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ISBN: 978-1-921983-04-7
Suggested citation:
Australian Commission on Safety and Quality in Health Care, National Safety and Quality Health Service Standards
(September 2012). Sydney. ACSQHC, 2012.
Acknowledgements
This document was prepared by the Australian Commission on Safety and Quality in Health Care in collaboration with numerous
expert working groups and members of the Commission’s standing committees who generously gave of their time and
expertise. Thanks also go to the numerous individuals and organisations, health services, practitioners, consumers, managers
and health departments who have provided the feedback that made these Standards possible.
National Safety and Quality Health Service Standards | 1
Contents
Introduction3
Terminology7
References72
The Hon Dr Kim Hames
Chair, Australian Health Ministers’ Conference
Minister for Health
AHMC Secretariat
PO Box 344
RUNDLE MALL SA 5000
Dear Minister
The Commission developed the Standards following extensive public and stakeholder consultation. The
Standards are a critical component of the Australian Health Services Safety and Quality Accreditation Scheme
endorsed by the Australian Health Ministers in November 2010.
The Standards provide a nationally consistent and uniform set of measures of safety and quality for application
across a wide variety of health care services. They propose evidence-based improvement strategies to deal
with gaps between current and best practice outcomes that affect a large number of patients.
The Standards are designed to assist health service organisations to deliver safe and high quality care.
The document presents the ten National Safety and Quality Health Service Standards and details the tasks
required to fulfil them.
I acknowledge the contribution, effort and enthusiasm of the many clinicians, managers, consumers and
organisations involved in their development. And I commend the diligence and commitment of our staff who
developed them.
Yours sincerely
William J Beerworth
Chair
19 May 2011
National Safety and Quality Health Service Standards | 3
Introduction
This document presents the ten National Safety and standards of safety and quality are met, and a quality
Quality Health Service (NSQHS) Standards. The improvement mechanism that allows health services
NSQHS Standards were developed by the Australian to realise aspirational or developmental goals.
Commission on Safety and Quality in Health Care
(ACSQHC) in consultation and collaboration with Accreditation is recognised as an important driver
jurisdictions, technical experts and a wide range for safety and quality improvement and Australia’s
of stakeholders, including health professionals health accreditation processes are highly regarded
and patients. internationally1. The Standards are integral to the
accreditation process as they determine how and
The primary aims of the NSQHS Standards are to against what an organisation’s performance will be
protect the public from harm and to improve the assessed. The Standards have been designed for use
quality of health service provision. They provide a by all health services. Health service organisations
quality assurance mechanism that tests whether can use the Standards as part of their internal quality
relevant systems are in place to ensure minimum assurance mechanisms or as part of an external
accreditation process.
2. Partnering with Consumers which describes the systems and strategies to create a
consumer-centred health system by including consumers in the development and design of quality
health care.
4. Medication Safety which describes the systems and strategies to ensure clinicians safely
prescribe, dispense and administer appropriate medicines to informed patients.
Patient Identification and Procedure Matching which describes the systems and strategies
5.
to identify patients and correctly match their identity with the correct treatment.
6. Clinical Handover which describes the systems and strategies for effective clinical
communication whenever accountability and responsibility for a patient’s care is transferred.
7. Blood and Blood Products which describes the systems and strategies for the safe,
effective and appropriate management of blood and blood products so the patients receiving
blood are safe.
8. Preventing and Managing Pressure Injuries which describes the systems and strategies
to prevent patients developing pressure injuries and best practice management when pressure
injuries occur.
10. Preventing Falls and Harm from Falls which describes the systems and strategies to reduce
the incidence of patient falls in health service organisations and best practice management when
falls do occur.
Introduction
Introduction
This section outlines the role for each group of The role of the non-clinical workforce is also
participants in ensuring the safe and effective important to the delivery of quality health care. This
delivery of healthcare services in a health workforce group may be paid or consist of volunteers.
service organisation. By actively participating in organisational processes
– including the development and implementation of
Patients and carers have an important role to play safety systems, improvement initiatives and related
in the safe delivery of health care. As a partner with training – the limitations of safety systems can be
health service organisations and their healthcare identified and addressed. A key role for this group is
providers, patients and carers will be involved in notifying the clinical workforce when concerns exist
making decisions for service planning, developing about a patient.
models of care, measuring service and evaluating
systems of care. They will also participate in making Health service managers implement and maintain
decisions about their own health care and for this systems, materials, education and training that ensure
they will need to know and exercise their healthcare the clinical workforce delivers safe, effective and
rights and be engaged in their health care and reliable health care. They support the establishment
treatment decisions. Patients and carers will have a of partnerships with patients and carers when
need to access information about options and agreed designing, implementing and maintaining systems.
treatment plans. Health care can be improved when Their key role is managing performance and
patients and carers share – with their health care facilitating compliance across the organisation
provider – issues that may impact on their compliance and within individual areas of responsibility for
with treatment plans. the governance of safety and quality systems.
They are leaders who can model behaviours that
The clinical workforce is essential to the delivery of optimise safe and high quality care. Safer systems
safe and high-quality health care. Improvement to the can be achieved when health service managers
system can be achieved when the clinical workforce consider safety and quality implications in their
actively participates in organisational processes, decision‑making processes.
safety systems, improvement initiatives, and is
trained in the roles and services for which they are The role of health service executives and owners
accountable. The clinical workforce can make health is to plan and review integrated governance systems
systems safer and more effective if they: that promote patient safety and quality and to
• understand their broad responsibility for safety clearly articulate organisational and individual
and quality in health care accountabilities for safety and quality throughout
the organisation. The explicit support for the role
• follow safety and quality procedures
of patients and carers in safety, models of care,
• supervise and educate other members of program design and review of the organisations
the workforce performance is key to the establishment of effective
• participate in the review of performance partnerships with health service managers and the
procedures individually, or as part of a team. clinical workforce.
When the clinical workforce forms partnerships
with patients and carers, not only can a patient’s
experience of care be improved, but the design and
planning of organisational processes, safety systems,
quality initiatives and training can be more effective
as well.
Terminology
Accreditation: A status that is conferred on an Antibiotic: A substance that kills or inhibits the
organisation or an individual when they have been growth of bacteria.6
assessed as having met particular standards. The two
conditions for accreditation are an explicit definition Antimicrobial: A chemical substance that inhibits
of quality (i.e. standards) and an independent review or destroys bacteria, viruses and fungi, including
process aimed at identifying the level of congruence yeasts or moulds.6
between practices and quality standards.2 Antimicrobial stewardship: A program implemented
Acute health care facility: A hospital or other health in a health service organisation to reduce the risks
care facility providing healthcare services to patients associated with increasing microbial resistance and to
for short periods of acute illness, injury or recovery.3 extend the effectiveness of antimicrobial treatments.
Antimicrobial stewardship may incorporate a broad
ACSQHC: Australian Commission on Safety and range of strategies including the monitoring and
Quality in Health Care. reviews of antimicrobial use.6
Advance care directive: Instructions that consent Approved patient identifiers: Items of information
to, or refuse the future use of, specified medical accepted for use in patient identification, including
treatments (also known as a healthcare directive, patient name (family and given names), date of
advance plan or another similar term).3 birth, gender, address, medical record number
and/or Individual Healthcare Identifier. Health
Advanced life support: The preservation or service organisations and clinicians are responsible
restoration of life by the establishment and/or for specifying the approved items for patient
maintenance of airway, breathing and circulation identification. Identifiers such as room or bed number
using invasive techniques such as defibrillation, are not to be used.
advanced airway management, intravenous access
and drug therapy.3 Basic life support: The preservation of life by
the initial establishment of, and/or maintenance
Adverse drug reaction: A drug response that of, airway, breathing, circulation and related
is noxious and unintended, and which occurs at emergency care, including use of an automated
doses normally used or tested in humans for the external defibrillator.7
prophylaxis, diagnosis or therapy of disease, or
for the modification of physiological function.4 Blood: Includes homologous and autologous
whole blood. Blood including red blood cells,
Adverse event: An incident in which harm resulted platelets, fresh frozen plasma, cryoprecipitate and
to a person receiving health care. cryodepleted plasma.8
Adverse medicines event: An adverse event due Blood products: Plasma derivatives and recombinant
to a medicine. This includes the harm that results products, excluding medication products.8
from the medicine itself (an adverse drug reaction)
and the potential or actual patient harm that comes Carers: People who provide unpaid care and support
from errors or system failures associated with the to family members and friends who have a disability,
preparation, prescribing, dispensing, distribution or mental illness, chronic condition, terminal illness or
administration of medicines (medication incident).5 general frailty.9 Carers include parents and guardians
caring for children.
Terminology
Terminology
Escalation protocol: The protocol that sets out the Healthcare associated infections: Infections that
organisational response required for different levels are acquired in healthcare facilities (nosocomial
of abnormal physiological measurements or other infections) or that occur as a result of healthcare
observed deterioration. The protocol applies to the interventions (iatrogenic infections). Healthcare
care of all patients at all times.3 associated infections may manifest after people leave
the healthcare facility.19
Fall: An event that results in a person coming to
rest inadvertently on the ground or floor or another Health outcome: The health status of an
lower level.17 individual, a group of people or a population that is
wholly or partially attributable to an action, agent
Guidelines: Clinical practice guidelines are or circumstance.
‘systematically developed statements to assist
practitioner and patient decisions about appropriate Health service organisation: A separately
health care for specific circumstances’.18 constituted health service that is responsible for
the clinical governance, administration and financial
Governance: The set of relationships and management of a service unit(s) providing health
responsibilities established by a health service care. A service unit involves a grouping of clinicians
organisation between its executive, workforce and and others working in a systematic way to deliver
stakeholders (including consumers). Governance health care to patients and can be in any location
incorporates the set of processes, customs, policy or setting, including pharmacies, clinics, outpatient
directives, laws and conventions affecting the facilities, hospitals, patients’ homes, community
way an organisation is directed, administered or settings, practices and clinicians’ rooms.
controlled. Governance arrangements provide the
structure through which the corporate objectives Health service record: Information about a patient
(social, fiscal, legal, human resources) of the held in hard or soft copy. The health service record
organisation are set and the means by which the may comprise of clinical records (e.g. medical history,
objectives are to be achieved. They also specify treatment notes, observations, correspondence,
the mechanisms for monitoring performance. investigations, test results, photographs, prescription
Effective governance provides a clear statement of records, medication charts), administrative records
individual accountabilities within the organisation (e.g. contact and demographic information, legal
to help in aligning the roles, interests and actions and occupational health and safety reports) and
of different participants in the organisation to financial records (e.g. invoices, payments and
achieve the organisation’s objectives. In these insurance information).
Standards, governance includes both corporate
and clinical governance. High-risk medicines: Medicines that have a high
risk of causing serious injury or death to a patient if
Hand hygiene: A general term referring to any action they are misused. Errors with these products are not
of hand cleansing. necessarily more common, but the effects can be
more devastating. Examples of high-risk medicines
include anticoagulants, opioids and chemotherapy.20
Terminology
Hospital: A healthcare facility licensed by the Medication: The use of medicine for therapy or
respective regulator as a hospital or declared as for diagnosis, its interaction with the patient and
a hospital. its effect.
Human factors: Study of the interactions between Medication authorities: An organisation’s formal
humans and other elements of a system, and the authorisation of an individual, or group of individuals,
profession that applies theory, principles, data and to prescribe, dispense or administer medicines or
methods to design in order to optimise human categories of medicine consistent with their scope
wellbeing and overall system performance.21 of practice.
Incident: An event or circumstance that resulted, Medication error: Any preventable event that may
or could have resulted, in unintended and/or cause or lead to inappropriate medication use or
unnecessary harm to a person and/or a complaint, patient harm while the medication is in the control of
loss or damage. the healthcare professional, patient or consumer.24
Terminology
Monitoring plan: A written plan that documents Patient-centred care: The delivery of health care
the type and frequency of observations to be that is responsive to the needs and preferences
recorded as referred to in Standard 9, ‘Recognising of patients. Patient-centred care is a dimension
and Responding to Clinical Deterioration in Acute of safety and quality.
Health Care’.3
Patient clinical record: Consists of, but is not limited
Near miss: An incident that did not cause harm, to, a record of the patient’s medical history, treatment
but had the potential to do so.27 notes, observations, correspondence, investigations,
test results, photographs, prescription records and
Non-clinical workforce: The workforce engaged medication charts for an episode of care.
in a health service organisation who do not provide
direct clinical care but support the business of health Patient information: Formal information that is
service delivery through administration, hotel service provided by health services to a patient. Patient
and corporate record management, management information ensures the patient is informed before
support or volunteering. making decisions about their health care.
Terminology
Pressure injuries: These are localised to the System: The resources, policies, processes and
skin and/or underlying tissue, usually over a bony procedures that are organised, integrated, regulated
prominence and caused by unrelieved pressure, and administered to accomplish the objective of the
friction or shearing. Pressure injuries occur most Standard. The system:
commonly on the sacrum and heel but can • interfaces risk management, governance,
develop anywhere on the body. Pressure injury is operational processes and procedures, including
a synonymous term for pressure ulcer. education, training and orientation
Procedure: The set of instructions to make • deploys an active implementation plan and
policies and protocols operational and are specific feedback mechanisms
to an organisation. • includes agreed protocols and guidelines, decision
support and other resource material
Protocol: An established set of rules used for the
• employs a range of incentives and sanctions to
completion of tasks or a set of tasks.
influence behaviours and encourage compliance
Rapid response system: The system for providing with policy, protocol, regulation and procedures.
emergency assistance to patients whose condition is
Training: The development of knowledge and skills.
deteriorating. The system includes the clinical team or
individual providing emergency assistance, and may Treatment-limiting orders: Orders, instructions
include on-site and off-site personnel.3 or decisions that involve the reduction, withdrawal
or withholding of life-sustaining treatment. These
Recognition and response systems: Formal
may include ‘no cardiopulmonary resuscitation’ or
systems that help workforce promptly and reliably
‘not for resuscitation’.3
recognise patients who are clinically deteriorating,
and appropriately respond to stabilise the patient.3 Workforce: All those people employed by a health
service organisation.
Regular: Performed at recurring intervals. The
specific interval for regular review, evaluation, audit or
monitoring and so on need to be determined for each
case. In these Standards, the time period should be
consistent with best practice, be risk based, and be
determined by the subject and nature of the review.
Standard 1 – G
overnance for Safety and Quality
in Health Service Organisations
Standard 3 – P
reventing and Controlling Healthcare
Associated Infections
Standard 5 – P
atient Identification and
Procedure Matching
Standard 8 – P
reventing and Managing
Pressure Injuries
Explanatory notes
Although most health care in Australia is associated Economic projections for total health expenditure
with good clinical outcomes, patients still do not indicate that fiscal pressure on the system will only
always receive all the care that is recommended to rise in the future. An increase of $90.9 billion in total
them, and preventable adverse events continue to health expenditure was predicted between 2003 and
occur across the Australian healthcare system.32 2032–33.33 This figure could be reduced or the rate
of increase slowed, if safer and higher quality care
Presently, the data that measures the extent to which is provided.
problems are occurring are unavailable or unreliable.
This prevents the establishment of a baseline value A systematic approach to quality improvement
from which improvements in safety and quality of care identifies those accountable for action in health
can be measured. service organisations, and focuses on risk, quality
and patient safety to ensure that the necessary
However, in recent years, there has been a shift in monitoring and actions are taken to improve services.
both the awareness of, and investment in, safety and Safety and high quality care requires the vigilance and
quality by Australian health services. Health Service cooperation of the whole healthcare workforce.
organisations have developed and implemented
policy, educational materials and processes for
improvement (including credentialing, mortality
reviews, incident monitoring and root-cause analysis).
These changes have improved the safety and quality
of health care for patients. Still, more needs to be
done to ensure all patients are protected from harm
and receive the highest possible standard of care.
16 | National Safety and Quality Health Service Standards
1.1 Implementing a governance system 1.1.1 An organisation-wide management system is in place for
that sets out the policies, procedures the development, implementation and regular review of policies,
and/or protocols for: procedures and/or protocols
• establishing and maintaining a
clinical governance framework
• identifying safety and quality risks
• collecting and reviewing
performance data
• implementing prevention strategies
based on data analysis
1.1.2 The impact on patient safety and quality of care is
• analysing reported incidents
considered in business decision making
• implementing performance
management procedures
• ensuring compliance with legislative
requirements and relevant
industry standards
• communicating with and informing the
clinical and non-clinical workforce
• undertaking regular clinical audits
1.2 The board, chief executive officer 1.2.1 Regular reports on safety and quality indicators and other
and/or other higher level of governance safety and quality performance data are monitored by the
within a health service organisation executive level of governance
taking responsibility for patient safety and 1.2.2 Action is taken to improve the safety and quality
quality of care of patient care
1.3 Assigning workforce roles, 1.3.1 Workforce are aware of their delegated safety and quality
responsibilities and accountabilities to roles and responsibilities
individuals for: 1.3.2 Individuals with delegated responsibilities are supported
• patient safety and quality in their to understand and perform their roles and responsibilities,
delivery of health care in particular to meet the requirements of these Standards
• the management of safety and quality 1.3.3 Agency or locum workforce are aware of their designated
specified in each of these Standards roles and responsibilities
1.4 Implementing training in the 1.4.1 Orientation and ongoing training programs provide the
assigned safety and quality roles workforce with the skill and information needed to fulfil their
and responsibilities safety and quality roles and responsibilities
1.4.2 Annual mandatory training programs to meet the
requirements of these Standards
1.4.3 Locum and agency workforce have the necessary
information, training and orientation to the workplace to fulfil
their safety and quality roles and responsibilities
1.4.4 Competency-based training is provided to the clinical
workforce to improve safety and quality
1.5 Establishing an organisation-wide risk 1.5.1 An organisation-wide risk register is used and
management system that incorporates regularly monitored
identification, assessment, rating,
controls and monitoring for patient safety 1.5.2 Actions are taken to minimise risks to patient safety
and quality and quality of care
Clinical practice
Care provided by the clinical workforce is guided by current best practice.
1.7 Developing and/or applying 1.7.1 Agreed and documented clinical guidelines and/or
clinical guidelines or pathways that are pathways are available to the clinical workforce
supported by the best available evidence 1.7.2 The use of agreed clinical guidelines by the clinical
workforce is monitored
1.8 Adopting processes to support the 1.8.1 Mechanisms are in place to identify patients at increased
early identification, early intervention and risk of harm
appropriate management of patients at 1.8.2 Early action is taken to reduce the risks for at-risk patients
increased risk of harm
1.8.3 Systems exist to escalate the level of care when there is an
unexpected deterioration in health status
1.9 Using an integrated patient clinical 1.9.1 Accurate, integrated and readily accessible patient clinical
record that identifies all aspects of the records are available to the clinical workforce at the point of care
patient’s care 1.9.2 The design of the patient clinical record allows for
systematic audit of the contents against the requirements of
these Standards
1.10 Implementing a system that 1.10.1 A system is in place to define and regularly review the
determines and regularly reviews the scope of practice for the clinical workforce
roles, responsibilities, accountabilities 1.10.2 Mechanisms are in place to monitor that the clinical
and scope of practice for the workforce are working within their agreed scope of practice
clinical workforce
1.10.3 Organisational clinical service capability, planning and
scope of practice is directly linked to the clinical service roles
of the organisation
1.10.4 The system for defining the scope of practice is used
whenever a new clinical service, procedure or other technology
is introduced
1.10.5 Supervision of the clinical workforce is provided whenever
it is necessary for individuals to fulfil their designated role
1.11 Implementing a performance 1.11.1 A valid and reliable performance review process is in place
development system for the clinical for the clinical workforce
workforce that supports performance
improvement within their scope 1.11.2 The clinical workforce participates in regular performance
of practice reviews that support individual development and improvement
1.12 Ensuring that systems are in place 1.12.1 The clinical and relevant non-clinical workforce have
for ongoing safety and quality education access to ongoing safety and quality education and training
and training for identified professional and personal development
1.13 Seeking regular feedback from 1.13.1 Analyse feedback from the workforce on their
the workforce to assess their level of understanding and use of safety and quality systems
engagement with, and understanding
of, the safety and quality system of 1.13.2 Action is taken to increase workforce understanding
the organisation and use of safety and quality systems
1.14 Implementing an incident 1.14.1 Processes are in place to support the workforce
management and investigation system recognition and reporting of incidents and near misses
that includes reporting, investigating 1.14.2 Systems are in place to analyse and report on incidents
and analysing incidents (including
near misses), which all result in 1.14.3 Feedback on the analysis of reported incidents is
corrective actions provided to the workforce
1.14.4 Action is taken to reduce risks to patients identified
through the incident management system
1.14.5 Incidents and analysis of incidents are reviewed at
the highest level of governance in the organisation
1.15 Implementing a complaints 1.15.1 Processes are in place to support the workforce
management system that includes to recognise and report complaints
partnership with patients and carers 1.15.2 Systems are in place to analyse and implement
improvements in response to complaints
1.15.3 Feedback is provided to the workforce on the analysis
of reported complaints
1.15.4 Patient feedback and complaints are reviewed at
the highest level of governance in the organisation
1.16 Implementing an open disclosure 1.16.1 An open disclosure program is in place and is consistent
process based on the national open with the national open disclosure standard
disclosure standard 1.16.2 The clinical workforce are trained in open
disclosure processes
1.17 Implementing through organisational 1.17.1 The organisation has a charter of patient rights that is
policies and practices a patient charter of consistent with the current national charter of healthcare rights
rights that is consistent with the current 1.17.2 Information on patient rights is provided and explained
national charter of healthcare rights34 to patients and carers
1.17.3 Systems are in place to support patients who are at risk
of not understanding their healthcare rights
1.18 Implementing processes to enable 1.18.1 Patients and carers are partners in the planning
partnership with patients in decisions for their treatment
about their care, including informed 1.18.2 Mechanisms are in place to monitor and improve
consent to treatment documentation of informed consent
1.18.3 Mechanisms are in place to align the information provided
to patients with their capacity to understand
1.18.4 Patients and carers are supported to document clear
advance care directives and/or treatment-limiting orders
1.19 Implementing procedures that 1.19.1 Patient clinical records are available at the point of care
protect the confidentiality of patient
clinical records without compromising
appropriate clinical workforce access 1.19.2 Systems are in place to restrict inappropriate access
to patient clinical information to and dissemination of patient clinical information
1.20 Implementing well designed, valid 1.20.1 Data collected from patient feedback systems are used
and reliable patient experience feedback to measure and improve health services in the organisation
mechanisms and using these to evaluate
the health service performance
Explanatory notes
There is growing evidence about the importance of The importance of health systems and health services
partnerships between health service organisations that are based on partnerships with patients, families,
and health professionals, and patients, families, carers and consumers is reflected in national and
carers and consumers. Studies have demonstrated international quality frameworks.39 In Australia,
significant benefits from such partnerships in clinical consumer-centred care is one of the three dimensions
quality and outcomes, the experience of care, in the Australian Safety and Quality Framework
and the business and operations of delivering care. for Health Care.40 Partnerships with patients and
The clinical benefits that have been identified as consumers also form the basis of a range of national
being associated with better patient experience and jurisdictional health policies and programs.
and patient-centred care include:
• decreased mortality 35
• decreased readmission rates36
• decreased rates of healthcare acquired infections 37
• reduced length of stay 38
• improved adherence to treatment regimens39
• improved functional status.38
2.1 Establishing governance structures 2.1.1 Consumers and/or carers are involved in the governance
to facilitate partnerships with consumers of the health service organisation
and/or carers 2.1.2 Governance partnerships are reflective of the diverse
range of backgrounds in the population served by the health
service organisation, including those people who do not usually
provide feedback
2.2 Implementing policies, procedures 2.2.1 The health service organisation establishes mechanisms
and/or protocols for partnering with for engaging consumers and/or carers in the strategic and/or
patients, carers and consumers in: operational planning for the organisation
• strategic and operational/services
planning
2.2.2 Consumers and/or carers are actively involved in decision
• decision making about safety making about safety and quality
and quality initiatives
• quality improvement activities
2.3 Facilitating access to relevant 2.3.1 Health service organisations provide orientation and
orientation and training for consumers ongoing training for consumers and/or carers to enable them
and/or carers partnering with the to fulfil their partnership role
organisation
2.4 Consulting consumers on 2.4.1 Consumers and/or carers provide feedback on patient
patient information distributed information publications prepared by the health service
by the organisation organisation (for distribution to patients)
2.4.2 Action is taken to incorporate consumer and/or carers’
feedback into publications prepared by the health service
organisation for distribution to patients
2.5 Partnering with consumers 2.5.1 Consumers and/or carers participate in the design
and/or carers to design the way care and redesign of health services
is delivered to better meet patient
needs and preferences
2.6 Implementing training for clinical 2.6.1 Clinical leaders, senior managers and the workforce
leaders, senior management and the access training on patient-centred care and the engagement
workforce on the value of and ways to of individuals in their care
facilitate consumer engagement and how 2.6.2 Consumers and/or carers are involved in training the
to create and sustain partnerships clinical workforce
2.7 Informing consumers and/or carers 2.7.1 The community and consumers are provided with
about the organisation’s safety and information that is meaningful and relevant on the organisation’s
quality performance in a format that safety and quality performance
can be understood and interpreted
independently
2.8 Consumers and/or carers 2.8.1 Consumers and/or carers participate in the analysis
participating in the analysis of safety of organisational safety and quality performance
and quality performance information 2.8.2 Consumers and/or carers participate in the planning
and data, and the development and and implementation of quality improvements
implementation of action plans
2.9 Consumers and/or carers 2.9.1 Consumers and/or carers participate in the evaluation
participating in the evaluation of patient of patient feedback data
feedback data and development of 2.9.2 Consumers and/or carers participate in the implementation
action plans of quality activities relating to patient feedback data
Antimicrobial stewardship
Safe and appropriate antimicrobial prescribing
is a strategic goal of the clinical governance system.
Explanatory notes
Infectious organisms evolve over time and continue increase patient use of health services (such as
to present new challenges for infection prevention extending length of stay and reducing access to
and management within health care. Of major available beds) and place greater demands on the
current concern is the emergence and transmission clinical workforce (such as laboratory tests and other
of antimicrobial resistant bacteria, such as tools to diagnose the infection).
methicillin‑resistant Staphylococcus aureus (MRSA)
At least half of healthcare associated infections are
and vancomycin-resistant enterococci (VRE). Other
preventable. Australian and overseas studies have
new challenges have arisen with the increase of
shown that mechanisms exist that can reduce the
infection with Clostridium difficile and multi-resistant
rate of infections caused by these agents.
Gram-negative bacteria, including those producing
extended-spectrum beta-lactamases (ESBLs) Infection prevention and control aims to reduce the
or carbapenemases. development of resistant pathogens and minimise risk
of transmission through the isolation of the infectious
In Australian healthcare settings, large numbers organism or the patient, and by using standard and
of patients are treated in close proximity to each transmission-based precautions. However, just as
other. They often undergo invasive procedures, have there is no single cause of infection, there is no
medical devices inserted and receive broad-spectrum single solution to the problems posed by healthcare
antibiotics or immunosuppressive therapies. These associated infections. Successful infection control
conditions provide ideal opportunities for the adaption requires a range of strategies across all levels of
and spread of pathogenic, infectious organisms. the healthcare system and a collaborative approach
for successful implementation. These strategies
Each year, infections associated with health
include infection control, hand hygiene surveillance
care occur in a large number of patients, making
and improving the safe and appropriate use of
healthcare associated infections the most common
antimicrobials through antimicrobial stewardship.
complication affecting patients in hospitals. Some of
these infections require stronger and more expensive Systems and governance for infection prevention,
medicines (with the added risk of complications), control and surveillance must be consistent with
and may result in life-long disabilities or even death. relevant national documents, including Australian
In addition to significant patient harm caused by Guidelines for the Prevention and Control of Infections
healthcare associated infections, such infections in Health Care.19
28 | National Safety and Quality Health Service Standards
3.1 Developing and implementing 3.1.1 A risk management approach is taken when implementing
governance systems for effective policies, procedures and/or protocols for:
infection prevention and control to • standard infection control precautions
minimise the risks to patients of
• transmission-based precautions
healthcare associated infections
• aseptic technique
• safe handling and disposal of sharps
• prevention and management of occupational exposure
to blood and body substances
• environmental cleaning and disinfection
• antimicrobial prescribing
• outbreaks or unusual clusters of communicable infection
• processing of reusable medical devices
• single-use devices
• surveillance and reporting of data where relevant
• reporting of communicable and notifiable diseases
• provision of risk assessment guidelines to workforce
• exposure-prone procedures
3.1.2 The use of policies, procedures and/or protocols
is regularly monitored
3.1.3 The effectiveness of the infection prevention and control
systems is regularly reviewed at the highest level of governance
in the organisation
3.1.4 Action is taken to improve the effectiveness of infection
prevention and control policies, procedures and/or protocols
3.3 Developing and implementing 3.3.1 Mechanisms to regularly assess the healthcare associated
systems and processes for reporting, infection risks are in place
investigating and analysing healthcare
associated infections, and aligning 3.3.2 Action is taken to reduce the risks of healthcare
these systems to the organisation’s risk associated infection
management strategy
3.4 Undertaking quality improvement 3.4.1 Quality improvement activities are implemented to reduce
activities to reduce healthcare associated and prevent healthcare associated infections
infections through changes to practice 3.4.2 Compliance with changes in practice are monitored
3.4.3 The effectiveness of changes to practice are evaluated
3.5 Developing, implementing and 3.5.1 Workforce compliance with current national hand hygiene
auditing a hand hygiene program guidelines is regularly audited
consistent with the current national hand 3.5.2 Compliance rates from hand hygiene audits are regularly
hygiene initiative 43 reported to the highest level of governance in the organisation
3.5.3 Action is taken to address non-compliance, or the inability
to comply, with the requirements of the current national hand
hygiene guidelines
3.6 Developing, implementing and 3.6.1 A workforce immunisation program that complies with
monitoring a risk-based workforce current national guidelines is in use
immunisation program in accordance
with the current National Health and
Medical Research Council Australian
immunisation guidelines 44
3.7 Promoting collaboration with 3.7.1 Infection prevention and control consultation related to
occupational health and safety programs occupational health and safety policies, procedures and/or
to decrease the risk of infection or injury protocols are implemented to address:
to healthcare workers
• communicable disease status
• occupational management and prophylaxis
• work restrictions
• personal protective equipment
• assessment of risk to healthcare workers for
occupational allergies
• evaluation of new products and procedures
3.8 Developing and implementing a 3.8.1 Compliance with the system for the use and management
system for use and management of of invasive devices is monitored
invasive devices based on the current
national guidelines for preventing and
controlling infections in health care19
3.9 Implementing protocols for invasive 3.9.1 Education and competency-based training in invasive
device procedures regularly performed devices protocols and use is provided for the workforce who
within the organisation perform procedures with invasive devices
3.10 Developing and implementing 3.10.1 The clinical workforce is trained in aseptic technique
protocols for aseptic technique 3.10.2 Compliance with aseptic technique is regularly audited
3.10.3 Action is taken to increase compliance with the aseptic
technique protocols
3.11 Implementing systems for using 3.11.1 Standard precautions and transmission-based precautions
standard precautions and transmission- consistent with the current national guidelines are in use
based precautions 3.11.2 Compliance with standard precautions is monitored
3.11.3 Action is taken to improve compliance with
standard precautions
3.11.4 Compliance with transmission-based precautions
is monitored
3.11.5 Action is taken to improve compliance with
transmission‑based precautions
3.12 Assessing the need for patient 3.12.1 A risk analysis is undertaken to consider the need
placement based on the risk of infection for transmission-based precautions including:
transmission • accommodation based on the mode of transmission
• environmental controls through air flow
• transportation within and outside the facility
• cleaning procedures
• equipment requirements
3.13 Developing and implementing 3.13.1 Mechanisms are in use for checking for pre-existing
protocols relating to the admission, healthcare associated infections or communicable disease
receipt and transfer of patients with on presentation for care
an infection 3.13.2 A process for communicating a patient’s infectious
status is in place whenever responsibility for care is transferred
between service providers or facilities
Antimicrobial stewardship
Safe and appropriate antimicrobial prescribing is a strategic goal of the clinical governance system.
3.15 Using risk management principles to 3.15.1 Policies, procedures and/or protocols for environmental
implement systems that maintain a clean cleaning that address the principles of infection prevention
and hygienic environment for patients and control are implemented, including:
and healthcare workers • maintenance of building facilities
• cleaning resources and services
• risk assessment for cleaning and disinfection based
on transmission-based precautions and the infectious
agent involved
• waste management within the clinical environment
• laundry and linen transportation, cleaning and storage
• appropriate use of personal protective equipment
3.15.2 Policies, procedures and/or protocols for environmental
cleaning are regularly reviewed
3.15.3 An established environmental cleaning schedule is in
place and environmental cleaning audits are undertaken regularly
3.16 Reprocessing reusable medical 3.16.1 Compliance with relevant national or international
equipment, instruments and devices standards and manufacturer’s instructions for cleaning,
in accordance with relevant national disinfection and sterilisation of reusable instruments and devices
or international standards and is regularly monitored
manufacturers’ instructions
3.17 Implementing systems to enable the 3.17.1 A traceability system that identifies patients who have
identification of patients on whom the a procedure using sterile reusable medical instruments and
reusable medical devices have been used devices is in place
3.18 Ensuring workforce who 3.18.1 Action is taken to maximise coverage of the relevant
decontaminate reusable medical devices workforce trained in a competency-based program to
undertake competency-based training decontaminate reusable medical devices
in these practices
3.19 Ensuring consumer-specific 3.19.1 Information on the organisation’s corporate and clinical
information on the management and infection risks and initiatives implemented to minimise patient
reduction of healthcare associated infection risks is provided to patients and/or carers
infections is available at the point of care 3.19.2 Patient infection prevention and control information
is evaluated to determine if it meets the needs of the
target audience
Medication Safety
Standard 4
Explanatory notes
Medicines are the most common treatment used in Many solutions to prevent medication errors are found
health care. Because they are so commonly used, in standardisation and systemisation of processes.
medicines are associated with a higher incidence Other recognised solutions for reducing common
of errors and adverse events than other healthcare causes of medication errors include:
interventions. Some of these events are costly and • improving clinician-workforce and clinician-patient
potentially avoidable. communication
Over 1.5 million Australians are estimated to • using technology to support information
experience an adverse event from medicines each recording and transfer
year.46 This results in at least 400 000 visits to general • providing better access to patient information and
practitioners and 190 000 hospital admissions 47, clinical decision support at the point of care.
which represents 2–3% of all admissions. As many
as 30% of unplanned geriatric admissions are
associated with an adverse medicine event.5
Approximately 50% of these admissions are
considered potentially avoidable.48
Medication Safety
Standard 4
4.1 Developing and implementing 4.1.1 Governance arrangements are in place to support
governance arrangements and the development, implementation and maintenance of
organisational policies, procedures organisation‑wide medication safety systems
and/or protocols for medication safety,
which are consistent with national and 4.1.2 Policies, procedures and/or protocols are in place that are
jurisdictional legislative requirements, consistent with legislative requirements, national, jurisdictional
policies and guidelines and professional guidelines
4.2 Undertaking a regular, 4.2.1 The medication management system is regularly assessed
comprehensive assessment of
medication use systems to identify risks
to patient safety and implementing 4.2.2 Action is taken to reduce the risks identified in
system changes to address the the medication management system
identified risks
4.3 Authorising the relevant clinical 4.3.1 A system is in place to verify that the clinical workforce
workforce to prescribe, dispense and have medication authorities appropriate to their scope
administer medications of practice
4.3.2 The use of the medication authorisation system is
regularly monitored
4.3.3 Action is taken to increase the effectiveness of the
medication authority system
4.4 Using a robust organisation-wide 4.4.1 Medication incidents are regularly monitored, reported
system of reporting, investigating and investigated
and managing change to respond to 4.4.2 Action is taken to reduce the risk of adverse
medication incidents medication incidents
4.5 Undertaking quality improvement 4.5.1 The performance of the medication management system
activities to enhance the safety of is regularly assessed
medicines use 4.5.2 Quality improvement activities are undertaken to
reduce the risk of patient harm and increase the quality and
effectiveness of medicines use
4.6 The clinical workforce taking an 4.6.1 A best possible medication history is documented
accurate medication history when a for each patient
patient presents to a health service 4.6.2 The medication history and current clinical information
organisation, or as early as possible is available at the point of care
in the episode of care, which is then
available at the point of care
4.7 The clinical workforce documenting 4.7.1 Known medication allergies and adverse drug reactions
the patient’s previously known adverse are documented in the patient clinical record
drug reactions on initial presentation and 4.7.2 Action is taken to reduce the risk of adverse reactions
updating this if an adverse reaction to
a medicine occurs during the episode 4.7.3 Adverse drug reactions are reported within the organisation
of care and to the Therapeutic Goods Administration
4.8 The clinical workforce reviewing 4.8.1 Current medicines are documented and reconciled at
the patient’s current medication orders admission and transfer of care between healthcare settings
against their medication history and
prescriber’s medication plan, and
reconciling any discrepancies
Medication Safety
Standard 4
4.9 Ensuring that current and accurate 4.9.1 Information and decision support tools for medicines
medicines information and decision are available to the clinical workforce at the point of care
support tools are readily available to the 4.9.2 The use of information and decision support tools
clinical workforce when making clinical is regularly reviewed
decisions related to medicines use
4.9.3 Action is taken to improve the availability and effectiveness
of information and decision support tools
4.10 Ensuring that medicines are 4.10.1 Risks associated with secure storage and safe distribution
distributed and stored securely, safely and of medicines are regularly reviewed
in accordance with the manufacturer’s 4.10.2 Action is taken to reduce the risks associated with
directions, legislation, jurisdictional orders storage and distribution of medicines
and operational directives
4.10.3 The storage of temperature-sensitive medicines
is monitored
4.10.4 A system that is consistent with legislative and
jurisdictional requirements for the disposal of unused,
unwanted or expired medications is in place
4.10.5 The system for disposal of unused, unwanted or expired
medications is regularly monitored
4.10.6 Action is taken to increase compliance with the system
for storage, distribution and disposal of medications
4.11 Identifying high-risk medicines 4.11.1 The risks for storing, prescribing, dispensing and
in the organisation and ensuring they administration of high-risk medicines are regularly reviewed
are stored, prescribed, dispensed and 4.11.2 Action is taken to reduce the risks of storing, prescribing,
administered safely dispensing and administering high-risk medicines
4.12 Ensuring a current comprehensive 4.12.1 A system is in use that generates and distributes a current
list of medicines, and the reason(s) and comprehensive list of medicines and explanation of changes
for any change, is provided to the in medicines
receiving clinician and the patient 4.12.2 A current and comprehensive list of medicines is provided
during clinical handovers to the patient and/or carer when concluding an episode of care
4.12.3 A current comprehensive list of medicines is provided
to the receiving clinician during clinical handover
4.12.4 Action is taken to increase the proportion of patients
and receiving clinicians that are provided with a current
comprehensive list of medicines during clinical handover
4.13 The clinical workforce informing 4.13.1 The clinical workforce provides patients with patient
patients and carers about medication specific medicine information, including medication treatment
treatment options, benefits and options, benefits and associated risks
associated risks 4.13.2 Information that is designed for distribution to patients
is readily available to the clinical workforce
4.15 Providing current medicines 4.15.1 Information on medicines is provided to patients and
information to patients in a format carers in a format that is understood and meaningful
that meets their needs whenever new 4.15.2 Action is taken in response to patient feedback to
medicines are prescribed or dispensed improve medicines information distributed by the health service
organisation to patients
Explanatory notes
Patient identification and the matching of a patient to Since patient identification is an activity that is
an intended treatment is an activity that is performed performed frequently, it can often be seen as a
routinely in all care settings. Risks to patient safety relatively unimportant task. Taking human factors into
occur when there is a mismatch between a given account when planning patient safety emphasises
patient and components of their care, whether the design of systems to consider human capabilities,
those components are diagnostic, therapeutic limitations and characteristics.50 This approach
or supportive. suggests that the development of safety routines
for common tasks (such as patient identification)
Much of the information about the number of patient provides a powerful defence against simple mistakes
mismatching events comes from incident reporting that may progress and cause harm. These routines
systems. In 2008–09 there were eleven events in allow the workforce to focus their attention on those
Australia with procedures involving the wrong patient activities that require more cognitive processing
or body part resulting in a death or major permanent and judgement, such as the provision of clinical
loss of function.32 When less serious events from care.51 The use of tools such as the World Health
nonsurgical areas – such as pathology and radiology Organization Surgical Safety Checklist 52 and Ensuring
– are included in reporting systems the number of Correct Patient, Correct Site, Correct Procedure
reported events can rise considerably.49 protocols 53 provide a basis for the development of
such routines.
42 | National Safety and Quality Health Service Standards
5.1 Developing, implementing and 5.1.1 Use of an organisation-wide patient identification system
regularly reviewing the effectiveness of a is regularly monitored
patient identification system including the
associated policies, procedures and/or
protocols that:
• define approved patient identifiers
• require at least three approved patient
identifiers on registration or admission
5.1.2 Action is taken to improve compliance with the patient
• require at least three approved patient
identification matching system
identifiers when care, therapy or other
services are provided
• require at least three approved
patient identifiers whenever clinical
handover, patient transfer or discharge
documentation is generated
5.2 Implementing a robust organisation- 5.2.1 The system for reporting, investigating and analysis
wide system of reporting, investigation of patient care mismatching events is regularly monitored
and change management to respond to 5.2.2 Action is taken to reduce mismatching events
any patient care mismatching events
5.3 Ensuring that when a patient 5.3.1 Inpatient bands are used that meet the national
identification band is used, it meets specifications for patient identification bands
the national specifications for patient
identification bands 54
5.4 Developing, implementing and 5.4.1 A patient identification and matching system is
regularly reviewing the effectiveness of implemented and regularly reviewed as part of structured
the patient identification and matching clinical handover, transfer and discharge processes
system at patient handover, transfer
and discharge
5.5 Developing and implementing a 5.5.1 A documented process to match patients and their
documented process to match patients intended treatment is in use
to their intended procedure, treatment 5.5.2 The process to match patients to any intended procedure,
or investigation and implementing the treatment or investigation is regularly monitored
consistent national guidelines for patient
procedure matching protocol or other 5.5.3 Action is taken to improve the effectiveness of the process
relevant protocols53 for matching patients to their intended procedure, treatment
or investigation
Clinical Handover
Standard 6
Explanatory notes
Clinical handover refers to the transfer of professional Clinical handovers can also take place in the
responsibility and accountability for some or all presence or absence of the patient and carer.
aspects of care for a patient, or group of patients, to
another person or professional group on a temporary Approximately 7 068 000 clinical handovers occur
or permanent basis.12,55 annually in Australian hospitals and about 26 200 000
clinical handovers are carried out in community
Clinical handovers can vary depending on patient care settings.56
circumstance, including:
Current handover processes are highly variable and
• The situation of handover, such as
may be unreliable, causing clinical handover to be
– during a shift change a high risk area for patient safety. Breakdown in the
– when patients are transferred inter and transfer of information has been identified as one of
intrahospital the most important contributing factors in serious
– during patient admission, referral or discharge adverse events and is a major preventable cause of
• The method of handover, such as patient harm.57
– face-to-face Achieving sustainable improvement in clinical
– via telephone handover requires standardised processes and
– via written orders information sets. Clinical handover solutions must be
– when aided by electronic handover tools fit for purpose and appropriate to the clinical context
• The venue where handover takes place, such as in which handover occurs. When a standard process
– at the patient’s bedside for clinical handover is used, the safety of patient care
will improve as critical information is more likely to be
– in a common staff area
transferred and acted upon.58-61
– at a hospital or clinic reception.
46 | National Safety and Quality Health Service Standards
Clinical Handover
Standard 6
6.1 Developing and implementing an 6.1.1 Clinical handover policies, procedures and/or protocols are
organisational system for structured used by the workforce and regularly monitored
clinical handover that is relevant
to the healthcare setting and 6.1.2 Action is taken to maximise the effectiveness of clinical
specialities, including: handover policies, procedures and/or protocols
• documented policy, procedures and/
or protocols 6.1.3 Tools and guides are periodically reviewed
• agreed tools and guides
6.2 Establishing and maintaining 6.2.1 The workforce has access to documented structured
structured and documented processes processes for clinical handover that include:
for clinical handover • preparing for handover, including setting the location and
time while maintaining continuity of patient care
• organising relevant workforce members to participate
• being aware of the clinical context and patient needs
• participating in effective handover resulting in transfer
of responsibility and accountability for care
6.3 Monitoring and evaluating the agreed 6.3.1 Regular evaluation and monitoring processes for clinical
structured clinical handover processes, handover are in place
including:
• regularly reviewing local processes 6.3.2 Local processes for clinical handover are reviewed
based on current best practice in in collaboration with clinicians, patients and carers
collaboration with clinicians, patients
and carers
6.3.3 Action is taken to increase the effectiveness
• undertaking quality improvement of clinical handover
activities and acting on issues identified
from clinical handover reviews
• reporting the results of clinical 6.3.4 The actions taken and the outcomes of local clinical
handover reviews at executive level handover reviews are reported to the executive level
of governance of governance
6.4 Implementing a robust organisation- 6.4.1 Regular reporting, investigating and monitoring
wide system of reporting, investigation of clinical handover incidents is in place
and change management to respond 6.4.2 Action is taken to reduce the risk of adverse clinical
to any clinical handover incidents handover incidents
6.5 Developing and implementing 6.5.1 Mechanisms to involve a patient and, where relevant,
mechanisms to include patients and their carer in clinical handover are in use
carers in the clinical handover process
that are relevant to the healthcare setting
The intention of this Standard is to: Criteria to achieve the Blood and
Ensure that the patients who receive blood and Blood Products Standard:
blood products do so appropriately and safely. Governance and systems for
blood and blood product prescribing
Context: and clinical use
It is expected that this Standard will be applied Health service organisations have systems in
in conjunction with Standard 1, ‘Governance place for the safe and appropriate prescribing and
for Safety and Quality in Health Service clinical use of blood and blood products.
Organisations’ and Standard 2, ‘Partnering
with Consumers’. Documenting patient information
The clinical workforce accurately records a
patient’s blood and blood product transfusion
history and indications for use of blood and
blood products.
Explanatory notes
Treatment with blood and blood products can be The principles of good patient blood management
lifesaving however, as biological materials they are that provide for clinically appropriate and safe
not without risk. Screening and testing of donors management of patients while avoiding blood and
and donated blood and ensuring that decisions to blood product transfusions and its associated risks
transfuse follow consideration of all treatment options, are supported by this Standard.
their risks and benefits all contribute to minimising the
inherent risks. National and international research demonstrates
that the dual approach of implementing governance
The scope of this Standard covers all elements structures and evidence-based clinical guidelines
of the clinical process, including: is the most effective methodology to ensure
• making clinical decisions the appropriate and safe use of blood and
• obtaining recipient samples and assessing blood products.
compatibility with donated products
• safely administering the products to the
intended recipient
• disposing of the product
• reporting and investigating any adverse reactions
or incidents.
Governance and systems for blood and blood product prescribing and clinical use
Health service organisations have systems in place for the safe and appropriate prescribing and clinical use
of blood and blood products.
7.1 Developing governance systems 7.1.1 Blood and blood product policies, procedures and/or
for safe and appropriate prescription, protocols are consistent with national evidence-based guidelines
administration and management of for pre-transfusion practices, prescribing and clinical use of
blood and blood products blood and blood products
7.1.2 The use of policies, procedures and/or protocols is
regularly monitored
7.1.3 Action is taken to increase the safety and appropriateness
of prescribing and clinically using blood and blood products
7.2 Undertaking a regular, comprehensive 7.2.1 The risks associated with transfusion practices and clinical
assessment of blood and blood product use of blood and blood products are regularly assessed
systems to identify risks to patient safety 7.2.2 Action is taken to reduce the risks associated with
and taking action to reduce risks transfusion practices and the clinical use of blood and
blood products
7.3 Ensuring blood and blood 7.3.1 Reporting on blood and blood product incidents
product adverse events are included is included in regular incident reports
in the incidents management and 7.3.2 Adverse blood and blood product incidents are reported
investigation system to and reviewed by the highest level of governance in the health
service organisation
7.3.3 Health service organisations participate in relevant
haemovigilance activities conducted by the organisation
or at state or national level
7.4 Undertaking quality 7.4.1 Quality improvement activities are undertaken to reduce
improvement activities to improve the risks of patient harm from transfusion practices and the
the safe management of blood clinical use of blood and blood products
and blood products
7.5 As part of the patient treatment 7.5.1 A best possible history of blood product usage and
plan, the clinical workforce accurately relevant clinical and product information is documented
documenting: in the patient clinical record
• relevant medical conditions
• indications for transfusion 7.5.2 The patient clinical records of transfused patients
are periodically reviewed to assess the proportion of
• any special product or transfusion
records completed
requirements
• known patient transfusion history
• type and volume of product 7.5.3 Action is taken to increase the proportion of patient
transfusion clinical records of transfused patients with a complete patient
• patient response to transfusion clinical record
7.6 The clinical workforce documenting 7.6.1 Adverse reactions to blood or blood products are
any adverse reactions to blood or documented in the patient clinical record
blood products 7.6.2 Action is taken to reduce the risk of adverse events
from administering blood or blood products
7.6.3 Adverse events are reported internally to the
appropriate governance level and externally to the pathology
service provider, blood service or product manufacturer
whenever appropriate
7.7 Ensuring the receipt, storage, 7.7.1 Regular review of the risks associated with receipt,
collection and transport of blood and storage, collection and transport of blood and blood products
blood products within the organisation is undertaken
are consistent with best practice 7.7.2 Action is taken to reduce the risk of incidents arising from
and/or guidelines the use of blood and blood product control systems
7.8 Minimising unnecessary wastage 7.8.1 Blood and blood product wastage is regularly monitored
of blood and blood products 7.8.2 Action is taken to minimise wastage of blood and
blood products
7.9 The clinical workforce informing 7.9.1 Patient information relating to blood and blood products,
patients and carers about blood and including risks, benefits and alternatives, is available for
blood product treatment options, and the distribution by the clinical workforce
associated risks and benefits 7.9.2 Plans for care that include the use of blood and blood
products are developed in partnership with patients and carers
7.10 Providing information to patients 7.10.1 Information on blood and blood products is provided
about blood and blood product use and to patients and their carers in a format that is understood
possible alternatives in a format that can and meaningful
be understood by patients and carers
7.11 Implementing an informed 7.11.1 Informed consent is undertaken and documented for all
consent process for all blood and transfusions of blood or blood products in accordance with the
blood product use informed consent policy of the health service organisation
Explanatory notes
Immobility, such as that associated with extended Solutions to the prevention of pressure injuries
bed rest in hospital, can cause pressure injuries. have been identified and are available in multiple
Research shows that pressure injuries are a major evidence‑based resources. Management of
contributor to the care needs of patients within the established pressure injuries has also progressed
health industry.62-63 In the majority of cases pressure with the increasing specialisation in wound
injuries are preventable. management. Implementing solutions and monitoring
for compliance will require education and an
Pressure injuries not only occur in geriatric patients, awareness of all risk factors.
but in all patients with any or all of the associated
risk factors. These factors are not restricted to Note: National and international bodies are
increased immobility, but include factors such as currently discussing the correct terminology for
nutritional status, skin integrity, age and the level of pressure‑induced wounds, often known as bed
oxygenation of the blood supply to pressure point sores or ulcers. This Standard adopts the alternate
injuries. A pressure injury can commence in any term ‘pressure injury’, which is in line with national
setting, including acute areas such as theatre and and international moves to recognise that ulcers are
intensive care. only one form of a pressure injury.
56 | National Safety and Quality Health Service Standards
Governance and systems for the prevention and management of pressure injuries
Health service organisations have governance structures and systems in place for the prevention
and management of pressure injuries.
8.1 Developing and implementing 8.1.1 Policies, procedures and/or protocols are in use that
policies, procedures and/or protocols are consistent with best practice guidelines and incorporate
that are based on current best screening and assessment tools
practice guidelines 8.1.2 The use of policies, procedures and/or protocols is
regularly monitored
8.2 Using a risk assessment 8.2.1 An organisation-wide system for reporting pressure
framework and reporting systems to injuries is in use
identify, investigate and take action to 8.2.2 Administrative and clinical data are used to regularly
reduce the frequency and severity of monitor and investigate the frequency and severity of
pressure injuries pressure injuries
8.2.3 Information on pressure injuries is regularly reported to the
highest level of governance in the health service organisation
8.2.4 Action is taken to reduce the frequency and severity
of pressure injuries
8.3 Undertaking quality improvement 8.3.1 Quality improvement activities are undertaken to
activities to address safety risks and prevent pressure injuries and/or improve the management
monitor the systems that prevent and of pressure injuries
manage pressure injuries
8.4 Providing or facilitating access to 8.4.1 Equipment and devices are available to effectively
equipment and devices to implement implement prevention strategies for patients at risk and plans for
effective prevention strategies and best the management of patients with pressure injuries
practice management plans
8.5 Identifying risk factors for pressure 8.5.1 An agreed tool to screen for pressure injury risk is
injuries using an agreed screening tool for used by the clinical workforce to identify patients at risk
all presenting patients within timeframes of a pressure injury
set by best practice guidelines 8.5.2 The use of the screening tool is monitored to identify the
proportion of at-risk patients that are screened for pressure
injuries on presentation
8.5.3 Action is taken to maximise the proportion of patients
who are screened for pressure injury on presentation
8.6 Conducting a comprehensive skin 8.6.1 Comprehensive skin inspections are undertaken and
inspection in timeframes set by best documented in the patient clinical record for patients at risk
practice guidelines on patients with a of pressure injuries
high risk of developing pressure injuries 8.6.2 Patient clinical records, transfer and discharge
at presentation, regularly as clinically documentation are periodically audited to identify at-risk
indicated during a patient’s admission, patients with documented skin assessments
and before discharge
8.6.3 Action is taken to increase the proportion of skin
assessments documented on patients at risk of pressure injuries
8.7 Implementing and monitoring 8.7.1 Prevention plans for all patients at risk of a pressure injury
pressure injury prevention plans and are consistent with best practice guidelines and are documented
reviewing when clinically indicated in the patient clinical record
8.7.2 The effectiveness and appropriateness of pressure injury
prevention plans are regularly reviewed
8.7.3 Patient clinical records are monitored to determine the
proportion of at-risk patients that have an implemented pressure
injury prevention plan
8.7.4 Action is taken to increase the proportion of patients at risk
of pressure injuries who have an implemented prevention plan
8.8 Implementing best practice 8.8.1 An evidence-based wound management system is in place
management and ongoing monitoring within the health service organisation
as clinically indicated 8.8.2 Management plans for patients with pressure injuries are
consistent with best practice and documented in the patient
clinical record
8.8.3 Patient clinical records are monitored to determine
compliance with evidence-based pressure injury
management plans
8.8.4 Action is taken to increase compliance with
evidence‑based pressure injury management plans
8.9 Informing patients with a high risk of 8.9.1 Patient information on prevention and management of
pressure injury, and their carers, about pressure injuries is provided to patients and carers in a format
the risks, prevention strategies and that is understood and is meaningful
management of pressure injuries
8.10 Developing a plan of management in 8.10.1 Pressure injury management plans are developed
partnership with patients and carers in partnership with patients and carers
Explanatory notes
Serious adverse events such as unexpected death Systems to recognise deterioration early and respond
and cardiac arrest are often preceded by observable to it appropriately need to deal with all of these
physiological and clinical abnormalities.64 Early factors, and need to apply across a healthcare
identification of deterioration may improve outcomes facility. The National Consensus Statement: Essential
and lessen the intervention required to stabilise Elements for Recognising and Responding to Clinical
patients whose condition deteriorates in hospital.65 Deterioration (National Consensus Statement)
was developed by the Australian Commission on
There is evidence that the warning signs of clinical Safety and Quality in Health Care (ACSQHC) and
deterioration are not always identified or acted on has been endorsed by Australian Health Ministers
appropriately.66 The organisation and workforce as the national approach for recognising and
factors that contribute to a failure to recognise and responding to clinical deterioration in acute care
respond to a deteriorating patient are complex and facilities in Australia.3 It provides a consistent national
overlapping. These include, but are not limited to: 67-69 framework to support clinical, organisational and
• not monitoring physiological observations strategic efforts to improve recognition and response
consistently or not understanding observed systems. This Standard builds on the National
changes in physiological observations Consensus Statement to drive implementation in
• lack of knowledge of signs and symptoms acute care facilities.
that could signal deterioration
This Standard applies to all patients in acute
• lack of formal systems for responding healthcare facilities including adults, adolescents,
to deterioration children and babies, and to all types of patients
• lack of skills to manage patients who including medical, surgical, maternity and mental
are deteriorating health patients. Acute healthcare facilities range from
• failure to communicate clinical concerns, large tertiary referral centres, to small district and
including in handover situations. community hospitals.
9.1 Developing, implementing and 9.1.1 Governance arrangements are in place to support
regularly reviewing the effectiveness the development, implementation, and maintenance of
of governance arrangements and the organisation-wide recognition and response systems
policies, procedures and/or protocols 9.1.2 Policies, procedures and/or protocols for the organisation
that are consistent with the requirements are implemented in areas such as:
of the National Consensus Statement
• measurement and documentation of observations
• escalation of care
• establishment of a rapid response system
• communication about clinical deterioration
9.2 Collecting information about the 9.2.1 Feedback is actively sought from the clinical workforce on
recognition and response systems, the responsiveness of the recognition and response systems
providing feedback to the clinical 9.2.2 Deaths or cardiac arrests for a patient without an agreed
workforce, and tracking outcomes and treatment-limiting order (such as not for resuscitation or do not
changes in performance over time resuscitate) are reviewed to identify the use of the recognition
and response systems, and any failures in these systems
9.2.3 Data collected about recognition and response systems
are provided to the clinical workforce as soon as practicable
9.2.4 Action is taken to improve the responsiveness and
effectiveness of the recognition and response systems
9.3 Implementing mechanism(s) for 9.3.1 When using a general observation chart, ensure that it:
recording physiological observations that • is designed according to human factors principles
incorporates triggers to escalate care
• includes the capacity to record information about respiratory
when deterioration occurs
rate, oxygen saturation, heart rate, blood pressure,
temperature and level of consciousness graphically over time
• includes thresholds for each physiological parameter or
combination of parameters that indicate abnormality
• specifies the physiological abnormalities and other factors
that trigger the escalation of care
• includes actions required when care is escalated
9.3.2 Mechanisms for recording physiological observations are
regularly audited to determine the proportion of patients that
have complete sets of observations recorded in agreement
with their monitoring plan
9.3.3 Action is taken to increase the proportion of patients with
complete sets of recorded observations, as specified in the
patient’s monitoring plan
9.4 Developing and implementing 9.4.1 Mechanisms are in place to escalate care and call
mechanisms to escalate care and call for emergency assistance
for emergency assistance where there 9.4.2 Use of escalation processes, including failure to act on
are concerns that a patient’s condition triggers for seeking emergency assistance, are regularly audited
is deteriorating
9.4.3 Action is taken to maximise the appropriate use
of escalation processes
9.5 Using the system in place to ensure 9.5.1 Criteria for triggering a call for emergency assistance are
that specialised and timely care is included in the escalation policies, procedures and/or protocols
available to patients whose condition 9.5.2 The circumstances and outcome of calls for emergency
is deteriorating assistance are regularly reviewed
9.6 Having a clinical workforce that is 9.6.1 The clinical workforce is trained and proficient in basic
able to respond appropriately when a life support
patient’s condition is deteriorating 9.6.2 A system is in place for ensuring access at all times to at
least one clinician, either on-site or in close proximity, who can
practise advanced life support
9.7 Ensuring patients, families and 9.7.1 Information is provided to patients, families and carers
carers are informed about, and are in a format that is understood and meaningful. The information
supported so that they can participate should include:
in, recognition and response systems • the importance of communicating concerns and signs/
and processes symptoms of deterioration, which are relevant to the patient’s
condition, to the clinical workforce
• local systems for responding to clinical deterioration,
including how they can raise concerns about
potential deterioration
9.8 Ensuring that information about 9.8.1 A system is in place for preparing and/or receiving advance
advance care plans and treatment- care plans in partnership with patients, families and carers
limiting orders is in the patient clinical 9.8.2 Advance care plans and other treatment-limiting orders
record, where appropriate are documented in the patient clinical record
9.9 Enabling patients, families and carers 9.9.1 Mechanisms are in place for a patient, family member
to initiate an escalation of care response or carer to initiate an escalation of care response
9.9.2 Information about the system for family escalation of care
is provided to patients, families and carers
9.9.3 The performance and effectiveness of the system for family
escalation of care is periodically reviewed
9.9.4 Action is taken to improve the system performance
for family escalation of care
Explanatory notes
Falls occur in all age groups; however the risk of falls The Australian Commission on Safety and Quality in
and harm from falls varies between individuals due to Health Care (ACSQHC) has developed guidelines for
factors such as eyesight, balance, muscle strength, falls prevention in older people in hospitals, residential
bone density and medication use. aged and community care.70-72 They are based on
evidence specific to these groups of older people.
The focus of this Standard is on prevention of They provide a valuable set of resources that can be
falls and the minimisation of harm from falls. It is used by health services when they are considering
not intended to address physical or psychological the needs of older people with impaired mobility or
harm management. with temporary or permanent reduction in mobility.
Falls remains a significant issue in the safety of Although the risk of falls is well documented for the
patients. Rates of fall-related age-standardised elderly, impaired mobility is also a major falls risk
hospitalisations have continued to steadily increase. and it is not age defined. Therefore, strategies such
Besides the cost implications, the impact of falls as screening to reduce falls and the harm from falls
on individuals is far reaching. The social impact of should not be limited to older Australians. Policies,
reduced independence through fear, the potential procedures and protocols for other age groups
for loss of independence and the increased burden need to be based on the available evidence and
on families can be significant. best practice.
68 | National Safety and Quality Health Service Standards
10.1 Developing, implementing and 10.1.1 Policies, procedures and/or protocols are in use that
reviewing policies, procedures and/or are consistent with best practice guidelines (where available)
protocols, including the associated tools, and incorporate screening and assessment tools
that are based on the current national 10.1.2 The use of policies, procedures and/or protocols is
guidelines for preventing falls and harm regularly monitored
from falls
10.2 Using a robust organisation‑wide 10.2.1 Regular reporting, investigating and monitoring of falls
system of reporting, investigation and incidents is in place
change management to respond to 10.2.2 Administrative and clinical data are used to monitor and
falls incidents investigate regularly the frequency and severity of falls in the
health service organisation
10.2.3 Information on falls is reported to the highest level
of governance in the health service organisation
10.2.4 Action is taken to reduce the frequency and severity
of falls in the health service organisation
10.3 Undertaking quality improvement 10.3.1 Quality improvement activities are undertaken to prevent
activities to address safety risks and falls and minimise patient harm
ensure the effectiveness of the falls
prevention system
10.4 Implementing falls prevention plans 10.4.1 Equipment and devices are available to implement
and effective management of falls prevention strategies for patients at risk of falling and
management plans to reduce the harm from falls
10.5 Using a best practice-based tool to 10.5.1 A best practice screening tool is used by the clinical
screen patients on presentation, during workforce to identify the risk of falls
admission and when clinically indicated 10.5.2 Use of the screening tool is monitored to identify the
for the risk of falls proportion of at-risk patients that were screened for falls
10.5.3 Action is taken to increase the proportion of at-risk
patients who are screened for falls upon presentation and
during admission
10.6 Conducting a comprehensive risk 10.6.1 A best practice assessment tool is used by the clinical
assessment for patients identified at risk workforce to assess patients at risk of falling
of falling in initial screening processes 10.6.2 The use of the assessment tool is monitored to
identify the proportion of at-risk patients with a completed
falls assessment
10.6.3 Action is taken to increase the proportion of at-risk
patients undergoing a comprehensive falls risk assessment
10.7 Developing and implementing a 10.7.1 Use of best practice multifactorial falls prevention
multifactorial falls prevention plan to and harm minimisation plans is documented in the patient
address risks identified in the assessment clinical record
10.7.2 The effectiveness and appropriateness of the falls
prevention and harm minimisation plan are regularly monitored
10.7.3 Action is taken to reduce falls and minimise harm for
at‑risk patients
10.8 Patients at risk of falling are referred 10.8.1 Discharge planning includes referral to appropriate
to appropriate services, where available, services, where available
as part of the discharge process
10.9 Informing patients and carers 10.9.1 Patient information on falls risks and prevention strategies
about the risk of falls, and falls is provided to patients and their carers in a format that is
prevention strategies understood and meaningful
10.10 Developing falls prevention plans 10.10.1 Falls prevention plans are developed in partnership
in partnership with patients and carers with patients and carers
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