence, as well as internal factors such
as alterations to buildings and changes in staffing or
services provided
March 2016 385

Criterion 3.2.4 Compliance

Emergency and disaster management In planning for emergencies, organisations must
supports safe practice and a safe environment. ensure staff and external service providers are aware
(continued) of their responsibilities and act in compliance with the
organisation’s policies and procedures.
Community health organisations that believe they may Organisations should ensure that:
be able to assist an emergency response in specific
circumstances should alert the relevant coordinating xternal service providers undertake a site orientation,
e
body of their interest and skills. and contracted staff working in consumer /
patient care areas are briefed on the emergency
When developing a coordinated plan, organisations communication system and evacuation procedures
should consider: from the location in which they are working’
the use of colour-coding for emergencies in line uring night shifts, school holiday periods and the flu
d
with acceptable international / national guidelines season, there are adequate numbers of consumer /
or standards patient care staff who have completed full fire training
identification of key responsibilities and accountabilities t all times, staff on duty are familiar with the location
a
specification of division of duties in an emergency and correct operation of the fire walls and doors, and
contingency plans for protecting consumers / patients
development of critical operating procedures
if an emergency arises
development of a communication infrastructure
there are current records of people working within
development of a crisis response infrastructure their buildings.
nsuring the availability of appropriate drugs, supplies
e
External service providers should:
and equipment for various medical emergencies to
assist a rapid and effective response ooperate with these procedures, as the record of
c
their presence will assist to identify them in case of
lanning for deployment of medical teams,
p
an emergency
where appropriate
e briefed and monitored to ensure they do
b
evelopment of an evacuation plan and procedures,
d
not inadvertently cause or contribute to an
including drills and debriefing processes
emergency situation.
regular training and exercises for a range of
potential threats.
Prompt points
hat systems / processes are used to
W
Prompt points ensure that tradespeople do not inadvertently
If the organisation becomes aware of cause or contribute to an emergency situation?
a disaster, who manages the allocation of
ow does the organisation ensure that any
H
duties? What policies / procedures allow the
external suppliers are traced outside the
coordinator to reallocate staff to an alternative
building if an evacuation has been called?
role? How would this be tracked?
egardless of whether they are permanent
R
as the organisation planned for the dispatch of
H
staff or contractors, what guidance is provided
a medical team? If so, what preparations have
to operating theatre staff on the appropriate
been made for the dispatch?
response to an alarm during surgery?
oes the organisation have an assigned role in
D
regional plans for emergencies? If it participates,
what role does the organisation play in regional
emergency / disaster planning?
Business continuity / resilience nsure that the standard of care throughout the
e
facility is not compromised because staff, supplies
Business continuity / resilience is defined as
and attention are diverted from those consumers /
management and planning for the continued availability
patients already requiring care to those affected by
of essential services during and after an emergency,
the emergency
including all the functions and resources associated
with the provision of these services. Business continuity nsure that the public is kept informed of the status of
e
planning should focus upon the analysis of risk, and then the organisation during the emergency
address those threats most likely to interrupt services.
nsure that its staff, and any other individuals
e
Good risk management will increase the organisation’s
working on the premises while employed by a
resilience, and minimise potential downtime.
different organisation, are educated in all aspects of
The response of an organisation to an emergency will emergency and disaster plans, and trained in putting
depend upon the type of organisation, the severity of the them into effect
incident and the number of staff affected. When planning
eet requirements in terms of numbers of trained first
m
for continuity of business during a state of emergency,
aid officers and access to appropriate first aid kits
an organisation with inpatients should consider
developing separate scenarios for: here relevant, plan for the possible dispatch of a
w
medical team, and ensure the business continuity plan
1. Continuing business as usual, while managing any
considers that the absence of the staff involved does
interruptions to staffing, consumer / patient flow
not impact negatively upon the organisation’s ability to
and/or supplies
meet its duty of care, particularly if in the event of an
2. Ceasing elective admissions, with ongoing emergency, the organisation is itself designated to act
management of admitted consumers / patients as a reception facility, or to receive a specific cohort
of victims
3. Ceasing elective admissions, and transferring
admitted consumers / patients to another facility. ecide upon the most suitable emergency
d
communication system for its size and specific needs
The organisation should:
nsure there are effective methods for activating
e
onsider its own locality and the chance that it will
c external services such as fire-fighting authorities.
get caught up in a particular kind of emergency
(earthquake, flooding, cyclone, bushfire), and the
impact of that emergency upon evacuation routes,
access roads, and other critical components
onsider that there are circumstances where an
c
external event can create an internal emergency
or disaster, for instance if access to a facility was
interrupted through a bridge failure, or cut off by
a bushfire
nticipate communication and transport challenges
a
in planning, and investigate the facilities and
capabilities of neighbouring organisations and
build relationships
onsider possibilities such as staff being isolated from
c
home and needing to rest / sleep, access to radio
communications, or where a helicopter might be used
for an equipment drop or evacuation
March 2016 387

Criterion 3.2.4 Organisations should develop an appropriate fire

Emergency and disaster management management plan and specific policies and
procedures that consider all people and all
supports safe practice and a safe environment. areas of the organisation, including:
(continued)
identification of fire and explosion risks
fire safety and preventive strategies
Prompt points fi re and explosion emergency procedures for
In the event of drastic understaffing, due preparedness, response and recovery
to natural disaster or epidemic, how does the
organisation plan to ensure continuity of care? raising the alarm
In the event of an emergency that impacts effective arrangements for a fire response team
directly upon the organisation, how does its n emergency communication system, including
a
business continuity / resilience plan ensure methods for activating external services such as fire-
ongoing access to medical gases? fighting authorities, ambulance, etc.
hat steps has the organisation taken towards
W ssignment of personnel to specific tasks
a
self-sufficiency in the event of an emergency? and responsibilities
If a natural disaster or an epidemic left the information readily available for staff throughout
organisation drastically understaffed, how would
the organisation
it assess whether it could maintain services for
consumers / patients already admitted? emergency services
hat are the components of the organisation’s
W fire-fighting response
emergency communication system?
evacuation from all parts of all buildings
ow would key communications be affected if
H
the power supply were disrupted? s taff training / education, and regular fire and
evacuation drills.
here are first aid kits situated within the
W
organisation? Who is responsible for Within the scope of this criterion, the expression ‘full fire
checking them? report’ is used to describe an inspection that includes a
review of fire safety risks associated with a building. The
terms used to describe building fire safety certificates
and reports vary between jurisdictions.
Fire safety
Fire safety is a key aspect of the organisation’s A ‘full fire report’:
emergency and disaster planning, and must be
is required at least once within the EQuIP cycle, or
managed so that consumers / patients, staff and others
according to notified jurisdictional variations
are not placed at undue risk
s hould be conducted by an approved assessor who
Fire safety officers, or fire wardens, as appropriate to the
has experience and/or a qualification that includes
size and type of the organisation, should be appointed
building fire safety risk mitigation, is familiar with
from amongst the staff. In a small organisation a single
the relevant building codes, and is external to
warden may be sufficient, while larger organisations /
the organisation
facilities will require the involvement of more individuals
with differing levels of responsibility (for example, Floor s hould independently assess each building at sites
Warden, Deputy Chief Fire Warden, Chief Fire Warden). where there are multiple buildings
Various companies provide accredited training for those s hould include findings in relation to the building’s
individuals willing to accept the position of fire warden, structure, its safety installations / measures, and their
and the organisation should provide the funds and the performance and maintenance
time for such training to be completed. The identity and
internal contact details of all fire wardens should be
clearly posted within all areas of the organisation.
s hould consider the use of the building, the mobility
of people within the building, and their capability to Prompt points
respond to an alarm.
ow does the organisation ensure that all
H
Organisational fire plans should be reviewed and staff are familiar with the components of its
revised annually. In addition, where there are known fire safety plan, including the communications
fire risks associated with the building(s) or site, the system and the position and correct use of fire
organisation should have an action plan that addresses walls / doors?
the management of that fire risk. The action plan
id all of the organisation’s staff complete fire drill
D
should record the organisation’s response to any
and fire-fighting training within the last calendar
recommendations made in the full fire report and set out
year? How is non-compliance followed up and
actions already taken or proposed by the organisation,
what action is taken? What actions ensure that
the rationale on which it is based, and the planned
casual and visiting staff are familiar with the
timetable for compliance. The timetable should show
emergency response and their responsibilities
evidence of priority being given to:
within the area that they are working?
recommendations which have a direct bearing on
hen was the organisation’s last cycle of
W
issues of safety for consumers / patients, staff
inspection and maintenance of essential safety
and visitors
measures undertaken?
arly compliance with recommendations that are
e
hat actions were taken in response to the last
W
readily achievable.
full fire report? What actions are proposed in
Note: the external fire inspection report demonstrating the future?
compliance and any subsequent action plan must
ow many fire wardens / safety officers does
H
be forwarded to ACHS six weeks prior to the
the organisation have? Where are the wardens’
onsite survey. Experience indicates that it may take
details posted?
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.
Consider whether the following will
help to address criterion 3.2.4
Emergency management plan
olicies, including information on both internal
P
and external emergencies
ppointment of personnel in preparation for an
A
emergency, for example, fire wardens
Staff education, including:
• fire training
• CPR training
Evidence of full fire inspection
Annual essential services reports
March 2016 389


Emergency and disaster management Attorney-General’s Department. Emergency management
supports safe practice and a safe environment. Australia. Canberra ACT: Australian Government. Available
from: https://www.ag.gov.au/emergencymanagement/Pages/
(continued) default.aspx Viewed 8 March 2016.
Standards Disaster Resilient Australia. Australian Emergency Management

Knowledge Hub. Available from: https://www.emknowledge.
AS 1670.4:2004 gov.au/ Viewed 8 March 2016.
Fire detection, warning, control and intercom systems - World Health Organization. Hospital Emergency Response
system design, installation and commissioning - sound Checklist: An all hazards tool for hospital administrators and
systems and intercom systems for emergency purposes. emergency managers. 2011. Available from: http://www.
Standard under review in March 2016. euro.who.int/__data/assets/pdf_file/0008/268766/Hospital-
emergency-response-checklist-Eng.pdf Viewed 8 March 2016.
Standards Australia. AS 1851: 2012
Routine service of fire protection systems and equipment. Rural Health Information Hub. Rural Emergency Preparedness
and Response. Available from: https://www.ruralhealthinfo.
Standards Australia. AS 3745:2010 org/topics/emergency-preparedness-and-response Viewed 8
Planning for emergencies in facilities. March 2016.
Standards Australia. AS 3959:2009 Safe Work Australia. Guide for Major Hazard Facilities:
Construction of buildings in bushfire-prone areas. Emergency Plans. 2013. Available from: www.
safeworkaustralia.gov.au/sites/SWA/.../Emergency%20Plans.
Standards Australia. AS 4083: 2010 doc Viewed 8 March 2016.
Planning for emergencies - health care facilities.
The Department of Health. National Health Emergency
Standards Australia. AS/NZS / ISO 31000: 2009 Response Arrangements. 2011. Available from: http://www.
Risk management — Principles and guidelines. health.gov.au/internet/main/publishing.nsf/Content/ohp-
response-arrangement-nov11-l Viewed 8 March 2016.
Standards Australia. HB 292:2006
Handbook and Practitioner’s Guide to Business The Department of Health. Preparing for Pandemic Influenza.
Available from: http://www.health.gov.au/internet/main/
Continuity Management.
publishing.nsf/Content/ohp-pandemic-influenza.htm Viewed 8
Standards Australia. HB221: 2004 March 2016.
Handbook: Business continuity management.
March 2016 391
Implementation
Criterion 3.2.5 a) Policy / guidelines addressing a) There is an organisation-wide

the management of security and system to assess security risks,
Security management supports safe
the minimisation of violence and determine priorities and eliminate
practice and a safe environment.
aggression are consistent with risks or implement controls.
b) There is an organisation-
guidelines and/or codes
wide violence and aggression
of practice.
management and
b) Service planning includes strategies minimisation program.
for security management.
c) Where appropriate, there is a
c) Major security risks are identified. system to manage security risks
associated with staff working
d) Staff are provided with orientation
off-site.
and ongoing education in security
risks and their responsibilities. d) Where appropriate, there is a
system to manage safety
e) External service providers are
and security during the
supplied with relevant information
intra-facility transportation of
and comply with the organisation’s
consumers / patients.
security controls.
e) Staff are consulted in decision
making that affects organisational
and personal risks.
f) Relevant staff are trained in the
correct response to incidents of
violence and aggression, including
de-escalation strategies.
g) Security management plans
are coordinated with relevant
external authorities.

Security management represents an important aspect Security management, particularly the management
of the organisation’s overall management of risk, of physical security, is an important aspect of the
encompassing the physical security of consumers / organisation’s integrated risk management framework
patients, staff and visitors and the maintenance of a (Criterion 2.1.2) and its creation of a safe environment
safe environment. This criterion requires organisations to (Standard 3.2). Maintenance of a safe environment
undertake a comprehensive program in which security by the organisation complements its implementation
risks are identified, assessed, prioritised, and eliminated of staff support systems (Criterion 2.2.5). The right
or controlled. of consumers / patients and visitors to be confident
with respect to the credentials and background of the
individuals with whom they interact in the healthcare
setting will be addressed via the organisation’s systems
for recruitment, selection and appointment (Criterion
2.2.2) and credentialing (Criterion 3.1.3). Security must
a) C
ompliance with the organisation’s a) The organisation shows distinction a) The organisation demonstrates
policy / guidelines for managing in security management. it is a leader in security
security risks is monitored and management systems.
made as required.
b) The security management system
is evaluated, in consultation
with external authorities when
appropriate, and improvements
c) T
he violence and aggression
management and minimisation
program is evaluated, and
as required.
d) The timeliness and appropriateness
of the response to security
incidents are evaluated, and
as required.
also be considered in the organisation’s management of This criterion requires healthcare

its assets, goods and general services (Criterion 3.2.2). organisations to:
Security management may be facilitated by the use of
external service providers (Criterion 3.1.4), and will often Implement an organisation-wide system to identify,
require the utilisation of information and communication assess, prioritise and eliminate or control security
technology (Criterion 2.3.4). Failure to manage security risks, which is coordinated as appropriate with
so as to maintain a safe environment may result in external authorities.
incidents and complaints (Criteria 2.1.3 and 2.1.4). Minimise and manage violence and aggression.
onsult with staff about security issues, including staff
C
security on and off-site.
nsure that staff are educated and, where
E
appropriate, trained in their security responsibilities
and responding to incidents of violence or aggression.
March 2016 393

Criterion 3.2.5 e supported by policy and procedures that

b
Security management supports safe practice define responsibility and accountability for security
and a safe environment. (continued) management and ensure effective governance
include processes for identification, assessment,
Organisational security elimination or mitigation of security risks, including (but
not limited to) with respect to:
Security risks within a healthcare organisation will
be identified and eliminated or controlled via • security and safety of staff, consumers / patients
management strategies that fall under four and visitors
broad and overlapping headings: • security of information
rocedural security: the policies and procedures
p • security of staff off-site, for example on home visits
implemented to eliminate or reduce security risks and
to enhance the safety of consumers / patients, staff • security in geographically remote areas or in isolation
and visitors • security of personal belongings
hysical security: the steps taken to prevent and/or
p • security of assets
minimise the incidence of violence and aggression
within the workplace, either by or towards staff, • security of pharmaceuticals
consumers / patients and visitors • security of payroll
ersonal security: the processes that ensure the
p e considered during the planning of new facilities and
b
credentials and background of staff, to enhance the the refurbishment of existing facilities, with respect to
safety of consumers / patients and staff potential high-risk areas / situations including (but not
logical security: security processes that utilise aspects limited to):
of the organisation’s information and communication • emergency departments
technology (ICT).
• treatment rooms
While an effective security management system
must encompass all four approaches, this criterion • plant rooms
will chiefly address procedural and physical security. • pharmacies and drug storage areas
Personal security will be managed via the processes of
recruitment, selection and appointment, as addressed • ATMs
within criterion 2.2.2, and credentialing, which is e an aspect of service planning, with resources
b
addressed within criterion 3.1.3; while the management allotted for security risk mitigation devices / strategies
of logical security is addressed within criterion 2.3.4. including (but not limited to):
The nature of the healthcare setting creates a variety • the provision of onsite security staff
of security risks which must be identified, assessed
and prioritised. The creation and maintenance of a • lighting in potential risk areas, such as car parks,
secure environment should be a fundamental aspect access paths and storage facilities
of the organisation’s management of its facilities, and • installation of locks and alarms, as appropriate
addressed during the design or redesign of its layout,
and also of its service planning. It is the organisation’s • installation and monitoring of CCTV
responsibility to eliminate as far as possible those • installation of personal / duress alarms, with
security risks which are within its control, and to mitigate connection to the police or other appropriate
the remaining risks. response team
Organisational security should: • installation of physical barriers, such as security glass
be an aspect of the organisation’s risk management • escape routes
reflect relevant legislation, standards, guidelines require display of official identification by staff at
and/or codes of practice all times
include processes for restriction of access to certain Consumer / patient and staff security
areas to appropriate personnel, for example, via swipe
The healthcare setting is associated with certain security
cards or code pads
risks to consumers / patients and staff which must be
nsure that external service providers understand
e identified and managed. Consumers / patients have the
and comply with the organisation’s security controls right to be confident in the credentials and background
and procedures of the health professionals and other staff with whom
they interact. Furthermore, the organisation has an
here external security services are contracted,
w
obligation to manage the safety and physical security of
ensure that personnel are appropriately trained
consumers / patients while they are within the healthcare
and licensed
setting or being transferred between facilities.
e developed in consultation with and/or coordinated
b
Staff within a healthcare organisation will be also
with relevant external authorities, to ensure that all
exposed to specific security risks. The organisation
security risks have been identified and appropriate
should consult with relevant staff in the identification of
measures taken
these risks, and in the implementation of strategies to
e supported by regular audits to assess risk
b mitigate risk and enhance the safety of staff. In particular,
mitigation and monitor compliance. a risk-management approach should be taken whenever
staff are required to travel between facilities and/or make
home visits to consumers / patients.
Prompt points Any security incident involving a consumer / patient or
hat legislation, standards and/or
W a member of staff should be investigated, and changes
guidelines are referenced in the organisation’s made to systems and processes as required.
security management policy and procedures?
Consumers / patients should:
hat physical / electronic systems for
W
e protected by robust processes for checking the
b
enhancing security has the organisation
identity, background and credentials of staff
installed, for example, security cameras, swipe
card access, duress alarms? e protected from incidents of violence or aggression
b
during an episode of care
oes the organisation have areas to which
D
access is restricted? How is access to those ave their physical security managed while being
h
areas monitored and/or controlled? transported between units / departments or facilities,
or when relevant between the organisation and
If the organisation has an emergency
their home.
department, how are consumers / patients and,
in particular, carers contained within this area
Staff security should:
after hours, when staffing and others resources
may be limited? e planned and managed in consultation with
b
relevant staff
H
external service providers understand and include risk assessment of specific actions, including
comply with its security arrangements? (but not limited to):
• working alone
• working off-site for any reason
• travelling between sites
• conducting home visits
March 2016 395

Criterion 3.2.5 It is important that the organisation recognise the multi-

Security management supports safe practice directional nature of the risk of associated with violence
and aggression: such incidents may involve consumers /
and a safe environment. (continued) patients, visitors or staff, who may be either the victims
or the aggressors.
e supported by protocols and devices as
b
appropriate, including (but not limited to): The organisation should also recognise that workplace
bullying constitutes an act of violence and aggression,
• duress alarms
and any reported incident of bullying by a member of
• mobile phones staff should be managed accordingly. Bullying and the
• GPS monitoring intimidation of whistleblowers are further addressed
within criteria 2.2.3 and 2.2.5.
• roadside assistance contracts
The organisation’s focus should be on prevention.
• 24-hour call-in centres However, when a violent incident does occur, action
• relevant training. should be taken to minimise its impact and as far
as possible prevent its recurrence, regardless of its
source. Appropriate support should be provided for staff
Prompt points involved in a violent incident.
ow does the organisation ensure the

H The prevention and minimisation of violence and
physical and personal security of aggression should:
consumers / patients? reflect relevant legislation, standards, guidelines
hat staff does the organisation consult with
W and/or codes of practice, and jurisdictional priorities
when planning security measures? e supported by policy and procedures that
b
ow does the organisation ensure the security
H define responsibility and accountability for the
of staff when travelling between facilities? management of violence and aggression, and
Conducting home visits? ensure effective governance
e linked to the organisation’s risk management system
b
and specifically the incident management system
Violence and aggression
include processes for the immediate response to an
Healthcare settings carry a heightened risk for incidents incident, including by staff, security personnel and/or
of violence and aggression. The organisation should the police, as appropriate
strive to implement systems and processes which
prevent as far as possible the occurrence of violence e supported by staff training in the correct response
b
and aggression, and which mitigate the risk that an to an incident, including de-escalation strategies
incident will result in physical or psychological harm. include appropriate support systems for staff involved
Many jurisdictions take a ‘zero tolerance’ approach to in a violent incident, including (but not limited to):
the management of violence and aggression, and the
organisation must ensure that its policy and procedures • debriefing
in this area fulfil its legal and jurisdictional obligations. • counselling
The term ‘violence and aggression’ encompasses any • access to the organisation’s Employee
incident in which an individual is assaulted, threatened Assistance Program
or abused. Such an incident may involve verbal, physical
• further training
or psychological abuse, threats or other intimidating
behaviours, intentional physical attacks, aggravated nsure that all incidents of violence and aggression
e
assault, threats with an offensive weapon, sexual are reported and investigated, and changes made to
harassment, or sexual assault. systems and processes as required.
hat legislation, standards and/or
W ow does the organisation ensure that
H
guidelines are referenced in the organisation’s staff are aware of implemented measures that
policy and procedures for preventing and will assist them to protect their personal safety,
minimising violence and aggression? for example, escape routes?
hat training is provided to staff to support
W hat staff does the organisation consult
W
them in responding to incidents of violence with when planning for training in the correct
and aggression? response to a violent incident? What staff
receive this training?
ow does the organisation ensure a prompt
H
and appropriate response when a violent ow does the organisation use the outcomes
H
incident occurs? of incident investigation to improve its systems
and educate staff?
hat support is provided for staff involved in a
W
violent incident?
hat changes have been made to systems or
W
processes as a result of a violent incident? The following evidence may help to
Staff education and training olicy and procedures reflecting legislation /
P
standards / guidelines, and jurisdictional priorities
The prevention and minimisation of violence and
aggression should be addressed during staff Current risk register
orientation, and should also be the subject of ongoing vidence of consultation with relevant
E
staff education. Staff should be made aware of the external authorities
correct response to the threat of violence, and of all
implemented strategies by which they may secure their Audits
personal safety, for example, escape routes, physical Implemented security measures such as CCTV,
barriers, or duress alarms. Where incidents occur, the key pads, duress alarms, etc.
outcomes of the subsequent investigation should be
C
made the basis of staff learnings. Any changes made
specifying compliance with security arrangements
to systems or processes as a result of an investigation
should be disseminated to all staff. Security risk assessment of staff tasks / duties
Staff should be aware of the risks that attend their ecords of completed staff training in violent
R
specific duties and, where relevant, provided with incident response
training in the correct response to an incident, including
de-escalation strategies. The organisation should
consult with staff regarding their requirements in this
respect, and ensure that all possible steps are taken
to equip staff with the appropriate skills and
response strategies.
March 2016 397

Criterion 3.2.5
Security management supports safe practice
and a safe environment. (continued)
Standards
AS/NZS ISO 31000 Set:2013
Risk Management Set.
AS 4083-2010
Planning for emergencies - Health care facilities.
HB 167:2006
Security risk management.
Suggested reading
World Health Organization (WHO). Violence against Health
Workers. Geneva CH; WHO; 2016. Available from: http://
www.who.int/violence_injury_prevention/violence/workplace/
en/ Viewed 10 March 2016.
Comcare. Customer aggression. Canberra ACT; Comcare;
2014. Available from: http://www.comcare.gov.au/preventing/
hazards/psychosocial_hazards/customer_aggression Viewed
10 March 2016.
NSW Health. Protecting People and Property: NSW Health
Policy and Standards for Security Risk Management in NSW
Health Agencies. North Sydney NSW; NSW Government; 2013.
Available from: http://www.health.nsw.gov.au/policies/manuals/
Documents/prot-people-prop.pdf Viewed 10 March 2016.
Victorian Auditor-General’s Office (VAGO). Occupational
health and safety risk in public hospitals. Melbourne VIC;
VAGO; 2013. Available from: http://www.audit.vic.gov.au/
publications/20131128-OHS-in-Hospitals/20131128-OHS-in-
Hospitals.html Viewed 6 March 2016.
Safe Work Australia. Managing the work environment and
facilities: Code of practice. Acton ACT; Safe Work Australia;
2011. Available from: https://www.safework.sa.gov.au/
uploaded_files/CoPManagingWorkEnvironmentFacilities.pdf
March 2016 399
SECTION 8 Glossary
Definitions in this glossary are for use in the context of the ACHS EQuIP6 standards, criteria, elements
and guidelines.
access the various pathways and processes via which the consumer / patient may enter the health
system and obtain required services
accessibility the ability of consumers / patients or potential consumers / patients to obtain required or
available services when needed within an appropriate time
accountability responsibility and requirement to answer for tasks or activities. This responsibility may not be
delegated and should be transparent
accreditation a public recognition by a healthcare accreditation body of the achievement of accreditation
standards by a healthcare organisation, demonstrated through an independent external peer
assessment of that organisation’s level of performance in relation to the standards
advance care instructions that consent to, or refuse, specified medical treatments. It becomes effective in
plan / directive situations where the consumer / patient is no longer able to make their own treatment decisions
Advanced in the context of EQuIP6:
Completion in
an opportunity for an organisation to promptly address outstanding issues to achieve an
60 days survey
acceptable level of performance within 60 days from an EQuIP survey date.
(AC60)
may be offered to an organisation in up to four criteria in order to address:
high priority recommendations (HPRs), and/or
an SA rating in mandatory criteria, and/or
an SA rating in non mandatory criteria
admission the point in the care journey at which an organisation acknowledges a consumer / patient as
a client, and accepts responsibility for his or her care; in some contexts, the term ‘registration’
may be used rather than admission. The point at which admission is considered to have
occurred, and the processes by which it happens, varies considerably according to the nature
of an organisation.
in the first instance, admission refers to the administrative process by which an individual’s
details are entered into the organisation’s systems so that the care journey may begin.
However, it is important to recognise that, depending upon the nature and sector of the
organisation, admission does not necessarily require the provision of accommodation, or
access to a specific facility
adverse event an incident that results in harm to a consumer / patient, where harm includes disease, injury,
suffering, disability and death
adverse reaction unexpected harm arising from a justified treatment
agreement a mutual arrangement describing the scope for cooperative ventures between parties and
documenting relevant responsibilities
analysis breakdown of the essential features into simple elements, such as a summary, outline or
identification of the essence of an issue
antimicrobial a chemical substance that inhibits or destroys bacteria, fungi or parasites. These include
antibiotics, antivirals and disinfectants
appropriate a service that is consistent with a consumer / patient’s expressed requirements and is
provided in accordance with current best practice
in the context of EQuIP6: is suitable, or fitting, to do
appropriateness doing what is necessary, and not doing what is not necessary. Occurs when consumers /
patients receive appropriate and necessary care, interventions and services in the most
appropriate setting
artificial nutritional parenteral and/or enteral nutrition therapy
support
(parenteral nutrition: intravenous administration of nutrients into a central or peripheral vein;
enteral nutrition: feeding provided through the gastrointestinal tract via a tube, catheter, or
stoma that delivers nutrients distal to the oral cavity)
as required as an action becomes necessary
assessment a process by which the characteristics and needs of consumers / patients, groups or
situations are evaluated or determined so that they can be addressed. Assessment forms the
basis of a plan for services or action. While assessment may be known by different names
and occurs in a broad variety of contexts, such as triage in an emergency department,
comprehensive assessment by an Aged Care Assessment Service, or screening and intake
by a community health or outreach service, the process remains consistent and as defined
above
at-risk consumer / a consumer / patient characterised by high risk or susceptibility (as to disease) or event e.g.
patient falls
benchmarking the continuous measurement of a process, product, or service compared to those of the
toughest competitor, to those considered industry leaders, or to similar activities in the
organisation in order to find and implement ways to improve it. One of the foundations of
both total quality management and continuous quality improvement. Internal benchmarking
occurs when similar processes within the same organisation are compared. Competitive
benchmarking occurs when an organisation’s processes are compared with best practices
within the industry. Functional benchmarking refers to benchmarking a similar function or
process, such as scheduling, in another industry
blood homologous and autologous whole blood
blood component fresh blood components including red cells, platelets, fresh frozen plasma, cryoprecipitate and
cryodepleted plasma
blood products plasma derivatives and recombinant products
business plan the current action plan for achieving organisation goals
by-laws rules, regulations or legislation adopted by the organisation for the regulation of both its
internal and external affairs
March 2016 401

SECTION 8 Glossary
care plan the documentation of items agreed to in a care planning process. This should include:
the date of development
participants in the development of care plan
consumer / patient-stated and agreed issues or problems
consumer / patient-stated and agreed goals
agreed actions and the name of the person or service responsible for each action
timeframe for attaining goals and actions
planned review date
consumer / patient acknowledgement of the care plan (signed or verbal)
actual review date
carers / support people who provide unpaid care and support to family members and friends who have a
persons disability, mental illness, chronic condition, terminal illness or who are frail. Carers include
parents and guardians caring for children
change the process of managing the effective implementation of organisational strategies, ensuring
management that permanent changes in goals, behaviours, relationships, processes and systems are
achieved to the organisation’s advantage
clinical audit a systematic independent examination and review to determine whether actual activities and
results comply with planned arrangements
clinical the process of translating data on diseases, conditions, injuries and interventions from a
classification consumer / patient record into a coded format using a relevant classification system
clinical the system by which the governing body, managers and health professionals share responsibility
governance and are held accountable for consumer / patient care, minimising risks to consumers / patients
and for continuously monitoring and improving the quality of clinical care
clinical handover the transfer of professional responsibility and accountability for some or all aspects of care
for a consumer / patient, or group of consumers / patients, to another person or professional
group on a temporary or permanent basis.
clinical indicator a measure of the clinical management and/or outcome of care that should screen, flag or
draw attention to a specific clinical issue. Clinical indicators identify the rate of occurrence of
an event and are used to assess, compare and determine the potential to improve care
clinical pathway sometimes called a care map, a consumer / patient management tool that organises,
sequences and times the major consumer / patient care activities and interventions of the
entire interdisciplinary team for a consumer / patient with a particular diagnosis or procedure
code of practice a published document that sets out commonly agreed sets of guidelines and informs all
parties of responsibilities and expectations under the code. Codes of practice can be:
v oluntary agreements where a group of companies or an industry sector agree to abide by
a particular code
uasi-regulation where the code may be developed by industry in cooperation
q
with government
o-regulation where the code describes required performance or behaviour or specifies
c
acceptable means of meeting broader performance-based obligations and there are
penalties for non-compliance with the code
community a group of people who share a common interest or background (e.g. cultural, social, political,
economic, health), which may also be, but is not necessarily, geographic
competence a guarantee that an individual’s knowledge and skills are appropriate to the service provided
and an assurance that the knowledge and skill levels are regularly evaluated
complaint expression of a problem, an issue, or dissatisfaction with services that may be verbal or
in writing
conditional survey in the context of EQuIP6:
an additional survey that is undertaken one year following an Organisation-Wide Survey or a
Periodic Review during which issues have been identified as needing to be addressed rapidly.
A recommendation for a Conditional Survey is made for issues for which a 60 day framework
is too short to achieve the level of change required, and provides the organisation with an
opportunity to address issues that require some time and resources in order to achieve an
acceptable level.
a Conditional Survey may be offered to an organisation in up to two criteria in order
to address:
High Priority Recommendations (HPRs), and/or
a SA rating in mandatory criteria
in addition, a Conditional Survey may be offered to an organisation in order to address:
LA/SA ratings in between six and 11 non-mandatory criteria
confidentiality guaranteed limits on the use and distribution of information collected from individuals
or organisations
consent, in the absence of a completed consent form, an acknowledgement of consent in the health
acknowledgement record, signed by the consumer / patient and the treating health professional, stating that the
of proposed treatment, the benefits and risks and any costs involved have been explained to the
consumer / patient
consent, informed a process of communication between a consumer / patient and their health professional that
results in the consumer / patient’s authorisation or agreement to undergo a specific medical
intervention. This communication should ensure the consumer / patient has an understanding
of all the available options and the expected outcomes such as the success rates and/or side
effects for each option
March 2016 403

SECTION 8 Glossary
consumer / a person, however titled, who makes either direct or indirect use of health services; that is,
patient a current or potential user of the health system, and/or their carer(s). This encompasses
consumers / patients receiving health care from a health professional, those with specific
health needs, or who may at some time have them, and those who have a general interest
in the health system and health funding. Many consumers / patients also have an indirect
influence upon the health system in the capacity of taxpayers
consumer / patient the process of involving consumers / patients and the community meaningfully in decision
participation making about their own health care, health service planning, policy development, setting
priorities and quality issues in the delivery of services
continuity of care the ability to provide uninterrupted, coordinated care or services across programs,
practitioners, organisations and levels over time
contract a mutual agreement between two or more competent parties that creates a legally
supportable obligation to do or not do something specified
coordinate to bring together in a common, ordered and harmonious action or effort
corporate the processes by which the organisation is directed, controlled and held to account. It
governance encompasses the systems, processes and arrangements by which authority, accountability,
stewardship, leadership, direction and control are exercised in an organisation. It influences
how objectives are set and achieved, how risk is monitored and assessed and how
performance is optimised
credentialing the formal process used to verify the qualifications, experience, professional standing and
other relevant professional attributes of health professionals for the purpose of forming a view
about their competence, performance and professional suitability to provide safe, high quality
health care and services within specific organisational environments
credentials documentation that an individual’s knowledge, skills, competence and qualifications comply
with specific requirements
criteria specific steps to be taken or activities to be done, to reach a decision or a standard
cultural the processes and practices implemented by an organisation that foster inclusiveness and
competence establish the progression of learning about diversity and differences, and their impact on
the way services are delivered, received, accessed and promoted. In the context of health
care, cultural competence focuses on the capacity of the organisation to improve health and
wellbeing for the individual and the community by integrating culture into the delivery of health
services
culture, the prevailing pattern of beliefs, attitudes, values and behaviours within an organisation
organisational
current an approach that has been shown to produce superior results, selected by a systematic
best-practice process, and judged as exemplary, or demonstrated as successful. It is then adapted to fit a
particular organisation
data unorganised facts from which information can be generated
data collection a store of data captured in an organised way for a specific defined purpose
data integrity accuracy, consistency and completeness of data
data security protection of data from intentional or unintentional destruction, modification or disclosure
defining the scope the process that follows on from the credentialing of health professionals which involves
of clinical practice delineating the extent of, and limits to, an individual’s clinical practice within a particular
organisation based on that individual’s credentials, competence, performance and
professional suitability, and the needs and the capability of the organisation to support the
individual’s scope of clinical practice
delegation the devolution of authority appropriate to individual roles and responsibilities within an
organisation for the operation of clinical and non-clinical services. A formal delegation system
ensures that clear lines of accountability exist, particularly where temporary delegations are
enacted
deteriorating a consumer / patient with worsening of pre-existing symptoms or the onset of an acute
consumer / condition. Applies to any consumers / patients receiving medical, surgical, maternity or
patient mental health care and is determined by observing and documenting changes in their clinical
circumstances. This includes both the absolute change in physiological measurements and
abnormal observations, as well as the rate of change over time for an individual
disaster recovery a set of pre-determined procedures that provides for substitute operations and a quick return
to normal after any disruption
discharge the release of a consumer / patient from care or movement of a consumer / patient from one
healthcare organisation to another
diverse the breadth of social, economic and cultural factors that influence an individual consumer /
background patient’s experience and perspective. This encompasses culturally and/or linguistically diverse
backgrounds
diverse needs the range of consumer / patient needs that may be found within the community that an
organisation serves, and which may form a barrier to health care if not addressed by the
organisation in meeting its duty of care. Such needs may be cultural, physical, linguistic,
economic or health-status related
document control a planned system for controlling the release, change and use of important documents within
system an organisation, particularly policies and procedures. The system requires each document
to have a unique identification, to show dates of issue, updates and authorisation. Issue
of documents in the organisation is controlled and all copies of all documents are readily
traceable and obtainable
education systematic instruction and learning activities to develop or bring about change in knowledge,
attitudes, values or skills
effective producing the desired result
effectiveness care, intervention or action that is relevant to the consumer / patient’s needs and based on
established standards. This care, intervention or action achieves the desired outcome
efficiency achieving desired results with the most cost-effective use of resources
electronic records a record on electronic storage media that is produced, communicated, maintained
and/or accessed by means of electronic equipment. An Electronic Health Record (EHR) is
a repository of information regarding the health status of a consumer / patient, in computer
processable form
March 2016 405

SECTION 8 Glossary
elements in the context of EQuIP6:

identify what should be in place to achieve the criterion at a certain rating level: a description
of what is required to achieve the criterion. These provide prompts for improvement and
best practice
employee a proven strategy for assisting staff members and their families with personal and work-
assistance related problems, difficulties and concerns which they may experience from time to time and
program can affect work performance
end-of-life care a quality management approach that evaluates the individual holistic needs of a consumer /
patient, their families and carers, and coordinates appropriate care. It recognises the
interdependent physical, social, emotional, cultural and spiritual aspects of care and includes
the combination of broad health and community services that care for a person at the end of
their life
entry a process by which a consumer / patient comes into a healthcare organisation to
receive services
environmental development that meets the needs of the present without compromising the ability of future
sustainability generations to meet their own needs. The ability to maintain the balance between non-living
organisms and resources, such as water, timber and solar energy, and living organisms such
as humans, animals and plants
error unintentionally being wrong in conduct or judgement. Errors may occur by doing the wrong
thing (commission) or by failing to do the right thing (omission)
ethics acknowledged set of principles which guide professional and moral conduct
evaluation assessment of the degree of success in meeting the goals and expected results (outcomes)
of the organisation, services, program or consumers / patients
evidence data and information used to make decisions. Evidence can be derived from research,
experimental learning, indicator data, and evaluations. Evidence is used in a systematic way
to evaluate options and make decisions
evidence based the use of systematically reviewed, appraised clinical research findings to aid the delivery of
optimum clinical care to consumers / patients; the transfer of knowledge from research into
healthcare practice
feedback a communication from a consumer / patient relaying how delivered products, services and
messages compare with consumer / patient expectations
flexible work working arrangements that assist staff members to meet personal responsibilities, such as
practices caring for a child or other family member. These may include:
changes in hours of work
changes in patterns of work
changes in location of work
follow-up processes and actions taken after a service has been completed
formalised documented processes and actions taken after a service has been completed
follow-up
governance the set of relationships and responsibilities established by a healthcare organisation between
its executive, workforce and stakeholders (including consumers). It incorporates the
processes, customs, policy directives, laws, and conventions affecting the way a healthcare
organisation is directed, administered or controlled. Governance arrangements specify the
mechanisms for monitoring performance
governing body a body that carries legal accountability and/or scope of organisational responsibility for the
services provided, such as an individual owner or a group of senior managers, a governing
body of directors, a board, a group of senior managers and/or a chief executive appointed by
a government agency
guidelines principles guiding or directing action. Clinical practice guidelines are systematically developed
statements to assist practitioner and consumer / patient decisions about appropriate health
care for specific circumstances. Guidelines in the EQuIP6 Guide provide essential information
for the achievement of the EQuIP6 standards
healthcare- infections acquired in healthcare facilities (nosocomial infections) and infections that occur as
associated a result of healthcare interventions (iatrogenic infections), and which may manifest after people
infections leave the healthcare facility
healthcare a team or individuals who, in cooperation with the consumer / patient, assume responsibility
provider for all aspects of an episode care in response to the diagnosis and needs of the
consumer / patient
health priority identified areas which contribute significantly to the burden of illness and injury, which have
areas potential for health gains and reduction in the burden of disease
health a trained healthcare provider, whether registered or non-registered, who spends the majority
professional of their time providing direct clinical care. The term encompasses medical practitioners,
nurses, dentists, paramedics and allied healthcare providers such as physiotherapists,
occupational therapists, speech pathologists, dietitians, radiographers, social workers,
psychologists, pharmacists and all others in active clinical practice, but excludes those in
training and junior practitioners who must work under supervision
health record collated data and reports describing a consumer / patient's episode of care and/or services
received from the organisation
health workforce the workforce that provides health care to consumers / patients; ranging from workers with
no formal qualifications providing support services in home-based settings through to highly
qualified specialists working in technology intensive super-acute hospital settings
high priority in the context of EQuIP6:
recommendation
a recommendation where there is an area of high risk identified by the surveying team when:
(HPR)
consumer / patient care is compromised, and/or
the safety of consumers / patients and/or staff is jeopardised.
the HPR is a trigger for the organisation to address the issue either at an AC60 or at a
Conditional Survey
home-ward outlier a consumer / patient who is being treated in an area of the organisation that normally treats
a different casemix, e.g. a consumer / patient with a medical condition such as diabetes who
may be admitted to a surgical ward due to a lack of available medical beds
iatrogenic arising from or associated with health care rather than an underlying disease or injury
March 2016 407

SECTION 8 Glossary
ICD - 10 - AM a system of codes, from a set of defined categories, which are used to categorise activity in
a consistent and systemised way: the International Classification of Diseases, 10th Revision,
Australian modification
incident an event or circumstance which could have or did lead to unintended and/or unnecessary
harm to a person, and/or complaint, loss or damage
include(s) a list that provides examples and is not limiting
indicator performance measurement tool, screen or flag that is used as a guide to monitor, evaluate,
and improve the quality of services. Indicators relate to structure, process and outcomes
infection control a documented plan that outlines the structure of an infection control program, its overall aims
management plan and objectives, associated quality management activities, program evaluation criteria and time
frames for review. The document should address the governance of infection control
and identify:
who is at risk and from what
the hazards involved
the procedures for minimising risk, and
ppropriate measures for infection control, based on standard precautions and when
a
required, additional precautions
information the process of planning, organising, analysing and controlling data and information. The
management management of information applies to both computer-based and manual systems
information the right of a person to control the use and disclosure of information that reveals their identity,
privacy health information or health status
information a system that provides access to information using hardware, software, supplies, policies,
system procedures and people
information mechanical and electronic devices designed for the collection, storage, manipulation,
technology (IT) presentation and dissemination of information
integrated an additional approach that aims to strengthen and streamline healthcare organisation
governance governance arrangements by focusing on quality as the driver of change and placing clinical
governance at the heart of governance arrangements. Considered a key building block of
good governance in health care
intervention any act performed to prevent harming of a consumer / patient or to improve the mental,
emotional or physical function of a consumer / patient
IT security a tangible set of physical and logical mechanisms which can be used to protect information
held in hard copy, computer systems and information and telecommunication infrastructure,
from unauthorised access
IT system a group of interacting, interrelated or interdependent elements forming or regarded as forming
a collective entity
leadership the ability to provide direction and cope with change. It involves establishing a vision,
developing strategies for producing the changes needed to implement the vision, aligning
people and motivating and inspiring people to overcome obstacles
legibility quality of writing, print or images that makes them easily readable / understood
legislation the body of laws made by Parliament. These consist of: Acts of Parliament; and Regulations,
Ordinances, Rules which are also called ‘subordinate’ or ‘delegated’ legislation
magnet hospital a term coined in the United States from research that sought to understand why certain
hospitals were able to attract and retain staff
management setting targets or goals for the future through planning and budgeting, establishing processes
for achieving those targets and allocating resources to accomplish those plans. Ensuring that
plans are achieved by organising, staffing, controlling and problem-solving
mandatory in the context of EQuIP6:
criterion
one where it is considered that without marked achievement (evaluation), the quality of care or
the safety of people within the organisation could be at risk
malnutrition a state of nutrition in which a deficiency or excess (or imbalance) of energy, protein, and
other nutrients causes measurable adverse effects on tissue / body form (shape, size and
composition) and function and clinical outcome
manual task a task comprised wholly or partly by any activity requiring a person to use any part of their
musculoskeletal system in performing their work. Manual tasks can include:
lifting, lowering, pushing, pulling, carrying or otherwise moving, holding or restraining any
person, animal or item
repetitive actions
sustained work postures
exposure to vibration
medication error any preventable event that may cause or lead to inappropriate medication use or consumer /
patient harm while the medication is in the control of the healthcare professional or
consumer / patient
medication the processes of dispensing, prescribing, storing, administering and monitoring the effects
management of medication
medico-legal requirements of or relating to both medicine and law
requirements
mission a broad written statement in which an organisation states what it does and why it exists. The
mission sets apart one organisation from another
monitor to check, supervise, observe critically, measure or record the progress of an activity, action or
system on a regular basis in order to identify change and/or track change
morbidity a diseased state or symptom or the incidence of disease: the rate of sickness in a specified
community or group
mortality the number of deaths in a given time or place or the proportion of deaths in a
given population
multidisciplinary care or a service given with input from more than one discipline or profession
National Chronic the overarching framework of national direction for improving chronic disease prevention
Disease Strategy and care across Australia. A nationally agreed agenda to encourage coordinated action
in response to the growing impact of chronic disease on the health of Australians and the
healthcare system
March 2016 409

SECTION 8 Glossary
near miss an incident that did not cause harm, but had the potential to do so
needs physical, mental, emotional, social or spiritual requirement for wellbeing. Needs may or may
not be perceived or expressed by those in need. They must be distinguished from demands,
which are expressed desires, not necessarily needs
non-clinical information that is not direct, personal consumer / patient information
information
non-surgical wounds that may arise following admission to a health service and only whilst the consumer /
wounds patient is in hospital. This encompasses pressure ulcers, or ulcers that may develop by other
means; skin tears, caused by friction and/or tearing; skin infections, etc. This does not include
wounds that would be the purpose of the admission, such as burns, wounds related to
cancers, radiation injuries, gravel rash, etc., as these would be covered under normal treatment
nutritional care interventions, monitoring, and evaluation designed to facilitate appropriate nutrient intake
based upon the integration of information from the nutrition assessment
nutrition a comprehensive approach to gathering pertinent data in order to define nutritional status and
assessment identify nutrition-related problems. The assessment often includes consumer / patient history,
medical diagnosis and treatment plan, nutrition and medication histories, nutrition related
physical examination including anthropometry, nutritional biochemistry, psychological, social,
and environmental aspects
nutrition screening the process of identifying consumers / patients with characteristics commonly associated with
nutrition problems who may require comprehensive nutrition assessment and may benefit
from nutrition intervention
objective a target that must be reached if the organisation is to achieve its goals. It is the translation of
the goals into specific, concrete terms against which results can be measured
ongoing care the active and supportive management of care for people with chronic or complex conditions
as well as the process that follows an admission to a healthcare organisation
open disclosure the open discussion of incidents that resulted in harm to a consumer / patient while receiving
health care. The criteria of open disclosure are an expression of regret and a factual
explanation of what happened, the potential consequences and the steps being taken to
manage the event and prevent recurrence
operational plan a short-term plan that details how aspects of a strategic plan will be accomplished
organisation all sites / locations under the governance of, and accountable to, the governing body / owner(s)
orientation a formal process of informing and training staff on entry into a position or organisation,
covering the policies, processes and procedures applicable to that healthcare organisation
outcome results that may or may not have been intended that occur as a result of a service
or intervention
palliative care plan a written statement developed for a consumer / patient who is suffering from a life limiting
illness, with little or no prospect of a cure, and for whom the primary treatment goal is quality
of life, which states the nursing and other interventions to be undertaken, the health outcomes
to be achieved and the review of care which will occur at regular intervals
pathway a multidisciplinary plan of care that commences before or on admission and finishes
at discharge
patient master permanent listing or register of health information held by an organisation on consumers /
index patients who have received or are scheduled to receive services
personal information or an opinion (including information or an opinion forming part of a database),
information whether true or not, and whether recorded in a material form or not, about an individual
whose identity is apparent, or can reasonably be ascertained, from the information or opinion
policy written statement(s) which acts as a guideline and reflects the position and values of the
organisation on a given subject. All procedures and protocols should be linked to a
policy statement
pressure ulcer a localised injury to the skin and/or underlying tissue, usually over a bony prominence and
caused by unrelieved pressure, friction or shear. Pressure ulcers occur most commonly on the
sacrum and heel but can develop anywhere on the body
prevention and a systematic approach adopted by all sections of an organisation to ensure appropriate
management identification and actions for consumers / patients at risk of an illness or condition
procedure a set of documented instructions conveying the approved and recommended steps for a
particular act or sequence of acts
process a series of actions, changes / functions that bring about an end or a result
psycho-social pertaining to a combination of psychological and social factors
quality activities activities which measure performance, identify opportunities for improvement in the delivery of
care and services, and include actions and follow-up
quality framework an overarching approach to quality improvement that promotes integration of risk
management with quality improvement strategies and informs decision making and planning
quality ongoing response to quality assessment data about a service in ways that improve the
improvement processes by which services are provided to consumers / patients
quality use of the judicious, appropriate, safe and effective use of medicines
medicines
records field of management responsible for the efficient and systematic control of the creation,
management receipt, maintenance, use and disposition of records
record storage the function of storing records for future retrieval and use
recruitment and process used to attract, choose and appoint qualified staff
selection
referral the process of directing or redirecting a consumer / patient to an appropriate specialist or
agency for definitive treatment
relevant when something is connected with a matter; when there is a logical connection
research an active, diligent and systematic process of inquiry in order to discover, interpret or revise
facts, events, behaviours, or theories, or to make practical applications with the help of such
facts, laws or theories
March 2016 411

SECTION 8 Glossary
risk the effect of uncertainty on objectives which may be positive and/or negative. Objectives can
have different aspects, such as financial, health and safety, and environmental goals and can
apply at different levels, such as strategic, organisation-wide, project, product and process.
Risk is often expressed in terms of a combination of the consequences of an event and the
associated likelihood of occurrence
risk management coordinated activities to direct and control an organisation with regard to risk, such as
activities that identify, control and minimise threats to the ongoing efficiency, effectiveness and
success of its operations to deliver desired outcomes
risk management a set of components that provide the foundations and organisational arrangements for
framework designing, implementing, monitoring, reviewing and continually improving risk management
throughout the organisation. The framework should be embedded within the organisation’s
overall strategic and operational policies and practices
root cause a systematic process whereby the factors which contributed to an incident are identified
analysis
sample blood collected from a consumer / patient for purposes of blood or blood product /
component transfusion / infusion
sampling the collection of a sample from a consumer / patient
scope of clinical delineating the extent of an individual health professional’s clinical practice within a
practice particular organisation, based on the individual’s credentials, competence, performance and
professional suitability, and the needs and the capability of the organisation to support the
medical practitioner’s scope of clinical practice. This occurs after the process of credentialing
sentinel event an unexpected occurrence involving death or serious physical or psychological injury, or
the risk thereof. Serious injury specifically includes loss of limb or function. The phrase
“or the risk thereof” includes any process variation for which a recurrence would carry a
significant chance of a serious adverse outcome. Such events signal the need for immediate
investigation and response
services products of the organisation delivered to consumers / patients; units of the organisation that
deliver products to consumers / patients
skill mix the mix of posts, grades or occupations within an organisation. It may also refer to the
combinations of activities or skills needed for each job within the organisation
specialty ward an area of an organisation that normally treats consumers / patients with a specific casemix,
area for example, an orthopaedic ward, a paediatric ward, a maternity ward, etc
staff term which includes employed, visiting, sessional, contracted or volunteer personnel
staff development the process by which staff gain new skills or extend existing skills or qualifications
stakeholders individuals, organisations or groups that have an interest or share in services
standard a desired and achievable level of performance against which actual performance is measured
statutory any requirement laid down by an act of parliament
requirement
strategic plan a formalised plan that establishes an organisation’s overall objectives and that seeks to
position the organisation in terms of its environment
strategy a long-term plan of action designed to achieve a particular objective
surveillance the ongoing, systematic collection, analysis and interpretation of health-related data essential
to the planning, implementation and evaluation of public health practice, closely integrated
with the timely dissemination of these data to those responsible for prevention and control
survey in the context of EQuIP6:
external peer review which measures the performance of the organisation against an agreed
set of standards
system the resources, policies, processes and procedures that are organised, integrated, regulated
and administered to accomplish an objective
tracking creating, capturing and maintaining information about the movement and use of records
training the delivery of specialised education to develop practical skills related to the professional
development needs of the individual and organisation and which may be incorporated into
professional development programs
unique identifier universal number or code that uniquely identifies a person or other discrete entity
validate to make sound, ratify, confirm, substantiate or to give legal force to. Validity deals with the
relationship of the data obtained to the purpose for which it was collected, or measures what
it seeks to measure
values principles and beliefs that guide an organisation and may involve social or ethical issues
vision description of what the organisation would like to be
waiting list a register which contains essential details about consumers / patients who have been
assessed as needing elective care
when required required at the time
where required required in certain circumstances
March 2016 413

SECTION 9 Acknowledgements
The revision of the Evaluation and Quality Improvement Mr Anthony (Tony) Lawson
Program (EQuIP) is a major undertaking that extends BA, BSoc.Admin, FIPAA, FAIM, CPMgr
over several years. EQuIP6 represents the culmination of
Dr David Lord
dedication and commitment of many organisations
MBBS, DPM, FRANZCP
and individuals to the promotion of safety and quality
in health care. Mr Michael Roff
Grad Cert Mgt.
ACHS acknowledges the individuals and organisations
who have committed their knowledge, experience and, Dr Noela Whitby AM
more significantly, their time to this complex task. MBBS (Qld), Grad Dip HumNut, DPD, FRACGP, FAICD
The revision of EQuIP is led by the ACHS Standards A/Prof Brett Emmerson
Committee, whose role it is to steer the direction and (From November 2015)
content of the standards review and to advise on the MBBS, MHA, FRANZCP, FRACMA
applicability of the standards for implementation and
accreditation assessment. ACHS Standards Committee Members
The Standards Committee is a sub-committee of the Ms Chen Anderson (retired April 2015)
ACHS Board and reports its recommendations, through Group Manager - Group Risk, St John of God Health Care
the committee Chair, directly to the ACHS Board. Private Sector, WA
Ms Nancy Broer
ACHS Board of Directors Human Resources & Quality Manager, Presmed Australia
Mr John Smith PSM Day Procedure Centres, NSW
(President)
Dr Hobby Cheung
(Vice President to November 2015)
HCE of Kowloon Hospital and Hong Kong Eye Hospital
MHA, Grad Dip HSM, AFACHSM, CHE, FAHSFMA,
ACHSI / Hong Kong, HK (Joint Position)
AFAHRI, AFAIM, FAICD
Ms Manbo Man
Adjunct Associate Professor Karen Linegar
Nursing Director of HK Sanatorium Hospital, HK
(President to November 2015)
ACHSI / Hong Kong, HK (Joint Position)
RN, RM MHA B AppSc (Nursing), BB, Dip. Comm. Law,
FACN, JP Ms Margo Carberry
ACHS Surveyor, Community Health Manager, Hunter
Dr Len Notaras AM
New England Health Service, Narrabri, NSW
(Vice President from November 2015)
Rural / Public Sector / Allied Health / Community
AFCHSE, LLB, BA (Hons), DipComm, BMed, MHA, MA
Health / ACHS Surveyor, NSW
Mr Stephen Walker
Ms Cathy Cummings
(Treasurer)
Managing Director, DAA Group Ltd, New Zealand
Ass. Dip.Eng., B.Bus, Grad.Dip.Acc.,AFCHSE, MAICD
DAA, NZ
Ms Jennifer (Jennie) Baker
Dr Christine Dennis - ex officio
(To November 2015)
Chief Executive, ACHS
BHSc(Mgt), BBus(IR), MLegSt, MIR, FCHSM, CHE
Chief Executive ACHS, NSW
Dr Michael Cleary PSM
Ms Helen Dowling
MB BS (UQ), MHA (UNSW), FACEM, FRACMA,
ACHS Councillor, ACHS Board member, ACHS
AFACHSM
Surveyor. Chief Executive Officer, The Society of Hospital
Professor Geoffrey Dobb Pharmacists of Australia, VIC
BSc(Hons), MB BS, FRCP, FRCA, FANZCA, FCICM, Regional / Public Sector / Allied Health / ACHS Councillor /
FAMA ACHS Surveyor, NSW
Ms Helen Dowling
BPharm, DipHospPharmAdmin, GDipQIHCare, FSHP,
AICD
Assoc Prof Brett Emmerson Working Group 1
ACHS Councillor, ACHS Surveyor.
1.1.1 Assessment system
Executive Director, Division of Mental Health Services,
Metropolitan North Service District, Brisbane, QLD 1.1.2 Care planned and delivered in partnership
Mental Health/ Public Sector / ACHS Councillor / ACHS with patient
Surveyor, QLD 1.1.3 Consent
Dr Philip Hoyle (Committee Chair) 1.1.4 Care evaluation
ACHS Surveyor. Director of Medical Services, Northern 1.1.5 Discharge and transfer of care
Beaches Health Service, NSW 1.1.6 Ongoing care and management
Clinician / Public Sector / ACHS Surveyor, NSW
1.1.7 Decision making at end of life and
Ms Cathy Jones mortality management
National Manager Quality and Compliance, Healthscope 2.4.1 Health promotion, health protection
Private Sector, VIC and surveillance
Ms Joanne Levin
Director of Clinical Services, Currumbin Clinic Associate Professor Brett Emmerson, Chair / ACHS
Private Sector, QLD Standards Committee
Adj Assoc Prof Karen Linegar - ex officio Ms Patty Warn, ACHS Standards Committee /
ACHS President. Executive Director of Nursing and Consumer Representative
Midwifery, North West Area Health Service, TAS Ms Nancy Broer, ACHS Standards Committee
President ACHS, TAS
Ms Therese Cooke, ACHS Customer Services Manager
Mr Stephen Walker
ACHS Councillor, ACHS Board member. Dr Kah Lin Choo, Consultant (Medicine) / Coordinator
Chief Executive, St Andrew’s Hospital, Adelaide (Clinical Services), North District Hospital, New Territories
Administration / Private Sector / ACHS Councillor, SA East Cluster, Hospital Authority, HK
Ms Patricia Warn Ms Grace Yeung, General Manager (Nursing), Our Lady

Consumers Health Forum of Australia of Maryknoll Hospital, HK
Consumer Representative, NSW Dr Chi Hin Ho, Senior Medical and Health Officer
(Regulatory), Department of Health, The Government of
A member of the Standards Committee chairs an the HKSAR
individual Working Group established to assess the
existing program criteria for contemporary best practice Ms Leonie Tennant, Client Manager / Surveyor, DAA
and to recommend improvements and innovation. Group Ltd, NZ
Membership of each Working Group also includes an Ms Marushka Caldeiro, Client Manager,
ACHS Customer Services Manager. DAA Group Ltd, NZ
Ms Sally Percy, Group Quality and Risk Manager, Royal
District Nursing Service (Melbourne), VIC
Ms Alison Hoare, Director of Nursing and Midwifery,
Quorn Health Services, SA
Ms Kellie-Anne Thomas, Improvement Coordinator, The
Sydney Children’s Network, NSW
Ms Danielle O’Sullivan, Support Officer, Blue Care South
West, Toowoomba, QLD
March 2016 415

Working Group 2 Dr Fung Yee Teresa Li, Former Department Operations

Manager, Queen Mary Hospital. Hong Kong (1995-
1.2.1 Information about services
2012), Council Member of Hong Kong Association of
1.2.2 A
ccess is appropriate to needs and prioritised Orthopaedic Nurses. College of Nursing Hong Kong,
according to clinical need Council Member (2004-2013) and Co-opted Member
1.3.1 T
he right care and services are provided in the from 2014
right setting
Associate Professor Richard West, ACHS Surveyor /
1.4.1 C
are and services are best evidence based Honorary VMO Royal Prince Alfred Hospital, Surgeon to
and processes are effective BreastScreen Programme
Ms Chen Anderson, Chair / ACHS Standards Committee Ms Jacqueline Ludher, Patient Safety Officer, Sydney
Children’s Hospital, NSW
Ms Megan Nelson, ACHS Customer Services Manager
Ms Gabrielle O’Grady, Clinical Practice Improvement
Mr Timothy Gardner, ACHS Surveyor / Hospital Project Officer / Registered Nurse, The Children’s
Administrator, American Heart Association Coordinator, Hospital at Westmead, NSW
International Patient Service Coordinator, International
Hospital of Bahrain Ms Deborah Lewis, ACHS Surveyor / Ex-Director of
Clinical Services
Ms Laurel Mimmo, Quality Manager / Clinical
Improvement Officer, Sydney Children’s Hospital, NSW Ms Sue Gilham, ACHS Survey Coordinator
Ms Christine Best, ACHS Surveyor / After Hours Ms Becky Ho, Cluster General Manager (Nursing),
Coordinator, Kilmore and District Hospital, VIC Prince of Wales Hospital, Hospital Authority, HK
Ms Melanie Taylor, Director of Allied Health, Eastern Ms Noreen Cubis, ACHS Surveyor / Quality Manager,
Health, VIC South Eastern Sydney Medicare Local, NSW
Mr Edwin Chow, Manager, Quality and Standards Working Group 4

Department, Quality and Safety Division, Hospital
Authority Head Office, HK 1.6.1 Involvement of consumers in the
health service
Dr John Monagle, ACHS Surveyor / Private clinical practice
1.6.2 Rights and responsibilities
Ms Barbara Slaughter, ACHS Surveyor / Quality and 1.6.3 Diverse needs and diverse backgrounds
Clinical Governance Consultant
2.1.1 Quality improvement
Mr Karl Kang Young, Consultant, Adult ICU, Queen Mary 2.1.2 Risk management; clinical and corporate
Hospital, HK
2.1.3 Incident management
Working Group 3 2.1.4 Complaints and feedback management
1.5.1 Medication safety Dr Hobby Cheung, Chair / ACHS Standards Committee

1.5.2 Infection control
Ms Linda Brennan, ACHS Customer Services Manager
1.5.3 Skin integrity
Ms Patricia Warn, ACHS Standards Committee /
1.5.4 Falls prevention and management
Consumers Health Forum of Australia
1.5.5 Blood management
Ms Nancy Broer, ACHS Standards Committee
1.5.6 Correct patient, correct procedure, correct site
1.5.7 Nutrition Dr Hing-yu So, Service Director in Quality and Safety,
New Territories East Cluster, HK
Ms Helen Dowling, Chair / ACHS Standards Committee Dr Wai Lai Darwin Mak, Senior Medical Officer
Ms Raman Dhaliwal, ACHS Customer Services Manager (Regulatory) 4, Department of Health, HK
Ms Patty Warn, ACHS Standards Committee /

Consumers Health Forum of Australia
Ms Ka Pui Gladys Cheng, Kowloon East Cluster Ms Sharon Godleman, EO / DON, Yorketown Hospital
Information Security and Privacy Officer / Manager & Health Service and Melaleuca Court Nursing Home,
(Quality & Standards / Risk Management), United CHSALHN (Yorke & Northern Rural Region), SA
Christian Hospital, HK
Mr Ian Fuller, Director of Workforce, Sydney Children’s
Ms Bonnie Wong, Cluster Manager (Quality & Safety), Hospitals Network, NSW
Tuen Mun Hospital, HK
Ms Karin Mulligan, Project Officer, Quality Unit, Royal
Ms Sal Faid, Consumer Auditor, DAA Group, NZ Darwin Hospital / Executive Officer Top End Health
Service Board, Department of Health, NT
Ms Robyn Ware, Quality Coordinator, St Andrew’s
Hospital, SA Dr David Lester-Smith, General Paediatrician / Network
Associate Director Medical Education Co-Lead, Sydney
Mr Vince Gaglioti, Quality Manager, St Vincent’s Hospital
Children’s Hospital Network, NSW
Melbourne (public), VIC
Ms Maria Stickland, ACHS Consultant Coordinator
Mr David Poon, Quality and Safety Consumer Consultant,
Tasmanian Health Organisation - South, TAS
Working Group 6
Ms Maria Darby, Senior Manager, Quality, Client Safety
and Governance, Minda Incorporated, SA 1.1.8 Health records content
2.3.1 Health records management
Ms Kay Babalis, Network Manager Improvement,
Sydney Children’s Hospitals Network, NSW 2.3.2 Corporate records management
2.3.3 Collection, use and storage of data
Ms Christine Fuller, Chief Nursing Officer, GEO Care
and information
Australia, Southbank, VIC
2.3.4 Information and communications technology
Dr Peter Kendall, ACHS Surveyor / Staff Physician,
Fremantle Hospital, WA Ms Cathy Cummings, Chair / ACHS Standards Committee
Mr Robin Mead, ACHS Customer Services Manager
Working Group 5
Ms Wai Man Au, Health Information and Records
2.2.1 Human resources planning
Manager 1, Queen Elizabeth Hospital / Hospital
2.2.2 Recruitment, selection and appointment Authority, HK
2.2.3 Continuing employment /
Ms Glynda Summers, Executive Director of Nursing and
professional development
Midwifery, Cairns and Hinterland and Hospital Health
2.2.4 Learning and development system Service, QLD
2.2.5 Support and workplace relations
Ms Maria McLaughlin-Rolfe, Service Delivery Manager,
Blue Care / Uniting Care, QLD
Ms Margo Carberry, Chair / ACHS Standards Committee
Ms Kaye Hogan, ACHS Survey Coordinator
Mr Michael Wright, ACHS Customer Services Manager
Ms Jodie Reynolds, Audit and Information Coordinator,
Ms Siu Fong Fanny Wong, Quality Assurance Manager /
Cabrini, VIC
Planning and Training Officer, Union Hospital, HK
Ms Helen Milne, ACHS Survey Coordinator
Ms Pui-Hung Wong, Department Operations Manager,
Princess Margaret Hospital, HK Ms Dodo Kwok, Health Information & Records Manager
1, United Christian Hospital / Hospital Authority, HK
Ms Glenda Ray, Quality Manager, Mercy Hospice,
Auckland, NZ
Ms Rosalind O’Sullivan, ACHS Surveyor / Director of
Corporate Affairs, NSW Bureau of Health Information,
NSW
March 2016 417

Working Group 7 Ms Julie Li, General Manager (Administrative Services),

Tung Wah Eastern Hospital, HK
3.1.1 Strategic and operational planning
3.1.2 G
overnance structures, delegations and Ms Andrea Taylor, Director, Mental Health Drug &
financial management Alcohol, Northern Sydney LHD, NSW
3.1.3 C
redentialing and defining the scope of Mr Kenneth Campbell, ACHS Surveyor
clinical practice Mr Graeme Houghton, Chair, Tasmanian Health
3.1.4 External services providers Organisations, TAS
3.1.5 Corporate and clinical policies Ms Esther Law, General Manager (Admin. Services),
2.5.1 Encouraging and governing research Cheshire Home, Shatin / Cluster Coordinator (General
Support Services), New Territories East Cluster, HK
Dr Philip Hoyle, Chair / ACHS Standards Committee
Mr David Miller, Consultant Surveyor
Ms Raman Dhaliwal, ACHS Customer Services Manager
Dr Kin-hang Kung, Senior Medical and Health Officer, Specialist Reference Groups were established to
Department of Health, HK review some specific EQuIP6 criteria.
Mr Peter Clark, Surveyor / Auditor, DAA Group Ltd., NZ Reference Group Leads
Ms Karen Edwards, ACHS Survey Coordinator / Chief Professor Emeritus Douglas E Joshua, University of
Executive Officer and Director of Nursing, Calvary Health Sydney. Haematologist, Royal Prince Alfred Hospital.
Care Sydney, NSW
Mr Steve Burke, Operations Manager, Australasian
Mr Alex Bennie, ACHS Surveyor / Consultant College for Infection Prevention and Control.
Ms Susan Woodard, Quality Project Officer, Women’s
and Children’s Health Network, SA ACHS would also like to acknowledge the
following members and surveyors for their
Ms Leonie Fowke, General Manager, Blue Care Metro invaluable feedback during the Field Review phase
South, QLD of the development of EQuIP6
Dr Robert Griffin, ACHS Surveyor
Amanda Gill, Clinical Quality Coordinator, Arohanui
Mr Wayne Singh, Consultant Surveyor Hospice, NZ
Working Group 8 Amanda Singleton, ACHS Surveyor
3.2.1 W
orkplace health and safety (including Athene Anderson, Social Worker, Radiation Oncology,
dangerous goods, hazardous substances & CACHS, The Canberra Hospital, ACT
radiation, manual handling) Brian Bell, ACHS Surveyor
3.2.2 B
uildings, signage, plant, equipment, supplies, Chan Yuk Sim, Director of Nursing, Gleneagles Hong
utilities and consumables Kong Hospital & ACHS Surveyor
3.2.3 Waste and environmental management
Christine Best, ACHS Surveyor
3.2.4 Emergency and disaster management
3.2.5 Security management Deborah Lewis, ACHS Surveyor
Florence Fung, Administration Executive, Union Hospital,
Mr Stephen Walker, Chair / ACHS Standards Committee HK
Ms Dijana Karaconji, ACHS Customer Services Manager Glenda Ray, Quality Manager, Mercy Hospice,
Mr Yiu Wing Kwan, Manager-in-Charge (Quality & Auckland NZ
Safety), Hong Kong Baptist Hospital, HK Hilary Ashby, Quality Co-ordinator, RDNS SA Ltd (Part of
Ms Yuen Ting Julie Ma, Manager (Occupational Safety & Silver Chain Group), SA
Health) 1, Hospital Authority, HK Janet Varnam, SLHD Haemovigilance CNC, NSW Health
Pathology - Sydney Local Health District, NSW
John Monagle, ACHS Surveyor The following healthcare organisations and
surveyors generously participated in the trials
Judy Hindrup, Former CEO, Atawhai Mercy Assisi Home
of the EQuIP Standards as pilot organisations,
and Hospital, NZ
and provided invaluable information during the
Karl Kang Young, Consultant, Queen Mary Hospital, development of EQuIP6.
HK / ACHS Surveyor
Kaye Hogan AM, ACHS Surveyor Pilot Sites
Kwan Yiu Wing, Manager I/C (Quality & Safety), Quality & Te Oranganui Iwi Health Authority. (TOIHA), New Zealand
Safety Department, Hong Kong Baptist Hospital, HK DAA Group, New Zealand
Lee Shui Kuen Bernadette, Senior Nursing Officer, Tsuen Robin Steed (coordinator)
Wan Adventist Hospital, HK / ACHS Surveyor Charmaine Pene (surveyor)
Len Payne, ACHS Surveyor
Prince of Wales Hospital, Hong Kong
Maria Stickland, ACHS Surveyor
Hong Kong Hospital Authority
Marilyn Sneddon, ACHS Surveyor Marilyn Sneddon (coordinator)
Marjorie Pawsey AM, Visiting Fellow, Centre for Carmel Peek (surveyor)
Healthcare Resilience and Implementation Science,
Australian Institute of Health Innovation, Macquarie Gladys Kwan (surveyor)
University, NSW Manbo Man (surveyor)
Noreen Cubis, Quality Manager, SESML / ACHS Surveyor Mary Foong (trainee)
Paula Elliott, ACHS Surveyor Peter Kendall (surveyor)
Rebecca Ng, Honorary Advisor (CND) Queen Elizabeth Philip Hoyle (surveyor)
Hospital, HK / ACHS Surveyor
Rita Chan (surveyor)
Sally Percy, Manager, Quality and Risk, RDNS Ltd, VIC /
ACHS Surveyor Teresa Li (surveyor)
Samantha Thorogood, QI Coordinator and Project ACHS Executive

Officer, Watershed DAREC, NSW Christine Dennis, Chief Executive Officer
Sharon Godleman, Multi Campus Executive Desmond Yen, Executive Director -
Officer / Director of Nursing, Yorke and Northern Rural International Business
Region, Country Health SA Local Health Network,
SA / ACHS Surveyor Lena Low, Executive Director - Corporate Services &
Surveyor Workforce
Shirley Batho, ACHS Surveyor
Linda O’Connor, Executive Director - Customer Services
Sue Jovanovich, Manager, Quality and Accreditation, & Development
Central Adelaide Local Health Network, SA
Valda Allen, Quality Coordinator, The
Haymarket Foundation, NSW
Vivienne Chau, A/SLHD Haemovigilance CNC, NSW
Health Pathology - Sydney Local Health District, NSW
Wayne Singh, ACHS Surveyor
March 2016 419

ACHS EQuIP6 Project Team

Linda O’Connor, Executive Director - Customer Services
& Development
Deborah Jones, Manager - Standards and Product
Development (Project Manager)
Elizabeth Kingsley, Project Officer - Standards and
Product Development
Mark Burgess, Project Officer - Standards and
Product Development
Ian McManus, Manager - Communications
Sareeta Ngairangbam, Manager - International
Business Services
Janelle Lee, EA to Executive Director - Customer
Services & Development
March 2016 421
Safety
Quality
Performance
Enquiries regarding EQuIP6, other ACHS accreditation

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

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The ACHS EQuIP6 GUIDE

Section 1 The Standards (Corporate Function) 319

ACHS and Accreditation 7 Section 8

March 2016 213

 ffectively manages all corporate and clinical risks in

 ontinuously improves all aspects of the organisation

March 2016 215

Criterion 2.1.1 a) Policy / guidelines addressing a) Quality improvement is planned

Overview Relationships of 2.1.1 with other criteria

March 2016 217

Criterion 2.1.1 identify the strengths and weaknesses of the

March 2016 219

March 2016 221

Criterion 2.1.2 a) Policy / guidelines addressing a) There is integration between quality

Overview Relationships of 2.1.2 with other criteria

March 2016 223

Criterion 2.1.2 implementation of financial management systems

March 2016 225

Criterion 2.1.2 Standards

 trategic, operational and business plans that

Criterion 2.1.3 a) Policy / guidelines addressing a) There is an integrated incident

March 2016 229

Criterion 2.1.3 Supporting the identification and reporting

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Criterion 2.1.3 Supporting the principles of

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Criterion 2.1.4 a) Policy / guidelines addressing a) T

Overview Relationships of 2.1.4 with other criteria

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Criterion 2.1.4  nsure complaints are actioned and all participants

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2.2 Human Resources The standard for human resources management

The standard is: Workforce planning supports the organisation’s

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Criterion 2.2.1 a) Policy / guidelines / tools a) The workforce strategic plan is

Overview Relationships of 2.2.1 with other criteria

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Criterion 2.2.2 a) Policy / guidelines addressing a) The recruitment, selection and

Overview Relationships of 2.2.2 with other criteria

This criterion requires healthcare Recruitment, selection and appointment

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Criterion 2.2.2 Suggested reading

Criterion 2.2.3 a) Accurate and complete personnel a) The performance management

Overview Relationships of 2.2.3 with other criteria

Effective implementation and management of appropriate This criterion requires healthcare

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Criterion 2.2.3 promote staff retention. While it may not be necessary or

 onitor compliance with organisational policy and

 ow are staff and volunteers made aware of the

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Criterion 2.2.3 Standards

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Criterion 2.2.4 a) There is a planned and a) There is an evidence-based

Relationships of 2.2.4 with other criteria This criterion requires healthcare

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Criterion 2.2.4 • training in management skills, for example,

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Overview Relationships of 2.2.5 with other criteria

This criterion requires healthcare Workplace rights and responsibilities

ffectively manages all corporate and clinical risks in

ontinuously improves all aspects of the organisation

Criterion 2.1.1 a) Policy / guidelines addressing a) Quality improvement is planned

Criterion 2.1.1 identify the strengths and weaknesses of the

Criterion 2.1.2 a) Policy / guidelines addressing a) There is integration between quality

Criterion 2.1.2 implementation of financial management systems

trategic, operational and business plans that

Criterion 2.1.3 a) Policy / guidelines addressing a) There is an integrated incident

Criterion 2.1.4 a) Policy / guidelines addressing a) T

Criterion 2.1.4 nsure complaints are actioned and all participants

The standard is: Workforce planning supports the organisation’s

Criterion 2.2.1 a) Policy / guidelines / tools a) The workforce strategic plan is

Criterion 2.2.2 a) Policy / guidelines addressing a) The recruitment, selection and

Criterion 2.2.3 a) Accurate and complete personnel a) The performance management

onitor compliance with organisational policy and

ow are staff and volunteers made aware of the

Criterion 2.2.4 a) There is a planned and a) There is an evidence-based

Criterion 2.2.4 • training in management skills, for example,

nsure that the safety and security of consumers /

nsure that remedial or disciplinary action is taken

Criterion 2.3.1 a) Policy / guidelines addressing a) There is a health records

Criterion 2.3.1 onduct clinical classification in accordance with

This criterion requires healthcare • damage

vidence of monitoring / tracking of health

etention / destruction schedule for health

Criterion 2.3.2 a) Policy / guidelines for corporate a) There is a corporate records

Criterion 2.3.3 a) Policy / guidelines addressing a) An implemented information

Criterion 2.3.3 nsure that corporate data and information are

e collected within defined timeframes and in defined

• inpatient statistics ow are health professionals involved in data

Criterion 2.3.4 a) There is effective governance of a) The organisation’s ICT planning

Criterion 2.3.4 include the implementation of organisation-wide

Criterion 2.4.1 a) Policy / guidelines addressing a) The organisation optimises the

• harm from UV exposure ow does the organisation ensure that

e designed at a level appropriate to the health

• socioeconomic factors ow were staff consulted in the development of

Criterion 2.4.1 e factored into the evaluation of all organisational

Staff education and training should: Relevant referrals in discharge plans

ssist the organisation to increase its capacity to

nsure that staff understand their responsibilities in

ddress health literacy, and ensure that staff are aware

Criterion 2.5.1 a) The organisation fosters and a) The organisation’s research

Criterion 2.5.1 it was coordinated by an external health authority,

In general, an organisation would be considered to be any project requiring blood sampling.

Criterion 2.5.1 e overseen by a nominated individual or committee,