Equip 5 Book 1 - South West Alliance of Rural Health

The ACHS EQuIP5 Guide:Book 1 – Accreditation, Standards and Guidelines – Clinical FunctionPublished by The Australian Council on Healthcare Standards (ACHS)Copies available from the ACHS Publications ServicePhone: +61 2 9281 9955Fax: +61 2 9211 9633Copyright © The Australian Council on Healthcare Standards (ACHS)This work is copyright. Apart from any use as permitted under the CopyrightAct 1968, no part may be reproduced by any process without prior writtenpermission from The Australian Council on Healthcare Standards. Requests andenquiries concerning reproduction and rights should be addressed to the ChiefExecutive, The Australian Council on Healthcare Standards, 5 Macarthur Street,ULTIMO NSW 2007 AustraliaRecommended citation: The Australian Council on Healthcare Standards (ACHS),The ACHS EQuIP5 Guide: Book 1 – Accreditation, Standards and Guidelines –Clinical Function. Sydney Australia; ACHS; 2010.The EQuIP Guide:First published 1996Second edition 1998Second edition revised 1999Third edition 2002Fourth edition 2006Fifth edition 20105th EditionISBN-13: 978 1 921806 00 1 (paperback)ISBN-10: 1 921806 00 1 (paperback)ISBN-13: 978 1 921806 02 5 (web)ISBN-10: 1 921806 02 8 (web)

ForewordOn behalf of the Board of Directors, it is my pleasureto present the 5th edition of the Evaluation and QualityImprovement Program (EQuIP5). This edition will applyto all participating members from 1 July 2011.Principles guiding the review process includeemphasis on patient outcomes, the importance ofmeasuring performance and the national agenda forsafety and quality.Alterations to the standards, criteria and elementsfor achievement have been largely editorial in nature,although the new provisions relating to nutritionalservices, separation of corporate and clinical records,and the separation of incidents and complaintsmanagement systems are significant.The Australian Council on Healthcare Standards(ACHS) has engaged widely across the health industryseeking both strategic and technical input. Thegenerous response of time and expertise is indicativeof the esteem held within the health industry for ACHS.For this we are very grateful.The Australian Commission on Safety and Qualityin Health Care is well advanced in the developmentof National Standards relating to high-risk safetyissues and applicable to all accreditation programs.ACHS strongly supports this initiative. Theimplementation of National Standards will impact onEQuIP, which must evolve to encompass the nationalcompliance requirements.This edition is introduced at an important time in theevolution of the national quality and safety healthservices agenda and incorporates many changes inhow the program will function. Together with processefficiencies and improvements to electronic tools itremains comprehensive, robust and relevant to theneeds of both consumers and health service providers.On behalf of the Board and Council, I commend toyou the Evaluation and Quality Improvement Program5th edition.Assoc. Professor Peter WoodruffPresident, ACHSOctober 2010October 2010 1

ContentsForeword 1Introduction 4Section 1ACHS and accreditation 51.1 About the Australian Council onHealthcare Standards 51.2 What is accreditation? 6Section 2Overview of EQuIP 72.1 The EQuIP cycle 72.2 What is EQuIP? 82.3 The self assessment 82.4 Organisation-Wide Survey (OWS) 82.5 Periodic Review (PR) 92.6 EQuIP membership 92.6.1 ACHS EQuIP Certification Program 9Section 3EQuIP Surveys 103.1 The EQuIP Self-Assessment process 103.1.1 Benefits and objectives of theself assessment 103.1.2 The self-assessment process 103.1.3 The EQuIP Self-Assessmentfeedback report 113.1.4 Changes to the self-assessmentformat from EQuIP 4 to EQuIP5 113.1.5 Before starting a Pre-SurveyAssessment 113.2 Pre-Survey Assessment (PSA) 123.2.1 How to start a PSA 123.2.2 The PSA format 123.2.3 Points to remember inpreparing a PSA 153.2.4 The Electronic AssessmentTool (EAT) 153.3 EQuIP onsite surveys and processes 163.3.1 The survey schedule 163.3.2 Additional surveys 173.3.3 Getting ready for the survey −one page summaries 183.3.4 Survey timetables 193.3.5 Surveyors’ meeting with theleadership team 203.3.6 The survey presentation 203.3.7 The survey process 203.3.8 Verification 213.3.9 The Summation Conference 213.4 EQuIP survey reports 223.4.1 How to use the survey report 223.4.2 Public release of accreditationinformation 223.5 Accreditation levels, survey recommendationsand achievement ratings 233.5.1 Accreditation outcomes 233.5.2 Criterion achievement ratings 233.5.3 Expectations for ratings 253.5.4 High Priority Recommendations(HPRs) 263.5.5 Achieving accreditation 273.5.6 Non-accreditation 273.5.7 An appeals process 272 The ACHS EQuIP5 Guide Book 1 Accreditation, Standards and Guidelines Clinical Function

Section 4How to use this EQuIP Guide 284.1 The EQuIP framework 284.2 Key changes in EQuIP5 294.2.1 EQuIP5 functions, standards, criteria 304.3 The criteria 324.3.1 Structure of the criteria (an example) 324.3.2 Mandatory criteria 344.3.3 Not applicable (NA) criteria / elements 344.4 Further information 344.4.1 Aboriginal and Torres StraitIslander people 344.4.2 Policies, procedures, protocols,guidelines and by-laws 354.4.3 Jurisdictions 364.4.4 Performance measures 364.4.5 Clinical indicators 374.4.6 National E-Health TransitionAuthority (NEHTA) 414.4.7 National Safety and QualityHealth Service Standards(Australian Commission on Safetyand Quality in Health Care) 41Section 5Standards, criteria, elementsand guidelines 43Book 1 Clinical Function(Standards 1.1 – 1.6) 43Book 2 Support Function(Standards 2.1 – 2.5) 251Corporate Function(Standards 3.1 – 3.2) 375Section 66.1 Glossary and AcronymsGlossary (Book 1) 229Glossary (Book 2) 463Acronyms (Book 1) 245Acronyms (Book 2) 4796.2 Acknowledgements (Book 2) 482October 2010 3

Section 1ACHS and accreditation1.1 About the Australian Councilon Healthcare StandardsThe Australian Council on Healthcare Standards(ACHS) is an independent, not-for-profit organisationdedicated to improving the quality of health care inAustralia through the continual review of performance,assessment and accreditation. The ACHS wasestablished in 1974 and is the leading independentauthority on the measurement and implementationof quality improvement systems for Australianhealthcare organisations.The ACHS mission is to improve the quality andsafety of health care. Its vision is to be recognisednationally and internationally as the leading Australianorganisation that independently assesses performanceand promotes and improves the quality and safetyof health care.ACHS accreditation programs are based onpartnerships and consultations with key stakeholdersand participants in the healthcare industry, so thatthe standards and accreditation services reflect theirneeds and encourage ownership of the program.The ACHS Council is comprised of individuals whorepresent peak industry bodies in health, professionalcolleges and associations, governments andhealthcare consumers. The ACHS is governed bya board of directors elected by and from Councilmembers. The ACHS Board is supported by acorporate management structure that overseesstandards development and the evaluation of healthservices against those standards by surveyorswho have professional experience within relevanthealthcare service sectors.The principles upon which all ACHS programs aredeveloped reflect the characteristics displayed byan improving organisation. These principles can beapplied to all aspects of service within an organisation.A consumer focus in care provision is demonstrated by:• understanding the needs and expectations ofpresent and potential consumers / patients• ensuring consumers / patients are the priority• evaluating the service from the consumer /patient perspective.Effective leadership demonstrates responsibility andcommitment to excellence in care provision, qualityimprovement and performance by:• providing direction for the organisation /health service• pursuing the ongoing development of strategies,systems and methods for achieving excellence• inspiring and motivating the workforce andencouraging employees to contribute, developand learn• considering proposals that are innovativeand creative.Continuous improvement – management and staffdemonstrate how they continually strive to improve thequality of care. Continuous improvement assists theorganisation / health service through:• looking for ways to improve as an essential partof everyday practice• consistently achieving and maintaining qualitycare that meets consumer / patient needs• monitoring outcomes in consumer / patient careand seeking opportunities to improve both thecare and its results.Evidence of outcomes – organisations depend on themeasurement and analysis of performance. Indicatorsof good care processes or, wherever possible,outcomes of care, demonstrate a commitmentto maintaining quality and striving for ongoingimprovement by:• providing critical data and information about keyprocesses, outputs and results• reflecting those factors that lead to improvedhealth and/or quality of life for consumers /patients or to better operational performance.October 2010 5

Section 1ACHS and accreditationStriving for best practice – the organisation comparesits performance with, or learns from, others andapplies best-practice principles. Organisations mightdemonstrate their efforts through:• discovering new techniques and technologies, andusing them to achieve world-class performance• learning from others to increase the efficiencyand effectiveness of processes• improving consumer / patient satisfactionand outcomes.1.2 What is accreditation?Accreditation is public recognition by a healthcareaccreditation body of the achievement of accreditationstandards by a healthcare organisation, demonstratedthrough an independent external peer assessment ofthat organisation’s level of performance in relation tothe standards. 1Accreditation systems are considered to comprisefive key elements 2 :1. A governance or stewardship function2. A standards-setting process3. A process of external evaluation of complianceagainst those standards4. A remediation or improvement process followingthe review5. Promotion of continuous quality improvement.1 International Society for Quality in Health Care (ISQua). The ISQua surveyor training standards programme. Dublin IRL; ISQua; 2009.2 Standards and accreditation framework working group. Standards setting and accreditation systems in health: consultation paper.Canberra; Australian Council for Safety and Quality in Health Care; 2003.6 The ACHS EQuIP5 Guide Book 1 Accreditation, Standards and Guidelines Clinical Function

Section 2Overview of EQuIPThe following information provides an outline of the components of the ACHS EQuIP accreditation processesin which member organisations participate. The full details of the accreditation process and requirements areprovided in Sections 2 and 3 of this guide.2.1 The EQuIP cycleThe cycle of events in which healthcare organisations submit at least one activity every year of their four-yearEQuIP membership period is shown below.EQuIP CycleEQuIP QualityProgram BeginsPhase 1Self assessment¼¼¼¼¼¼New members provide a selfassessment against all criteria.Existing members provide aself assessment of progressagainst the recommendationsfrom the Periodic Review.Organisations update andsubmit their register of keyorganisation risks (risk register).Phase 4Periodic Review (PR)¼¼¼¼Members provide a Pre-SurveyAssessment against allmandatory criteria, progressagainst recommendations andan updated risk register.Mandatory criteria aresurveyed and progress onrecommendations from theOrganisation-Wide Surveyis reviewed.Phase 2Organisation-WideSurvey (OWS)¼¼¼¼Members provide a Pre-SurveyAssessment against all criteriaand an updated risk registerapproximately 6 weeks priorto the organisation-wideonsite survey.All criteria are surveyed andprogress on recommendationsfrom the PR is reviewed.Phase 3Self assessment¼¼¼¼Members provide a selfassessment of progress againstthe recommendations from theOrganisation-Wide Survey.Organisations update andsubmit their register of keyorganisation risks (risk register).ACHSAccreditationOctober 2010 7

Section 2Overview of EQuIP2.2 What is EQuIP?EQuIP is the Evaluation and Quality ImprovementProgram, developed and conducted by the ACHS.This framework for managing health services to ensurequality and safe care and services and for achievingquality improvement has been used in Australian healthservices since 1996. Every four years, the EQuIPprogram is reviewed and revised; EQuIP5 will apply toperformance assessment from July 2011.EQuIP is a four-year quality assessment andimprovement program for organisations / healthservices that supports excellence in consumer / patientcare and services. If this is achieved, accreditationwill follow. The arrangement of elements under gradedratings that reflect increasing maturity of qualityimprovement activity has been designed to assist andsupport organisations / health services in their qualityimprovement efforts.This guide contains the standards, criteria, elementsand guidelines that constitute EQuIP5.The key components of EQuIP are:• the standards that organisations work to achieve• a yearly self assessment to evaluate performanceagainst the standards• ACHS assistance and guidance around theorganisation’s self assessment• biennial onsite surveys by an external,experienced team of accreditation surveyorsto provide an independent assessment of theorganisation’s performance against the standards• the improvement process undertaken byorganisations to address the recommendationsfrom the onsite surveys.2.3 The self assessmentSelf assessment is an important component of theEQuIP cycle and is designed to assist organisations tomonitor their progress in partnership with the ACHS.The self assessment is a regular and continual part ofthe EQuIP process and is undertaken during all phasesof the EQuIP cycle.In Phases 1 and 3, the self assessment is a reviewof progress against the recommendations of theprevious survey.During Phases 2 and 4, the self assessment becomesa Pre-Survey Assessment completed prior to the onsiteOrganisation-Wide Survey or Periodic Review.2.4 Organisation-Wide Survey (OWS)Within the four-year EQuIP cycle, there are two onsitesurveys. The first of these is the Organisation-WideSurvey. The aims of the Organisation-Wide Survey are:• to verify the organisation’s self assessment• to conduct an external peer assessment ofthe organisation’s performance• to review the progress on recommendationsgiven at a previous survey• to provide feedback and offer advice to theorganisation that may assist with furtherimprovement• to award accreditation.The OWS involves the review of progress andachievement of the organisation against all the EQuIPcriteria determined to be relevant to the organisation.(Refer to not applicable (NA) criteria / elements inSection 4.3.3)8 The ACHS EQuIP5 Guide Book 1 Accreditation, Standards and Guidelines Clinical Function

Section 3EQuIP Surveys3.1 The EQuIP Self-Assessment processSelf assessment is an important component of theEQuIP cycle and is designed to assist organisations tomonitor their progress in partnership with the ACHS.The self assessment is a regular and continual part ofthe EQuIP process and is undertaken during all phasesof the EQuIP cycle.In Phases 1 and 3, the self assessment is a review ofprogress against the recommendations of the previoussurvey. This allows all organisations to continueto improve in the areas that were identified at theprevious survey as needing development. In addition,the organisation submits an updated register of keyorganisational risks, which includes a risk rating andaction plan for the key risks to the organisation as awhole. This demonstrates that the major risk areasto the organisation are being proactively managedand that this is contributing to the overall safety of theorganisation and to quality improvement.During EQuIP Phases 2 and 4, the self assessmentbecomes a Pre-Survey Assessment completed priorto the onsite OWS or PR. This assessment againstthe EQuIP standards provides the outline for theevidence that the surveyors will verify at survey.Pre‐Survey Assessments provide the ACHS surveyorswith an understanding of the organisation, its currentachievements and the way in which it operates.3.1.1 Benefits and objectives ofthe self assessmentThe main benefit of the self assessment is to provide aformal and systematic assessment of an organisation’sprogress against recommendations from the previoussurvey. Other benefits include:• to provide an internal tool for quality improvement• to increase consumer / patient satisfaction byshowing the organisation’s commitment to safetyand quality• to focus and energise the organisation usingidentified goals• to increase involvement of staff in continuousquality improvement• to provide a communication and supportchannel with the ACHS• to prepare for the accreditation survey.3.1.2 The self-assessment processNew EQuIP membersNew members of the EQuIP5 program begintheir quality management process in Phase 1 byundertaking an initial self assessment. This initial selfassessment is against all of the EQuIP5 standards.The self assessment provides a gap analysis thatthe organisation can use as a basis for planning,by identifying opportunities for improvement andproviding a starting point for an organisation tomeasure and improve performance.Existing EQuIP membersDuring a four-year EQuIP cycle, an organisation willcomplete a self assessment during Phases 1 and 3.These self assessments report the progress againstrecommendations from the previous survey. Inaddition, the organisation provides an updated riskregister of the key organisational risks.When addressing recommendations from the previoussurvey, organisations will be required to use theRecommendations from the previous survey section inthe Electronic Assessment Tool (EAT). The followinginformation is included in the Action taken sectionwhen addressing the recommendations: the position ofthe person responsible for the recommendation, targetor completion date of the recommendation, and theactual action taken to address the recommendation.10 The ACHS EQuIP5 Guide Book 1 Accreditation, Standards and Guidelines Clinical Function

When addressing the recommendationsfrom a previous survey, the followingguidelines are important:¼¼¼¼¼¼¼¼¼¼¼¼¼¼Who is involved in addressing therecommendation?What is the intent of the recommendation?What is the timeframe for addressing therecommendation? – timeframes and prioritieswill ensure a realistic action plan is developed.Maintain a focus on outcomes / results. Whatoutcomes / results do you expect to achieveby addressing the recommendation?How have you incorporated the principles ofEQuIP in the response? – that is, consumer /patient focus, effective leadership, culture ofimproving, striving for best practice.How do you know the actions you implementedare effective?How can you be confident that the steps youhave taken have led to an improvement in yourservices? What measures or indicators willyou use to monitor these actions?3.1.3 The EQuIP Self-Assessmentfeedback reportThe self assessment from each organisation isreviewed by ACHS staff or a consultant and awritten feedback report is provided. This reviewmechanism assists organisations to identify areasfor improvement and aids in the preparation forfuture surveys. Organisations may also request ascheduled telephone discussion to further discussthe self‐assessment report.3.1.4 Changes to the self-assessmentformat from EQuIP 4 to EQuIP5The self-assessment format has undergone someimportant changes and improvements since EQuIP 4,which are summarised in the following table.EQuIP 4Self-AssessmentIn EQuIP 4, memberswere required todocument a summaryof supportive evidenceagainst each EQuIP 4criterion.Replaced by EQuIP5Self-AssessmentIn EQuIP5, theself assessmentaddresses only theprogress against therecommendations andthe key organisationalrisks. It is only in thePre‐Survey Assessmentthat members arerequired to addresseach criterion.3.1.5 Before starting a Pre-SurveyAssessmentPrior to commencing the Pre-Survey Assessment, thereare some key issues to be considered. These include:• ensuring there is executive supportand commitment• ensuring resources such as expertiseand time are available• facilitating a climate of trust, with openparticipatory management and anorganisational desire to improve• using staff training and education toempower staff in quality and improve theirinput to the self assessment.October 2010 11

Section 3EQuIP Surveys3.2 Pre-Survey Assessment (PSA)3.2.1 How to start a PSAThe organisation should begin the process as early aspossible. The Pre-Survey Assessment will need to besubmitted six weeks prior to the survey.The Pre-Survey Assessment is an opportunity for theorganisation to ensure as many staff and stakeholdersas possible contribute to the preparation for survey.This can be assisted by circulating information aboutEQuIP and the Pre-Survey Assessment to all staff anddeveloping systems to empower and encourage themto contribute.Many organisations have found it useful to appointan appropriate person to take responsibility foreach standard / criterion. In some cases, this will bethe chair of a committee or a designated memberof staff with an interest in the area. It is suggestedthat ‘champions’ are selected to assist in preparingresponses to each criterion.Alternatively, some organisations form working groupswith responsibility for the EQuIP process, or a workinggroup for each function or standard.Note that it is the quality coordinator’s responsibilityto coordinate the submission of the Pre-SurveyAssessment report, rather than to create it.Well-prepared Pre-Survey Assessments willgreatly assist the organisation in continuousquality improvement, and will also assist the ACHSsurveyors in the verification procedures requiredfor onsite surveys.3.2.2 The PSA formatSummary of Supportive EvidenceThe Summary of supportive evidence is a list of all theelements of each criterion with a section allowing abrief summary of how the organisation demonstratesthat it fulfils those elements. This section assists anorganisation to rate itself against each criterion andforms a gap analysis against the criteria.Each criterion needs to be self-rated as LA, SA, MA,or EA (the levels of achievement are detailed in Section3.5.2 Criterion achievement ratings). The rating forthe criterion is determined by systematically workingthrough all its elements and assessing whether theorganisation has achieved the stated requirementin those elements. Where a specific element is notapplicable, this can be flagged by clicking the NAoption in the Electronic Assessment Tool (EAT), andwhere explanation is required, may be outlined in theSummary of supportive evidence section.Handy hints when rating a criterion:• Rate the criterion using the elementsas a guide.• Evaluate your progress against theelements of the criterion.There are three response options provided for eachelement in the Summary of supportive evidencesection: Yes, Work in Progress (WIP) and NotApplicable (NA). A brief explanation of the evidenceneeds to be entered into the Summary of supportiveevidence section. There is a 1000 character limit forthe supportive evidence sections. Organisations needto ensure that the brief evidence they include in thePre-Survey Assessment is able to assist the surveyteam to verify the stated level of achievement.The rating levels for the Pre-Survey Assessment are:LAAwarenessSAImplementationMAEvaluationEAExcellenceOALeadershipLA elementsLA elements plusSA elementsLA, SA elementsplus MA elementsLA, SA, MAelements plusany ONE of theEA elementsThis can onlybe rated by thesurveyors atthe survey12 The ACHS EQuIP5 Guide Book 1 Accreditation, Standards and Guidelines Clinical Function

Summary of Supportive Evidence screenNote that an organisation may be achieving in areas other than the listed elements under each criterion as the elements are not limiting.Evidence that does not respond directly to the wording of the elements, but is relevant to the criterion statement, may be included in theSummary of supportive evidence section.A variety of methods to collect the evidence canbe used. These may include:• routine data collections that are already underway, for example reports to State / Territory andCommonwealth governments or data to healthinsurance funds• special data collections such as surveys andfocus groups where applicable• asking staff, including management, whatimprovements they have been involved withor how they can demonstrate quality service• asking both staff and managers fromdifferent areas a set of questions to verify thatprocesses have in fact been implemented• finding out from staff what they would like toimprove and if they have a workable plan forthat improvement• asking managers to ensure they can verifyevidence of meeting the elements of the criteriain their area• use of clinical indicators or performanceindicators.October 2010 13

Section 3EQuIP SurveysKey ImprovementsThe Key improvements section isdesigned to provide an organisation withthe opportunity to summarise its qualityor safety implementation initiatives inhigh-volume, high-risk or significantareas within the member organisation.Up to ten of the most significant results /outcomes with verifying data for eachcriterion are required. This meansthat, particularly in larger and morecomplex organisations, the Pre-SurveyAssessment will need to be selectiveand target issues of the greatest volume,risk and significance in relation to thecriterion. There is a 1000 character limitfor this section.The Key improvements section allowsmembers and surveyors to obtain anoverview of achievement against thecriterion since the last onsite surveyby showing:• the improvement project• what the organisation changed• the outcomes / results of the project.Plans for ImprovementThe Plans for improvement section willprovide members and surveyors withan indication of how the organisation isprogressing against each criterion sincethe last onsite survey by providing themajor areas for future improvement.Up to ten organisational plans forimprovement can be recorded againsteach criterion. There is a 1000 characterlimit for this section.If you need help to complete thePre-Survey Assessment orassistance with understanding EQuIP,the Customer Services Managerappointed to your organisation willbe able to assist you.14 The ACHS EQuIP5 Guide Book 1 Accreditation, Standards and Guidelines Clinical Function

3.2.3 Points to remember in preparing a PSA• Ensure that you are familiar with the EQuIPPre-Survey Assessment system and the formatof the Pre-Survey Assessment.• Consult your Customer Services Managerif you need advice.• Plan your reporting process carefully, involvingstaff and stakeholders.• Delegate areas of responsibility for completion.• Ensure the reporting processes are systematicand accurate.• Begin the Pre-Survey Assessment processas early as possible, as evaluation can takelonger than estimated.• Keep the summary of supportive evidence brief.• Ensure that the evidence noted in the Pre-SurveyAssessment is cross-referenced and is ableto be verified during the onsite survey by thesurvey teams.The due date for the submission of the Pre-SurveyAssessment will be advised in writing by the CustomerServices Manager at the commencement of theaccreditation contract. It will be six weeks beforethe onsite survey.3.2.4 The Electronic Assessment Tool (EAT)The ACHS Electronic Assessment Tool (EAT) is aweb-based application used by ACHS memberorganisations and surveyors to capture data as part ofthe ACHS accreditation program. The latest version ofEAT is designed to accommodate the specificationsof EQuIP5 standards and related accreditationsurvey processes.EAT data are transmitted using 128 bit SSLencryption to ensure confidentiality and the tool isavailable 24 hours per day with the exception ofmaintenance periods.EAT is designed to perform on various currentoperating systems and popular internet browsers.It requires a reliable direct internet connection(not via proxy server) to ensure optimal performance.Survey submissionEAT users can submit their survey data electronicallyonline. There are data submission requirements inEAT and they are designed according to the EQuIP5program requirements, to ensure sufficient informationis provided from the organisation and the survey team.Member detailsMember details data should always be updated forall survey phases. An organisation will not be ableto submit their data if they do not enter a physicaladdress or identify sites for survey.Organisation-Wide Survey (OWS)Data are required for all standard and criterion sections,and for recommendations from the last onsite survey.Periodic Review (PR)Data are required for mandatory standards andcriterion sections, and for recommendations from thelast onsite survey.Self assessment phasesData are required for recommendations from thelast onsite survey. The risk register should alsobe submitted.RatingsRating requirements must be satisfied priorto submission.EAT ResourcesFor further information on EAT please refer to the EATlogin screen for:• Overview EAT access• Frequently Asked Questions (FAQ)• EAT Help Manual.EAT SupportPlease notify ACHS immediately if you are experiencingdifficulties with the Electronic Assessment Tool:Telephone: +61 2 9281 99558:30am – 5:30pm (Australian Eastern Standard Time)Email: eat@achs.org.auOctober 2010 15

Section 3EQuIP Surveys3.3 EQuIP onsite surveys and processesAn ACHS survey is an objective and evidencebasedassessment of a healthcare organisation’sperformance against a set of standards, undertakenby surveyors who are from the healthcare industry.There are two scheduled onsite surveys within theEQuIP cycle. These are conducted during Phase 2 andPhase 4.The accreditation surveys consist of an Organisation-Wide Survey in Phase 2 and a Periodic Review duringPhase 4.An Organisation-Wide Survey (OWS) is a reviewof the achievements of the healthcare organisationagainst all of the ACHS EQuIP5 standards and criteria,including the recommendations that were made at thelast survey.The Periodic Review (PR) is a review of theachievements of a healthcare organisation against the15 mandatory criteria and the recommendations fromthe last onsite survey.In addition, if the survey team finds a ‘risk’ in a nonmandatorycriterion during the PR, this will need tobe included in the survey report.The surveyors will verify the organisation’s Pre‐SurveyAssessment against the standards by reviewing theevidence presented to them. This will be in the form ofinterviews with staff, reviewing documentation such aspolicies, and other information such as clinical indicatorreports, incidents and complaints management.In most cases, the two onsite surveys will differ in thenumber of days and surveyors allocated.The survey length and the number and selection ofsurveyors are determined by several criteria including:• the size of the organisation• the type of care and services offered• whether the organisation is public or private• whether the organisation is rural or metropolitan.The ACHS aims to match surveyor expertise andexperience with the organisation.ACHS survey teams are made up of professionals fromthe healthcare industry. The Survey Coordinator will bethe main contact point between the ACHS survey teamand the organisation. If an organisation is relativelysmall – such as a day procedure centre – there willalways be at least two surveyors, with one surveyorcoordinating the entire onsite process. However, if theorganisation is large with multiple sites of operation,the ACHS will appoint a Survey Coordinator to managethe activities with a team perhaps as large as 8 to 10surveyors. It is very important to make contact withthe Survey Coordinator as early as possible. TheSurvey Coordinator will be able to assist during thesurvey preparation period with timetable drafting,presentations and evidence for the survey.The ACHS has a formal selection process forsurveyors. All ACHS-appointed surveyors participatein initial training and annual refresher courses, andare expected to ensure the currency of their expertise.Evaluation forms are completed by the organisationand by the surveyors after every survey to assist incontinuous improvement within the surveyor workforceand of the ACHS policies and procedures.Consumer SurveyorsAn additional option for member organisations isthe inclusion of a consumer surveyor at one of theonsite surveys. Although surveys of mental healthorganisations regularly use consumer surveyors,there are also significant benefits to organisationsoutside this speciality in having a consumer surveyoron survey:• greater focus on patient-centred care• better engagement with local consumergroups and community groups• access to a consumer perspective onstandards of care.3.3.1 The survey scheduleThe dates for onsite surveys are pre-determined atthe commencement of the EQuIP contract period.While these dates are negotiable to some degree,it is important to be aware of when the next eventsin the EQuIP cycle occur. ACHS Customer ServicesManagers work with the organisation to determineconvenient dates for the survey, the locations to besurveyed, the duration of the survey and any associatedcosts at the set up of the membership. The duration ofthe survey may be one day for small organisations, andup to five days for large organisations.If an organisation needs to change the dates of anyEQuIP event, particularly an onsite survey, the ACHSshould be notified as soon as possible. Refer to theEQuIP Terms and Conditions of Membership forinformation regarding fees for deferring surveys. Eachmember organisation has a designated CustomerServices Manager backed up by a support teamthat is able to provide coordination and assistancethroughout the membership period. The CustomerServices Manager will be in contact with the healthcareorganisation prior to a survey to discuss issues inrelation to the upcoming survey.16 The ACHS EQuIP5 Guide Book 1 Accreditation, Standards and Guidelines Clinical Function

3.3.2 Additional surveysIn addition to the OWS and the PR, there are othersurveys that your organisation may be involved in andthey include the following:Advanced Completion in 60 days surveyAn Advanced Completion in 60 days (AC60) surveymay be offered to an organisation in up to four criteriain order to address:• High Priority Recommendations (HPRs), and/or• an SA rating in mandatory criteria, and/or• an SA rating in non-mandatory criteria.If the Survey Coordinator, during discussion withthe organisation being surveyed, believes thatan organisation would benefit from 60 days fromthe survey date to achieve an acceptable level ofperformance, an Advanced Completion surveywill be offered. This provides the organisation withan opportunity to promptly address issues priorto the completion of survey report processingand the subsequent accreditation decision. Costsassociated with the AC60 must be met by themember organisation.Conditional SurveyFollowing either an OWS or PR, the survey teammay recommend a Conditional Survey to allow anorganisation a year to achieve an acceptable level ofperformance; this provides the organisation with anopportunity to address issues which require sometime and resources to achieve an acceptable levelof performance.A Conditional Survey may be offered to an organisationin 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 toan organisation in order to address:• SA / LA ratings in from 6 to 11non-mandatory criteria.For issues in which a 60-day framework is too shortto achieve the level of change required, a ConditionalSurvey gives the organisation one year to achieve therequired level of performance.At the end of this time, the survey team will assess theorganisation’s performance against the criteria whichled to the Conditional Survey. They may also, at therequest of the organisation, survey additional criteriato assist the organisation in its quality journey.If, at the Conditional Survey, the organisation meets therequired standard, the organisation will regain its fullaccreditation status. The accreditation expiry date willremain as it was following the last OWS.If, at the Conditional Survey, the organisation has notresolved the identified areas of poor performance, theorganisation will become non-accredited.Costs associated with the Conditional Survey will bemet by the member organisation.Alignment SurveyThe Alignment Survey assists organisations to maintaintheir accreditation status if several organisationsamalgamate their membership. An Alignment Surveymay also be conducted if there is a restructure ofrelated organisations. The Alignment Survey allows theACHS to ensure that quality and safety continue to beaddressed throughout the organisation’s transition.An Alignment Survey will be a review of:• all mandatory criteria• all Clinical Function criteria• Criterion 3.1.4 External service providers• recommendations from the previous onsite survey.The Alignment Survey may be conducted as areduced OWS or as an expanded PR. The extentof the Alignment Survey will be discussed withthe organisation and agreed with the CustomerServices Manager. If the organisation demonstratesan appropriate level of achievement, a two-yearaccreditation status will be granted.In-Depth ReviewAn In-Depth Review is a more detailed review ofparticular services within an organisation using theACHS standards and relevant specialty standards andguidelines for that particular service. The In-DepthReview, undertaken by a surveyor or surveyors witha background in the particular specialty, is valuablein helping to improve services and to demonstrateto consumers and funders that the service provideshigh quality care. Services undertaking an In-DepthReview may be awarded a Certificate of Recognitionof the application of the specialty standards. The In-Depth Review is conducted at an additional cost to themember organisation and is conducted at the sametime as the OWS.October 2010 17

Section 3EQuIP SurveysSpecialty standards and guidelines are used inIn-Depth Reviews of:• mental health services• pharmacotherapy clinics• palliative care services.Unscheduled SurveysTo ensure that organisations continue to meet theACHS standards and to provide the required standardof care and service, the ACHS has introduced thepossibility of an Unscheduled Survey. There arecertain circumstances under which such a surveywill occur, including the failure on the part of anorganisation to provide sufficient evidence thatprevious recommendations are being progressed.The next survey in the organisation’s EQuIP cycle willbe rescheduled to an earlier date to accommodatethis onsite survey. This survey will be conductedto ascertain whether the healthcare organisation ismeeting the EQuIP standards to the required level.3.3.3 Getting ready for the survey –one page summariesBefore an onsite survey, it is recommended that largerorganisations complete one page summaries.One page summaries provide a useful tool forsurveyors and organisations to identify and focus onthe major achievements made in each of the EQuIP5functions (Clinical, Support and Corporate) byindividual departments, divisions or service streams.It is an excellent tool to showcase major achievementsthat are not covered in the organisation’s Pre-SurveyAssessment document.One page summaries should be exactly that – aconcise, single page of listed achievements undereach function, prepared by individual departments,divisions or service streams. A summary needs toclearly identify the department, division or stream,and to be dated and submitted to the survey teamsix weeks prior to the survey – together with thePre-Survey Assessment.An example of a one page summary prepared by a department; it provides an instant understanding of the serviceand notes the major achievements in the department for each function.Radiology department: Summary of Achievements 11 October, 2007The Radiology department underwent re-location and renovation during 2005. This enabled a review ofthe department’s facilities, in particular its outpatient services and information systems. A review was alsoundertaken on volunteer staffing levels and training.Clinical Support CorporateA re-designed layout of facilities,additional consumer / patientsupport equipment and procedureshave resulted in improvedfalls managementA revised consumer / patient recordtransfer has improved informationsecurity and efficiencySignage at appropriate external andinternal sites has been improvedPartnerships with consumerfocus groups identified areasfor improvementPublic health information is betterpresented and accessible within theconsumer / patient waiting areaWaste management systems havebeen reviewed for safety andefficiencyA staff awareness program hasbeen introduced to better identifyand appropriately manage CALDconsumers / patientsParticipating volunteers in thehospital system now providesupport services in the consumer /patient waiting areaImproved documentation providesconsumers / patients with clearerinformation on procedures andx-ray systemsSmall, single-function facilities are not required to complete one page summaries prior to onsite surveys.18 The ACHS EQuIP5 Guide Book 1 Accreditation, Standards and Guidelines Clinical Function

3.3.4 Survey timetablesOne of the first preparation activities for an onsitesurvey is the development of an agreed surveytimetable. A survey timetable allows efficient timemanagement for the survey team and the organisation.It is helpful to have an initial discussion with the SurveyCoordinator prior to drafting the timetable, to clarifyany specific issues and requirements. The drafttimetable can then be prepared well in advance andforwarded to the Survey Coordinator for comment. TheSurvey Coordinator will assess its workability and maysuggest some practical changes. The timetable maygo through several adjustments before a final versionis decided upon.When preparing the survey timetable organisationsneed to consider the key people to be identifiedand included.This will depend on the size and type of theorganisation. For example, for a day hospital, thesurveyors will need to meet with the director, nursingstaff and medical staff. For larger organisations, thiswill include the executive team, the quality and riskteams, the lead clinicians, heads of departments andso on. The focus needs to be on teams for most of theinterviews for large organisations. Some of these teamswill include service delivery / frontline staff rather thanmanagement. Many teams will be the committees thatare responsible for particular criteria. For example,the Occupational Health and Safety committee wouldmeet regarding the safety management criteria. Inlarge organisations, the surveyors will always need tomeet with the senior medical staff, and with the juniormedical staff as a group. At a rural organisation, it isexpected that the survey team will meet with the localGPs. It is also usual for the survey team to meet withthe Medical Advisory Council.Survey time with consumers / patients and stakeholdergroups also needs to be taken into account inthe timetable.Part of a survey timetable prepared for a large healthcare organisation. For a smaller organisation, there may onlybe two surveyors, although the principles remain the same. Each verification and meeting has a cross-reference tothe ACHS criterion to which it applies.SurveyCoordinatorMr Alex SmithTimeSurveyor 1Ms Jill BrownSurveyor 2Mr John Other8.30–8.45amMeet in main foyer withquality coordinatorMeet in main foyer withquality coordinatorMeet in main foyer withquality coordinator8.45–9.15am Hospital tour Hospital tour Hospital tour9.15–9.30amEscort to the surveyors’work areaEscort to the surveyors’work areaEscort to the surveyors’work area9.30–10.30amWelcome by organisationexecutive and presentationto survey team – Board roomWelcome by organisationexecutive and presentationto survey team – Board roomWelcome by organisationexecutive and presentationto survey team – Board room10.30–11.00 am Verification time forsurvey team11.00am–12.30pm 1.5.2Meeting with Clinical NurseSpecialist, infection controlcommittee – CNS officeVerification time forsurvey team1.2.1, 1.1.6Meet with Mgr CardiacRehab Centre and team –Rehabilitation CentreVerification time forsurvey team3.1.5Meeting with Directorof Nursing and policycommittee – Board Room12.30–1.00pmLunch –Board RoomBefore an onsite survey commences, ACHS survey teams will have familiarised themselves with the organisation through itsPre-Survey Assessment and the pre-survey discussions that the Coordinator has conducted with the organisation.October 2010 19

Section 3EQuIP SurveysEssential tips for completing the survey timetable:• Be prepared to adjust the timetable duringthe survey.• Circulate the final timetable to everyone in thequality management team and to the variousdepartments to be surveyed.• List locations as well as names, position titlesand times, and the criteria that will be of interestduring the meeting.• Take into account the time factor for surveyortravel from location to location.• Ensure that the timetable includes all sitesthat need to be visited.• Ensure that the survey timetable includesadequate time for verification of evidenceand opportunities for the survey team to haveunscheduled discussions and meetings with staff.• Provide a location map with the timetable forthe survey team.• Carefully assess the complexity of eachdepartment’s functions and the time the surveyor /survey team will need. Clinical units will usuallyrequire a generous time allocation.• Include the organisation’s presentation inthe timetable.• Check that your survey team has an accurateorganisation map and a list of key personnelwith contact details.• Ensure that the survey team has appropriatesecurity identification.Include a scheduled meeting with the organisation’sleadership team and senior management on a dailybasis. Some Survey Coordinators like to meet in theevening, while others would prefer an early morningmeeting to discuss how the survey is progressing.3.3.5 Surveyors’ meeting with theleadership teamAn essential part of the opening phase of the surveyis an informal meeting between the survey teamand the organisation’s leadership team and seniormanagement. This brief meeting should take placeat the beginning of the first day, and provides anopportunity to discuss issues that may need to beraised, to review the objectives of the survey, to ensurethat the management team is aware of the evaluationprocess and to discuss any areas of significance. Atour of the organisation may take place at this point. Inaddition, the survey team or Coordinator is requiredto meet with the executive on a daily basis and thisneeds to be included in the timetable. The best timefor this daily meeting should be determined with theCoordinator prior to the survey. This meeting is toensure that any issues raised during the survey areimmediately addressed.3.3.6 The survey presentationThe survey presentation allows the organisation toshowcase its improvements and achievements.A formal presentation will follow the introductorymeeting. Presentations provide an organisation withthe opportunity to present an overview of outcomesand achievements since the last onsite survey. It isimportant to discuss with the Survey Coordinator theexpectations of the presentations as early as possible,so that your preparation is appropriate.Presentations may be in different forms, such as aPowerPoint presentation or simple documentation.A small organisation with a small quality managementstructure may prefer to produce a written overview thatcan be discussed with the survey team, rather thanmake a formal presentation. The total presentationshould be brief, ideally running from 30 minutes to1 hour, and needs to be outcome-based, providinga summary of the organisation’s quality initiativesand achievements.Individual departments should be encouragedto discuss their own management strategies andaccomplishments during the verification meetingswith surveyors – this should not be in the form ofa presentation in their own department.3.3.7 The survey processAfter the introductory meetings with seniormanagement and the presentation, the surveyorsshould be shown to their designated work room.Although the surveyors will be conducting meetingsthroughout the organisation, it is essential they beprovided with a relatively quiet, private area in whichthey can work and meet. Surveyors will need to verifyevidence. Ideally, the room should be lockable.Surveyors will need access to the internal telephonelisting and be reasonably comfortable about findingtheir way around the organisation. Surveyors willalso need to access a computer and the intranet iforganisations have policies available electronically.If evidence is presented electronically, the surveyorswill require one computer each, and the organisationshould provide a timetabled session on navigating theelectronic evidence at the beginning of the survey.20 The ACHS EQuIP5 Guide Book 1 Accreditation, Standards and Guidelines Clinical Function

The quality manager / coordinator / designated staffmember should be readily accessible throughout thesurvey to assist with any administration matters orto adjust the next day’s timetable if required.The role of the quality manager / coordinator /designated staff member is to support the surveyteam but not participate in meetings. It is best to leavethe surveyors to their own devices unless assistanceis requested.Members of the organisation executive should notaccompany surveyors to departments.The survey team will need to meet with the appropriatestaff in each department. The departmentalrepresentative can review its operations with thesurveyor(s) and identify quality initiatives andachievements. The surveyor(s) will then need toaccess information and records to verify the levelof performance. Appropriate department staffwill need to be accessible to the survey team.3.3.8 VerificationVerification needs to be evidence-based. Throughoutthe survey, the survey team will:• review documents• observe how well the organisation and its variousservices are functioning• conduct formal and informal discussions with staff,consumers / patients and carers.The surveyors will continuously ask two questions:“How have you improved?” and“What evidence do you have to substantiatethe improved outcomes?”In each individual department throughout theorganisation, the survey team will need to know whatthat department does, how it provides its services andhow the performance levels have improved through theevaluation process.Prior to the survey, the organisation will need to identifythe documented evidence the survey team may requireand verify its location. The Survey Coordinator willassist with this prior to the survey. Generic informationsuch as meeting minutes could be categorised into therelevant EQuIP5 functions and located in the surveyorroom. The policies and procedures that apply toclinical staff do not need to be copied and put into thesurvey room. As the survey team will determine thespecific evidence needed, it is unnecessary to providecopies of documents in the surveyor room that maynot be required. Surveyors will need to know how toaccess documentation and this should be discussedwith the Survey Coordinator prior to the survey.3.3.9 The Summation ConferenceAt the completion of the onsite survey the surveyteam will make a summation of the survey.Throughout the survey, the surveyors will havediscussed their findings with each other to obtainan accurate and balanced assessment of theorganisation’s performance. During its daily meetings,the survey team will determine the ratings for eachcriterion. The team will also evaluate the progress fromprevious recommendations and determine any matterswhich require attention.Before the Summation Conference, the surveyteam will discuss its findings with the organisation’sexecutive team and identify any areas of concern,and acknowledge achievements.The organisation’s executive will then join theACHS surveyors for the Summation Conference.The organisation itself will determine who attendsthe survey summation. Generally, any staff can beinvited, as well as those who are part of the qualitymanagement team and heads of departments.The surveyor summation is designed to:• provide a generalised feedback on theorganisation’s performance• acknowledge quality initiatives and achievements• provide recommendations forperformance improvement• provide an indication of any High PriorityRecommendations.The surveyor summation will NOT provide informationon expected accreditation outcomes, as survey resultsrequire lengthy analysis and evaluation.October 2010 21

Section 3EQuIP Surveys3.4 EQuIP survey reportsEach organisation receives an ACHS report followingparticipation in a survey. The survey report canbe used as a management tool to assist an EQuIPmember to improve, and also to recognise itsachievements. ACHS survey reports are a summaryof an organisation’s performance at the onsite survey.The report will include evidenced findings, commentsand recommendations, including suggestions forimprovement. It is expected that the organisation willuse the EQuIP survey report as a consultancy report.The accreditation survey report is a statement ofevidence on whether an organisation has met theappropriate standards to be awarded accreditationor to maintain its accreditation.Any matters of concern that may appear in thesurvey report about the organisation’s performanceare advised to the organisation’s executive prior tothe Summation Conference and on a daily basisduring the survey. In addition, if agreed by theexecutive, these issues will be discussed during theSummation Conference.Organisations are provided with a copy of thecompleted survey report in draft format prior to thereport being finalised. This allows an organisation toensure that the report is factually correct and that theform of expression is appropriate to the environmentin which the organisation operates. Organisations canalso request clarification of recommendations wherethey may appear unclear or based on what appear tobe incorrect facts.Organisations will be provided with an opportunityto review the draft survey report for the following:• any statements containing inaccurate information,errors of fact or omissions• any statements which may be found to bemisleading, for example, where the phrasing ofa comment is expressed in a way which couldbe misinterpreted.The draft survey report process supports the EQuIPconsultative processes and encourages a continualcollaboration from the initial assessment processesto the final product.Should the ACHS receive a request for a clarification offact in the draft survey report, the Survey Coordinatorwill be consulted by the Customer Services Managerregarding the proposed changes. The SurveyCoordinator then liaises with the survey teammembers. The Survey Coordinator will endorse anyfinal amendments to the draft survey report.The survey reports are made up of aFunction Summary, surveyor comments andrecommendations, and surveyor ratings foreach criterion.A Function Summary identifies the organisation’sstrengths, as well as opportunities for furtherimprovement. Any areas requiring high priorityimprovement will also be identified in the FunctionSummary. Risk ratings and risk comments will beincluded where applicable.The surveyors will make a comment on all themandatory criteria, giving an indication of why theorganisation is achieving at the given rating.Identification of actions taken from previousrecommendations will be reviewed and documented.Surveyors are required to make a recommendationwhere an LA or SA rating has been assigned in acriterion, as guidance and to provide an organisationwith an opportunity to improve.3.4.1 How to use the survey reportAs the report provides a full quality and performanceanalysis it should be used to:• provide feedback to staff• identify where improvements are needed• compare the organisation’s performance over time• evaluate existing quality management procedures• assist the monitoring of risks andtheir management• highlight strengths and opportunitiesfor improvement• demonstrate evidence of achievementto stakeholders.Upon receipt and authorisation from the organisationexecutive, it is a good idea to circulate the surveyreport throughout the organisation including to thequality team, consumer representatives and otherstakeholder groups.3.4.2 Public release ofaccreditation informationInformation about the accreditation status ofEQuIP members is made publicly available onthe ACHS website.22 The ACHS EQuIP5 Guide Book 1 Accreditation, Standards and Guidelines Clinical Function

Since July 2004, member organisations have beenencouraged to publish a jointly agreed statementof their performance from the survey – an AgreedPerformance Statement. The statement is madeavailable on the ACHS website. Alternatively,an organisation may provide access to the fullaccreditation report on the organisation’s own websitevia a link from the ACHS website. The ACHS is alsoable to host the full report on its website if required.3.5 Accreditation levels, surveyrecommendations andachievement ratings3.5.1 Accreditation outcomesThe possible accreditation awards granted toorganisations following an onsite survey (OWS or PR) inEQuIP are full accreditation, conditional accreditationor non-accreditation.The accreditation awards for an Alignment Survey arethe same as those for the OWS and PR except thatfull accreditation is for two years only.FULL ACCREDITATION (4 Years)NON-ACCREDITATION¼¼¼¼¼¼¼¼High Priority Recommendations (HPRs) fromprevious survey not addressedHigh Priority Recommendations (HPRs) orSA Ratings in mandatory criteria in more thantwo criteria that are not able to be resolvedin 60 daysLA ratings in any mandatory criteria12 or more LA or SA ratings innon-mandatory criteria3.5.2 Criterion achievement ratingsEach of the 47 EQuIP5 criteria has five levelsof achievement:Level 1 Little Achievement (LA)Organisations that achieve an LA rating will havean awareness or knowledge of responsibilities andsystems that should be implemented, but may haveonly basic systems in place. At this level, compliancewith legislation and policy that relates to the criterionwould be expected.¼¼¼¼¼¼¼¼A Marked Achievement (MA) rating level orhigher in ALL EQuIP mandatory criteriaAll previous recommendations are addressedReceive no High Priority RecommendationsHave no significant risksLevel 2 Some Achievement (SA)An organisation that achieves an SA rating willhave achieved all the elements of LA and willhave implemented systems for the organisation’sactivities. At this level there is little or no monitoring ofoutcomes, and so efforts at continuous improvementmay be limited by a lack of understanding about theeffectiveness of existing systems.CONDITIONAL ACCREDITATION (1 Year)¼¼A Little Achievement (LA) or Some Achievement(SA) rating level in from 6 to 11 non-mandatorycriteria irrespective of risk level¼¼High risk in any non-mandatory criteria¼¼Moderate risk recommendations from previoussurvey not addressed¼¼In a maximum of two criteria, High PriorityRecommendations (HPRs) and/or SA ratingsfor mandatory criteria that are not able to beresolved within 60 daysLevel 3 Marked Achievement (MA)The label for MA has changed from ‘ModerateAchievement’ to ‘Marked Achievement’ as the term‘Moderate’ did not reflect the high standard ofachievement that organisations reach within the MAaward level. An MA rating requires that achievementagainst the elements of LA and SA has beendemonstrated and that efficient systems have beenestablished for collecting relevant data on processesand preferably outcomes, monitoring this information,evaluating current procedures and planningimprovements in response.October 2010 23

Section 3EQuIP SurveysLevel 4 Extensive Achievement (EA)To achieve a rating of EA in EQuIP5, demonstratedachievement against the elements in LA, SA and MAmust be met. In addition, response to EA elements willbe reviewed and extensive achievement against thecriterion statement and/or its elements is required.Organisations will be able to demonstrate extensiveachievement in a criterion if they satisfy one, andpreferably more, of the following requirements:• internal or external benchmarking andsubsequent system improvement, and/or• the conduct of research that relates to theparticular criterion, and subsequent systemimprovement, and/or• proven, excellent outcomes in theparticular criterion.Level 5 Outstanding Achievement (OA)All elements of LA, SA, MA and EA must be achieved,as well as a demonstration of leadership in this criterion.Leadership in a criterion does not necessarily meanthat the organisation is a peer leader of performanceand excellence in Australia. However, it does require anorganisation to use concrete evidence to demonstratethat it is one of the best and, more importantly, that ithas taken a leadership stance in communicating itsoutcomes to other professionals, other organisationsand/or consumers / patients, or that the organisation isbeing recognised and sought out for its knowledge byother professionals and organisations.Further information on achieving MA, EA or OA ratingsis covered in Section 3.5.3 Expectations for ratings.How should organisations and surveyorsrate achievement?Organisations and surveyors will use the elements ineach of the criteria to rate the level of the organisation’sachievement. The elements are not meant to be anaudit checklist; they describe the practices thatcontribute to the achievement of each level. Themanner in which the elements are implemented and theevidence presented may differ between organisations.However, organisations should demonstrate that theirpractices address the intent of the element, and theirevidence responds to its aim or purpose.The following figure will assist organisations to betterunderstand how the elements can assist ratingachievement. Surveyors will use this model whenassigning ratings for organisations.The criterion rating formatAwarenessof basicrequirements.Policy andlegislativecomplianceis in placeImplementationSystems havebeen developedand implementedEvaluationData are collected;evaluation of thesystem occurs toensure the systemworks effectively.Improvementefforts supportbetter resultsExcellenceBenchmarkingand/or researchand/or advancedimplementationstrategies and/orexcellentoutcomesare achievedLeadershipThe organisationis a peer leaderin systems andoutcomesLA SA MA EA OALittleAchievementLA elementsSomeAchievementLA elements plusthe SA elementsMarkedAchievementLA, SA elementsplus the MAelementsExtensiveAchievementLA, SA, MAelements plusany ONE of theEA elementsOutstandingAchievementAll elements inLA, SA, MA, EAand OA24 The ACHS EQuIP5 Guide Book 1 Accreditation, Standards and Guidelines Clinical Function

3.5.3 Expectations for ratingsAchieving MAThe Marked Achievement (MA) rating in each ofthe 47 criteria requires that organisations evaluatetheir systems. The goal is to determine whether thesystem(s) that the organisation has implementedworks effectively, whether there is potential to improve,and perhaps to give insight into how this might beachieved. This applies not only to the evaluation ofclinical systems but also to the evaluation of policyand programs.Evaluation is judging the value of something bygathering valid information about it in a systematicway and by making a comparison. The purpose ofevaluation is to help to decide what to do, to justifyearlier actions or to contribute to scientific knowledge. 1There are many different methods of evaluation thatcan be used in health services. The ACHS RiskManagement and Quality Improvement Handbookprovides further information on assessing performanceand evaluation.Evaluation of a process or system involves a reviewof performance measures and other qualitative dataincluding the opinions of those directly involved in, oraffected by, a process. It may include comparisonsagainst earlier times, other departments / organisationsor classes of consumers / patients or personnel.Organisations should then assess whether theprocess or system is meeting the organisation’sand its consumers / patients’ goals, and whetherthere is scope for improvement. Areas identified forimprovement may require further investigation beforea decision is made to progress. Evidence of datacollection, its evaluation, and action taken, or reasonsfor inaction, would be expected for an MA rating. Thereis more to evaluation and quality improvement thanmeasuring a process or system.Significant quality improvement projects withdocumented evidence of baseline measurement,considered options for improvement, anddemonstrated positive outcomes from the changesimplemented would be a good foundation foradvancing to achievement of an EA rating.Achieving EAFor organisations to achieve an EA rating, they musthave implemented innovative systems. The use of ‘and/or’ in the EA elements means that organisations mayselect one or more elements to show improvement on aparticular program or process.Organisations will need to provide information on howany improvements have progressed over time. This isto say, that a program or process has been evaluatedand where improvement was required, changeswere made, and then evaluation of those changesoccurred. However, the program or process must beimplemented across the organisation, and not justin one department / ward, or where the program orprocess has been trialled in one department / ward,a plan should be provided on how the improvementfrom it will be implemented across the organisation.To show that improvements have evolved overtime, they should be documented and dated, sothat surveyors can see how the organisation hasprogressed and that the same improvement is notpresented again.Benchmarking and ResearchElements in the EA column generally address eitherbenchmarking or research. For those elementsthat require benchmarking, an EA rating cannotbe awarded for conducting only compulsorygovernment benchmarking.Benchmarking is the continuous measurement of aprocess, product, or service compared to those ofthe toughest competitor, to those considered industryleaders, or to similar activities in the organisationin order to find and implement ways to improve it.This is one of the foundations of both total qualitymanagement and continuous quality improvement.Internal benchmarking occurs when similar processeswithin the same organisation are compared. 2If an organisation participates in benchmarkingactivities, it is important to complete the requirementsof a proper benchmarking exercise; that is, notonly to compare processes and outcomes but toinstitute improvements.1 Øvretveit J. Action evaluation of health programmes and changes: a handbook for a user-focused approach.Oxford UK; Radcliffe Medical Press; 2002.2 Joint Commission on Accreditation of Healthcare Organisations (JCAHO). Sentinel event glossary of terms. Oakbrook Terrace USA:JCAHO. Accessed from http://www.jointcommission.org/SentinelEvents/se_glossary.htm on 9 September 2010.October 2010 25

Section 3EQuIP SurveysIf organisations do not have access to comparativedata, they should seek alternative ways to gaugethe efficiency and effectiveness of their systems /processes. Departments / wards may be able tocompare processes with other departments / wardsin the same organisation, considering the similaritiesand differences between their sites. Similar functionsand processes, such as scheduling or the collectionof customer feedback, could be compared againstother industries. The objective of benchmarking is toconsider and test alternative systems and processes,and adopt those that will best meet the organisation’sneeds. Through benchmarking, an organisationwill understand the advantages and recognise anycompromises in its processes.Research is defined as a contribution to an existingbody of knowledge through investigation, aimed atthe discovery and interpretation of facts. 1Where an element requires an organisation toconduct research, it is referring to high-level qualityimprovement projects that have a robust structure,and are about a redesign of systems, processes andperformance, rather than a review. The organisationshould address the research elements by highlightingthese types of projects.Organisations that wish to present their researchto surveyors to evidence a self-rated EA shouldunderstand that surveyors have an expectationof a project conducted and presented at a‘publishable’ standard.Inclusions in a quality improvement report are:• background of the project• assessment of problems• results of assessment / measurement• strategies for quality improvement / change• lessons and messages.Achieving OATo achieve an OA rating, all applicable EA elementsneed to be met.The requirement for achieving the OA level isa demonstration of leadership in that criterion.Leadership does not necessarily mean that theorganisation is the best in Australia. It may mean thatthe organisation can demonstrate that it is outstandingamongst peers.In EQuIP5, organisations will not be able to self rateat an OA level, however, if an organisation believesthat it is a leader in a criterion, surveyors shouldbe provided with a brief (one page) submissionsummarising the steps taken to achieve this and proofthat the organisation is considered to be a leader.Surveyors will then evaluate the submission and theevidence provided and determine whether an OA canbe awarded.Surveyors may also award an OA rating without asubmission from the organisation. If surveyors consideran organisation is performing at an OA level, theywill assist the organisation to develop a one-pagesummary describing the leadership status, which willthen be included in the survey report.3.5.4 High Priority Recommendations (HPRs)A High Priority Recommendation (HPR) is given toan organisation when:• consumer / patient care is compromised, and/or• the safety of consumers / patients and/or staffis jeopardised.Surveyors complete a risk assessment to validatetheir decision to allocate an HPR, which shouldbe addressed by the organisation in the shortesttime possible.The British Medical Journal (BMJ) group journal,Quality and Safety in Health Care, provides anoutline of the structure of a ‘publishable qualityimprovement report’ – see http://qshc.bmj.com/site/about/guidelines.xhtml, and scroll down to ‘QualityImprovement Reports’.1 International Society for Quality in Health Care (ISQua). The ISQua Surveyor Training Standards Programme. Dublin IRL; 2009.26 The ACHS EQuIP5 Guide Book 1 Accreditation, Standards and Guidelines Clinical Function

3.5.5 Achieving accreditationAn organisation which is awarded accreditation statusby the ACHS has reached a high level of achievement.ACHS accreditation signals to the communityand staff that an organisation is striving for bestpractice, and has a quality improvement culture andcommitted quality management systems in place.Accreditation also sends the important message thatthe organisation has a focus on consumer / patientneeds and safety.Accreditation success should be communicatedthroughout the organisation, to stakeholders andto the community. Organisations may choose tostrategically announce accreditation achievement viatheir website, newsletters or other preferred means ofcommunication. The ACHS publishes accreditationachievements on its website.3.5.6 Non-accreditationThe ACHS provides an extensive support network fororganisations that have not reached full accreditation.This includes additional support from the CustomerServices Manager as well as customised EQuIPworkshops and training days. Individual consultationscan also be arranged to assist with the implementationof improvement practices.Following non-accreditation, the organisation must gothrough a full OWS in order to become re-accredited.The Customer Services Manager will work withthe organisation to determine the best time for thatsurvey to occur.3.5.7 An appeals processAccreditation decisions may be appealed, in writing,by current financial members. All appeals must beaddressed according to the Terms and Conditions ofthe organisation’s EQuIP membership.October 2010 27

Section 4How to use this EQuIP Guide4.1 The EQuIP frameworkEQuIP5 focuses on the issues considered to be of thegreatest importance in providing high quality and safehealth care. The standards have been developed inconsultation with the healthcare industry and addressthe Clinical, Support and Corporate Functions ofthe organisation.The standards and criteria express goals that arecommon to different types of services. This means thatalthough the evidence presented by different healthservices or service providers for a criterion may vary,consideration of evidence can be made in the contextof organisational structure, geography, consumer /patient type and services.EQuIP5 is structured in a hierarchy, as follows:• functions• standards• criteria• elements• guidelines.FunctionA function is a group of standards.StandardThe standard describes the overall goal; for example,Standard 1.1 Consumers / patients are provided withhigh quality care throughout the care delivery process.CriteriaThe criteria describe key components of the goal,which are necessary for meeting the goal; for example,Criterion 1.1.1 Assessment ensures current andongoing needs of the consumer / patient are identified.ElementsFor each criterion there is a series of elements which:• explain the criteria• describe some important practices for each levelof achievement• should not limit practices; organisations areencouraged to undertake and present additionalactivities that respond to the criterion statement• should be regarded as a framework for totalquality rather than a checklist of compliance• provide direction for improvement activitiesand for achieving better practice.Each element identifies what should be in place to atleast fulfil the requirements of the criterion at a certainrating level. (Refer to Expectations for Ratings onpage 25 of this guide.)GuidelinesThe guidelines give definitions and provide moreinformation and guidance on demonstratingachievement against the standards at the criterion level.EQuIP5 has 3 functions, 13 standards, and 47 criteria.The arrangement of the standards and criteria intothe three functions of Clinical, Support and Corporateidentifies the fundamental responsibilities of the keyprovider groups within a health service.• The Clinical Function sets out the standards thatare predominantly associated with clinical care.Achievement of these standards is largely theresponsibility of clinicians.• The Support Function contains standards andcriteria in which quality improvement requiresclinical and corporate staff to work together,sometimes with assistance from internal ‘supportstaff’ or external consultants.• The Corporate Function identifies those standardsand criteria for which the governors of theorganisation are predominately responsible.The arrangement of the EQuIP5 functions provides abasic model for understanding corporate and clinicalgovernance. Corporate governance 1 is understoodto be the system by which organisations are directedand controlled. Clinical governance 2 involves anunderstanding and acceptance that the governingbody has a responsibility for the quality of caredelivered by a service and that this accountability isshared equally with the clinicians providing this care.The Clinical and Support Functions (see figure onpage 30) reflect clinical governance; the Support andCorporate Functions reflect corporate governance.1 Committee on the Financial Aspects of Corporate Governance, and Gee and Co Ltd. Financial aspects of corporate governance.London UK; Committee on the Financial Aspects of Corporate Governance; 1992.2 Australian Council on Healthcare Standards. News in brief: Clinical governance defined. ACHS News, 2004; 12(Spring): 4.28 The ACHS EQuIP5 Guide Book 1 Accreditation, Standards and Guidelines Clinical Function

Function 1 – Clinical has six standards:1.1 Continuity of care1.2 Access1.3 Appropriateness1.4 Effectiveness1.5 Safety1.6 Consumer focusFunction 2 – Support has five standards:2.1 Quality improvement and risk management2.2 Human resources management2.3 Information management2.4 Population health2.5 ResearchFunction 3 – Corporate has two standards:3.1 Leadership and management3.2 Safe practice and environmentThe table on the following pages identifies ata glance the three functions, the 13 standards(colour highlighted) and each of the 47 criteria.4.2 Key changes in EQuIP5New criteria and elements have been introducedto EQuIP5 to:• incorporate the most recent evidence on providingand improving health services• fill gaps in earlier editions of the standards, whichhave been identified through feedback fromsurveyors and members, growing awareness,formal investigations and inquiries, new evidenceand expanding knowledge of quality systems• increase the focus on the clinical care that isprovided by health services, respond to consumerfeedback on healthcare service provision andexpand consumer participation in serviceevaluation and development.Specific changes include:The achievement of an Outstanding Achievement (OA)rating level in any EQuIP5 criterion will be determinedby the ACHS survey team. Organisations are notrequired to self assess to achieve OA rating levels.The evaluation rating level (MA) is now termed MarkedAchievement to better reflect the level of achievementrequired to implement quality improvement activity andassessment of performance outcomes.An additional non–mandatory criterion on consumer /patient nutrition has been introduced to the Safetystandard. Criterion 1.5.7 addresses the fundamentalaspects of patient nutrition, nutritional screening andprevention of malnutrition.Some criteria have been separated, combinedor broadened:• Separation of criteria to report and respond toincidents, 2.1.3, and complaints, 2.1.4• Separation of criteria to specify key requirementsfor health records management, 2.3.1, andcorporate records management, 2.3.2• The collection, use and storage of data combinedinto criterion 2.3.3• The broadening of Corporate elements, 3.1.2and 3.2.3, to focus governance responsibility forethical decision making and to provide greaterscope for organisations to demonstrate proactiveenvironment management.For further information on key changes in the criteriaand elements from EQuIP 4 to EQuIP5, please referto the ACHS website.October 2010 29

Section 4How to use this EQuIP Guide4.2.1 EQuIP5 functions,standards, criteriaKey:StandardsMandatory Criteria1. CLINICAL1.1 Consumers / patients are provided with high quality care throughout thecare delivery process.1.1.1 Assessment ensures current and ongoing needs of the consumer / patientare identified.1.1.2 Care is planned and delivered in collaboration with the consumer / patientand when relevant, the carer, to achieve the best possible outcomes.1.1.3 Consumers / patients are informed of the consent process, and they understandand provide consent for their health care.1.1.4 Outcomes of clinical care are evaluated by healthcare providers and whereappropriate are communicated to the consumer / patient and carer.1.1.5 Processes for clinical handover, transfer of care and discharge addressthe needs of the consumer / patient for ongoing care.1.1.6 Systems for ongoing care of the consumer / patient arecoordinated and effective.1.1.7 The care of dying and deceased consumers / patients is managed with dignityand comfort and family and carers are supported.1.1.8 The health record ensures comprehensive and accurate informationis collaboratively gathered, recorded and used in care delivery.1.2 Consumers / patients / communities have access to health services and careappropriate to their needs.1.2.1 The community has information on health services appropriate to its needs.1.2.2 Access and admission / entry to the system of care is prioritised accordingto healthcare needs.1.3 Appropriate care and services are provided to consumers / patients.1.3.1 Health care and services are appropriate and delivered in themost appropriate setting.1.4 The organisation provides care and services that achieve effective outcomes.1.4.1 Care and services are planned, developed and delivered based on the bestavailable evidence and in the most effective way.1.5 The organisation provides safe care and services.1.5.1 Medications are managed to ensure safe and effective consumer /patient outcomes.1.5.2 The infection control system supports safe practice and ensures asafe environment for consumers / patients and healthcare workers.1.5.3 The incidence and impact of breaks in skin integrity, pressure ulcers andother non-surgical wounds are minimised through wound prevention andmanagement programs.1.5.4 The incidence of falls and fall injuries is minimised through afalls management program.1.5.5 The system to manage sample collection, blood, blood components / bloodproducts and patient blood management ensures safe and appropriate practice.1.5.6 The organisation ensures that the correct consumer / patient receives thecorrect procedure on the correct site.1.5.7 The organisation ensures that the nutritional needs of consumers / patientsare met.1.6 The governing body is committed to consumer participation.1.6.1 Consumers / patients, carers and the community participate in the planning,delivery and evaluation of the health service.1.6.2 Consumers / patients are informed of their rights and responsibilities.1.6.3 The organisation meets the needs of consumers / patients and carerswith diverse needs and from diverse backgrounds.30 The ACHS EQuIP5 Guide Book 1 Accreditation, Standards and Guidelines Clinical Function

2. SUPPORT2.1 The governing body leads the organisation inits commitment to improving performance andensures the effective management of corporate andclinical risks.2.1.1 The organisation’s continuous quality improvementsystem demonstrates its commitment to improving theoutcomes of care and service delivery.2.1.2 The integrated organisation-wide risk managementframework ensures that corporate and clinical risksare identified, minimised and managed.2.1.3 Healthcare incidents are managed to ensureimprovements to the systems of care.2.1.4 Healthcare complaints and feedback are managedto ensure improvements to the systems of care.2.2 Human resources management supports qualityhealth care, a competent workforce and a satisfyingworking environment for staff.2.2.1 Workforce planning supports the organisation’scurrent and future ability to address needs.2.2.2 The recruitment, selection and appointment systemensures that the skill mix and competence of staff, andmix of volunteers, meets the needs of the organisation.2.2.3 The continuing employment and performancedevelopment system ensures the competenceof staff and volunteers.2.2.4 The learning and development system ensuresthe skill and competence of staff and volunteers.2.2.5 Employee support systems and workplace relationsassist the organisation to achieve its goals.2.3 Information management systems enablethe organisation’s goals to be met.2.3.1 Health records management systems supportthe collection of information and meet the consumer /patient and organisation’s needs.2.3.2 Corporate records management systemssupport the collection of information and meetthe organisation’s needs.2.3.3 Data and information are collected, stored andused for strategic, operational and serviceimprovement purposes.2.3.4 The organisation has an integrated approach to theplanning, use and management of information andcommunication technology (I&CT).2.4 The organisation promotes the health ofthe population.2.4.1 Better health and wellbeing is promoted by theorganisation for consumers / patients, staff,carers and the wider community.2.5 The organisation encourages and adequatelygoverns the conduct of health and medical researchto improve the safety and quality of health care.2.5.1 The organisation’s research program developsthe body of knowledge, protects staff and consumers/ patients and has processes to appropriately managethe organisational risk associated with research.3. CORPORATE3.1 The governing body leads the organisation’sstrategic direction to ensure the provision of quality,safe services.3.1.1 The organisation provides quality, safe health careand services through strategic and operationalplanning and development.3.1.2 Governance is assisted by formal structures anddelegation practices within the organisation.3.1.3 Processes for credentialling and defining the scopeof clinical practice support safe, quality health care.3.1.4 External service providers are managed to maximisequality, safe health care and service delivery.3.1.5 Documented corporate and clinical policies andprocedures assist the organisation to provide quality,safe health care.3.2 The organisation maintains a safe environmentfor employees, consumers / patients and visitors.3.2.1 Safety management systems ensure safety andwellbeing of consumers / patients, staff, visitorsand contractors.3.2.2 Buildings, signage, plant, medical devices,equipment, supplies, utilities and consumables aremanaged safely and used efficiently and effectively.3.2.3 Waste and environmental management supports safepractice and a safe and sustainable environment.3.2.4 Emergency and disaster management supportssafe practice and a safe environment.3.2.5 Security management supports safe practiceand a safe environment.October 2010 31

Section 4How to use this EQuIP Guide4.3 The criteria4.3.1 Structure of the criteria (an example)The figure below provides an example of the structure of a criterion. EQuIP has a unique format that codeselements according to the maturity of quality improvement processes within the area of interest. Through its left toright progression, this layout enables the reader to easily visualise the steps required to improve performance andreach a higher level of achievement.Criterion structure example – Clinical criterion 1.1.1Function 1 – ClinicalStandard 1.1 Consumers / patients are provided with high quality carethroughout the care delivery process.CriterionLittle AchievementLASome AchievementSACriterion 1.1.1Assessment ensurescurrent and ongoing needsof the consumer / patientare identified.This is amandatorycriterionAwarenessa) Guidelines are madeavailable to assist staff toassess physical, spiritual,cultural, psychological andsocial needs, includingthe identification of ‘at-risk’consumers / patients.b) Guidelines are available on thespecific needs of self identifiedAboriginal and Torres StraitIslander consumers / patients.c) There is policy / guidelines toassess a consumer / patient’sneed for health promotion.d) Referral systems to otherrelevant service providers exist.ImplementationLA plus the followinga) Assessment guidelinesbased on current professionalstandards and evidence-basedpractice are implemented.b) Assessments are conductedin a timely manner.c) The needs of ‘at-risk’consumers / patients areidentified and managed.d) A support person / carer isinvolved in the assessmentsystem where appropriate.e) Information is provided to theconsumer / patient on theirhealth status.f) Planning for discharge /transfer of care commencesat assessment, ismultidisciplinary whereappropriate, and coordinated.32 The ACHS EQuIP5 Guide Book 1 Accreditation, Standards and Guidelines Clinical Function

MarkedAchievementMAEvaluationSA plus the followinga) The assessment processis evaluated and improvedas required.b) Processes for assessing andmanaging ‘at-risk’ consumers /patients are evaluated andimproved as required.c) Planning for discharge /transfer of care is evaluatedto ensure it:(i) consistently occurs(ii) is multidisciplinarywhere appropriate(iii) meets consumer / patientand carer needs.d) Referral systems are evaluatedand improved, as required.ExcellentAchievementEAExcellenceMA plus the followinga) Assessment and discharge /transfer of care planningpractices are compared withinternal and external systemsand improvements are made toensure better practice.and/orb) The organisation undertakesresearch on assessment anddischarge / transfer of carepractices and improvementsare made to ensure betterpractice.OutstandingAchievementOALeadershipEA plus the followinga) The organisation demonstratesit is a leader in consumer /patient assessment andseparation planning.October 2010 33

Section 4How to use this EQuIP Guide4.3.2 Mandatory criteriaMandatory criteria are those where a rating of MarkedAchievement (MA) or higher is required to gain ormaintain ACHS accreditation. A mandatory criterionis one where it is considered that without evaluation,the quality of care or the safety of people within theorganisation could be at risk.The ACHS Board determined that the followingquestion be used to decide mandatory status forEQuIP5 criteria: Is this ACHS criterion so importantthat failure to achieve an MA rating should result innon-accreditation?The rules for selection were that the criterionis fundamental:• to consumer rights, and/or• as a core component of safe, quality care, and/or• to staff, visitor and consumer safety... and the criterion could not be adequately coveredby an overarching mandatory criterion such ascare delivery, quality improvement, and/or riskmanagement.There are 15 mandatory criteria in EQuIP5.The figure on pages 30–31 highlights the mandatorycriteria in each of the three functions. The mandatorycriteria are identified throughout EQuIP5 byitalicised text.4.3.3 Not applicable (NA) criteria / elementsThere are a few criteria and elements that may notbe applicable to some organisations. Criteria maybe described as not applicable when the topic of thecriterion would never occur or would never have thepotential to occur in the organisation.An organisation will need to formally discuss and agreewith its Customer Services Manager any criteria andelements that are not applicable to the organisationprior to an onsite survey being undertaken. AllEQuIP criteria will be considered applicable to allorganisations, except where it has been formallyagreed that they are not applicable. It is acceptedthat in some organisations there may be some criteriawhich are only partially relevant, but in these cases thecriteria will still be applicable for ACHS onsite surveypurposes. The table below shows some exampleswhere a particular criterion may not be applicable:NumberCriterionExamples where thecriterion may be NA1.1.6 Ongoing care day procedure centres,advisory services1.1.7 Care of dying day procedure centres,advisory services1.5.3 Skin integrity advisory services1.5.5 Bloodand bloodcomponents2.5.1 Researchprogram4.4 Further informationservices that neveradminister blood orblood products ortake pre-transfusionblood samplesorganisations that neverundertake or participatein research of any kind4.4.1 Aboriginal and Torres StraitIslander peopleAlthough there is inclusion of specific elementsaddressing the self identification of Aboriginal andTorres Strait Islander consumers / patients withinsome EQuIP5 criteria, organisations should considerthis demographic throughout all of the standards andcriteria of EQuIP.A consumer / patient’s cultural and geneticbackground may have diagnostic significance andso should be part of routine medical history taking.Research has demonstrated that Aboriginal and TorresStrait Islander people may not receive equivalentcare to that provided for people of other racialbackgrounds in similar circumstances 1 , a situationwhich should be proactively managed by healthcareproviders. Provision of guidelines should assist staff tounderstand, identify and manage any Aboriginal andTorres Strait Islander consumers / patients.1 Cunningham J. Diagnostic and therapeutic procedures among Australian hospital patients identified as indigenous.Med J Aust 2002; 176(2): 58-62.34 The ACHS EQuIP5 Guide Book 1 Accreditation, Standards and Guidelines Clinical Function

Disparities in reported life expectancy exist betweenaboriginal and non-aboriginal peoples in Australia,USA, Canada and New Zealand, four comparabledeveloped countries with indigenous and nonindigenousresidents. Of these four countries, thehighest disparity has been reported in Australiabetween the general population and for Aboriginal andTorres Strait Islander peoples. 1 The life expectancyof Aboriginal and/or Torres Strait Islander peopleis some 10 to 17 years less than other Australians,with levels of disease roughly three times that ofnon‐indigenous people.People who self identify as Aboriginal or Torres StraitIslander may be eligible for specific governmentfundedhealth services, such as the health check itemsand specific immunisation programs that have beentargeted to address the needs of this community.The Australian Government has implemented arange of health initiatives specifically tailored to theneeds of Aboriginal and Torres Strait Islander people.Organisations will find information at: http://www.health.gov.au/tackling-chronic-diseaseThe National Aboriginal and Torres Strait IslanderCommunity Services Information Plan includes aset of principles regarding personal informationmanagement developed by Aboriginal and TorresStrait Islander representatives to assist communityservice organisations. 2Organisations should ensure their policy andprocedures address how staff approach the questionof self identification and provide responses to ensureAboriginal and Torres Strait Islander consumers /patients are aware of why this information isbeing collected. Consumers / patients should bereassured that:• the information will not affect their accessto services• this information is collected on allconsumers / patients• it is important information for ensuringappropriate services are provided• the information will remain confidential.In organisations where Aboriginal and Torres StraitIslander consumers / patients are seen rarely, it isimportant that this priority group is not overlooked;for the small number of consumers / patients who doself identify, staff should have access to appropriateguidelines and other information when needed.Further, organisations will benefit from providingCultural Safety Training (CST) to improve the qualityof service delivered by healthcare providers toAboriginal and Torres Strait Islander people, as wellas the experience of service for Aboriginal and TorresStrait Islander people. Information is available atHealthinfonet: http://www.healthinfonet.ecu.edu.au/health-resources/courses-training?fid=262, as well asmany other sites on the internet.4.4.2 Policies, procedures, protocols,guidelines and by-lawsThe purpose of a policy is to provide a clear,documented statement of the expectations of tasksand concepts that is consistent with organisationalobjectives. In English usage, policies are ‘made’ and‘implemented’ in the same way that decisions aremade and implemented. Yet it is possible to havepolicies that are not, or cannot be, implemented, sothat conceptually, actions that implement policies neednot necessarily be specified within the policy. In thecontext of EQuIP5, the term ‘policy’ refers to a writtenstatement(s) which acts as a guideline and reflectsthe position and values of the organisation on a givensubject. All procedures and protocols should be linkedto a policy statement.Although a policy is like a decision, it is not just a ‘oneoff’independent decision. A policy is a set of coherentdecisions with a common long-term purpose(s). Ininstances where policy is developed by another body,such as an area health service or corporate office,organisations may have guidelines, procedures or adocument that bears some other name, to address theimplementation of the policy.1 Cunningham J. Diagnostic and therapeutic procedures among Australian hospital patients identified as indigenous.Med J Aust 2002; 176(2): 58-62.2 Aboriginal and Torres Strait Islander Health and Welfare Information Unit. National Aboriginal and Torres Strait Islander communityservices information plan. Canberra ACT; Australian Institute of Health and Welfare (AIHW) and Australian Bureau of Statistics(ABS); 2002.October 2010 35

Section 4How to use this EQuIP GuideOrganisations should be aware that they are notexpected to have a separate policy for every elementthat mentions a policy. A range of issues may beaddressed under a single policy, and when this is thecase, organisations should inform the surveyors of this.Because the items included within a named policy mayvary between jurisdictions, it would be wise to notedetails (such as page numbers, chapters or clauses)and provide this information to surveyors, so thatevidence can quickly be validated if required.Procedures are the specific methods employedto implement and carry out policies in day-to-dayactivities of the organisation.Together, policies and procedures ensure that a pointof view held by the governing body of an organisationis translated into steps that result in an outcomecompatible with that view.A guideline is any document that aims to streamlineparticular processes according to a set routine. Bydefinition, following a guideline is never mandatory.(Protocol would be a better term for a mandatoryprocedure.) Guidelines are an essential part of thelarger process of governance.It is important to differentiate clinical guidelines, whichoutline decisions and criteria regarding diagnosis,management, and treatment in specific areas of healthcare. Clinical guidelines are usually based on a reviewof evidence by experts who reach a consensus onpractical approaches to diagnosis, management ortreatment. Their aim is to standardise medical care, toraise the quality of care and to reduce several kindsof risk.Guidelines may be issued by and used by anyorganisation (government, public or private) to makethe actions of its employees or departments morepredictable, and presumably of higher quality.By-law can refer to a law of local or limited application,passed under the authority of a higher law specifyingwhat may be regulated by the by-law, or it can refer tothe internal rules of a company or organisation.In a healthcare setting, by-laws are usually intendedto guide the conduct of visiting accredited medical,dental and allied health practitioners. The by-lawsdocument generally sets out those organisationalpolicies, procedures and guidelines that are applicableto visiting health practitioners.During onsite surveys, surveyors will verify theorganisation’s Pre-Survey Assessment against thestandards by reviewing the evidence presentedto them. Some of this evidence will draw upon theorganisation’s policies, guidelines, procedures and/or by-laws. If an organisation provides access tothe intranet so that the surveyors can view thesedocuments, it is important that the evidence listsinclude navigation paths to assist surveyors tolocate relevant information easily. Organisationsshould also ensure that the level of access underany issued passwords is sufficient for full access,without the surveyors having to seek assistance fromorganisational staff.4.4.3 JurisdictionsThroughout EQuIP5, reference is made to jurisdictionsin the context of guidelines, legislation, regulations,requirements, priorities, common law, policy and/orstandards. In the context of EQuIP5, jurisdiction meanswhatever governing body oversees the development,implementation and/or compliance with a particularitem. Within specific contexts a jurisdiction could be therelevant Department of Health, either State, Territoryor Commonwealth, or a College or other professionalrepresentative group that has developed specificstandards, such as the College of Anaesthetists(ANZCA), the National Pathology Accreditation AdvisoryCouncil (NPAAC), or authorities involved in bloodmanagement (NBA, RCBS, ANZSBT, HSANZ, etc.).Organisations should be aware of the differentlegislation, guidelines, regulations, requirements,priorities, common law, policy and/or standards thatare relevant to their operation. These will be influencedby the organisation’s location, ownership structures(public or private), services provided, staff profile,building structures and many other factors.4.4.4 Performance measuresIn the context of EQuIP5, the term ‘performancemeasures’ differentiates between indicators fromthe ACHS Clinical Indicator Program, and thesuggested performance measures that are listedafter each criterion.Performance measures are most fundamentallydata that can be used for evaluation. Performancemonitoring is only a part of evaluation. Performancemeasures inform the evaluation process and mayhelp to identify or flag further issues or questionsfor investigation.36 The ACHS EQuIP5 Guide Book 1 Accreditation, Standards and Guidelines Clinical Function

To assist healthcare organisations to measure andevaluate their performance, some examples ofperformance measures are included in the EQuIP5guide and are listed at the end of each criterion. Themeasures suggested are not the only ones available.Not all of the measures will be suitable for all types oforganisations. Organisations may wish to modify thesuggested measures to meet their own needs. Wehave included measures that may be useful to a rangeof health services including day procedure centres,large hospitals, small hospitals, mental health facilitiesand community centres, and that can be adapted todifferent services and situations.The suggested measures are designed to helporganisations develop their unique and reliableindicators by:• more clearly defining terms in the context of theirown operations• specifying numbers, volumes and timing for thecalculations• determining the frequency of calculation of ameasure and its evaluation.Performance monitoring over time provides anindication of rising or falling performance against arepeatable measure. Organisations should continueto collect any pre-existing performance measures thatare meeting quality improvement needs; there is noexpectation that an organisation must collect any of thesuggested performance measures.An organisation may choose to benchmark particularmeasures with other similar organisations or with otherunits / departments within their organisation. The ACHSwill not collect these suggested performance measuresand does not provide any national aggregate rate orbenchmarking rates for the measures listed within theEQuIP guide.4.4.5 Clinical indicatorsThe use of clinical indicators (CIs) by healthcareorganisations continues to be an important componentof EQuIP. The collection of specific ACHS ClinicalIndicators is not mandatory and organisations maychoose to develop their own indicators or use otherindicators. Indicators assist healthcare organisationsto identify clinical areas that may benefit from a reviewof their processes and activities, with the goal ofimproving the quality of care.A clinical indicator is defined simply as a measure ofthe clinical management and/or outcome of care. Awell-designed indicator should ‘screen’, ‘flag’ or ‘drawattention’ to a specific clinical issue. Usually ratebased,indicators identify the rate of occurrence of anevent. Indicators do not provide definitive answers;they are designed to indicate potential problemsthat should be addressed, usually demonstrated bystatistical outliers or variations within data results. Theindicators are used to assess, compare and determinethe potential to improve care. 1 Indicators are, therefore,tools that assist an organisation to assess whether astandard of consumer / patient care is being met.Members of the ACHS Clinical Indicator Program cansubmit clinical indicator data to the ACHS on a sixmonthly basis. Organisations are sent the nationalaggregate data following this submission. Using PIRTOnline (the CI data submission tool), organisationscan produce Comparative Reports from the nationaldata set and for their peer group. Each reportprovides information to identify statistically significantdifferences between the individual organisation, allorganisations and peer groups. The reports alsoidentify potential gains to be made if an organisation’srate was improved to that of the average and providesinformation on peer as well as Australian andNew Zealand participation.The ACHS clinical indicator program does not incurany additional charge for member organisationsof EQuIP.Further information about the specific clinicalindicator sets and the Comparative Report serviceare available for EQuIP members from the ACHSwebsite http://www.achs.org.au, or by contacting theACHS Performance and Outcomes Service.Email: pos@achs.org.auUtilisation of clinical indicator data for external andinternal benchmarking assists healthcare organisationsto identify areas in which there is the potential toimprove the quality of care being delivered. Whilst thecollection of specific ACHS clinical indicators is notmandatory, their use for evaluation of performance andany subsequent changes can be used as evidencefor supporting an organisation to attain an MA MarkedAchievement award.1 Howley PP and Gibberd R. Using hierarchical models to analyse clinical indicators: a comparison of the gamma-Poisson andbeta-binomial models. Int J Qual Health Care 2003; 15(4): 319-329.October 2010 37

Section 4How to use this EQuIP GuideThe table below contains ACHS clinical indicators relevant for the listed criteria.Criteria not listed are those for which no clinical indicators are suggestedCriterion Indicator Set Version* ACHS Clinical Indicators1.1.1 Anaesthesia 5 1.1, 3.1, 3.3, 3.4, 3.6, 5.1, 5.2, 6.1Day Surgery 4 1.2, 1.3Emergency Medicine 5 1.1, 1.2, 1.3, 1.4, 1.5, 2.1, 4.1, 4.2, 6.2, 7.1, 7.2, 7.3, 7.4,8.1, 8.2Gynaecology 6 5.1, 5.2, 5.3, 7.1, 7.2Hospital in the Home 4 2.1, 2.2, 2.3, 2.4Hospital-Wide 11 1.1, 2.1, 2.2, 3.1, 4.1, 4.2, 5.2, 5.3, 7.1, 9.1Intensive Care 4 2.1, 3.1, 6.1, 6.2Internal Medicine 5 2.1, 3.1, 3.3, 4.1, 4.2, 4.3, 5.2, 5.3, 5.4, 7.1Medication Safety 3 5.1, 6.1Mental HealthCommunity Based 2 1.4Mental Health Inpatient 6 1.1, 2.1, 4.2, 5.4, 5.5, 5.8, 6.1, 6.2, 6.3, 6.4, 6.5, 6.6,7.1, 10.1Obstetric 7 9.1, 10.1Ophthalmology 4 1.1, 1.2, 2.1, 2.2, 3.1, 3.2, 3.4, 4.1, 4.2, 4.5Oral Health 2 1.2, 4.2, 4.3, 5.1, 5.2, 5.3, 5.4, 5.5, 5.6, 5.7, 5.8, 5.9Paediatric 4 5.1Radiology 4 2.1, 2.2, 2.3, 2.4Rehabilitation Medicine 4 1.1, 2.1, 5.1, 6.1Surgical 3 1.2, 2.5, 3.1, 6.1, 6.2, 8.1, 8.2, 9.11.1.2 As every indicator can be utilised to evaluate care planning and delivery, all are relevant to this criterion1.1.3 Anaesthesia 5 1.2, 6.3Dermatology 2 2.8Hospital-Wide 11 7.21.1.4 As every indicator can be utilised to evaluate and improve care, all are relevant to this criterion1.1.5 Emergency Medicine 5 6.1, 6.2Medication Safety 3 5.3Mental Health Inpatient 6 9.1, 9.2Radiation Oncology 3 2.5Rehabilitation Medicine 4 4.1* ACHS aims to review each set of indicators every three years. Changes are incorporated into a new version of the indicator set. It isimportant that EQuIP members, who are using indicator data to validate performance against EQuIP5 criteria, check the ACHS websitefor updates to their indicator sets and consider any changes in the context of EQuIP requirements for evidence.38 The ACHS EQuIP5 Guide Book 1 Accreditation, Standards and Guidelines Clinical Function

Criterion Indicator Set Version* ACHS Clinical Indicators1.1.6 Anaesthesia 5 1.1Emergency Medicine 5 4.1, 4.2, 6.1, 6.2, 8.1, 8.2Internal Medicine 5 1.4, 3.6, 5.1Mental HealthCommunity Based 2 2.2Radiation Oncology 3 2.5Rehabilitation Medicine 4 4.1, 6.11.1.8 Anaesthesia 5 1.1, 1.2, 2.2, 5.1, 5.2, 6.3Dermatology 2 2.6, 2.7, 2.8, 2.9, 2.10, 2.11Emergency Medicine 5 6.1, 6.2, 7.1, 7.2, 7.3, 7.4, 8.1, 8.2Hospital-Wide 11 1.2, 1.3, 7.2Intensive Care 4 5.1, 5.2, 6.1, 6.2Internal Medicine 5 3.1, 3.2, 3.3, 3.4, 3.5, 3.6, 3.8, 4.1, 4.2, 4.3, 5.2, 5.3, 5.4,6.3, 8.1Mental HealthCommunity Based 2 2.1Mental Health Inpatient 6 1.2, 1.3, 2.1, 9.1, 9.2, 10.1Oral Health 2 3.1, 3.2Paediatric 4 1.1, 1.2, 3.1, 3.2Radiation Oncology 3 1.2, 1.3, 2.5Radiology 4 2.1Rehabilitation Medicine 4 1.1, 2.1, 3.1, 4.1, 5.11.2.1 Mental HealthCommunity Based 2 1.1, 1.2, 1.31.2.2 Dermatology 2 3.2, 3.3, 3.4, 3.6, 3.7, 3.8, 3.9, 3.10, 3.11Emergency Medicine 5 1.1, 1.2, 1.3, 1.4, 1.5, 3.1, 3.2, 3.3, 4.1, 4.2, 8.1, 8.2Intensive Care 4 1.1, 1.2, 1.3, 1.4, 1.5Mental HealthCommunity Based 2 1.1, 1.2, 1.3Paediatric 4 4.1, 4.2, 4.3, 4.4, 4.5Radiation Oncology 3 1.1, 1.3, 2.1, 2.21.3.1 As the use and reviewing of clinical indicators is evidence of clinical audit, an important componentfacilitating the delivery of appropriate care, all indicators are relevant to this criterion* ACHS aims to review each set of indicators every three years. Changes are incorporated into a new version of the indicator set. It isimportant that EQuIP members, who are using indicator data to validate performance against EQuIP5 criteria, check the ACHS websitefor updates to their indicator sets and consider any changes in the context of EQuIP requirements for evidence.October 2010 39

Section 4How to use this EQuIP GuideCriterion Indicator Set Version* ACHS Clinical Indicators1.4.1 As the use of clinical indicators can be an inherent component in the use of evidence based careand the evaluation and improvement of key care processes, all are relevant to this criterion1.5.1 Hospital-Wide 11 1.1, 1.2, 1.3Medication Safety 3 2.1, 3.1, 4.1, 5.3, 5.5, 6.11.5.2 Emergency Medicine 5 5.1Infection Control 3 All 49 indicators: 1.1–1.18, 2.1–2.14, 3.1–3.5, 4.1–4.6,5.1–5.4, 6.1–6.2Intensive Care 4 4.1, 4.2Obstetric 7 5.1Surgical 3 6.11.5.3 Hospital-Wide 11 4.1, 4.21.5.4 Hospital-Wide 11 5.1, 5.2, 5.3, 5.41.5.5 Hospital-Wide 11 7.1, 7.2, 7.3Internal Medicine 5 6.12.1.1 Obstetric 6 11.12.1.2 Obstetric 6 11.12.1.3 Gastrointestinal Endoscopy 8 1.1, 1.2, 1.3, 1.4, 2.1, 2.2, 2.3, 3.1Gynaecology 6 2.1, 3.1, 3.2, 3.3, 5.1, 5.2, 5.3Hospital-Wide 11 1.1, 5.2, 5.3, 5.4, 7.1Infection Control 3 6.1, 6.2Medication Safety 3 1.1, 2.1, 3.1, 4.1Mental Health Inpatient 6 4.2, 5.5, 5.8, 6.1, 6.2, 6.3, 6.4, 6.5, 6.6Obstetric 6 11.1Radiology 4 2.2, 2.4Surgical 3 7.1, 8.1, 8.2, 9.12.5.1 Radiation Oncology 4 1.3* ACHS aims to review each set of indicators every three years. Changes are incorporated into a new version of the indicator set. It isimportant that EQuIP members, who are using indicator data to validate performance against EQuIP5 criteria, check the ACHS websitefor updates to their indicator sets and consider any changes in the context of EQuIP requirements for evidence.40 The ACHS EQuIP5 Guide Book 1 Accreditation, Standards and Guidelines Clinical Function

4.4.6 National E-Health Transition Authority(NEHTA)NEHTA was established by the Australian, State andTerritory governments in 2005, to develop better waysof electronically collecting and securely exchanginghealth information. NEHTA’s strategic priorities andinitiatives are to orchestrate the uptake of e-healthsystems of national significance, and to enable theprogression and accelerate the adoption of e-healthby delivering urgently needed integration infrastructureand standards for health information.NEHTA is promoting a number of capabilities fornational adoption, including identifiers for individuals,providers and organisations, authentication, securemessaging, clinical terminologies, supply chain,pathology requests and reports, diagnostic imagingrequests and reports, medication management,referrals and discharge summaries.Some of NEHTA’s capabilities will be relevant at alllevels of EQuIP as they are finalised; other deliverableswill apply more to the EA and OA ratings.Some EQuIP5 criteria and elements were developed inconsultation with NEHTA. ACHS will continue to liaisewith NEHTA during the term of this edition of EQuIPand will deliver EQuIP updates as new initiatives cometo fruition.4.4.7 National Safety and QualityHealth Service Standards(Australian Commission on Safetyand Quality in Health Care)The Australian Commission on Safety and Quality inHealth Care (the Commission) was established by theAustralian, State and Territory Governments in January2006, to develop a national strategic framework andassociated work program that will guide its efforts inimproving safety and quality across the healthcaresystem in Australia.The NSQHS Standards address the following areas:• Governance for Safety and Quality inHealth Service Organisations• Healthcare Associated Infection• Medication Safety• Patient Identification and Procedure Matching• Clinical Handover• Partnering for Consumer Engagement• Blood and Blood Product Safety• Prevention and Management of Pressure Ulcers• Recognising and Responding to ClinicalDeterioration in Acute Health Care• Preventing Falls and Harm from Falls.The draft NSQHS Standards are due for release in 2011and implementation will follow. The Commission hascommenced piloting of the draft NSQHS Standards.The Standards provide an explicit statement of theexpected level of safety and quality of care to beprovided to consumers / patients by health services,and provide a means for assessing an organisation’sperformance. The draft NSQHS Standards weredeveloped in collaboration with experts, theCommission’s Accreditation Implementation ReferenceGroup and standing committees, jurisdictions andkey stakeholders.ACHS will continue to liaise with the Commissionduring the term of this edition of EQuIP and will deliverEQuIP updates as new information about the NSQHSStandards becomes available.Following the initial review of National Safety andQuality Accreditation Standards in 2007, an alternativemodel of accreditation was developed by theCommission. This model proposes substantial reformsof the accreditation system, having the potential toinitiate far-reaching change.Consultation is continuing with those groups directlyaffected by the proposed alternative model ofaccreditation and the Commission is focusing on thedevelopment of a set of National Safety and QualityHealth Service (NSQHS) Standards.October 2010 41

Section 5Standards, criteria,elements and guidelines1.1 Continuity of Care StandardThe standard is:Consumers / patients are provided with high qualitycare throughout the care delivery process.The intent of the Continuity of Care standard is toensure that organisations provide high quality careand a caring environment to the consumer / patientat all times. They should do this:• from the time that the consumer / patient entersthe healthcare organisation or service• through to when the consumer / patientis discharged or transferred to anotherorganisation / service; and• during any ongoing care they provideafter discharge.The specific needs of Aboriginal and Torres StraitIslander people should be considered throughout thecriteria of standard 1.1.The Australian Pharmaceutical Advisory Council(APAC) 1 guiding principles should be read inconjunction with all Continuity of Care criteria.The Age-friendly principles and practices should beread in conjunction with all Continuity of Care criteriaand referred to when treating older people. 2There are eight criteria in this standard. They are:1.1.1 Assessment ensures current and ongoingneeds of the consumer / patient are identified.1.1.2 Care is planned and delivered in collaborationwith the consumer / patient and whenrelevant, the carer, to achieve the bestpossible outcomes.1.1.3 Consumers / patients are informed of theconsent process, and they understand andprovide consent for their health care.1.1.4 Outcomes of clinical care are evaluated byhealthcare providers and where appropriateare communicated to the consumer / patientand carer.1.1.5 Processes for clinical handover, transfer ofcare and discharge address the needs of theconsumer / patient for ongoing care.1.1.6 Systems for ongoing care of the consumer /patient are coordinated and effective.1.1.7 The care of dying and deceased consumers /patients is managed with dignity and comfortand family and carers are supported.1.1.8 The health record ensures comprehensive andaccurate information is collaboratively gathered,recorded and used in care delivery.1. Australian Pharmaceutical Advisory Council (APAC). Guiding principles to achieve continuity in medication management. CanberraACT; Australian Department of Health and Ageing. Accessed from http://www.sport.gov.au/internet/main/publishing.nsf/Content/nmp-guiding on 20 September 2010.2. Australian Health Ministers’ Advisory Council (AHMAC). Age-friendly principles and practices: Managing older people in the healthservice environment. Canberra ACT; Department of Health and Ageing; 2005.October 2010 43

Section 5Standards, criteria, elements and guidelinesStandard 1.1: Consumers / patients are provided with high quality carethroughout the care delivery processCriterion LA – Awareness SA – ImplementationLA plus the followingCriterion 1.1.1Assessment ensurescurrent and ongoing needsof the consumer / patientare identified.This is amandatorycriteriona) Guidelines are madeavailable to assist staff toassess physical, spiritual,cultural, psychological andsocial needs, includingthe identification of ‘at risk’consumers / patients.b) Guidelines are available on thespecific needs of self identifiedAboriginal and Torres StraitIslander consumers / patients.c) There is policy / guidelines toassess a consumer / patient’sneed for health promotion.d) Referral systems to otherrelevant service providers exist.a) Assessment guidelinesbased on current professionalstandards and evidence-basedpractice are implemented.b) Assessments are conductedin a timely manner.c) The needs of ‘at risk’consumers / patients areidentified and managed.d) A support person / carer isinvolved in the assessmentsystem where appropriate.e) Information is provided to theconsumer / patient on theirhealth status.f) Planning for discharge /transfer of care commences atassessment, is multidisciplinarywhere appropriate, andcoordinated.IntentThe intent of this criterion is to ensure that theassessment system meets the needs of theconsumer / patient, the carer when appropriate, andthe organisation. As a first step in care planning anddelivery, the assessment phase should promote aconsultative, collaborative approach that activelyinvolves the consumer / patient and carer. Qualityassessment processes for admission of a newconsumer / patient, or assessment as part of ongoingcare, will ensure that care is planned and deliveredin an holistic, coordinated, efficient manner and thatthe consumer / patient and carer understand whatis occurring.In the context of this criterion, discharge means totransfer care of a consumer / patient beyond theorganisation, and includes discharge to anotherhealthcare organisation.Relationships of 1.1.1 with other criteriaThe organisation’s delivery of high quality care(Standard 1.1) begins for each consumer / patient withthe process of assessment. This will determine accessto the system and/or admission according to need(Criterion 1.2.2), and will impact upon the planningand delivery of care (Criterion 1.1.2). The notes takenduring assessment will form part of a comprehensiveand accurate health record (Criterion 1.1.8) and willfacilitate handover of care (Criterion 1.1.5). Effectiveassessment requires the active involvement of theconsumer / patient and, when appropriate, his orher carer(s) (Criterion 1.6.1). It will also ensure thatconsumers / patients with diverse needs and fromdiverse backgrounds (Criterion 1.6.3) are providedwith the appropriate support and services.44 The ACHS EQuIP5 Guide Book 1 Accreditation, Standards and Guidelines Clinical Function

MA – EvaluationSA plus the followingEA – ExcellenceMA plus the followingOA – LeadershipEA plus the followinga) The assessment processis evaluated and improvedas required.b) Processes for assessing andmanaging ‘at risk’ consumers /patients are evaluated andimproved as required.c) Planning for discharge /transfer of care is evaluatedto ensure it:(i) consistently occurs(ii) is multidisciplinary whereappropriate(iii) meets consumer / patientand carer needs.d) Referral systems are evaluatedand improved, as required.a) Assessment and discharge /transfer of care planningpractices are compared withinternal and external systemsand improvements are madeto ensure better practice.and/orb) The organisation undertakesresearch on assessment anddischarge / transfer of carepractices and improvementsare made to ensure betterpractice.a) The organisation demonstratesit is a leader in consumer /patient assessment andseparation planning.Assessment processesAssessment is the process by which the current andongoing needs of the consumer / patient are identifiedand documented.An episode of care begins with assessment andrequires contact between clinical staff and theconsumer / patient. An ineffective or incompleteassessment will increase the risk of errors that mayaffect health outcomes, and/or consumer / patientsatisfaction with the service.In addition to reflecting consumer / patient needs,guidelines for the assessment process should bespecific to the needs of the organisation, or evendepartment, and so may vary significantly betweenorganisations. 1, 2 Assessment guidelines may also bedeveloped specifically for the needs of a professionalgroup, such as the guidelines developed bymedical colleges.Holistic assessment should identify the physical,spiritual, cultural, psychological and social needsof the consumer / patient.Where relevant, assessment notes should include:• planning for discharge: the return to home posesparticular challenges for consumers / patientswho live alone, who have children, or who supportfamily members with a disability, mental illness orterminal condition• access to care: consumers / patients isolatedthrough a rural location or transport issues maystruggle to meet some appointment schedules• cultural and religious beliefs: may impact decisionmaking in areas such as blood transfusion andpain management• fertility preferences: important for planning beforeinitiating many chemotoxic therapies• dietary restrictions and preferences.In addition, assessment processes should identifyany risks to the consumer / patient’s ongoing healthand wellbeing. Guidelines for assessing consumer/ patient need for promotion of better health andwellbeing in the long term should also be available.Policies and procedures should address organisationalexpectations and requirements, and how these shouldbe achieved by clinical staff.October 2010 45

Section 5Standards, criteria, elements and guidelinesStandard 1.1: Consumers / patients are provided with high quality carethroughout the care delivery processCriterion 1.1.1Assessment ensures current andongoing needs of the consumer / patientare identified. (continued)Assessment should be multidisciplinary, with morethan a single professional background contributing tothe review of the consumer / patient. This may be assimple as a medical practitioner and a nurse, or mayinvolve consultation with medical specialists, alliedhealth professionals, and even non-medical expertisefrom areas such as education, community servicesor security.Prompt points¼¼What assessment information is recorded inthe health record? How is it relevant? Can itbe located when needed?¼¼Are there completed assessments in consumer /patient health records? Do they follow aconsistent structure / format?Assessment of ‘at-risk’consumers / patientsRisks to consumer / patient safety that should be notedduring assessment will vary between organisationsand clinical settings.Expanded assessment processes may be usedto assess specific risks. 3 Examples include(but are not limited to):• aged care assessment• falls risk assessment 4• mental health assessment 5• pressure ulcer / skin integrity risk assessment 6• nutritional risk assessment 7• manual handling / task risk assessment 8• pain assessment 9• anaesthetic risk assessment 10• VTE risk assessment. 11Prompt points¼¼Who undertakes the assessment? Who recordsinformation in the assessment report? Areany other partners, such as anaesthetists,dietitians, community services, a GP or carersinvolved in the assessment? How does theconsumer / patient health record demonstratea multidisciplinary approach to assessment /diagnosis? In a multidisciplinary environment,what measures avoid repeating the samequestioning / paperwork?¼¼¼¼What features of this organisation andconsumer / patient pool determine how ‘at-risk’consumers / patients are defined? How arethese consumers / patients identified? Whatchanges are made to better manage theseidentified risks?How are records of expanded assessments,such as falls risk or anaesthesia riskassessments, integrated with the health record?¼¼What measures are used to evaluate theeffectiveness of the assessment process?Are audits of health records used? How dohealth record audits demonstrate compliancewith assessment processes? Followingevaluation, what actions have been taken toimprove compliance?Timely assessmentThe timeliness of completion of assessments mayvary based on the needs of the consumer / patient,the clinical staff and the organisation. However, policyshould direct what is considered satisfactory timing,which should aim to ensure that information is availablewhen needed. Reassessment should occur at regularintervals, and following any change in the health statusof the consumer / patient. Failure to undertake a riskassessment in a timely manner, particularly whereother staff assume it has been done, can have serioussafety implications.46 The ACHS EQuIP5 Guide Book 1 Accreditation, Standards and Guidelines Clinical Function

Section 5Standards, criteria, elements and guidelinesStandard 1.1: Consumers / patients are provided with high quality carethroughout the care delivery processCriterion 1.1.1Assessment ensures current andongoing needs of the consumer / patientare identified. (continued)Referral systemsA referral system requires:• strong relationships with a variety of referralpartners, preferably reflected in clear, agreedreferral protocols• access to up-to-date service directories of referraloptions that meet a range of consumer / patientneeds (including accessibility, opening hours,cost, etc.)• clear policy and procedures for associatedfunctions, which include:––holistic identification of consumer /patient need(s)––assessment of risks faced by the consumer /patient and/or staff––documentation, or integration with consumer /patient management system softwareapplications––selection of suitable referral option(s) inpartnership with the consumer / patientand/or carer––checking suitability of referral option(s), forexample, area of expertise, services offered,accessibility, eligibility criteria, priority forservice and waiting times––sharing of relevant health information withexplicit, informed consumer / patient consent––documenting the consumer / patient consentto share identified health information with aspecified referral option––minimising duplication of effort or actions thatrequire the consumer / patient to re-tell his/her ‘story’––sending / transmitting information accordingto privacy requirements––timely acknowledgement of receipt of referral,preferably within an agreed timeframe––clear and universally applied eligibility criteria––prioritisation according to clinical need,preferably according to priority of accesspolicy and agreed criteria––timely response to referral, or applicationof demand management measures suchas referring on if necessary––advising referrer of referral outcome,preferably within an agreed timeframe.Prompt points¼¼¼¼¼¼Is there a system of referral through thedepartment / organisation – if so, does itcontribute to consistency, legibility, detail and/ortimeliness of information transfer?Does it include a centrally updated listing ofrelevant service providers and their contactdetails that will facilitate appropriately directedreferral communications?How effective is the process? How satisfied areclinicians with the process? Has there been anyfeedback from organisations receiving referralsfrom your facility?Self identified Aboriginal andTorres Strait Islander peopleAboriginal and Torres Strait Islander status cannot bedetermined by physical appearance alone. “Are youof Aboriginal or Torres Strait Islander origin?” is anaccepted question developed by the Australian Bureauof Statistics and has been adopted as the nationalstandard for collecting Aboriginal and Torres StraitIslander origin in administrative data collections. 12Identification is not the final step; improving processes,cultural accountability and awareness of communityare also necessary. In addition, organisations shouldbe aware of other questions that should be asked, forexample, in maternity units, the father’s descent shouldbe noted in addition to the mother’s.Organisations should inform consumers / patients whythey are asking the question to ensure people can becomfortable to self identify. For example, organisationsshould provide advice about ‘Closing the Gap’ andimproving health care 13 , and collect information onAboriginal and Torres Strait Islander origin routinely aspart of registration / admission (e.g. name, address,sex, date of birth, next of kin).48 The ACHS EQuIP5 Guide Book 1 Accreditation, Standards and Guidelines Clinical Function

The collection and verification of the informationshould form part of normal work practices. In addition,organisations should consider adopting a system thatflags the health record of an identified Aboriginal andTorres Strait Islander person more clearly than a tickedentry on the admission form.Prompt points¼¼¼¼¼¼¼¼What guidelines / other resources are availableto the organisation’s staff to assist them tounderstand and meet the specific needs of anyAboriginal and Torres Strait Islander people whomay require service?How are Aboriginal and Torres Strait Islanderconsumer / patient records identified? Is thestandard question “Are you of Aboriginal orTorres Strait Islander origin?” part of normalwork practices?How does the organisation’s staff learn aboutcultural boundaries? How is orientation used?Is identification of Aboriginal and Torres StraitIslander consumers / patients used for clinicaltreatment? If so, how?Evidence commonly presentedConsider whether the following willhelp to address criterion 1.1.1¼¼¼¼¼¼¼¼¼¼¼¼¼¼Admission process / procedure (clinician and/orconsumer / patient satisfaction)Pre-admission assessment records forelective proceduresCare and assessment plansHealth record – consumer / patient details/ history, referral documents, clinical notes(potentially demonstrating multidisciplinaryinput) – audits of completenessDischarge policy / discharge planning procedureWards’ discharge board(s) / discharge planningteams / referral systemsTransition care programs¼¼Triage systems / guidelines /performance tracking¼¼¼¼¼¼¼¼¼¼¼¼¼¼¼¼¼¼Notes from multidisciplinary meetings (caseconferences) to discuss management forconsumers / patients with complex care needsMedication reconciliation processesAdditional forms for recording expandedassessmentsInformation brochures for consumers / patients,for example regarding admission or preparationfor surgeryGuidelines that specifically cover Aboriginal andTorres Strait Islander issues in the context of theorganisation’s clinical interests and consumer /patient poolConsistent reporting systems, such asSBAR (Situation, Background, Assessment,Recommendation)Tagging of consumers / patients or their healthrecords to highlight risk, such as for allergiesor high risk of fallsAudit of records, for example the health recordor referral documentation, or tracking of clinicalindicators to measure performanceFeedback from consumers / patients and/orreferral physicians and organisations sought, forexample, by satisfaction surveyOctober 2010 49

Section 5Standards, criteria, elements and guidelinesStandard 1.1: Consumers / patients are provided with high quality carethroughout the care delivery processCriterion 1.1.1Assessment ensures current and ongoing needs of the consumer / patient are identified.(continued)Performance measurementThis criterion states that: “Assessment ensures current and ongoing needs of the consumer / patient are identified”.The organisation should be able to demonstrate that it has processes for health assessment that are relevant toits operations, respond to the risks of its consumer / patient pool and meet the needs of the consumer / patient,as well as fulfilling the requirements of its referral partners.Some common suggested performance measures are as follows:Number of health records containing evidence of multidisciplinary assessmentTotal number of health records auditedNumber of consumers / patients admitted who had a completed and documented assessmentwithin 24 hours of admissionTotal number of consumers / patients admittedNumber of consumers / patients booked into an elective surgery facility whose procedure was cancelled aftertheir arrival at the facilityTotal number of consumers / patients who were booked into the facility for elective surgeryComment: consider reasons for cancellation, e.g. pre-existing medical condition, consumer /patient on inappropriate medication, etc.Number of consumers / patients admitted with a certain diagnosis where a key diagnostic test wasrequired and performedTotal number of consumers / patients admitted with a certain diagnosisComment: diagnostic tests could include CT scans, blood tests, etc.Number of consumers / patients who received pre-admission assessmentTotal number of consumers / patients flagged for pre-admission assessmentNumber of long-term consumers / patients who have regular reassessmentsTotal number of long-term consumers / patientsComment: ‘long-term consumers / patients’ and ‘regular reassessment’ to be defined by theorganisation as per policy50 The ACHS EQuIP5 Guide Book 1 Accreditation, Standards and Guidelines Clinical Function

References1. Australian Department of Health and Ageing (DoHA) andAustralasian College for Emergency Medicine (ACEM).Approved private emergency department program.Canberra ACT; DoHA; 2001.2. Royal College of Pathologists of Australasia (RCPA).Pre-operative assessment. RCPA Manual. Sydney NSW;RCPA. Accessed from http://www.rcpamanual.edu.au/ on15 December 2009.3. Carroll V, Antonio G and North Coast Area Health Service.Early detection through first rate patient assessment.ARCHI e-library 2008. Accessed from http://www.archi.net.au/e-library/demand/access/early-detection on18 December 2008.4. Peninsula Health Falls Prevention Service and VictorianDepartment of Human Services (DHS). Falls risk assessmenttool (FRAT). Melbourne VIC; DHS; 1999.5. NSW Health. Suicide risk assessment and managementprotocols. Sydney; NSW Health. Accessed from http://www.health.nsw.gov.au/pubs/2004/general_hosp_ward.html on5 January 2010.6. SA Department of Health. Pressure ulcer prevention andmanagement. In: McErlean B. Adelaide; SA Departmentof Health. Accessed from http://www.safetyandquality.sa.gov.au/Default.aspx?PageContentID=17&tabid=76 on5 January 2010.7. Australian Resource Centre for Healthcare Innovations(ARCHI). The Mini Nutrition Assessment Tool: A step in theright direction. Health Administration item 0031. Accessedfrom http://www.archi.net.au/documents/e-library/health_administration/health_awards/risks/0031-nutrition.pdf on5 January 2009.8. NSW Health & Community Services Industry ReferenceGroup, NSW Nurses Association and Workcover NSW.Manual handling for nurses: Program B(1) Patient riskassessment. Gosford NSW; Workcover NSW. Accessedfrom http://www.smartmove.nsw.gov.au/ContentFiles/WorkCoverManualHandling/Documents/manual_handling_training_package_nurses_section_b1_4798.pdf on5 January 2010.9. National Palliative Care Program, Australian Departmentof Health and Ageing (DoHA). CareSearch: Pain assessmenttools. Canberra ACT; DoHA. Accessed from http://www.caresearch.com.au/caresearch/ClinicalPractice/Physical/Pain/AssessmentTools/tabid/748/Default.aspxon 5 January 2010.10. Qaseem A, Snow V, Fitterman N et al. Risk assessmentfor and strategies to reduce perioperative pulmonarycomplications for patients undergoing noncardiothoracicsurgery: A guideline from the American College ofPhysicians. Ann Intern Med 2006; 144(8): 575-580.11. National Institute of Clinical Studies (NICS). Stop the clot:Integrating VTE prevention guideline recommendations intoroutine hospital care. Second edn. Melbourne; NationalHealth and Medical Research Council; 2008.12. Aboriginal and Torres Strait Islander Health and WelfareInformation Unit. National Aboriginal and Torres StraitIslander Community Services information plan. CanberraACT; Australian Institute of Health and Welfare (AIHW) andAustralian Bureau of Statistics (ABS); 2002.13. Chong A, Renhard R, Wilson G et al. Aboriginal and TorresStrait Islander patients: quality improvement toolkit forhospital staff. Melbourne VIC; The Lowitja Institute; 2010.October 2010 51

Section 5Standards, criteria, elements and guidelinesStandard 1.1: Consumers / patients are provided with high quality carethroughout the care delivery processCriterion LA – Awareness SA – ImplementationLA plus the followingCriterion 1.1.2Care is planned anddelivered in collaborationwith the consumer / patientand when relevant, thecarer, to achieve the bestpossible outcomes.This is amandatorycriteriona) Evidence-based guidelineson care planning and deliveryare available.b) Care is provided in responseto consumer / patient needsin a timely manner and inaccordance with policyand procedures.c) Care planning reflectsjurisdictional priorities forself identified Aboriginaland Torres Strait Islanderconsumers / patients.a) Care planning and deliveryare based on the assessmentof consumer / patient needs,in collaboration with theconsumer / patient and whenappropriate their carer.b) Consumers / patients areinformed of factors impactingon their health and a planfor promoting their individualwellbeing is discussed.c) Care planning decisions,actions and changes aredocumented in the consumer /patient health record.d) Care is coordinated, plannedand delivered by skilled andtrained individuals within amultidisciplinary team with anidentified team leader.e) Consumers / patients andwhen appropriate, carers areprovided with information thatallows them to understand theircare and care delivery optionsand any variations to their care.f) A system exists for the effectiveidentification and managementof a deteriorating consumer /patient.52 The ACHS EQuIP5 Guide Book 1 Accreditation, Standards and Guidelines Clinical Function

MA – EvaluationSA plus the followinga) Policy and procedures forcare delivery are evaluatedand improved as required.b) The care planning and deliveryprocesses are evaluated andimproved as required.c) Multidisciplinary teamprocesses for care deliveryare evaluated and improvedas required.d) The system for the effectiveidentification and managementof a deteriorating patientis evaluated and improvedas required.EA – ExcellenceMA plus the followinga) Care planning and deliverypractices, together with data onvariances, are compared withinternal and external systemsand improvements are madeto ensure better practice.and/orb) Multidisciplinary team work iscompared with other healthservices and/or industries andimprovements are made toensure better practice.and/orc) The organisation undertakesresearch relevant to careplanning and the deliveryof care, and acts on results.OA – LeadershipEA plus the followinga) The organisation demonstratesit is a leader in care planningand delivery practices.October 2010 53

Section 5Standards, criteria, elements and guidelinesStandard 1.1: Consumers / patients are provided with high quality carethroughout the care delivery processCriterion 1.1.2Care is planned and delivered in collaborationwith the consumer / patient and whenrelevant, the carer, to achieve the bestpossible outcomes. (continued)IntentThe intent of this criterion is to ensure that careplanning and delivery are responsive to consumer /patient needs and that there is a consultative,collaborative approach to the provision of health carethat will actively involve the consumer / patient and hisor her carer.Relationships of 1.1.2 with other criteriaCare planning and care delivery are an integral partof the consumer / patient journey (Standard 1.1).Care planning should consider the processes ofaccess and admission (Criterion 1.2.2), how the mosteffective care can be delivered (Criterion 1.4.1), thevarious aspects of ongoing care (Criterion 1.1.6), andhow the most appropriate care can be delivered in themost appropriate setting (Criterion 1.3.1). All decisionsmade should be recorded in the health record(Criterion 1.1.8). The outcomes of the care planned anddelivered should be evaluated (Criterion 1.1.4).Consumers / patients should participate in theirown care planning (Criterion 1.6.1), which is oneof their healthcare rights (Criterion 1.6.2). Planningshould encompass the diverse needs and diversebackgrounds of consumers / patients (Criterion 1.6.3),and how these may impact upon the delivery ofcare. Effective care planning and delivery are facetsof the organisation’s integrated risk managementframework (Criterion 2.1.2), and failures in this areamay lead to incidents (Criterion 2.1.3) and complaints(Criterion 2.1.4).Care planning – the processThe planning, delivery and coordination of care is thecore business of all healthcare organisations.The key considerations in care planning are:• care is planned and documented according tothe assessment of consumer / patient needs• there is input from the consumer / patient andrelevant care providers• there is consideration that a second opinionmay be sought• care planning and delivery are based on thebest available evidence• care is delivered by competent individualsand competent multidisciplinary teams• care is coordinated between all members ofthe team (including carers)• the needs of high-risk consumers / patientsare identified and managed appropriately• the environment within which care is provided iscomfortable, caring and appropriate to consumer /patient needs.Effective planning, delivery and coordination of caremay draw upon:• guidelines developed by professional collegesand/or associations• clinical pathways / care plans• legislative requirements, medico-legalrequirements, standards, codes of practice,ethics and frameworks• the organisation’s policies and procedures• guidelines for consumers / patients identified asbeing at high risk, such as standard protocolsfor cardiac arrest or acute psychotic episodes• organisational strategies to deal with highriskactivities, which will vary within the healthsector and be influenced by the consumer /patient. Examples of known high-risk activitiesinclude management of blood transfusions ormedication management• strategies to promptly identify / detect anddeal with poor nutritional status, delirium, acutepsychotic episodes, falls, depression, deteriorationin consumer / patient health condition andcardiac arrest• systems to identify and manage changes inconsumer / patient health status includingappropriate referral within the organisation orto community services following discharge.Examples include the management of pressureareas, incontinence, post-surgical complications,deterioration in clinical status, development ofiatrogenic complications, transfer to an intensivecare unit (ICU) and postnatal care• evidence-based research and guidelines.54 The ACHS EQuIP5 Guide Book 1 Accreditation, Standards and Guidelines Clinical Function

The care plan or clinical pathway may include:• goals to be achieved which should reflect theclinical condition of the consumer / patient• tests and investigations to be conducted• procedures and interventions to be provided• multidisciplinary team referrals• consumer / patient education strategiesto be implemented• timeframes to be met• delineation of responsibilities• discharge planning / planning for transfer• transfer of care.Care planning and coordination includes ensuringthat the outcomes of the care delivered are evaluated.The evaluation could involve review of:• processes around care coordination andcommunication within the organisation andwith external providers• internal referral processes• appropriate mechanisms for escalation of carewhen a consumer / patient is deteriorating• clinical handover processes• the consumer / patient’s understandingof his/her progress• consumer / patient participation in caseconferencingand carers’ discussion• review against best practice guidelines.Prompt points¼¼¼¼¼¼¼¼Are clinical pathways / guidelines used incare planning referenced to evidence-basedsource(s)? How frequently are these reviewedand updated?Do organisational policies / programs for careplanning recognise and reflect jurisdictionalpriorities for Aboriginal and Torres Strait Islanderpeoples? Is this stated in the documentsor referenced?Are medico-legal requirements considered andmet by the care planning processes? How isthis recorded?Have policy / processes been developedfor classes of consumers / patients ordisease states identified as ‘high-risk’ forthe organisation?Consumer / patient needsand involvementExplanation should be provided for consumers /patients and carers so that they understand thediagnosis, prognosis, treatment options and illnessprevention strategies. Delivery of the informationshould be timely, and provided in a suitable way for theindividual consumer / patient to understand his or hertreatment options in collaboration with their carer(s).Consumers / patients and, where appropriate,carers should understand that there are multiplechoices navigated by their physicians on their behalfwhen planning their care. Despite the developmentof a framework for participatory doctor-patientcommunications, achieving collaborative care planningcan be very challenging. 1Where appropriate, carers should be made aware of,and referred to, services and support for carers. Careplans should be documented in the health record.A framework for shared decision making was outlinedby Towle and Godolphon 1 to evaluate whethercare planning was undertaken as a partnershipbetween consumer / patient and physician. 2The framework includes:• establishing or reviewing the consumer / patient’spreferences for information (such as amountor format)• establishing the consumer / patient’s preferencesfor their role in decision making• explaining any uncertainty about the ‘best’ courseof action to take• ascertaining and responding to the consumer /patient’s ideas, concerns and expectations• identifying options available, evidence on theirefficacy and their relevance for the consumer /patient’s existing situation• helping the consumer / patient to reflect on andassess the impact of alternative decisions withregard to his or her lifestyle and values• advising of any variation in clinical care• negotiating a decision in partnership• agreeing on an action plan and making next steparrangements.Where decisions are complex or will involve familymembers, consumers / patients may be provided witha ‘take home’ summary to assist them to recall theiroptions and consider them with others.October 2010 55

Section 5Standards, criteria, elements and guidelinesStandard 1.1: Consumers / patients are provided with high quality carethroughout the care delivery processCriterion 1.1.2Care is planned and delivered in collaborationwith the consumer / patient and whenrelevant, the carer, to achieve the bestpossible outcomes. (continued)Organisations should consider the timeliness oftheir care delivery based on the clinical urgency ofthe consumer / patient’s condition and their systemfor scheduling appointments, and should reviewperformance against predetermined measures.A ‘timely manner’ may be viewed differently byconsumers / patients and healthcare providers,suggesting the need to also consider consumer /patient response to the delivery of services. Clearpolicy and procedures should be in place, whichfacilitate the provision of services in the most timelymanner and in response to consumer / patient need.Organisations should be aware of jurisdictionalpriorities that aim to address disparities in healthcareprovision for Aboriginal and Torres Strait Islanderpeople. 3-5 Some health departments have specificoffices and programs that focus on Aboriginaland Torres Strait Islander health within theirconstituencies 6,7 , and evidence-based knowledge offactors contributing to successful outcomes in minoritypopulations are now better understood. 8Prompt points¼¼¼¼¼¼¼¼What standard information is provided toconsumers / patients to help them understandthe care delivery process?How is communication about care processesdocumented in the consumer / patienthealth record?What records are used to document discussionswith consumers / patients about promotingbetter health? Are offers of education / supportprograms to promote better chronic diseasemanagement recorded in the health record?How are recommendations to receptiveconsumers / patients followed up?Are consumer / patient health records upto-dateand complete during care delivery?How is compliance with health recordpolicies assessed?¼¼¼¼¼¼Where a mix of electronic and printed materialsis used, how are the documents cross-linkedso that the consumer / patient journey throughassessment, diagnosis, care planning anddelivery to discharge (where appropriate) canbe traced?What waiting times are considered ‘appropriate’for the services provided by the organisation,for example, emergency care, elective surgery,chronic disease self management support?How are consumer / patient and organisationalneeds considered when timeliness is defined?What organisational actions facilitate the timelyprovision of care?How is timely delivery of care assessed on anorganisational basis? Are consumer / patientperceptions of timeliness also evaluated?Environment for delivery of careThe environment in which care is provided willvary depending upon the healthcare organisation,consumer / patient needs and presentingcircumstances. Care begins in the waiting rooms /admission area and extends to consulting rooms,surgical preparation areas, wards, and specialtyfunction areas such as gymnasia used in rehabilitationor sound studios in audiology. All these environmentswill impact on the consumer / patient; all areas shouldbe perceived as comfortable, caring and clean.The quest for feedback from consumers / patientswith regard to the environment should ideally extendbeyond an absence of complaints. Follow-up phonecalls provide an opportunity to seek feedback onthe perceived quality of care and the environment.Satisfaction surveys and focus groups can help todetermine consumer / patient perceptions througheither general or specific questioning. 9Prompt points¼¼¼¼Does the organisation record complaints andcompliments regarding the environment inwhich care is provided? Have any actions beenundertaken in response to complaints about thehealthcare environment?Does the organisation review consumer / patientsatisfaction including whether consumers /patients perceived the care delivery environmentas comfortable, caring and clean?56 The ACHS EQuIP5 Guide Book 1 Accreditation, Standards and Guidelines Clinical Function

Section 5Standards, criteria, elements and guidelinesStandard 1.1: Consumers / patients are provided with high quality carethroughout the care delivery processCriterion 1.1.2Care is planned and delivered in collaborationwith the consumer / patient and whenrelevant, the carer, to achieve the bestpossible outcomes. (continued)Prompt points¼¼¼¼¼¼Is there evidence of multidisciplinary care inthe health record? How is prime responsibility(the team leader) for consumer / patientcare assigned and demonstrated within thehealth record?When are case conferences used to coordinatecare? How are they managed?Are the members of multidisciplinary teamschosen by the team leader or is this determinedby organisational policy / procedures?Evidence commonly presentedConsider whether the following willhelp to address criterion 1.1.2¼¼¼¼¼¼¼¼¼¼¼¼¼¼Clinical pathways / care plans(with references or original source)Policies or guidelines that are used in careplanning – easily accessible formatPolicies / procedures on record keepingto facilitate care planningHealth records demonstratingmultidisciplinary input with responsibleclinician identified consistentlyCase conference notesEvaluation of communication delivery or ofits comprehension by consumers / patientsEvaluation of consumer / patient satisfactionincluding satisfaction with the environment inwhich care was received¼¼Existence of a policy / guideline specificallyon management of deterioratingconsumers / patientsPerformance measurementThis criterion states that: “Care is planned and delivered in collaboration with the consumer / patient and whenrelevant, the carer, to achieve the best possible outcomes”. The process of care planning and its collaborativeaspects should be documented throughout the care journey of the consumer / patient, and evident in healthoutcomes and consumer / patient satisfaction.Some common suggested performance measures are as follows:Number of consumers / patients satisfied with decision making about / involvement in their careTotal number of consumers / patients surveyedNumber of consumers / patients satisfied with their care goals being achievedTotal number of consumers / patients surveyed58 The ACHS EQuIP5 Guide Book 1 Accreditation, Standards and Guidelines Clinical Function

Number of consumers / patients who have signed off on their care pathwayTotal number of consumers / patients who have a care pathwayComment: a care pathway, some times called a care map or plan, is a consumer / patient managementtool that organises, sequences and times the major consumer / patient care activities andinterventions of the entire multidisciplinary team for consumers / patients with a particulardiagnosis, or undergoing a particular procedure. 16Number of variances identified in a pathway in relation to care planningTotal number of possible variances in the pathwayComment: a variance is defined as “a deviation from the expected consumer / patient or family goals,outcomes and staff interventions outlined in the clinical pathway that potentially affects theexpected outcome of the consumer / patient”. Consider the reasons for the variance.Number of unplanned readmissions to the organisation / service within X daysTotal number of separationsComment: the organisation to define ‘X’Number of care goals / program goals achieved within the designated timeframeTotal number of care goals / program goalsNumber of consumers / patient fulfilling deterioration criteria who did not receive advanced resuscitationTotal number of consumers / patients fulfilling deterioration criteriaComment: the organisation to define deterioration criteria; advanced resuscitation could beimplemented by a Medical Emergency Team in a larger organisation, or by a GP ina smaller oneOctober 2010 59

Section 5Standards, criteria, elements and guidelinesStandard 1.1: Consumers / patients are provided with high quality carethroughout the care delivery processCriterion 1.1.2Care is planned and delivered in collaborationwith the consumer / patient and whenrelevant, the carer, to achieve the bestpossible outcomes. (continued)References1. Towle A, Godolphin W, Grams G and Lamarre A. Puttinginformed and shared decision making into practice.Health Expectations 2006; 9(4): 321-323.2. Bird S. Discussing benefits and risks with patients.Aust Fam Physician 2004; 33(4): 266-267.3. Victorian Department of Health and Victorian AboriginalCommunity Controlled Health Organisation. Aboriginalhealth promotion and chronic care partnership programguidelines. Melbourne; Vic Dept of Health; 2005.4. Australian Health Ministers’ Advisory Council (AHMAC)Standing Committee on Aboriginal and Torres Strait IslanderHealth. Cultural respect framework for Aboriginal andTorres Strait Islander health, 2004–2009. Adelaide SA;AHMAC; 2004.5. Australian Department of Health and Ageing (DoHA).Reconciliation action plan. Canberra ACT; DoHA; 2007.6. WA Department of Health. Office of Aboriginal Health.Perth WA: Government of WA. Accessed from http://www.aboriginal.health.wa.gov.au/home/ on 7 January 2009.7. Chong A, Renhard R, Wilson G, et al. Aboriginal and TorresStrait Islander patients: quality improvement toolkit forhospital staff. Melbourne VIC; The Lowitja Institute; 2010.8. Flores G. Devising, implementing, and evaluatinginterventions to eliminate health care disparities in minoritychildren. Pediatrics 2009; 124(Suppl3): S214-S223.9. Wolff AM and Taylor SA. Enhancing patient care: A practicalguide to improving quality and safety in hospitals. SydneyNSW; MJA books; 2009.10. Schein R, Hazday N, Pena M et al. Clinical antecedents toin-hospital cardiopulmonary arrest. Chest Surg Clin N Am1990; 98(6): 1388-1392.11. Australian Commission on Safety and Quality in Health Care(ACSQHC). Windows into safety and quality in health care2009. Sydney NSW; ACSQHC; 2009.12. Australian Commission on Safety and Quality in HealthCare (ACSQHC). National Consensus Statement: essentialelements for recognising and responding to clinicaldeterioration. Sydney NSW; ACSQHC; 2010.13. May J, Cooper R, Magin P and Critchley A. Integratedmodels or mayhem? Lessons learnt from three integratedprimary health care entities in regional New South Wales.Aust Health Rev 2008; 32(4): 595-604.14. Nagel T and Thompson C. Motivational care planning:Self management in indigenous mental health.Aust Fam Physician 2008; 37(12): 996-1001.15. Zwar NA, Hermiz O, Comino EJ, et al. Do multidisciplinarycare plans result in better care for patients with type 2diabetes? Aust Fam Physician 2007; 36(1/2): 85-89.16. Abdelhak M, Grostick S, Hanken MA and Jacobs E. Healthinformation: Management of a strategic resource. Secondedn. Philadelphia USA; Saunders; 2001.60 The ACHS EQuIP5 Guide Book 1 Accreditation, Standards and Guidelines Clinical Function

October 2010 61

Section 5Standards, criteria, elements and guidelinesStandard 1.1: Consumers / patients are provided with high quality carethroughout the care delivery processCriterion LA – Awareness SA – ImplementationLA plus the followingCriterion 1.1.3Consumers / patientsare informed of theconsent process, andthey understand andprovide consent for theirhealth care.This is amandatorycriteriona) There is policy / guidelinesfor consent that is consistentwith jurisdictional legislativerequirements.b) Healthcare providers areadvised of the consentpolicy / guidelines.c) Consumers / patients areprovided with information onrecommended investigations,treatment or procedures,and costs prior to providingconsent for that health care.a) Consent is obtained forinvestigations, treatmentor procedures and costsin accordance with theorganisation’s policy /guidelines.b) There is a process to manageconsent where it is unable to begiven at the appropriate time.c) There is a processto obtain consent forpersonal information to becommunicated to healthcareworkers outside the service,to carers or to other relevantpersons when required.IntentThe intent of this criterion is to ensure that the processof obtaining consent is managed appropriately.In this document, the term ‘consent’ covers a numberof different legal requirements:• The consumer / patient and/or carer should beinformed in broad terms of the nature of anyinvasive procedure which is to be performed.This consent protects the consumer / patient andalso operates as a defence to legal action.• The consumer / patient and/or carer should beinformed of material risks inherent in the procedureor treatment. This is part of the duty of careowed to the consumer / patient by the appointedclinician who provides treatment.• Consent for collection of health information, andto any use of that information and/or disclosure bythe organisation to third parties, is required underCommonwealth and applicable State / Territoryprivacy laws.• The consumer / patient and/or carer must beprovided with adequate information to allowinformed financial consent.Relationships of 1.1.3 with other criteriaThe need for the organisation to obtain informedconsent from the consumer / patient to treatmentis a vital aspect of the planning and delivery ofcare (Criterion 1.1.2). Consent is also necessaryin advance planning for end-of-life care (Criterion1.1.7), including decisions about organ donation. Theconsumer / patient has a right to understand his or hertreatment options, and to give or withhold informedconsent (Criterion 1.6.2), and to have access tosupport services such as interpreters when required(Criterion 1.6.3). The consent process is an aspectof the organisation’s integrated risk managementframework (Criterion 2.1.2), and failure to manageconsent processes correctly may lead to complaints(Criterion 2.1.4).62 The ACHS EQuIP5 Guide Book 1 Accreditation, Standards and Guidelines Clinical Function

MA – EvaluationSA plus the followingEA – ExcellenceMA plus the followingOA – LeadershipEA plus the followinga) The consent process isevaluated and improvedas required.b) Compliance with the consentprocess is evaluated andstrategies for improvement areimplemented as required.a) Documents and practices forconsent are compared withinternal and external systemsand improvements are madeto ensure better practice.a) The organisation demonstratesit is a leader in its systemsfor obtaining consent.Consent is defined and providersare advisedConsent is a significant aspect of the assessment ofconsumer / patient needs both from a clinical and anon-clinical perspective. Organisations should beaware of all legislative requirements and any relevantguidelines, and regularly review existing practices.Consent can include financial, procedural, ethics and/or research consent.The requirements for gaining consent should bedefined in the organisation’s policy; this will influencehow the procedural details are addressed. 1 Theconsent policy should reflect jurisdictional legislationand address the following:• the organisation’s responsibilities in regardto gaining consent• the procedures, care, treatment and investigationoptions and costs that require written, verbalor implied consent• the process used to obtain consent, includingthe ways that information may be provided to theconsumer / patient (verbally, brochures, usinginterpreters)• how consent is to be documented in theconsumer / patient’s health record• when a surrogate decision maker, rather thanthe consumer / patient, may give consent• the use of interpreters / interpreter serviceswhen the consumer / patient is not proficientin the primary language of the organisation’srepresentatives• situations where procedures, care and treatmentnormally requiring consent may be givenwithout consent.Healthcare providers may be advised of the policythrough the orientation process, minutes of MedicalAdvisory Committee (MAC) meetings, other groupmeetings and the organisation’s newsletters. In privatehospitals, the obligations of visiting medical staff toprovide consent documentation will be covered in thefacility’s by-laws.Orientation programs for new clinicians should includethe consent process. An understanding of the consentpolicy by healthcare providers cannot be assumed.Legislation varies between Australian jurisdictions,and healthcare organisations differ in the philosophicalprinciples on which their care principles are based.Despite the World Health Organization’s internationalprotocol on consent 2 , overseas-trained clinicians mayhave trained or worked under very different policies.October 2010 63

Section 5Standards, criteria, elements and guidelinesStandard 1.1: Consumers / patients are provided with high quality carethroughout the care delivery processCriterion 1.1.3Consumers / patients are informed of theconsent process, and they understandand provide consent for their health care.(continued)Prompt points¼¼¼¼Does the organisation have a consent policy?Does it state the procedures / circumstancesto which the policy applies? How does theorganisational policy address potentiallycontroversial situations?Is consent covered in orientation or othertraining for clinical staff? How is theorganisation’s consent policy made readilyaccessible to staff?Informed consent is obtainedA completed consent process should includea discussion of the following issues 3 :• the nature of the proposed care, treatment,services, medications, interventions, investigationsor procedures• possible benefits, risks, complications andside effects• the probability of achieving care andtreatment goals• reasonable alternatives to the proposed care andtreatment, and the relevant risks, complicationsand side effects of alternate treatments includingthe possible results of receiving no treatmentor care• any limitations on the confidentiality of informationgained from or about the consumer / patient.Discussions / outcomes should be documented inthe consumer / patient’s health record in any situationwhere this information is not included on the printedconsent form.Consent should be obtained and documented inaccordance with the organisation’s policy. Therelationship between a healthcare organisation and amedical practitioner will impact upon the organisation’sresponsibilities in the consent process. In the privatesector, there are cascading levels of consent; forexample, the treating clinician will usually obtainconsent for recommended investigations, treatmentor procedures and their costs within their own roomsprior to providing that health care. In these cases,there should be a copy of the documented, signedconsent obtained by the treating clinician, or an‘acknowledgement of the consent’, in the consumer /patient health record.Private hospitals are not required to provide specificcosts for surgeons, anaesthetists and such, but shouldinform consumers / patients that these costs will bein addition to the hospital costs. Private consumers /patients should be directed to inquire directly to theclinician’s rooms for cost estimates.Organisations should have specific policies and/or procedures to address circumstances whereprocedural consent has not been provided, andrelevant medical practitioners should be advisedof these.Organisations should make every effort to ensureunderstanding by the consumer / patient. 2 Thefollowing approaches may be useful:• use diagrams and models to illuminateverbal descriptions• respond to questions from the consumer /patient and his or her family• recognise that some consumers / patients mayneed time for decision making in partnership withfamily members, carers and/or community orreligious consultants / elders• employ a professional interpreter rather thanrelying on family members in situations whereEnglish is not the consumer / patient’s firstlanguage and there are doubts about proficiency 1 ;consent obtained without the use of an interpretermay not be legally binding• ask consumers / patients to repeat back what theyhave been told to gauge their understanding. 4In organ donation, consent issues can be particularlychallenging and hospitals undertaking organtransplants must have policy in place. There is a needfor more organ donation to save the lives of individualsneeding a transplant. At the time that decisionsregarding the organs of dying consumers / patientsmust be made, the consumer / patient will be unable toparticipate in the process. Healthy people are thereforeasked to provide an advance directive by includingtheir names on the Australian Organ Donor Registrycoordinated by Medicare and by notifying their familyof their wishes. 564 The ACHS EQuIP5 Guide Book 1 Accreditation, Standards and Guidelines Clinical Function

Organisations should use trained staff who havebeen designated to seek consent for organ donationand there should be an agreed approach to themanagement of the ethical conflict between griefcounselling, promoting understanding and efforts togain approval for organ harvesting. 6 A predefinedprocess and nominated personnel responsible fordetermining brain death will help to reduce proceduralconfusion as death approaches.Prompt points¼¼¼¼¼¼¼¼Are audits 7 undertaken to check that consentis being obtained in accordance to theorganisation’s policy?Are consent levels considered satisfactory?What actions have been taken to maintainor improve consent levels or to reduce risksassociated with consent?What processes are used to manageconsent where English language proficiencyis uncertain?What processes are used to manage requestsfor organ donation (where this may apply)?¼¼Where a procedure is explained to consumers /patients at the organisation, what information isprovided to assist them to understand the risksand benefits of the procedure?¼¼¼¼What procedure is used to provide accuratefinancial estimates to consumers / patients?Does the organisation take action to ensurethat consumers / patients understand thecost implications?How is compliance with the consentprocess evaluated?When consent cannot be obtainedValid informed consent is premised on the disclosureof appropriate information to a competent consumer /patient who is permitted to make a voluntary choice.When consumers / patients lack the competence tomake a decision about treatment, substitute decisionmakers must be sought. The determination of whetherconsumers / patients are ‘competent’ is importantfor maintaining the autonomy of individuals who arecapable of making informed decisions, while protectingthose with cognitive impairment. 8Some settings, such as intensive care units, includea significant proportion of consumers / patients whomay not be competent. Assessing competence canbe challenging, particularly differentiating impairmentfrom incapacity. 8 Legal standards for decision makingcapacity for consent to treatment vary somewhatacross jurisdictions, but generally for adults over18 years an assessment of competence should involvethree aspects 1 :1. Does the person understand?2. Does the person believe what they are being told?3. Can the person make a judgment based onthis information?Specific situations where consent conditions donot apply should be covered by policy accordingto jurisdictional requirements and organisational /professional ethics. Subjects likely to becovered include 1 :• emergency situations• advance care directives• treatments authorised by statute or court order.Organisations may also have policy to covercircumstances where the transfer of paperwork has notoccurred and it is in the consumer / patient’s assumedbest interests to proceed. 9,10Prompt points¼ ¼ Under what circumstances are consumers /patients deemed incompetent in theorganisation? Is there policy / guidelines formanaging situations where consent may nothave been obtained from a consumer / patient?October 2010 65

Section 5Standards, criteria, elements and guidelinesStandard 1.1: Consumers / patients are provided with high quality carethroughout the care delivery processCriterion 1.1.3Consumers / patients are informed of theconsent process, and they understandand provide consent for their health care.(continued)Consent to communicatepersonal informationThe National Privacy Principles aim to ensure thatpersonal information collected for the legitimateactivities of a healthcare organisation is used only forpurposes related to the reason for which the data wereoriginally collected.This requires that consent be sought, except in somespecifically stated circumstances, before informationis transferred to other organisations or people. 11Evidence commonly presentedConsider whether the following willhelp to address criterion 1.1.3¼¼¼¼¼¼¼¼¼¼¼¼Organisational consent policyHealth records containing consent formsor notes on discussions about consentTraining and information resources forhealthcare professionals on consentEstimates of procedure costs withsigned consentComplaints management in situationsrelated to consentHealth records audit to assess levels of consentand quality of processPrompt points¼¼Review of consent forms and communicationdocuments for ease of understanding¼¼Under what circumstances does theorganisation seek a signed consent for thetransfer of information? How is any riskassociated with information provision broachedwith consumers / patients?Performance measurementThis criterion states that: “Consumers / patients are informed of the consent process, and they understand andprovide consent for their health care”. The organisation should be able to demonstrate that it has policies andprocedures in place to comply with the jurisdictional requirements governing the gaining of informed consent,and also that it is able to manage those situations where variations to the standard procedure are necessary.Some common suggested performance measures are as follows:Number of consent forms that have been signed by consumers / patients prior to their admissionfor elective surgeryTotal number of consumers / patients admitted for elective surgeryNumber of consent forms signed by an appropriate medical practitioner / health professionaland the consumer / patientTotal number of consent forms reviewed66 The ACHS EQuIP5 Guide Book 1 Accreditation, Standards and Guidelines Clinical Function

Number of consumers / patients who were given verbal or written information about risks associatedwith a treatment / procedure, which was then documented in their health recordTotal number of consumers / patients undergoing a treatment / procedureNumber of consumers / patients giving financial consent to a treatment / procedureTotal number of consumers / patients undergoing the treatment / procedureNumber of culturally and linguistically diverse (CALD) consumers / patients accessingthe interpreter service to gain assistance with giving informed consentTotal number of consumers / patients identified as CALDReferences1. ACT Health. Procedure: Consent to treatment.Canberra; ACT Health; 2008.2. World Health Organization. Best practice protocols:Clinical procedures safety. Geneva CH; WHO; 2007.3. National Health & Medical Research Council (NHMRC).Communicating with patients: Advice for medicalpractitioners. Canberra ACT; Commonwealth ofAustralia; 2004.4. Wu HW, Nishimi RY, Page-Lopez CM and Kizer KW.Learning from early adopters: Improving patient safetythrough informed consent in limited english proficiency/lowliteracypopulations. Washington DC USA; National QualityForum; 2005.5. Medicare Australia. Australian organ donor register.Australian Government. Accessed from http://www.medicareaustralia.gov.au/public/services/aodr/index.jspon 14 January 2010.6. Truog RD. Consent for organ donation — balancingconflicting ethical obligations. N Engl J Med 2008; 358(12):1209-1212.7. Siddins MT, Klinken EM and Vocale LR. Adequacy ofconsent documentation in a specialty surgical unit: time forcommunity debate? Med J Aust 2009; 191(5): 259-262.8. Appelbaum PS. Assessment of patients’ competenceto consent to treatment. N Engl J Med 2007; 357(18):1834-1840.9. WA Department of Health. Consent to treatmentpolicy for the Western Australian health system.Perth; WA Health; 2009.10. WA Department of Health. Form F: Authorisation to proceedwith surgery on a patient without a valid consent form.Perth; WA Health; 2010.11. Office of the Federal Privacy Commissioner. National privacyprinciples. Information sheet. Canberra ACT; Office of thePrivacy Commissioner; 2008.October 2010 67

Section 5Standards, criteria, elements and guidelinesStandard 1.1: Consumers / patients are provided with high quality carethroughout the care delivery processCriterion LA – Awareness SA – ImplementationLA plus the followingCriterion 1.1.4Outcomes of clinicalcare are evaluated byhealthcare providersand where appropriateare communicated tothe consumer / patientand carer.This is amandatorycriteriona) Healthcare providers areaware of the organisation’ssystems for the evaluation ofclinical care.b) Policy / guidelines existfor providing feedbackabout clinical care toconsumers / carers.c) Consumers / patients andwhen appropriate carers areenabled to provide feedbackon the care provided.a) Formal processes areimplemented across theorganisation for the reviewof clinical care.b) Prior to discharge, healthcareproviders discuss theoutcomes of care with theconsumer / patient and whenappropriate the carer, andthis is documented.IntentThe intent of this criterion is to ensure thatorganisations evaluate the outcomes of the care andservices that they provide. Care should be evaluatedon a case-by-case basis, as well as organisation-wide.Outcomes of care evaluation must be communicatedto key clinical staff in senior nursing, medical and alliedhealth roles, to ensure that appropriate responses areidentified and implemented in order to improve thequality of care provided.Relationships of 1.1.4 with other criteriaOrganisations must evaluate the clinical care that theyprovide to ensure the delivery of high quality healthcare to the consumer / patient, and with the goal ofcontinuous improvement of services (Standard 1.1).Evaluation should consider the effectiveness(Criterion 1.4.1), appropriateness (Criterion 1.3.1),safety and quality (Standard 1.5) of care. Theorganisation must have processes in place to reviewand revise policy and processes on the basis of careevaluation, and to ensure that recommended changesare implemented (Criterion 3.1.5).Consumers / patients, their families and/or carers havethe right to participate actively in the planning, deliveryand evaluation of care (Criterion 1.6.1) and to commenton any aspect of the care provided (Criterion 1.6.2).Feedback and complaints from consumers / patients(Criterion 2.1.4) may provide insight into areas of carerequiring improvement. Evaluation is an aspect of theorganisation’s integrated risk management framework(Criterion 2.1.2). Failure to evaluate and improveclinical care may lead to incidents, including adverseevents, which under the principles of open disclosureshould be discussed with the consumer / patient(Criterion 2.1.3).Feedback on clinical careOrganisational feedback to consumers / patients maybe provided in two different contexts:• feedback to an individual consumer / patientand their family / carer(s) about the care thatthe consumer / patient personally received at anorganisation• more general feedback on the overall performanceof the organisation in relation to its clinical care.68 The ACHS EQuIP5 Guide Book 1 Accreditation, Standards and Guidelines Clinical Function

MA – EvaluationSA plus the followinga) Clinical audit is supportedacross the organisation andreviewed by the relevantclinician groups to evaluateand improve health care.b) Individual and groupconsumer / patient care andoutcomes data (including ‘atrisk’ patients) are evaluatedand improved as required.c) Data collected from thefeedback of consumers /patients are used by theorganisation in the evaluationof clinical care.d) Consumers / patients and whenappropriate, carers participatein the evaluation of care.EA – ExcellenceMA plus the followinga) Performance measures forprocess and outcome data areused across the organisationand compared with internaland external systems andimprovements are made toensure better practice.and/orb) The organisation contributesto national databases andcomparative reports fromthe databases are regularlyreviewed and improvementsare made to ensurebetter practice.OA – LeadershipEA plus the followinga) The organisation demonstratesit is a leader in the evaluationof care as demonstrated byits processes and consumer /patient outcomes.It is likely that organisations will have distinct policy /guidelines to cover these separate situations.Some State / Territory health departments and privatehospital groups track performance using indicators.Organisations will hold a position on whether thisinformation is reported to the consumers on theircommittees and to the general public; this positionwill be reflected in policy and/or guidelines.Increasingly, there are moves to provide consumers withconcrete figures to enable performance comparisons;this happens to some extent for various measures inoverseas countries. There are equally strong questionsabout the value of providing information that can beranked into ‘league tables’ which may be open tointerpretation without due context.Objectives being pursued through the AustralianCommission on Safety and Quality in HealthCare may mean that a broad range of healthcareproviders across Australia will provide regulardata for benchmarking on carefully selectedperformance indicators. 1Organisations may choose to release performanceinformation to the public through various avenuesincluding their public relations departments or theirwebsites; the information selected for public disclosureis generally the ‘good news’ or the ‘positive angle’.Prompt points¼¼Is there policy or guidelines on communicatingclinical care outcomes to consumers / patients?What guidance, if any, does the organisation’spolicy on feedback provide to clinicians?October 2010 69

Section 5Standards, criteria, elements and guidelinesStandard 1.1: Consumers / patients are provided with high quality carethroughout the care delivery processCriterion 1.1.4Outcomes of clinical care are evaluated byhealthcare providers and where appropriateare communicated to the consumer / patientand carer. (continued)Feedback is given to consumers /patients before discharge / transferof careThe importance of consumers / patients understandingtheir health status, any resultant limitations, obligationsor changes, and then committing to proactivelymanaging their health following discharge or transferof care cannot be over-estimated.In cases where the original care plan required variationduring the course of treatment, a discussion of thecircumstances that led to the change should beincluded as part of the care dialogue. A structureddiscussion of a consumer / patient’s care outcomesand expectations of their ongoing recovery and/orcare needs may help the individual to better managerecovery, and to recognise and respond to anyadverse events post-discharge. 2Prompt points¼¼¼¼¼¼Is there a record of what information aboutoutcomes of care has been discussed withthe consumer / patient (in the health record,discharge summary, care plans, casemanagement reviews)?Does discharge planning at the organisationpermit / encourage a discussion regarding theoutcomes of clinical care?How variable is the manner in which outcomesof care are discussed with consumers /patients? What impact does the individualpersonality of the consumer / patient and/orclinician play in discussions about outcomesof care?Consumers / patients can providefeedback on their careConsumers / patients may not be able to assess thetechnical aspects of the clinical choices made by theirhealthcare providers, but they do expect that theirtreatment or procedure should lead to an improvementin their health and wellbeing. Similarly, most consumers/ patients can assess whether they had input into thedecisions made on their behalf, and whether their careplanning was respectful of and responsive to theirindividual preferences, needs and values. 3 Obviously,Australian health care cannot meet everyone’s ideals,however the options available and their respectivecosts and benefits should be made available toconsumers / patients and explained, to enable themto be considered on their merits.Considering the views of consumers / patients in asystematic and thoughtful manner is the first step toincorporating this perspective into clinical practice. 4Organisations may differ in how they facilitateconsumer / patient participation. They should consideropportunities for consumers / patients to discusstheir discharge and ongoing care before leavingthe facility, and there is scope for retrospective careevaluation on an individual basis to be formalisedas part of this discharge discussion. An alternativeis to seek feedback during any follow-up contactafter discharge 5 , although organisations shouldbe mindful that too great a delay may result in lesseffective feedback.Mechanisms that can invite and enablefeedback include:• a post-discharge email or phone call• an email address that specifically includesthe word ‘feedback’, and is promoted in theorganisation’s brochures and website• the addition of a question or reminder duringdischarge planning.70 The ACHS EQuIP5 Guide Book 1 Accreditation, Standards and Guidelines Clinical Function

Prompt points¼¼¼¼¼¼Based on single cases or episodes of care, canthe organisation demonstrate that the servicemade a difference to the consumer / patient’shealth status? Were the care goals met? Wereconsumer / patient-oriented goals met? Did theconsumer / patient understand and participate inhis or her care?What systems are in place to encourage,enable, record, monitor and respond toconsumer / patient feedback?How does the organisation manage thecommunication of information to consumers /patients following an adverse event?Review of clinical careIndividual care evaluation, including review of thecare processes provided, should take place todetermine whether the best possible outcomes wereachieved for a consumer / patient. Subsequently,the aggregate results for many consumers / patientsshould be evaluated, possibly refining the informationby grouping consumers / patients according to theirdemographic parameters (for example, gender, age,ethnicity), disease state and/or procedures.As an example, not only should the care processand outcome for a single consumer / patient havinga coronary artery bypass operation be reviewed,but also the care and outcomes for all consumers /patients undergoing the same procedure in a givenperiod of time, such as the previous six months.Similarly, a consumer / patient with a history of noncompliancewith medication may be provided withadditional support, while at an organisational level, ahealth record audit of all consumers / patients over theprevious six months with a similar history is undertakento determine whether there are any common featuresin these cases that might be used to improve care.Evaluation practices should also consider how thefindings and recommendations arising from previousreviews have been followed up.‘At-risk’ consumers / patients form a special group.These consumers / patients have been recognisedearly in their care as having a higher likelihood of anadverse outcome, based on their identified risk factors.Consumers / patients may be ‘at-risk’ of blood clots(VTE), falls, allergic reactions, malnutrition or otheradverse events. Evaluation could consider whetherthe incidence of adverse outcomes among the‘at-risk’ group was reduced to levels similar to thosefor consumers / patients without this risk factor.Some important considerations for healthcareproviders include 6 :• whether the care plan worked• whether healthcare providers made a differencein the health status of the consumer / patient• what the organisation measures to determinewhether the care made a difference• the reliability of data collected fromclinical pathways• whether the care goals were met• where appropriate, whether requirements forseamless integrated care provision were met.Organisations can use formalised data collection andtracking processes to monitor their performance.A range of indicators are tracked by healthdepartments and other organisations. ACHS offersits members a clinical indicator data collation andanalysis service through its Performance andOutcomes Service. Before committing to collection ofany indicator, its usefulness to the organisation shouldbe considered:• Does the indicator measure an importantaspect of clinical practice?• Will the data collected on this indicator assistin improving clinical care?• Will the information be useful and meaningfulto clinicians in demonstrating how the service isperforming and ways that it may be improved?• Will the data be accessible to clinicians to allowfor monitoring of the indicator?• Are existing resources sufficient for ongoingmonitoring of the indicator?For integrity to be maintained by those submitting datafor grouped analysis, it is important that the goal beto respond to issues identified, rather than to penalisethose whose performance is not meeting goals. 7Once consistency in the collection and review processis achieved, data can be monitored over time to trackchanges in performance. Changes in organisationaldata may result from many factors independent of staffperformance; all potential contributing factors shouldbe considered as part of the review process.October 2010 71

Section 5Standards, criteria, elements and guidelinesStandard 1.1: Consumers / patients are provided with high quality carethroughout the care delivery processCriterion 1.1.4Outcomes of clinical care are evaluated byhealthcare providers and where appropriateare communicated to the consumer / patientand carer. (continued)Prompt pointsEvidence commonly presentedConsider whether the following willhelp to address criterion 1.1.4¼¼Processes for consumer / patient /carer feedback¼¼Policy / guidelines on care evaluation¼¼What processes are used to evaluate clinicalcare in the organisation?¼¼¼¼Evaluation of care plans and deliveryClinical outcome reviews¼¼¼¼¼¼How are data reconciled across thecontinuum of care?Describe how a review of care led to a changein consumer / patient management with theobjective of reducing an identified risk?Can the organisation track its performanceagainst specific measures over time? Whatprecautions are taken to protect the integrity ofthese measures?¼¼¼¼¼¼¼¼Clinical indicators or other performanceindicators, ideally tracked over time andbenchmarked against other departments /organisationsEvaluation of instances of adverse eventsand the circumstances surrounding themMinutes or notes taken at reviewcommittee meetingsDemonstrated changes made in responseto a problem identified by consumer / patientcomplaints or a review of carePerformance measurementThis criterion states that: “Outcomes of clinical care are evaluated by healthcare providers and where appropriateare communicated to the consumer / patient”. The organisation should be able to demonstrate that it has policyand procedures in place to evaluate clinical care, and that improvements are made as necessary; and thatprocesses for facilitating consumer feedback, and for communicating with the consumer / patient in the eventof an adverse event, are in place.Some common suggested performance measures are as follows:Note: Clinical indicators may be used as supporting evidence for this criterion. Please refer to the Clinical IndicatorSummary Guide on the ACHS website, http://www.achs.org.auNumber of formal follow-ups / investigations of clinical indicator outlier cases identified through the ACHSclinical indicator reportsTotal number of outliers identified through ACHS clinical indicator reportsNumber of formal review processes devoted to the review of aggregated medical / surgical casesTotal number of formal review processesComment: examples of formal review processes are peer review meetings, mortality and morbiditymeetings, departmental meetings, etc.72 The ACHS EQuIP5 Guide Book 1 Accreditation, Standards and Guidelines Clinical Function

Number of evaluated programs / services that have been adjusted to meet identified community needsTotal number of evaluated programs / servicesNumber of adverse events discussed with the consumer / patient and/or his or her family, as per theNational Open Disclosure StandardTotal number of adverse eventsNumber of adverse events subjected to formal case reviewTotal number of adverse eventsReferences1. Australian Commission on Safety and Quality in Health Care(ACSQHC). Windows into safety and quality in health care2009. Sydney NSW; ACSQHC; 2009.2. Tsilimingras D and Bates D. Addressing postdischargeadverse events: a neglected area. Joint Comm J Qual &Patient Safety 2008; 34(2): 85-97.3. Newell S. The consumer voice and experience mustunderpin and shape safety and quality in health care.Health Issues 2009; 98(Autumn): 10-11.4. Black N and Jenkinson C. Measuring patients’ experiencesand outcomes. Br Med J 2009; 339: b2495.5. Studer Q. Discharge phone calls deliver quality care, higherpatient satisfaction. Hospital News.(5 Jan 2006): Accessedfrom http://www.studergroup.com/dotCMS/knowledgeAssetDetail?inode=252512 on 1 September 20106. Promotion and Prevention Section of Mental Health andSpecial Programs Branch. Evaluation – a guide to goodpractice. Canberra ACT; Australian Dept of Health andAgeing; 2001.7. Deloitte Touche Tohmatsu. NSW Department of Health:Triage benchmarking review. Sydney; NSW Health; 2008.October 2010 73

Section 5Standards, criteria, elements and guidelinesStandard 1.1: Consumers / patients are provided with high quality carethroughout the care delivery processCriterion LA – Awareness SA – ImplementationLA plus the followingCriterion 1.1.5Processes for clinicalhandover, transfer of careand discharge address theneeds of the consumer /patient for ongoing care.This is amandatorycriteriona) Guidelines for discharge andtransfer of care are available.b) Arrangements with otherservice providers and, whereappropriate, the carer, aremade with consumer / patientconsent and input, andconfirmed prior to dischargeor transfer of care.a) There is an effective,organisation-wide systemfor discharge / transferof care which ensurescontinuity of care and timelynotification between referrersand providers.b) Clinical handover processesare utilised to ensure continuityof care.c) Results of investigations followthe consumer / patient throughthe referral system.d) There is evidence todemonstrate that serviceproviders receive timelynotification about consumer /patient discharge to their care.e) Discharge information isdiscussed with the consumer /patient and a written dischargesummary is provided.f) Formalised follow-up occurs for‘at risk’ consumers / patients.IntentThe intent of this criterion is to ensure that clinicalhandover is effective and that healthcare organisationshave and follow established processes to ensureconsumers / patients a smooth and safe transitionwhen an episode of care is completed, or when there isa change in clinical personnel.Relationships of 1.1.5 with other criteriaEffective processes for handover, transfer of care anddischarge are a vital component of the journey of care(Standard 1.1). Planning for discharge should beginwhen a consumer / patient is admitted (Criterion 1.2.2)and be considered during assessment (Criterion 1.1.1)and care planning (Criterion 1.1.2). Clinical handover /transfer of care is key to effective ongoing carewithin an organisation (Criterion 1.1.6) as well asfollowing discharge. Discharge information shouldfeed into a system of ongoing care that will promotesmooth recovery or satisfactory management ofa chronic condition.Good discharge planning should ensure that ongoingcare and services are appropriate for consumer /patient needs and capabilities, and delivered in themost appropriate setting (Criterion 1.3.1).Good communication at clinical handover andappropriately detailed discharge information aims topromote consumer / patient safety (Standard 1.5).In particular, there are key relationships to safe andeffective medication practices (Criterion 1.5.1),maintenance of skin integrity (Criterion 1.5.3), reducingthe likelihood of falls (Criterion 1.5.4) and ensuringthat consumers / patients, particularly the frail agedor those who are incapacitated, receive appropriatehydration and nutrition to facilitate their recovery(Criterion 1.5.7).74 The ACHS EQuIP5 Guide Book 1 Accreditation, Standards and Guidelines Clinical Function

MA – EvaluationSA plus the followingEA – ExcellenceMA plus the followingOA – LeadershipEA plus the followinga) The processes for discharge /transfer of care are evaluated,and improved as required.b) Discharge and referralinformation for consumers /patients, other serviceproviders and the systemsfor providing the informationare evaluated and improvedas required.a) Performance measures fordischarge / transfer of care areused, compared with internaland external systems, andimprovements are made toensure better practice.and/orb) Advanced strategies are inplace for notification of ongoingcare needs to other serviceproviders.a) The organisation demonstratesit is a leader in discharge /transfer of care systems.Involving consumers / patients in discharge planningcan present challenges, but will help to avoidmisunderstandings that might lead to re-admission,as well as ensuring that organisations meet theirresponsibilities to those with diverse needs and fromdiverse backgrounds (Criterion 1.6.3).Processes for clinical handover,transfer of care and dischargeGood handover and communication with ongoingproviders and carers are at the heart of an effectivehealthcare system and stand alongside consumer /patient clinical documentation, letters of referral andtransfer and discharge documentation. Together,these make up the links in the chain of continuity ofconsumer / patient care. 1Organisations should ensure there is policy / guidelinesthat address the requirements for clinical handover,transfer of care and discharge, as well as a system forimplementing the policy / guidelines and a method forevaluating whether these processes are effective.October 2010 75

Section 5Standards, criteria, elements and guidelinesStandard 1.1: Consumers / patients are provided with high quality carethroughout the care delivery processCriterion 1.1.5Processes for clinical handover, transfer ofcare and discharge address the needs ofthe consumer / patient for ongoing care.(continued)Clinical handover refers to the transfer of professionalresponsibility and accountability for some or allaspects of care for a consumer / patient, or group ofconsumers / patients, to another person or professionalgroup on a temporary or permanent basis. 1, 2 Effectiveclinical handover results in the safe transfer of care ofconsumers / patients. Organisations seeking furtherinformation could refer to the Australian MedicalAssociation’s Safe handover: Safe patients. Guidanceon clinical handover for clinicians and managers,available from the AMA website 1 , and the resourcesavailable on the website of the Australian Commissionon Safety and Quality in Health Care. 3Common handover scenarios include 1 :• nursing ‘change of shift’ report• Junior Medical Officer (JMO) handover toafterhours medical cover• transfer of care between hospital teams andfrom hospital to community teams• transfer of care to general practitioner (GP)• transfer of care between facilities• handover in specific clinical situations, for examplemanagement of the deteriorating patient• communication with consumer / patient andfamily / carer.Handover occurs 2 :• from one provider or team of providers to another• at points of consumer / patient transition acrosssettings• between services or levels of care• due to the need to organise clinical work intomanageable shifts... and includes handover of consumer / patientinformation and material risks.Community settings may approach clinical handoverin a different manner from acute settings. Whateverprocess is used, it is important that it is documented,that staff are aware of the procedure and thatcompliance with the handover process is evaluated.Policy / guidelines should include 4 :• the handover situations to which it applies• persons who should be involved in thecommunication, and appropriate responseswhere face-to-face briefings are not possible• care information––diagnoses and current condition of theconsumer / patient––recent changes in condition or treatment––anticipated changes in condition or treatment––suggestions on what to watch for in the nextinterval of care• print or electronic information that should beavailable to the incoming carer / clinician.Discharge refers to the release of a consumer / patientfrom care 5 or movement of a consumer / patient fromone setting of care to another. 6The key issues to be considered in the discharge ortransfer of a consumer / patient are that:• the discharge or transfer has been appropriatelyplanned with the consumer / patient and/or theircarer and the multidisciplinary team• it is actioned in a smooth and timely fashion• all necessary information about past, presentand future care is communicated clearly tothe consumer / patient and/or to ongoingcare providers• the consumer / patient and carer understandwhat is to happen and why.There is an expectation that a discharge summary willbe provided to:• the consumer / patient• the healthcare provider to whom the consumer /patient is discharged• the referring healthcare provider• the health record.In some cases, such as in rural / remote areas, thetreating healthcare provider within the organisationmay be the same as the healthcare provider caringfor the consumer / patient following discharge fromthe organisation. On condition that the health recordis accessible to the healthcare provider in both theorganisation and following discharge, the copy of thedischarge summary in the health record is sufficient tosatisfy the requirement for the discharging healthcareprovider to receive a copy. The purpose of thedischarge summary is to ensure that the consumer/ patient, the referring healthcare provider and any76 The ACHS EQuIP5 Guide Book 1 Accreditation, Standards and Guidelines Clinical Function

other relevant healthcare providers are aware of, andunderstand, ongoing plans and their responsibilities inongoing management of the consumer / patient.The National E-Health Transition Authority’s (NEHTA’s)Continuity of Care Program is a national initiativeto support the development of emerging e-healthinfrastructure that is currently taking shape acrossAustralia. This program is implementing a seriesof Discharge Summary and Referral specificationsto improve continuity of consumer / patient care.Information on the development of e-dischargesummaries, including examples of templates, isavailable at www.nehta.gov.auPrompt points¼¼¼¼¼¼¼¼¼¼What policy / guidelines / processes doesthe organisation use to manage discharge?Internal transfer of care, e.g. betweendepartments / healthcare facilities? Handoversat shift changes?Are the same processes used organisationwide?If not, where, why and how have specificadaptations to the processes been made?What standardised processes are used toensure continuity of care at clinical handover?Are these processes followed throughoutthe organisation? How effective have theseprocesses proven to be?Are there any situations where face-to-faceclinical handover cannot occur? If so, whathappens under these circumstances? Whatdocumentation, forms or records, support orreplace a face-to-face transfer of care?Have the incident monitoring system orcomplaints processes identified any problemsresulting from communication failures at clinicalhandover? If so, what efforts have been madeto reduce the problems?Test results follow the consumer / patientRequests for investigations and the movement ofblood or other tissues or images between healthprofessionals should be standardised, but allowclinicians to consciously limit details according to theirprofessional view of what is relevant to procedure.The process should ensure that staff receiving theconsumer / patient know that he or she has arrivedand should provide an opportunity to properly identifythe consumer / patient and the test(s) to be done. Theinclusion of special precautions for specific consumers/ patients, such as isolation, fall risk or suicide risk,may be useful when sending a consumer / patient fordiagnostic tests or investigations. 4 Because additionalquestions may arise, it is important that the name ofthe referring doctor and a contact number be clearlyprinted (if written) or entered (if computerised) on thepathology request form, with an alternative contact incase of unavailability if appropriate. 7As consumers / patients move through amultidisciplinary care process, it is important that theirdiagnostic test results are available. Repeating thesame tests within a short time interval has long beenidentified as a potentially wasteful practice.Prompt points¼¼¼¼What processes ensure that pathology andimaging results are available to all clinicianswho may need them for decision making? Whatare the systems for archiving and retrievalof images?How does the health record system linkconsumers / patients, their care plans andongoing monitoring data with test and imageresults? Can the information be accessed fromthe bedside / within the ward / other locations?How are test / imaging results transferred whenthe consumer / patient moves to another part ofthe organisation or visits another clinician?October 2010 77

Section 5Standards, criteria, elements and guidelinesStandard 1.1: Consumers / patients are provided with high quality carethroughout the care delivery processCriterion 1.1.5Processes for clinical handover, transfer ofcare and discharge address the needs ofthe consumer / patient for ongoing care.(continued)Consumer / patient participationin discharge planningWell-informed consumers / patients who understandthe planning of their care are more capable ofmanaging their condition proactively, and potentiallydecreasing rehospitalisation. 8The capability of consumers / patients and theircarers to participate in discharge planning will beinfluenced by their health literacy. 9 Because this mayat times be difficult to assess, discharge plannersshould be alert for misunderstandings resultingfrom their communications. Communication inrelation to medication management, particularly forproducts such as warfarin, require that consumers /patients understand the need for ongoing monitoringand adjustment, be alert for adverse events suchas abnormal bleeding, and that the clinician(s)10, 11responsible for ongoing care is fully informed.An example of proactive discharge planning withconsumer / patient involvement might include assigninga specific discharge person to work with consumers /patients prior to their discharge 8 to:• arrange follow-up appointments• confirm medication reconciliation• conduct consumer / patient education withan individualised instruction booklet• conduct post-discharge follow-up to ensurethere have been no problems in relation todischarge planning• provide education materials to the primarycare provider.Prompt points¼¼What processes are in place for discharge /transfer of consumers / patients? Is there asystem of review of discharge summariessent to GPs (and specialists) for quality andcontent? Are clinical staff trained in the use ofthe software where discharge summaries aredone electronically?¼¼¼¼¼¼¼¼Is there a system that provides opportunities toidentify impending discharges / transfers for thesame or following day?Does the discharge / transfer process enableenough time for discussion of ongoing care withthe relative / carer?Are discharge summaries ready at the time oftransfer / discharge of the consumer / patient?Is there a system in place to identify whene-discharge summaries do not reachthe destination?Referral organisations notifiedIn the context of discharge planning, the timeliness ofinformation received by a referring physician about adischarged consumer / patient will be reflected in thesatisfaction of referring physicians and an absence ofcomplaints / feedback from consumers / patients whohave been discharged from care.Consumer / patient transfer to primary care providersrequires a transfer of information that may includea discharge care plan to accompany the dischargesummary. The inclusion of this information enhancesthe capacity of a GP / specialist to provide high qualitycontinuing care following any admission. 1Important items of information to be included in thedischarge summary are 12 :• treatment whilst in hospital• a list of diagnoses• follow-up treatment• management and outcomes• list of medications at discharge• dates of admission and discharge.78 The ACHS EQuIP5 Guide Book 1 Accreditation, Standards and Guidelines Clinical Function

Prompt pointsPrompt points¼¼What information is provided by clinicians /organisations / primary care providers to which /whom consumers / patients are transferred?What feedback is received from recipientsregarding the usefulness of this information /timeliness of its arrival?¼¼Is there evidence in the consumer / patientsatisfaction process that appropriate dischargeinformation is provided to community carers?¼¼¼¼¼¼Which consumers / patients are followed-uppost-discharge? What is the method of followup?What is the timing of this contact and whyhas this timing been chosen?What factors does the organisation use todetermine whether consumers / patients mightbe ‘at-risk’ of difficulties after discharge?Are risk assessments conducted prior todischarge and does a copy of this go tothe referrer?Follow-upThe timing and mode of follow-up should beestablished for the service provided, assessed risksto consumers / patients and needs of the consumer /patient population. The most common form of followuphas been a post-discharge phone call 13, 14 , butwhere the consumer / patient population has accessto them, modern technologies such as email and SMSmay offer alternative methods of sending reminders orseeking further information from consumers / patients. 15Whichever form the follow-up takes, it should bedocumented in the health record and the consumer /patient should receive a copy of the follow-up plan.Formalised follow-up of ‘at-risk’ consumers / patientsinvolves a planned process for after the consumer /patient has been discharged or transferred from thetreating health facility / clinician. Some forms of followupinclude organising a date for review with a healthprovider or arranging a community support visit.The categories of consumers / patients considered‘at-risk’ will vary between health services.Organisations should form a clear view of how theyidentify ‘at-risk’ consumers / patients. Examplesinclude consumers / patients:• judged to be at risk of suicide 16• with chronic diseases 17 , particularly those withcomplex monitoring or medication needs, asoccurs in asthma, diabetes mellitus, rheumatoidarthritis and acute coronary syndrome• who are frail aged, debilitated, intoxicatedor children• who experienced an adverse event while admitted.The communication processThere is growing awareness of the variation in needsbetween different consumers / patients for healthcareinformation. Key to judging the effectiveness of anycommunication is retrospective feedback from thetarget audience that considers receipt of information,but also whether it was understood and acted upon.The most effective communication will be capable ofeducating the recipient and influencing behaviour.The following suggestions can be utilisedto communicate health information toconsumers / patients 18 :• avoid complex language and too much jargon• avoid busy layouts and small print• risk communication may be too negative withinsufficient information on the benefits of takingthe medicine, making it difficult for the consumer /patient to assess risk versus benefit• the information should supplement a discussionwith the prescriber and be consistent with advicegiven (ideally a brochure / leaflet could be used inthe conversation)• provide sources for further information particularlyin relation to specific diseases• include helpline numbers and website addressesas pointers to further information• comparative information and information aboutlifestyle issues can aid consumer / patientdecision making.October 2010 79

Number of consumers / patients who cannot be discharged on the expected discharge dateTotal number of consumers / patients scheduled for discharge on a particular dateComment: the organisation may choose to collect the different reasons for failure to discharge,e.g. clinical, anaesthetic, socialNumber of consumers / patients whose criteria for discharge have been fully met by the planneddate of dischargeTotal number of consumers / patients scheduled for discharge within a given time periodComment: consider a documented discharge planNumber of consumers / patients who received a discharge summary / letter at the time of dischargeTotal number of consumers / patients dischargedNumber of consumers / patients who have a final discharge summary recorded in the health record withinX days of facility discharge / community care dischargeTotal number of consumers / patients dischargedComment: the organisation to define ‘X’Number of consumers / patients satisfied with their discharge instructionsTotal number of consumers / patients surveyedNumber of phone calls / contacts from discharged consumers / patients querying their discharge instructionsTotal number of consumers / patients dischargedNumber of unplanned re-entries / intakes into the serviceTotal number of consumers / patients dischargedNumber of transfers from community-based services to residential / inpatient servicesTotal number of consumers / patients accessing the community-based serviceOctober 2010 81

Section 5Standards, criteria, elements and guidelinesStandard 1.1: Consumers / patients are provided with high quality carethroughout the care delivery processCriterion 1.1.5Processes for clinical handover, transfer ofcare and discharge address the needs ofthe consumer / patient for ongoing care.(continued)References1. Australian Medical Association (AMA). Safe handover: safepatients. Guidance on clinical handover for clinicians andmanagers. Canberra ACT; AMA; 2006.2. Australian Commission on Safety and Quality in Health Care(ACSQHC). Windows into safety and quality in health care2008. Sydney NSW; ACSQHC; 2008.3. Australian Commission on Safety and Quality in Health Care(ACSQHC). OSSIE guide to clinical handover improvement.Sydney NSW; ACSQHC; 2009.4. Joint Commission on Accreditation of HealthcareOrganizations (JCAHO). Hand-off communications.National Patient Safety Goal 020501. Oak Terrace USA;JCAHO. Accessed from http://www.jointcommission.org/AccreditationPrograms/Hospitals/Standards/09_FAQs/NPSG/Communication/NPSG.02.05.01/hand_off_communications.htm on 25 January 2010.5. MedlinePlus Medical Dictionary. Medical Dictionary.Merriam-Webster. Accessed from http://www.merriamwebster.com/medlineplus/at%20riskon 12 August 2010.6. Ma E, Coleman E, Fish R et al. Quantifying posthospitalcare transitions in older patients. J Am Med Dir Assoc 2004;5(2): 71-74.7. Garling P, SC. Final report of the special commission ofinquiry: Acute care services in NSW public hospitals.Sydney; NSW Special Commission of Inquiry; 2008.8. Jack BW, Chetty VK, Anthony D et al. A reengineeredhospital discharge program to decrease rehospitalization:a randomized trial. Ann Intern Med 2009; 150(3): 178-187.9. Nutbeam D. The evolving concept of health literacy.Soc Sci Med 2008; 67(12): 2072-2078.10. Makeham MAB, Saltman DC and Kidd MR. Lessons fromthe TAPS study. Warfarin: a major cause of threats to patientsafety. Aust Fam Physician 2008; 37(10): 817-818.11. Lowthian JA, Diug BO, Evans SM et al. Who is responsiblefor the care of patients treated with warfarin therapy?Med J Aust 2009; 190(12): 674-677.12. Alderton M and Callen J. Are general practitioners satisfiedwith electronic discharge summaries? Health Inf Manag J2007; 36(1): 7-12.13. Queensland Health Quality and Safety Program. 2006/07Patient satisfaction: Maternal post-birth survey. Brisbane;Qld Health. Accessed from http://www.health.qld.gov.au/quality/pat_sat_survey/patsat2007.asp on 27 January 2010.14. Hordacre A-L, Pirone C and Taylor A. Poster: the SA patientevaluation of hospital services (PEHS). Adelaide; SADepartment of Health, Population Research and OutcomesStudies Unit; 2009.15. South Eastern Sydney Illawarra Area Health Service. Impactof an electronic SMS appointment reminder system onwaiting times at a large publicly funded sexual health centre.Sydney NSW; Australian Resource Centre for HealthcareInnovations (ARCHI). Accessed from http://www.archi.net.au/e-library/performance/flow/sms-reminder on27 January 2010.16. Australian Department of Health and Ageing.LIFE: A framework for prevention of suicide in Australia.Canberra; Dept of Health and Ageing; 2008.17. Victorian Department of Human Services (DHS).HARP chronic disease management guidelines. MelbourneVIC; DHS; 2004.18. Committee on Safety of Medicines Working Group onPatient Information. Always read the leaflet. Getting the bestinformation with every medicine. London UK; Medicines andHealthcare Products Regulatory Agency; 2005.82 The ACHS EQuIP5 Guide Book 1 Accreditation, Standards and Guidelines Clinical Function

October 2010 83

Section 5Standards, criteria, elements and guidelinesStandard 1.1: Consumers / patients are provided with high quality carethroughout the care delivery processCriterion LA – Awareness SA – ImplementationLA plus the followingCriterion 1.1.6Systems for ongoing care ofthe consumer / patient arecoordinated and effective.a) There are formal processes forcoordinating ongoing care bymultiple service providers in atimely manner.a) Care coordination and/orcase management is availablefor appropriate consumers /patients and their carer.b) There are systems forscreening, prioritisation andreadmission of consumers /patients with chronicconditions.c) Strategies are developed toreduce acute presentationsand avoidable admissionsof consumers / patientswith chronic conditions.IntentOngoing care refers to the active and supportivemanagement of care for people with chronic orcomplex conditions as well as the process thatfollows an admission to a healthcare organisation. Theintent of this criterion is to ensure that all healthcareorganisations and individuals involved in the ongoingcare of consumers / patients actively contribute toa seamless continuum of care for the consumer /patient and fulfil their responsibilities for their part ofthis process.Relationships of 1.1.6 with other criteriaSystems for coordinated ongoing care are a majoraspect of the management of the consumer /patient’s care journey (Standard 1.1), and shouldbe integrated with the organisation’s procedures foraccess and admission (Criterion 1.2.2), assessment(Criterion 1.1.1), collaborative care planning (Criterion1.1.2), clinical handover, transfer of care and discharge(Criterion 1.1.5) and care of the dying (Criterion 1.1.7).84 The ACHS EQuIP5 Guide Book 1 Accreditation, Standards and Guidelines Clinical Function

Section 5Standards, criteria, elements and guidelinesStandard 1.1: Consumers / patients are provided with high quality carethroughout the care delivery processCriterion 1.1.6Systems for ongoing care of the consumer /patient are coordinated and effective.(continued)Collaborative strategies undertaken in outpatient orhome care settings may reduce acute presentationsand avoidable admissions.Effective ongoing care should not be hampered byprogram or organisational boundaries: organisationsshould focus on meeting individual consumer / patientneeds over and above their own immediate goals. 1Care coordination should enable continuity of care andavoid duplication in service provision.Effective processes for ongoing care may beevident in:• clear arrangements for liaison and referralbetween services and organisations• roles and responsibilities that reflect amultidisciplinary integrated care approach• involvement of care providers, the consumer /patient and, where appropriate, their carer inongoing care planning• active support to enable the consumer / patientto understand and manage his or her condition• support services for carers• maintenance of ambulatory care whereverpossible, but with appropriate access to acutecare where it cannot be avoided• integration of record systems to facilitate secureand reliable information exchange• an understanding of consumer / patient rightsthat facilitates access by consumers / patients.Prompt points¼¼¼¼¼¼¼¼¼¼How are relationships developed with otherservice providers? What types of facilities /health professionals does the organisationmost commonly liaise with when planningand delivering ongoing care?What formal arrangements or protocols forongoing care provision tie the organisationto these ‘partners’ in care provision?How are clinicians informed about and updatedregarding referral options for ongoing care?Which, if any, consumers / patients receive carecoordination / case management support atthis organisation?When was the ongoing care process lastreviewed? What were the findings? Assumingthere were some changes following the review,how effective have they been?Screening, prioritising and readmittingpatients with chronic conditionsEducation and training initiatives support consumers /patients to manage their disease so as to reduce therisk of acute crises that might require readmission.Education should reflect the appropriate level of careaccording to consumers / patients’ circumstances,including the capacity to understand and carry outsuch care, and risk factors.Organisations should work to develop processesfor effective identification and screening of new andreturning consumers / patients with chronic conditions.This will help to correctly direct consumers / patients toan appropriate level of care and facilitate prioritisationof cases. Acute facilities might establish fast-trackadmission and readmission processes that provideaccess to direct assessment by clinicians skilled inthe particular area for some classes of consumers /patients with chronic conditions at times when they arevulnerable to acute deterioration.86 The ACHS EQuIP5 Guide Book 1 Accreditation, Standards and Guidelines Clinical Function

Regardless of whether the chronic disease is theirprimary reason for presentation at the healthcareorganisation, these consumers / patients will requireongoing care of their condition(s), and all assessmentsand selections of services must take the chroniccondition(s) and its management into consideration.Chronic diseases that may impact ongoing carefollowing surgery or after an acute injury includediabetes, arthritis, cardiovascular disease, autoimmunediseases, obesity and asthma.The potential for frail aged consumers / patients tosuffer from delirium should also be a consideration,especially where it may impact or be impacted bythe chronic disease. Coordination of ongoing carefollowing surgery or other acute illness should beundertaken with the consumer / patient, and the carer,to ensure decisions are appropriate, manageableand achievable. 2Prompt pointsAn organisation may provide consumer / patienteducation in diverse settings and using differentmedia, such as:• written information• a consultation or mentoring session• a small group training session• larger seminars• pre-recorded video segments• web-based programs including multimedia thatmight include online live discussions.Prompt points¼¼What chronic disease self management supportprograms or strategies are provided by theorganisation? Which clinicians are educated andsupported in the delivery of such interventions?How is this service publicised and what referralmechanisms are in place?¼¼¼¼Where demand for services exceeds supply,how does the organisation screen and prioritiseconsumers / patients requiring ongoing care?Are there processes in place to manageconsumers / patients who regularlyreturn and require readmission due to anongoing condition?Education for consumers / patientsrequiring ongoing careThe overarching goal of chronic disease care isself management; education and coaching arekey to achieving effective daily management byconsumers / patients. 3Ensuring effective management during recoveryfrom surgery or a serious injury is also likely torequire planning and education to facilitate recovery,develop strength, and promote independence.All organisations have a responsibility to provideeducation or facilitate its availability for consumers /patients who need it to progress from inpatient tooutpatient care.¼¼¼¼¼¼¼¼For whom does the organisation’s chronicdisease management support programsor strategies cater? How is the educationdelivered?In cases where consumers / patients attendeducation provided by another supplier, how arereferrals made and outcomes followed-up? Howis the appropriateness and suitability of referralsmeasured?What specific consumer / patient educationprograms are in place? How does theorganisation measure the consumer / patientoutcomes and impact of these programs?Where there are no formal education programsoffered by the facility, what action wouldbe taken for a consumer / patient whoseunderstanding of his or her chronic conditionand approach to self management couldbe improved?October 2010 87

Section 5Standards, criteria, elements and guidelinesStandard 1.1: Consumers / patients are provided with high quality carethroughout the care delivery processCriterion 1.1.6Systems for ongoing care of the consumer /patient are coordinated and effective.(continued)Reducing acute presentations andavoidable admissionsConsumers / patients with chronic conditions andpoor continuity of care have more visits to emergencydepartments and more medical non-elective hospitaladmission than consumers / patients with regularcontact with a healthcare professional. 4 Bettercontinuity of care reduces unplanned admissionsand emergency department presentations, as well asmeeting consumer / patient requirements. 4, 5Consumers / patients with chronic conditions whohave a known risk for acute deterioration may be givenalternative means to approach care management.Where diagnosis and risk have been established, fasttrack pathways can bypass emergency departmenttriage procedures with their focus on determining thediagnosis and prioritising consumers / patients formedical attention.Strategies to avoid acute presentations, preventavoidable admissions and any alternative processesused to admit high-risk consumers / patients shouldbe regularly reviewed and improvements made inaccordance with the findings of that review.Prompt pointsFollowing diagnosis and initiation of treatment, the majorgoal in the management of chronic conditions is to delayor avert complications. Ongoing care may include:• regular monitoring of the condition by a singlepractitioner or a multidisciplinary team• use of pathology tests that can alert deterioratingcontrol or the onset of complications• educating the consumer / patient to managehis or her condition and recognise signs ofdeterioration in control• facilitating supportive networking by consumers /patients / carers managing similar conditions.Achieving large scale strategic goals that may avoidacute presentations at emergency departments /casualty is likely to require a multifaceted approach.Consider the potential impact of 6 :¼¼¼¼¼¼¼¼How does the organisation screen and prioritisethe needs of consumers / patients with chronicor complex conditions?What chronic conditions common inthe organisation’s community result insignificant numbers of acute presentations oravoidable admissions?What strategies are in place to reduce acutepresentations and avoidable admissions tohospital (for example, self management, bettercoordination of care or choice of different clinicalinterventions)?How is the effectiveness of these strategiesmeasured and what improvements havebeen made?• improving communication and cohesionbetween services• identifying ‘at-risk’ consumers / patients andproviding additional clinical oversight or selfmanagement skills• proactively managing consumers / patientswho fail to report for scheduled appointmentsto review their care• providing better continuity of care following anacute presentation• improving responsiveness to earlier approachesmade by consumers / patients, even if their issueswere not clearly stated• improving self management training• changing workforce capability through changedrosters, recruitment strategies or professionaldevelopment and training.Evidence commonly presentedConsider whether the following willhelp to address criterion 1.1.6¼¼¼¼¼¼¼¼¼¼¼¼Case management system and evaluationArrangements with other providers such asaged care services, disease education services,allied health providersSurveys of consumer / patient perceptionsClinicians’ feedback regarding arrangementsfor ongoing careClinicians’ feedback regarding their abilityto access data from earlier admissionsReadmission rates and other chronicdisease indicators.88 The ACHS EQuIP5 Guide Book 1 Accreditation, Standards and Guidelines Clinical Function

Performance measurementThis criterion states that: “Systems for ongoing care of the consumer / patient are coordinated and effective”.The organisation should be able to demonstrate processes that result in a seamless, integrated episode of carefor the consumer / patient within and without the organisation, as well as implement strategies for improving selfmanagement of chronic disease by the consumer / patient that help to improve community health and to reduceacute admissions.Some common suggested performance measures are as follows:Note: Organisations may choose to look at chronic disease management for particular conditions,e.g. diabetes, or compare performance across different chronic conditions.Number of consumers / patients with a chronic condition involved in a self management programTotal number of consumers / patients with a chronic conditionNumber of consumers / patients with a chronic condition admitted to the organisation who are involvedin a self management programTotal number of consumers / patients with a chronic condition involved in a self management programNumber of consumers / patients with a chronic condition who undertake education and/or participatein support activitiesTotal number of consumers / patients with a chronic conditionNumber of consumers / patients flagged for ‘fast track’ admission who are subsequently admittedTotal number of consumers / patients flagged for ‘fast track’ admissionNumber of consumers / patients flagged for ‘fast track’ admission who undergo a standardassessment upon presentationTotal number of consumers / patients flagged for ‘fast track’ admissionNumber of consumers / patients who follow up on an internal referral to an outpatient serviceTotal number of consumers / patients given an internal referral to an outpatient serviceOctober 2010 89

Section 5Standards, criteria, elements and guidelinesStandard 1.1: Consumers / patients are provided with high quality carethroughout the care delivery processCriterion 1.1.6Systems for ongoing care of the consumer / patient are coordinated and effective. (continued)Number of consumers / patients receiving care coordinationTotal number of consumers / patients eligible for care coordinationNumber of clinicians within the organisation satisfied with the timeliness and completeness of informationtransferred during continuous care episodesTotal number of clinicians surveyedReferences1. Victorian Department of Human Services (DHS), Primaryand Community Health Branch. Community health services– creating a healthier Victoria. Melbourne VIC; DHS; 2004.2. O’Connor B. Wanting to be heard and included: Carers’experiences of hospitals. Health Issues 2007; 90(Autumn):15-18.3. National Health Priority Action Council (NHPAC). Nationalchronic disease strategy. Canberra ACT; Australian HealthMinisters’ Advisory Council (AHMAC); 2005.4. Glazier R, Moineddin R, Agha M et al. The impact of nothaving a primary care physician among people with chronicconditions. Toronto CAN; Institute for Clinical EvaluativeSciences (ICES); 2008.5. Jencks S, Williams M and Coleman E. Rehospitalizationsamong patients in the Medicare fee-for-service program.N Engl J Med 2009; 360(14): 1418-1428.6. Victorian Department of Human Services, MetropolitanHealth and Aged Care Services Division. Improving care– hospital admission risk program (HARP). Melbourne;Victorian Government; 2006.90 The ACHS EQuIP5 Guide Book 1 Accreditation, Standards and Guidelines Clinical Function

October 2010 91

Section 5Standards, criteria, elements and guidelinesStandard 1.1: Consumers / patients are provided with high quality carethroughout the care delivery processCriterion LA – Awareness SA – ImplementationLA plus the followingCriterion 1.1.7The care of dying anddeceased consumers /patients is managedwith dignity and comfortand family and carersare supported.a) Policy and procedures for themanagement of consumer /patient end-of-life care areconsistent with jurisdictionallegislation, common lawand policy.b) The organisation has accessto palliative care and/or to painmanagement services.c) There is policy / guidelines forsupporting staff, consumers /patients and carers involvedin organ and tissue donation.a) Policy and procedures areimplemented throughoutthe organisation.b) Relevant staff are educatedabout the policy andprocedures for end-of-life careof a consumer / patient.c) When clinically indicated,consumers / patients arereferred to palliative care, painmanagement services and/orother support services.d) A support system is used toassist staff, relatives, carersand patients affected bya death.IntentThe intent of this criterion is to ensure that healthcareorganisations place a high priority on the care andmanagement of consumers / patients at the end oflife, and provide appropriate support services forfamilies / carers.Note:This criterion will apply to healthcare organisationsin varying degrees; however, some organisationswill address requirements within another criterion.While a death in facilities such as a day hospital orcommunity health service may occur unexpectedlyand be considered a sentinel event, occasionally aconsumer / patient will die in such facilities and policyand procedures covering this rare and tragic event areneeded. All organisations should also be aware of localend-of-life care options and be able to refer inquiriesregarding eventually fatal conditions and end-of-lifecare to appropriate sources.Relationships of 1.1.7 with other criteriaThis criterion covers a distinct phase of the consumer /patient care journey (Standard 1.1). In some cases,a transition occurs from striving to combat a diseasecourse according to an original care plan (Criterion1.1.2) to managing the passage to death with endof-lifeor palliative care, although in many cases thetwo care pathways are delivered in alignment. Sucha transition may occur along with a transfer of care(Criterion 1.1.5), such as to home, a hostel or otherpalliative care facility, where there will also be atransfer of responsibility.Because death and dying occur within the contextof cultural beliefs and traditions, and spiritual andreligious values, organisations must provide forconsumers / patients with diverse needs and fromdiverse backgrounds (Criterion 1.6.3).92 The ACHS EQuIP5 Guide Book 1 Accreditation, Standards and Guidelines Clinical Function

MA – EvaluationSA plus the followingEA – ExcellenceMA plus the followingOA – LeadershipEA plus the followinga) Processes surrounding dyingand death are evaluated andimproved as required.b) Clinical review committees,including morbidity / mortalityand case review, evaluate theappropriate referral of end-oflifepatients to palliative careand/or to pain managementservices, and improvementsare made as required.a) Staff are provided withadvanced training forend-of-life management ofconsumers / patients.and/orb) End-of-life care and mortalitymanagement processesare compared with internaland external systems andimprovements are made toensure better practice.a) The organisationdemonstrates that it is aleader in end-of-life care.End-of-life careSupporting and managing the inevitable processesof dying and death is commonplace in health care.The frequency and nature of this varies widely, bothaccording to the organisation type and the stage of thedying process at which the consumer / patient comesinto contact with the organisation.The end of life is considered that part of life where aperson is living with, and impaired by, an eventuallyfatal condition, even if the prognosis is ambiguous orunknown. An eventually fatal condition is a progressivecondition that has no cure and can be reasonablyexpected to cause the death of a person within aforeseeable future, i.e. a person has an eventuallyfatal condition if their death in the foreseeable futurewould not be a surprise. This definition is inclusiveof malignant and non-malignant illness and ageing. 1This period can be very brief but may also be quiteextended and organisation policy and proceduresshould incorporate flexibility in responsiveness to thisvariability. Moreover, sudden or unexpected death canoccur in any location without warning, and policy andprocedures to manage such an event should be inplace in all organisations.Needs-based end-of-life care is a quality managementapproach that evaluates the individual holistic needsof the consumer / patient and his or her family / carer,and coordinates appropriate care. It recognises theinterdependent physical, social, emotional, cultural andspiritual aspects of care and includes the combinationof broad health and community services that care fora person at the end of their life. 1 The goal of end-of-lifecare is to maximise quality of life through appropriateneeds-based care for each person, with a focus onsymptom control and comfort rather than cure. Use ofa term such as ‘comfort care’ to describe end-of-lifecare is recommended 2 , as comfort is a familiar andunambiguous concept in everyday experience.The end-of-life care pathway should address timelysymptom control, support for carers and families,and needs-based referral to specialist palliative careproviders, and encompass both likely deterioration aswell as the potential for active treatment, i.e. plan fordeath while remaining hopeful. Palliative care shouldbe integrated with disease-modifying therapy as partof routine care.Dying consumers / patients are cared for in manysettings, including the home, community, hospicefacilities, aged care facilities, hospital wards andintensive care units. Sometimes the process will involvemoving in and out of facility-based care depending onneeds at different stages of the journey. No matter whatthe setting(s), systems should be in place to supportthe consistent implementation of end-of-life policiesorganisation-wide.October 2010 93

Section 5Standards, criteria, elements and guidelinesStandard 1.1: Consumers / patients are provided with high quality carethroughout the care delivery processCriterion 1.1.7The care of dying and deceased consumers /patients is managed with dignity and comfortand family and carers are supported.(continued)Components of systems for end-of-life care include:• decision making guidelines• advance care planning• recognition of cultural, spiritual andreligious factors• access to cultural, spiritual and religious resources• referral to chaplaincy, spiritual or pastoral care• care of the dying• referrals to palliative care, pain managementand/or other services• conflict resolution 3• legal requirements• management of recognised risks• mortality management.End-of-life care should be delivered according to theStandards for Providing Quality Palliative Care for allAustralians 4 , which address nationally agreed areasto ensure optimal care for those at end of life. Thesestandards are available from Palliative Care Australiaat: http://www.palliativecare.org.au/Legislated obligations vary between jurisdictionsand depend on the detail of the law. Healthcareorganisations should be familiar with, and ensure thatpolicies and procedures reflect relevant legislationpertaining to:• consumers / patients’ decision-making capacityand matters relating to these decisions, such asadvance care directives• legal guardianship / responsible person issuesregarding children or young people• substitute decision making and applicabilityof guardianship / health attorney / Enduring orMedical Power of Attorney / Public Advocaterole for consumers / patients who lackdecision‐making ability• treatment limitation decisions and the withholdingor withdrawal of life-sustaining treatment• assisted suicide and euthanasia• brain death and agreements for organ /tissue transplant• death certification and reporting to the coroner• reporting of deaths to organ and tissue donationagencies and/or tissue and eye banks to facilitateeye and tissue donation• responsibility for transfer of a deceased personwith no next-of-kin, or where finances areinsufficient for a funeral.Advance care planning is a process of preparing forlikely scenarios near the end of life. It includes anassessment of, and dialogue about, a consumer /patient’s understanding of his or her medical historyand condition, values, preferences and personal andfamily / familial resources. Advance care planningsupports consumers / patients in communicatingtheir wishes about their end of life. Where possible,organisations should encourage the use of advancecare plans. 4An advance care directive is a document that containsinstructions that consent to, or refuse, specifiedmedical treatments and that articulate care andlifestyle preferences in anticipating future events orscenarios. It becomes effective in situations where theconsumer / patient is no longer able to make decisions.For this reason, advance care directives are sometimesreferred to as living wills. 5 As an advance caredirective has legal status, it is governed by legislativearrangements in each jurisdiction.All people, regardless of religion, faith or culturalbackground, may have pastoral and spiritual careneeds. In regards to end-of-life care, the organisationshould therefore:• acknowledge the importance of faithand spirituality• have policy and procedures in place regardingspiritual and pastoral care• promote and provide access to a range ofaccredited practitioners in pastoral and spiritualcare to meet consumer / patient, family / carers,and staff needs• provide staff education by a practitioner qualifiedin pastoral and spiritual care on:––faith practices, spirituality and spiritual care––culturally appropriate spiritual care needsin relation to the organisation’s particularculturally and linguistically diverse (CALD)communities––staff provision of spiritual care regardlessof their discipline––the use of a spiritual care screening tool 3 ,as appropriate• ensure that spiritual or pastoral care is deliveredaccording to relevant standards. 694 The ACHS EQuIP5 Guide Book 1 Accreditation, Standards and Guidelines Clinical Function

Mortality management refers to care of the family andthe deceased after death. Mortality managementshould include:• management of the deceased in regard tonotification, infection control, property, etc.• management of the death certification process 4• referral to the coroner when and where appropriate• consideration of relevant cultural, religious andspiritual issues for the deceased person and his orher family / familial group, particularly if a postmortemexamination is involved• interaction with the police when appropriate• consent for post-mortem as appropriate, withparticular consideration of cultural, religiousand spiritual issues and appropriateness• consent for organ and tissue donationas appropriate• interaction with other agencies such asfuneral directors• emphasis on documentation of decisionsboth before and after death.To ensure that all consumers / patients witheventually fatal conditions, as well as those who dieunexpectedly, and family, carers and friends haveaccess to appropriate and integrated end-of-life care,relevant policies and procedures must be embeddedthroughout, consistently applied and monitored acrossthe organisation.Prompt points¼¼¼¼¼¼What end-of-life policy and procedures arein place?What are the relevant legislation or common lawobligations and does policy reflect this?How does the organisation’s philosophy,values, culture, structure and environmentcontribute to the provision of competent andcompassionate end-of-life care?Access and appropriate referralThe end-of-life needs of many are provided alonga continuum of care. Quality care at the end of lifeis provided by a range of carers, professional andotherwise – from community or family members withprimary or generalist care providers, to specialistpalliative care providers, based on the individual’sneeds and choices. 1 Care needs can be appropriatelymet by primary care (generalist, and other specialistand support care) providers, with specialist palliativecare providers contributing direct or indirect care,or consultation advice, as required. This approachrecognises that consumers / patients with morecomplex needs may require periodic or ongoing directcare from specialist palliative care providers and thatcare delivery needs to be as individual and flexible asthe end-of-life journey. 1Pain management, psychosocial support, carersupport and home care services also address theneeds of consumers / patients with a wide range ofeventually fatal conditions, or those of their families.It is crucial that the organisation has strong referralrelationships with such services, either within theorganisation or in the broader service system, toensure good continuum of care as the consumer /patient journeys along the end-of-life pathway.Prompt points¼¼¼¼¼¼What pain management, palliative care,grief support and other services does theorganisation provide, or have good referralrelationships with?What protocols are in place to guide cliniciansregarding assessment and referral forsuch services?How does the organisation measure andevaluate the appropriateness and timing ofreferrals to specialist palliative care, painmanagement, chaplaincy, psychological andother support services?¼¼¼¼¼¼¼¼How is advance care planning and decisionmaking undertaken? How are such decisionsdocumented?How is faith support and spiritual or pastoralcare delivered?How does the organisation measureimplementation across the organisation?What reflective practices are in place and howdo they contribute to continuous improvementof end-of-life care?October 2010 95

Section 5Standards, criteria, elements and guidelinesStandard 1.1: Consumers / patients are provided with high quality carethroughout the care delivery processCriterion 1.1.7The care of dying and deceased consumers /patients is managed with dignity and comfortand family and carers are supported.(continued)Staff educationMany staff participate in the care of dying or deceasedconsumers / patients, including clinicians, technicians,chaplains, ward assistants, porters, mortuaryattendants and other relevant staff. Volunteers can alsoplay a role. The organisation should provide educationand support to ensure that staff and volunteers areappropriately qualified for the level of service offered,and also demonstrate ongoing participation incontinuing professional development. 4Education should be tailored to the specific groups,and cover areas such as:• the philosophy, values, culture, structure andenvironment for the provision of competent andcompassionate end-of-life care 4• relevant policies and procedures, includingfor organ donation• communication skills• symptom control and effective pain management• use of technology in end-of-life care• skills to competently begin and guide discussionsaround end of life and facilitate consumers /patients’ decision making• advance care planning• navigating ethical issues such as ongoinguse of technology to sustain life and tissueor organ donation• organ and tissue retrieval following death• mortality management• addressing spiritual care needs.Additionally, in healthcare organisations whereorgan or tissue donation and retrieval may occur,organisations are responsible for the appointment,training and retention of suitably experienced staffto fulfil the governance role of the organ and tissuedonation Designated Officer. The Designated Officerhas responsibility for reviewing the entire processand ensuring that it occurs in accordance withorganisational policy / protocol, relevant professionalbodies’ standards and the law.Prompt points¼¼¼¼¼¼¼¼¼¼What orientation and education is in place forvarious staff and volunteer groups regardingend-of-life care?How does the organisation ensure that allrelevant staff receive appropriate educationand participate in ongoing professionaldevelopment?How are relevant volunteers educated regardingtheir role in end-of-life care?How are clinicians encouraged and supportedto initiate, discuss and document end-oflifecare issues and decision making withconsumers / patients?What organ and tissue donation educationprogram is in place?Organ and tissue donationLegal requirements for many aspects of organ andtissue donation vary between jurisdictions. As a result,legislation and regulation of Australia’s organ donationand transplantation sector, covering a broad range ofactivities and procedures including consent for organdonation, differs across the country. Clinicians arerequired to act within the legislation of the jurisdiction inwhich they practise. 7Organisational policy should cover areas such as 2, 7 :• roles, authority, appointment processes andongoing education of Designated Officer, DonorCoordinator and other staff• staff education and support• process of recognising the possibility of organand/or tissue donation• identification of potential donors using the ClinicalTrigger Tool and GIVE Protocol 2 , or similar• recognition of prior expressions by potentialdonors on donor registries or otherwise• discussing option of organ and/or tissuedonation with families• liaison with donor coordinators• confidentiality• determination and certification of brain deathaccording to relevant jurisdictional legislation96 The ACHS EQuIP5 Guide Book 1 Accreditation, Standards and Guidelines Clinical Function

• donation after cardiac death• medical management of the potential donor• retrieval surgery• donor family support• ethical and professional standards• staff support• donor / recipient correspondence• donor family follow-up.In circumstances where a consumer / patient wishes todonate their whole body or specific organs for scientificresearch or teaching purposes, arrangements can bemade with various organ and tissue donation agenciesor body bequest programs that exist across thejurisdictions. In respect of living donor transplantation,national protocols have been developed by theTransplantation Society of Australia and New Zealandand more recently for the Australian Paired Kidneyexchange (AKX) program by the Australian Organand Tissue Donation and Transplantation Authority.Organisations are directed to the Donatelifewebsite at http://www.donatelife.gov.au for theseand other resources.Prompt points¼¼¼¼¼¼¼¼What policy is in place regarding organand/or tissue donation?Is the organisation eligible to implement theClinical Trigger Tool and GIVE Protocol?Is it being utilised effectively?How are the Designated Officer, DonorCoordinator, and hospital-based medicaland nursing DonateLife positions allocatedand supported?How are organ and/or tissue donoractivities evaluated?Bereavement supportThe process of dying can involve a wide range oflosses that includes, but is not limited to, bereavement.Comprehensive spiritual care during end of life andbereavement can moderate the impact of psychosocialstress on physical and mental health. 8This care may include:• assessment of religious and/or spiritual needs• identification of formal and informalsupport systems• bereavement support strategies, such as:––access to social work, spiritual or pastoralcare support––bereavement information packs that includesPalliative Care Australia resources––in the case of the death of a child, the useof memento books, photos, clothing, blankets,etc., and facilitating preferred contact withthe deceased––bereavement follow-up program includingmemorial services.Staff in all roles can be affected by death and shouldbe encouraged to access bereavement support asnecessary. In addition to universal bereavementexperiences, healthcare staff can also experience awide range of feelings, such as:• seeing death as a medical failure• feeling there is no medical role in dying andundervaluing palliative care skills• feeling that the role of the clinician ends whencare shifts from curative to palliative• believing there is always more biotechnologyto prolong life• feeling anxiety about one’s own mortality.Access to debriefing sessions following a death,as well as self care, bereavement counselling andaccess to cultural, religious and spiritual staff supportsystems can provide opportunities for experiencessuch as these to be explored, normalised and putinto perspective.October 2010 97

Section 5Standards, criteria, elements and guidelinesStandard 1.1: Consumers / patients are provided with high quality carethroughout the care delivery processCriterion 1.1.7The care of dying and deceased consumers /patients is managed with dignity and comfortand family and carers are supported.(continued)Prompt points¼¼¼¼¼¼¼¼¼¼What bereavement support system is in place?How are consumers / patients and their familiesencouraged to access bereavement support?How is death and dying normalised within theculture of the organisation?How are staff and volunteers encouraged toaccess bereavement support?How is the system evaluated and improved?Evidence commonly presentedConsider whether the following willhelp to address criterion 1.1.7:¼¼¼¼¼¼¼¼¼¼¼¼¼¼Documented policies, including––staff education policies and evidence ofeducation in relevant areas, e.g. end-oflifecare, pain management, advance careplanning, mortality management, organand tissue donation, etc.––when and how end-of-life issues anddecision making is raised with consumers /patients, their carers and staff––decision making and documentationguidelines––cultural, religious and pastoral / spiritualcare guidelines––organ donation, including profile, triggers,processes and outcomesEvidence of mechanisms to deal withfamily / familial issuesEvidence of compliance with legislativerequirementsHealth record review for advance care plans,documented decisions and their outcomesEvidence of care provision by, or referral to,specialist palliative care, pain managementand other services, including evidence of staffeducation in end-of-life managementEvidence of access to and uptake ofbereavement support systemsEvidence of organ and tissue donationsundertaken according to national guidelines.98 The ACHS EQuIP5 Guide Book 1 Accreditation, Standards and Guidelines Clinical Function

Performance measuresThis criterion states that: “The care of dying and deceased consumers / patients is managed with dignity andcomfort and family and carers are supported”. The organisation should be able to demonstrate that it has policyand processes in place to facilitate end-of-life care, including support services for consumers / patients and theirfamily / carers, so that this part of the care journey is managed with dignity and comfort.Some common suggested performance measures are as follows:Number of staff and volunteers who receive orientation and education regarding end-of-life careTotal number of staff and volunteersNumber of consumers / patients who have an advance care planTotal number of consumers / patients with an eventually fatal conditionNumber of relevant consumer / patient health records with end-of-life decisions documentedTotal number of relevant health records reviewedNumber of consumers / patients who have a palliative care planTotal number of consumers / patients receiving palliative careNumber of relevant consumer / patient health records with a numeric pain score documented on admissionTotal number of relevant health records reviewedNumber of relevant consumer / patient health records with a numeric pain score documented every X daysTotal number of relevant health records reviewedComment: organisation to define ‘X’Number of referrals to pain management, palliative care, grief support and other related servicesTotal number of consumers / patients receiving end-of-life careOctober 2010 99

Section 5Standards, criteria, elements and guidelinesStandard 1.1: Consumers / patients are provided with high quality carethroughout the care delivery processCriterion 1.1.7The care of dying and deceased consumers / patients is managed with dignity and comfortand family and carers are supported. (continued)Number of staff who were associated with the care of a dying consumer / patient and attendeda debriefing sessionTotal number of staff associated with the care of a dying consumer / patientNumber of deaths that were appropriately referred to the coroner as required by legislationTotal number of deathsNumber of occasions when the Clinical Trigger Tool and GIVE protocol were implementedTotal number of consumers / patients eligible to become organ donorsNumber of organ or tissue retrievals and donations undertaken according to national guidelinesTotal number of organ or tissue retrievals and donationsNumber of relatives / carers satisfied with end-of-life careTotal number of relatives / carers surveyed100 The ACHS EQuIP5 Guide Book 1 Accreditation, Standards and Guidelines Clinical Function

References1. Palliative Care Australia (PCA). Palliative care –Glossary of terms. Melbourne VIC; PCA; 2008.2. Australian and New Zealand Intensive Care Society(ANZICS). The ANZICS statement on death and organdonation. Edn 3.1. Melbourne VIC; ANZICS; 2008(updated 2010).3. Carey L and Rumbold B. Pastoral care research projects inpalliative care settings. Spiritual Care Australia Conference.Melbourne VIC; Australian Health and Welfare ChaplainsAssociation (AHWCA). Accessed from http://www.spiritualcareaustralia.org.au/website/conference10.htmlon 20 June 2010.4. Palliative Care Australia (PCA). Standards for providingquality palliative care for all Australians. Canberra ACT;PCA; 2005.5. NSW Health. Guideline: Using advance care directives.Sydney; NSW Health; 2005.6. Australian Health and Welfare Chaplains Association(AHWCA). Health care chaplaincy guidelines.Melbourne VIC; AHWCA; 2004.7. National Health and Medical Research Council (NHMRC).Organ and tissue donation after death, for transplatation:Guidelines for ethical practice for health professionals.Canberra ACT; Australian Government; 2007.8. McWilliam L. Spiritual interventions in bereavementsupports: Theory strategies and a case study. Spiritual CareAustralia Conference. Melbourne VIC; Australian Health andWelfare Chaplains Association (AHWCA); 2010.Further readingPalliative Care Australia. Winter issue theme: Pain management.EoL – Towards quality care at the end of life 2009; 1(1).Palliative Care Australia. Spring issue theme: Equity.EoL – Towards quality care at the end of life 2009; 1(2).Palliative Care Australia. Winter issue theme: Health systemreform and care at the end of life. EoL – Towards quality careat the end of life 2010; 2(1).La Trobe University. Respecting patient choices – Advance careplanning e-learning course. Bendigo VIC; La Trobe University.Accessed on 6 September 2010.Palliative Care WA. Consent: Living wills in WA. Perth WA;Palliative Care WA. Accessed from http://www.palliativecarewa.asn.au/consent.php on 6 September 2010.Central Coast Division of General Practice. Advance CarePlanning. Gosford/Wyong; CCDGP. Accessed fromhttp://www.ccdgp.com.au/site/index.cfm?display=23902on 6 September 2010.Spiritual Care Australia. Welcome to Spiritual Care Australia.Melbourne VIC. Accessed from http://www.spiritualcareaustralia.org.au/website/home.html on 18 June 2010.Healthcare Chaplaincy Council of Victoria (HCCVI). Welcome.Melbourne VIC; HCCVI. Accessed from http://www.hccvi.org.au/about.html on 6 September 2010.ICD-10-AM Pastoral Care Intervention codes:• 96186-00• 96187-00• 96087-00• 6109-01• 95550-12October 2010 101

Section 5Standards, criteria, elements and guidelinesStandard 1.1: Consumers / patients are provided with high quality carethroughout the care delivery processCriterion LA – Awareness SA – ImplementationLA plus the followingCriterion 1.1.8The health record ensurescomprehensive andaccurate information iscollaboratively gathered,recorded and used incare delivery.This is amandatorycriteriona) Every consumer / patient hasa health record with a uniqueidentifier.b) Health record documentationpolicy and procedures areavailable for staff and meetrelevant professional andjurisdictional guidelines.c) Healthcare providers are awareof the organisation’s systemsfor healthcare record creationand management.d) Authorised internal andexternal healthcare providershave access to informationabout the consumer / patient inaccordance with jurisdictionalprivacy legislation.e) Consumers / patients are givenadvice / written guidelineson how to access theirhealth records.a) Healthcare providers use thehealth record to document andcommunicate all aspects ofcare delivery in accordancewith the organisation’spolicy / guidelines.b) Systems are implemented tomonitor the legibility of thehealth record.c) Results of reviews andclinical consultationsare made available tohealthcare providers.IntentThis criterion focuses on the collaborative gatheringand recording of information that provides the contentof individual health records, and how a consumer /patient’s record facilitates the delivery of care.Complete, accurate health records are fundamentalto the provision of safe, high quality care. The intent ofthis criterion is to ensure that consumer / patient healthrecords are comprehensive and efficiently maintained,and that consumer / patient confidentiality is protected.Relationships of 1.1.8 with other criteriaThis criterion addresses the gathering and entryof information into the health record, and how thatinformation is used in the delivery of care. This processwill be facilitated by records management systemsthat meet the needs of both the consumer / patientand the organisation (Criterion 2.3.1), and which inturn are supported by the organisation’s processesfor data collection and storage (Criterion 2.3.3) via itsintegrated approach to information and communicationtechnology (Criterion 2.3.4).The health record should accurately reflect theconsumer / patient’s journey through the care deliveryprocess (Standard 1.1), and ensure the provision ofsafe care and services (Standard 1.5). The entry ofdata into the health record is a vital aspect of effectiveand coordinated ongoing care (Criterion 1.1.6) and ofthe process(es) of clinical handover (Criterion 1.1.5),including the exchange of information betweenreferrers and providers by which continuity of care ismaintained (Criterion 1.2.2). Correctly managed healthrecords should allow meaningful evaluation of theoutcomes of clinical care (Criterion 1.1.4).The information in the health record should assist theorganisation in meeting its responsibility towards thosewith diverse needs and from diverse backgrounds(Criterion 1.6.3). The consumer / patient has a rightto access his or her own health record, and to expectthat privacy and confidentiality will be maintained(Criterion 1.6.2). Failure of the organisation to respectthese rights may lead to complaints (Criterion 2.1.4).102 The ACHS EQuIP5 Guide Book 1 Accreditation, Standards and Guidelines Clinical Function

MA – EvaluationSA plus the followingEA – ExcellenceMA plus the followingOA – LeadershipEA plus the followinga) Health records are evaluated toensure they meet medico-legalrequirements, professionaldocumentation standardsand jurisdictional healthdepartment guidelines.b) Health records are evaluated toensure that the clinical contentsupports high quality careand improvements are madeas required.c) Evaluation of legibility of thehealth record is addressedthrough the use of audits,and improvements are madeas required.d) Timeliness of inclusion ofreports and information fromreviews, tests and otherclinical investigations into thehealth record is evaluated andimproved, as required.a) The health recorddocumentation system iscompared with internaland external systems andimprovements are made toensure better practice.and/orb) Results of monitoring ofdocumentation are trended,and demonstrate thatdocumentation continuouslymeets all requirementsof external standardsand guidelines.a) The organisation demonstratesit is a leader in health recorddocumentation.The role of the health recordHaving a single health record for every consumer /patient is vital to continuity of care. The health recordshould outline all identified needs of consumers /patients, and the care / management received.Regardless of whether a record is electronic or paperbased,the location and if possible the appearance ofinserts / data attachments should be consistent andpredictable within each record.At the end of an episode of care, the record should beretained in accordance with legislative requirements;the health record will serve as a historical record andshould guide ongoing and future care. 1 A dischargesummary that outlines the episode of care shouldbe prepared and sent to those organisations /clinicians who will continue the consumer / patient’scare in the community. The health record may beused by coders and statisticians to produce data forcalculating the incidence of diseases, adoption ofdifferent treatment protocols, and for quality controland planning. 2 The information in the record mayalso be utilised by clinicians, administrators andresearchers; access and use should always bemanaged according to jurisdictional law, policy andthe organisation’s processes.October 2010 103

Section 5Standards, criteria, elements and guidelinesStandard 1.1: Consumers / patients are provided with high quality carethroughout the care delivery processCriterion 1.1.8The health record ensures comprehensiveand accurate information is collaborativelygathered, recorded and used in care delivery.(continued)The health record is primarily a medico-legal andcommunication document, which records thoseevents and decisions required by healthcareproviders to manage consumer / patient care bothcontemporaneously and in time sequence. It mayprovide evidence in lawsuits, hearings or inquests. 2The health record can protect the legal interests of theorganisation and the clinician, or it can become a legalrisk. 3 The health record is the backbone of evidencefor almost every medical professional liability action;it will be used to reconstruct the episode of care. 4 Itcan also be used as evidence in other types of legalproceedings, royal commissions and formal inquiries.Prompt points¼¼¼¼How does the design of the health recordfacilitate the recording and communicating ofkey aspects of care delivered within a ward ordepartment? For what structured documentsare standardised templates available and used(e.g. discharge summaries, pathology reporting,radiology reporting, specialist referrals)?Are healthcare providers completing the recordsto ensure that events and decisions required tomanage care are appropriately documented?Record creation and managementA consumer / patient attending a healthcare facilityfor the first time will require a health record to becreated. Various management strategies may be usedto ensure consistency and completeness of recordsand should include:• training of staff who open / create new records• computer prompts or reminder cards• limiting access to ensure only designated staffwill open / create new records.The structure of health records will vary according tothe specific needs of different organisations.Because record keeping is fundamental to the deliveryof quality care, new staff should be made aware duringorientation of organisational policies and systemsrelating to records 5 , and how those records arecreated. Staff should understand their responsibilitiesfor complete and accurate records and the need forconfidentiality of consumer / patient information. 6In private hospitals, the responsibilities of visitingmedical officers for health records should beoutlined in the organisation’s by-laws. In addition,orientation should provide sufficient information toagency staff about the organisation’s requirementsfor health records.Within teaching hospitals, junior medical officersare often key in clinical record keeping. Transientpersonnel such as junior medical officers andcontract / agency staff may spend only brief periodsin individual wards and often have demandingworkloads. 7 For this reason, it is important that theirexperience is reviewed during orientation to a newdepartment and that they receive some oversight andinstruction in the organisation’s requirements for healthrecord creation and management, before they becomecaught up in the immediate demands of their roles.Whatever system is used to capture the information,the consumer / patient health record should uniterelevant information so that it can be accessed byindividual clinicians as needed. Given the recognisedchallenges of paper-based record systems, transitionto an electronic system should be considered by allorganisations. Using standard forms and formats forall health records throughout the organisation is a keypreliminary step.104 The ACHS EQuIP5 Guide Book 1 Accreditation, Standards and Guidelines Clinical Function

Prompt pointsPrompt points¼¼¼¼¼¼How does the organisation ensure thathealthcare providers are aware of the systemsfor health record creation and management?What systems and processes ensure that anyproposed new forms or documents that willbe integrated into the record are consistentwith existing forms, and do not unnecessarilyduplicate their content?How does the organisation instruct its clinicaland administrative staff in their responsibilitiesfor documentation? How is their learningassessed both immediately and throughout theiron-the-job performance? How is the educationand its content assessed?¼¼¼¼¼¼How are individuals identified within the recordssystem? When an individual first presents, whatchecks ensure that he or she does not have apre-existing health record?Does every consumer / patient have their ownhealth record? Do duplicate records ever creepinto the system? What processes are usedto detect and correct duplications within therecord system?Does the organisation assign individualconsumers / patients or episodes of care witha unique key in its health records system? Howis the allocation of these unique key numberscoordinated across the organisation?¼¼How are the risks associated with recordkeeping and communication by transientand/or junior clinical staff managed bythe organisation?Unique identifierHealth records belonging to a single consumer /patient or single episode of care should be linkedby a unique identifier.The creation of unique identifiers for individualconsumers / patients, individual healthcareprofessionals, and individual organisations is afoundation platform in the development of a nationalelectronic health record system.Systems established by organisations should ensurethat any reports and/or results of investigations fromother organisations or departments are integrated intoeach consumer / patient’s record through links andcross-referencing to avoid misplacement, facilitateunderstanding by multiple parties, and ensure theretention of, and access to, a complete record.Policies and proceduresDespite the availability of many guidelines on theimportance of health record documentation, poordocumentation continues to be a major factor inmedical indemnity claims and adverse events.Australian standards do not cover the specific contentof health records due to the diversity of organisationsfunctioning in the health sector. Organisations shouldconsider the needs of their consumers / patients,healthcare providers and the organisation itselfwhen developing policies in relation to content of therecord. All staff should have access to the policy,and the location of the policy should be advisedduring orientation.Policy / by-laws and procedures should address theorganisation’s requirements for standard forms tobe incorporated into the health record as needed,for example, a form that identifies Aboriginal andTorres Strait Islander consumers / patients, or the‘Anaesthesia Event Report’ form developed by theAustralian Society of Anaesthetists. Whatever standardforms are used within an organisation, it is importantthat all users of the health record know what is tobe used, where the forms can be obtained and theinformation that should be recorded.There should be regular evaluation of the organisation’shealth records, to ensure that they meet alljurisdictional and medico-legal requirements.Further information about health records canbe found in Australian standards 8-10 and healthdepartment policies and guidelines, and be obtainedfrom various professional colleges, and medicaldefence organisations.October 2010 105

Section 5Standards, criteria, elements and guidelinesStandard 1.1: Consumers / patients are provided with high quality carethroughout the care delivery processCriterion 1.1.8The health record ensures comprehensiveand accurate information is collaborativelygathered, recorded and used in care delivery.(continued)Prompt points¼¼¼¼Are the documentation policies and proceduresused by the organisation referenced tolegislation, Australian standards and/orprofessional codes / guidelines? How frequentlyare they reviewed and updated? When was thelast review of health records policy undertaken?How do clinical and administrative staffmembers with health record responsibilitiesaccess policies or other guidance documents?LegibilityIllegible handwriting impacts on the standard oftreatment provided and can lead to errors. 7 Alterationsto handwritten notes without attribution are illegaland can be confusing. In the event of an adverseoutcome, they may also be a cause for suspicion andaccusations of ‘cover-up’.Entries to paper health records should be made inblue or black indelible ink. Entries should be datedand initialled, and always include time of action. Theyshould be made without erasure; where changesare needed, a strikethrough should be used and thechanges initialled. 8, 11 Handwriting must be legible, notonly to the author, but to other users of the record.Legibility can also be problematic with somecommunications technologies. Administrators shouldcheck incoming faxes and proactively request thatpoor quality or incomplete faxed materials be re-sent;this is the reason for using clearly typed coversheetsthat include total page numbers on all faxeddocuments. In addition, scanned items should bechecked for legibility prior to assignment to a consumer/ patient health record. When paper-based recordsare electronically scanned, the resolution must beadequate to ensure legibility of the scanned materials.Prompt points¼¼¼¼What types of audits of health record entriesand their legibility are undertaken? Is the reviewmanaged by a person with knowledge of clinicalcare, its conventions and risks? When problemshave been identified, how is the informationcommunicated to relevant staff and what actionsare undertaken to reduce the associated risks?If scanning is used in the organisation, doesthe review include checks on the legibilityof print documents scanned into electronicrecord systems?Access to records and informationby healthcare providers; confidentialityand privacyWherever possible, there should be capability forhealthcare providers to access all components of ahealth record, where there is a clinical need, bothduring and outside office hours. Similarly, in prioritysituations, health professionals at other sites should beable to consult a clinician who can source informationabout a discharged or transferred consumer /7, 12patient.Access to diagnostic images is an essential part ofcare delivery. Where digital systems are used, clinicalstaff should be trained in accessing and retrievingimages from current and archival systems to ensurethat after-hours care is not compromised.Release of information for ongoing care is oftenspecified as part of the consent for a procedure,however in some circumstances organisations mayrequest signed consent from the consumer / patientbefore transferring the record. 13Organisations should have access to privacylegislation, policies and guidelines related to theirservice. Current information is available from:http://www.privacy.gov.au/health/index.htmlInformation provided includes:• national privacy legislation• consumer information “My Health My PrivacyMy Choice”• information sheet on the Privacy Act• guidelines on health privacy• guidelines on research privacy106 The ACHS EQuIP5 Guide Book 1 Accreditation, Standards and Guidelines Clinical Function

... and http://www.privacy.gov.au/privacy_rights/laws/index.html provides links to:• privacy legislation in all States / Territories• international human rights instruments.There should be a process to incorporate and monitorcompliance with legislation and guidelines and thisshould be evident.Prompt points¼¼¼¼How does the organisation ensure that it meetsthe intent of the National Privacy Principles?How is this commitment communicated toconsumers / patients?Prompt points¼¼¼¼¼¼How does the organisation facilitate accessto all components of the record in a timelymanner? How is record access ensuredafter hours?How are healthcare providers who are newto a ward or organisation oriented to ensurethat they can access all aspects of an existingconsumer / patient’s health record?How does the organisation and/or its differentdepartments manage the competing demandsfor access to records and personal privacy /confidentiality?Consumer access to personalhealth recordsThe National Privacy Principles state that:“An organisation must set out in a document clearlyexpressed policies on its management of personalinformation. The organisation must make the documentavailable to anyone who asks for it”. NationalPrivacy Principle Six (6) describes the rights thatconsumers / patients have in gaining access to theirown health records. The overarching statement is:“If an organisation holds personal information aboutan individual, it must provide the individual with accessto the information on request by the individual”.The organisation should have processes in place bywhich the consumer / patient can gain access to his orher own health record, and this information should beproactively provided to the individual prior to or uponadmission. This aspect of consumer / patient rights isdiscussed in more detail within criterion 1.6.2.Monitoring health record qualityAudits or other monitoring should be undertakento ensure that policies relating to health recordsare actioned. Health record audits can also beused to support total quality management and riskmanagement activities. Health record review teamsshould be multidisciplinary wherever possible. 11Outcomes of audits and proposed solutions to anyidentified problems should be fed back to staff.A health record audit of the standard of documentationcan commence with a basic chart audit to determinewhether the entries are:• legible• in black or blue pen• corrected as per organisation policy• dated, timed and signed, with the enterer’s nameand professional designation printed in blockletters after the entry; a pager number or othercontact is also desirable... and that:• only approved abbreviations are used• any student entries are countersigned.Audits of timeliness of responses to referrals, andevidence that the advice has been documented andnoted need to be undertaken and improvements madeif necessary. This will require auditing of a varietyof referral sources over a period of time and carefulexamination of records to check for inappropriatedelays. ‘Timeliness’ should be interpreted according tothe timelines for procedures within the organisation /department and focus upon consumer / patient andclinician need, not administrative convenience.Where any deficiencies in health record quality oraccuracy are identified by audit, an action plan shouldbe developed, and all improvements documented.Wolff and Taylor’s book Enhancing patient careprovides a good discussion on the uses and limitationsof health record review in the management ofadverse events. 14October 2010 107

Section 5Standards, criteria, elements and guidelinesStandard 1.1: Consumers / patients are provided with high quality carethroughout the care delivery processCriterion 1.1.8The health record ensures comprehensiveand accurate information is collaborativelygathered, recorded and used in care delivery.(continued)Examples of checklists for monitoring health recordquality can be found online and adapted for specificorganisational needs: http://www.omic.com/resources/risk_man/forms/medical_office/MedicalRecordAudit.rtfPrompt points¼¼¼¼¼¼What systems are used in your organisationto monitor health record quality?How frequently are formal audits undertaken?How are the results disseminated to therelevant staff?What checks of the relevance and completenessof the record are included in the review process?Evidence commonly presentedConsider whether the following willhelp to address criterion 1.1.8¼¼¼¼¼¼¼¼¼¼¼¼¼¼¼¼Content of health records – cross-references toother records or evidence of flags or hyperlinksto indicate another record in another formatmay help to demonstrate techniques to facilitateprofessional accessResults of health record audits; anycommunications to staff or training materialsdeveloped to respond to audit findingsTechniques / systems used to ensure a uniqueidentifier on each record and avoid duplicationwhen it is assignedPolicies and procedures, including techniques oradditional materials used to respond to specificorganisational or department requirementsStandardised forms and templatesInstructional materials, such as lists of approvedabbreviations or ‘how to’ guidance to staffOrientation, training or review programs thatensure new or contract staff adopt correct andconsistent systems and processes in unfamiliarclinical settingsReviews to eliminate any duplication of recordsfor individual consumers / patients108 The ACHS EQuIP5 Guide Book 1 Accreditation, Standards and Guidelines Clinical Function

Performance measurementThis criterion states that: “The health record ensures comprehensive and accurate information is collaborativelygathered, recorded and used in care delivery”. The accuracy of the health record and the timeliness of data entryare fundamental to safe, high quality care. The organisation should be able to demonstrate that its processesensure accurate and timely entry of data into the health record.Some common suggested performance measures are as follows:Number of health records where care plans are not documentedTotal number of health records auditedNumber of health records where illegible writing resulted in an adverse eventTotal number of health records auditedComment: for instance, the medication dose and time when it was last given to the consumer / patientwere noted in the health record in a way that staff who needed to know these details wereunable to read themNumber of health records containing illegible faxes / scans / photocopies / imagesTotal number of health records auditedNumber of requests from coders to clinicians to clarify ‘content’ issuesTotal number of requests from coders to cliniciansComment: ‘content issue’ could be primary and secondary diagnosisNumber of health records audited for clinical content that are compliant with organisational policyTotal number of health records auditedNumber of health records with all entries dated, signed and designation of person recordedTotal number of health records auditedOctober 2010 109

Section 5Standards, criteria, elements and guidelinesStandard 1.1: Consumers / patients are provided with high quality carethroughout the care delivery processCriterion 1.1.8The health record ensures comprehensiveand accurate information is collaborativelygathered, recorded and used in care delivery.(continued)References1. Medical Practitioners’ Board of Victoria. Medicolegalguidelines: protecting patients, guiding doctors.Melbourne; Victoria Medical Practitioners’ Board; 2006.2. NSW Health. Medical records in hospitals and communitycare centres. Policy Directive PD2005_004. Sydney;NSW Health; 2005.3. Nurses and Midwives Board of WA. Management ofconsumer information and documentation guidelines.Perth WA; NMBWA; 2009.4. McWay DC. Legal aspects of health informationmanagement. 2nd edn. New York USA; Thomson DelmarLearning; 2003.5. Institute for Safe Medication Practices (ISMP). ISMP’s listof error-prone abbreviations. Horsham USA; ISMP; 2007.6. Government of South Australia and South Australia Health.A guide to maintaining confidentiality in the public healthsystem. Adelaide; SA Health; 2006.7. Garling P, SC. Final report of the special commission ofinquiry: Acute care services in NSW public hospitals.Sydney; NSW Special Commission of Inquiry; 2008.8. AS 2828:1999 Paper-based health care records.9. AS ISO 15489.1:2002 Records management: General.10. AS ISO 15489.2:2002 Records management: Guidelines.11. Abdelhak M, Grostick S, Hanken MA and Jacobs E. Healthinformation: Management of a strategic resource. Secondedn. Philadelphia USA; Saunders; 2001.12. Australian Medical Association (AMA). Position Statement:access to medical records by doctors who are not treatingthe patients concerned. Canberra ACT; AMA; 2002.13. Australian Medical Association (AMA). Transfer of medicalrecords between treating doctors. Canberra; AMA; 1998(revised 2002).14. Wolff AM and Taylor SA. Enhancing patient care: A practicalguide to improving quality and safety in hospitals.Sydney NSW; MJA books; 2009.110 The ACHS EQuIP5 Guide Book 1 Accreditation, Standards and Guidelines Clinical Function

Section 5Standards, criteria,elements and guidelines1.2 Access StandardThe standard is:Consumers / patients / communities have access tohealth services and care appropriate to their needs.The intent of the Access standard and criteria is toensure that communities and consumers / patientshave access to necessary health care and services.Health services should ensure that the communityhas information on available health services andthat access is determined by the clinical needs ofconsumers / patients.There are two criteria in this standard. They are:1.2.1 The community has information on healthservices appropriate to its needs.1.2.2 Access and admission / entry to thesystem of care is prioritised accordingto healthcare needs.Access is one of the fundamental dimensions of qualityin health care. 1 There will be different issues aboutaccess depending on the service (acute or community)and the sector (public or private). Each organisationshould interpret the criteria relevant to their sectorand service.1. Australian Commission on Safety and Quality in Health Care (ACSQHC). Windows into Safety and Quality in Health Care 2008.Sydney NSW; ACSQHC; 2008.October 2010 111

Section 5Standards, criteria, elements and guidelinesStandard 1.2: Consumers / patients / communities have accessto health services and care appropriate to their needsCriterion LA – Awareness SA – ImplementationLA plus the followingCriterion 1.2.1The community hasinformation on healthservices appropriateto its needs.a) Information is gatheredto define the needs of thecommunity.b) Information on theorganisation’s healthcareservices is available to thecommunity.c) Relevant external serviceproviders are provided withinformation on the healthservice and are informed ofreferral and entry processes.a) Consumers / patients haveinformation about the specificservice they are using.b) Healthcare providers within theorganisation have informationon relevant external services.c) There is collaboration betweenthe organisation, consumers /patients and where required,external service providers.IntentThe intent of this criterion is to ensure thatorganisations provide information on their servicesappropriate to the needs of the community they serve.Relationships of 1.2.1 with other criteriaHealthcare organisations should provide relevantinformation for consumers / patients, their carers andmembers of the general public about the organisationand its services, including clear information forconsumers / patients about the treatment and carethey may receive. Information should also be providedto health professionals who are involved in ongoing(Criterion 1.1.6) or transfer of care (Criterion 1.1.5),or who may refer consumers / patients to the service(Criterion 1.2.2).Information content should be provided withconsideration for consumers / patients with diverseneeds and from diverse backgrounds (Criterion 1.6.3),and in addition to services provided, should addressissues such as access to health care and admissionprocesses (Criterion 1.2.2), consent processes(Criterion 1.1.3) and consumer / patient rights andresponsibilities (Criterion 1.6.2).Defining community needsThe community that the organisation serves may bedefined in two ways. Public healthcare organisationshave a responsibility for providing health services toa general community, usually defined geographically.A private healthcare organisation’s community,however, is those consumers / patients who arereferred to the health service, by whatever means,for care. Most private health services do not have aresponsibility for satisfying the needs of a geographiccommunity; their community is usually defined by theirreferrers. Private organisations may be assisted inunderstanding the diverse needs and backgroundsof their community by contacting their referrersfor this information.Defining its community often poses a challenge for aday procedure centre, whose consumers / patientsmay be both local to the organisation and referredfrom much greater distances; or, for some specialisedservices, even from overseas. The organisation shouldconsider both its geographical area and its referralbase when defining its community.112 The ACHS EQuIP5 Guide Book 1 Accreditation, Standards and Guidelines Clinical Function

MA – EvaluationSA plus the followinga) The organisation reviewsand evaluates content andprocesses for disseminationof information on services,and makes improvementsas required.b) Collaboration between theorganisation, consumers /patients, carers and externalservice providers is evaluated,and improvements are madeas required.EA – ExcellenceMA plus the followinga) The organisation workswith its community and keystakeholders to implementinnovative methods forinformation provision anddistribution.and/orb) The organisation comparescontent and processes fordissemination of informationon services with externalsystems and processes, andimprovements are made toensure better practice.and/orc) The organisation undertakesresearch into informationsystems and processes,and acts on the results.OA – LeadershipEA plus the followinga) The organisation demonstratesit is a leader in providinginformation on healthservices appropriate to thecommunity’s needs.It is important that an organisation defines itscommunity and/or the usual accessors of its services,in order to understand the cultural influencesor specific requirements within that community.Demographic data derived through the census andavailable from the Australian Bureau of Statistics canassist in understanding a geographic community, andassessing its needs.Following definition of its ‘community’, an organisationwill be better equipped to determine the range ofservices to be provided, and the information thatconsumers / patients and the community will need inorder to access those services. It will then be able toaddress any special needs of consumers / patients,for example, making kosher and halal meals available,or providing a designated play area for children.The community and the role that the organisationhas within it are usually defined in the organisation’sstrategic and/or operational plans. The organisation’sdefinition of its community may depend on the type ofservices it provides. For example, if the organisationis a community centre, its community may be youngfamilies within the area. If, however, the organisationis a private hospital that specialises in ophthalmicsurgery, then its community will be consumers /patients who are referred to the organisation by(probably) ophthalmic surgeons, as well as theophthalmic surgeons themselves. Day procedurecentres / private organisations should include theirreferring general practitioners (GP), specialistphysicians and surgeons as part of their community.Prompt points¼¼¼¼How has the organisation defined itscommunity? Who did the organisationcontact to do this?How are the needs of the communityaddressed?October 2010 113

Section 5Standards, criteria, elements and guidelinesStandard 1.2: Consumers / patients / communities have accessto health services and care appropriate to their needsCriterion 1.2.1The community has information on healthservices appropriate to its needs. (continued)Providing information abouthealthcare servicesThe Australian Charter of Healthcare Rights,adopted by the Australian Health Ministers in 2008,summarises seven basic rights that consumers /patients are entitled to receive when accessinghealthcare services.These rights cover:• access• safety• respect• communication• participation• privacy• comment.The fourth right of consumers / patients accessingthe Australian healthcare system is for appropriatecommunication. Organisations must provide enoughinformation, and in the appropriate formats, to addressthe right of consumers / patients to be informed aboutservices, treatments, options and costs in a clear andopen way. 1Information on health services may be provided inmany different formats; the most appropriate formatswill depend on the message and for whom it isintended. Information about services may rely on:• directories or lists of organisational andcommunity-based services• brochures and handouts• websites• news media (including items resulting frompress releases) and documentaries• paid advertising• signage• other forms of telecommunication, such as DVDs,online video files, phone text reminders, etc.The information that organisations are required toprovide to their community includes:• services available within the organisation, such asspecialty medical services, emergency services,outpatient services, pharmacy, counselling,rehabilitation and education classes, as well asauxiliary services such as cafes or onsite attachedaccommodation for out-of-town relatives / carers• how the organisation will handle health information,irrespective of whether consent is given. Thisinformation should be provided at the earliestopportunity and in line with the National PrivacyPrinciples (NPP) 2 and privacy legislation of therelevant jurisdiction• inclusion and/or exclusion criteria for admissionto the health service• collaborative links between the organisation andspecific community / advocacy / support groups• schedule of programs and/or education sessions• transport and/or parking information.There are a variety of ways in which the organisationcan inform its community about the services that itprovides, including presenting education sessionsfor community groups, holding open days, settingup information booths at shopping centres, anddistributing newsletters. The organisation shouldalso take these opportunities to discuss its provisionof information, and determine how it could bettercommunicate with the various groups that make upits community.Consumers / patients being admitted to a specificservice should be provided with all necessaryinformation, and in an appropriate format andlanguage. This should not only address the procedure,treatment, test or assessment that the consumer /patient will undergo, but give all necessary detailsabout when and how to access the service, what forms(if any) to fill in before doing so, and what to bring.The organisation should also inform the consumer /patient of his or her rights and responsibilities underthe Australian Charter of Healthcare Rights. Theorganisation’s own responsibilities in this respect,including what information should be provided and inwhat formats and languages, are addressed in moredetail within criteria 1.6.2 and 1.6.3.In addition to providing information about theirown services, organisations should provideconsumers / patients with information about relatedexternal services and their providers, to ensure thatconsumers / patients can access these services,114 The ACHS EQuIP5 Guide Book 1 Accreditation, Standards and Guidelines Clinical Function

where appropriate. Usually, the organisation willmaintain a service directory, which will supplyoperational and contact details for relevant externalservices as required by the consumer / patient.Prompt points¼¼¼¼¼¼How is information on the health serviceprovided to the community? In what formats?In what languages? How did the organisationdecide upon these languages?How often is the content and processes fordissemination of information on servicesevaluated? What recent changes have beenmade to the content? What recent changes havebeen made to the system of dissemination?If no changes have been made, explainthe reasons in relation to the results of anyevaluation of health service information?External service providersOrganisations will have relationships with externalservice providers who refer consumers / patients to theorganisation, and who may later resume responsibilityfor their ongoing care. In order to facilitate theseprocesses, the organisation should provide its referrerswith all necessary information about its access andadmission processes, the channel(s) by which itshould receive referrals, and the means and timeframewithin which it in turn will transfer consumer / patientinformation to the referrer. These issues are addressedin more detail within criterion 1.2.2.In addition, external service providers within acommunity may speak to their consumers / patientsabout services provided by the organisation, initiatingindependent contact without formal referral. Theseexternal healthcare providers should therefore benotified of any changes to hours of operation, accessconditions, location of specialty services, contactdetails and any other relevant information, in orderto ensure that the information provided in turn toconsumers / patients is accurate and up-to-date.Collaboration between the organisation itself andexternal facilities, services and groups has thecapability to significantly extend and enhance therange of services available to the consumer / patient,and to more thoroughly and efficiently meet the needsof the community. When an organisation finds itselfregularly referring consumers / patients to anotherprovider, it should follow up with the externalprovider and discuss the existing relationship, inorder to formalise the relationship if necessary, andto identify any joint strategies by which they maybetter meet consumer / patient needs. Both parties tothe collaboration should use their usual channels fordissemination of information to inform their communityof the links between them, and the way in which theprovision of care is improved by the relationship.Prompt points¼¼¼¼¼¼How are consumers / patients and healthcareproviders within the organisation informedabout external service providers? How does theorganisation ensure the information is relevant?What collaborations exist between theorganisation and external service providers inits community? Are these formal or informal?How does the organisation know whether itscollaborations are helping it to meet the needsof its community?Evidence commonly presentedConsider whether the following willhelp to address criterion 1.2.1¼¼Information sheets provided for community,including information on:––public transport routes and timetables––available parking options––locations of community or affiliatedpharmacies¼¼Media releases / advertising / newsletters /open days / public displays¼¼¼¼¼¼¼¼¼¼¼¼Results of consumer surveysOrganisational service directoryEvidence of new or extended services providedas a result of consumer feedbackNew community groups that are accessinginformationDetails of other aligned service providersthat assist with post-operative careContact number for referrers and processesof referral if requestedOctober 2010 115

Section 5Standards, criteria, elements and guidelinesStandard 1.2: Consumers / patients / communities have accessto health services and care appropriate to their needsCriterion 1.2.1The community has information on health services appropriate to its needs. (continued)Performance measurementThis criterion states that: “The community has information on health services appropriate to its needs”. It is theresponsibility of the organisation to ensure that its community in general is informed of the services that it provides;that consumers / patients and their carers accessing those services are provided with all information necessaryabout their health care; and that it actively pursues collaborations with external service providers so as to enhanceits range of services.Some common performance measures are as follows:Number of consumers / patients accessing services due to education session / open day / public displayTotal number of consumers / patients surveyedNumber of consumers / patients satisfied with pre-admission informationTotal number of consumers / patients surveyedNumber of staff able to provide information on external servicesTotal number of staff surveyedNumber of consumers / patients provided with information about external servicesTotal number of consumers / patients requiring external service provisionNumber of referrers satisfied with the organisation’s provision of consumer / patient informationTotal number of referrers surveyedNumber of collaborations established with external service providers in the current 12 monthsTotal number of collaborations with external service providers116 The ACHS EQuIP5 Guide Book 1 Accreditation, Standards and Guidelines Clinical Function

References1. Australian Commission on Safety and Quality in HealthCare (ACSQHC). Australian charter of healthcare rights(for consumers). Sydney NSW; ACSQHC; 2008.2. Office of the Federal Privacy Commissioner. Nationalprivacy principles (extracted from the Privacy Amendment(Private Sector) Act 2000.) Sydney NSW; AustralianGovernment; 2001.October 2010 117

MA – EvaluationSA plus the followingEA – ExcellenceMA plus the followingOA – LeadershipEA plus the followinga) The organisation evaluates theeffectiveness of its prioritisationguidelines, and these areimproved as required.b) The organisation evaluates theadmission / entry processes,and makes improvementsas required.a) The organisation comparesadmission / entry processesinternally and externally, andimprovements are made toensure better practice.and/orb) The organisation undertakesresearch on access systemsand processes, and acts onthe results.a) The organisation demonstratesit is a leader in prioritisingaccess according to healthcare needs.AccessThe term access refers to the various pathways andprocesses via which the consumer / patient may enterthe health system and obtain required services. Itencompasses both the physical process of access(i.e. the location of the organisation, its hours ofoperation, transport, ramps, signage) as well as meansfor making contact, and broader concepts such aseligibility criteria and the catchment boundaries forthe services provided. Access is the first step in theconsumer / patient’s journey of care.From the perspective of the organisation, consumer /patient access may be planned or unplanned. Plannedaccess is when an appointment or booking has beenmade, and the consumer / patient attends at a prearrangedtime to receive specific, agreed services;while unplanned access is contact by a consumer /patient other than to make an appointment, or thearrival of a consumer / patient at a healthcare facilitywithout immediate prior contact, whose clinical needmust then be determined.Ideally, access to a healthcare organisation is arelatively straightforward process. However, theunpredictability of acute care will sometimes resultin access block, that is, overcrowding and/or delayin care provision. 1 This may be a consequence ofhigh occupancy and non-availability of appropriatebeds, excessive demand on equipment or heavystaff workloads. Although the circumstances thatresult in access block may be beyond the control ofthe organisation, it is vital that the organisation’s ownprocesses do not contribute to the problem. Researchhas demonstrated that procedures facilitating theintegration of the consumer / patient’s journey, thatstrive for seamless rather than compartmentalisedcare and minimise opportunities for breakdowns incommunication and delays in clinical handover, assistin streamlining consumer / patient movements throughthe system, with reduction in the incidence of accessblock and its associated harmful outcomes. 2Prompt pointsThe pathway by which the consumer / patient gainsaccess to the health system will vary according tothe nature and urgency of his or her clinical need,and the character and situation of the organisationbeing accessed.¼¼¼¼How many ways may the consumer / patientaccess this organisation? Is referral alwaysnecessary?Is access block an issue for this organisation?What means does the organisation employ toreduce or overcome access block?October 2010 119

Section 5Standards, criteria, elements and guidelinesStandard 1.2: Consumers / patients / communities have accessto health services and care appropriate to their needsCriterion 1.2.2Access and admission / entry to the systemof care is prioritised according to healthcareneeds. (continued)PrioritisationPrioritisation is the process by which the urgency ofthe consumer / patient’s clinical need is determined. 3It involves a risk assessment and a clinical judgementinformed by the equivalent and comparableassessment of the need of others seeking care ofthe same kind or at the same facility. Prioritisationoccurs at different points in the healthcare journey,and may occur multiple times in the journey of asingle consumer / patient. The process and itscriteria will vary according to the nature of theorganisation, but clinical need should always be theoverriding consideration.Triage is a form of prioritisation most commonlyassociated with emergency situations. 4 It is a means ofassigning a consumer / patient to a ‘category’ in orderto ensure that he or she receives care in a mannercommensurate with clinical urgency. Traditionally,Accident & Emergency Departments have used asystem of five categories, from resuscitation (i.e. actionwithin seconds) to non-urgent; although alternativeapproaches, including identifying urgent need beforedividing the remaining cases into ‘likely to be admitted’and ‘likely to be discharged’, have been trialled andfound effective. 5In healthcare organisations where self presentation orself referral is the means of access for the consumer /patient, a system of frontline prioritisation, or demandmanagement, is necessary to ensure the mostappropriate and timely response. At the same time,in circumstances in which those same organisationsemploy a formal booking system for their services,or in organisations where a formal appointmentsystem is employed at all times, prioritisation willusually occur before the consumer / patient accessesthe facility. The process of referral can itself be anexample of prioritisation: the referring clinician willjudge the urgency of the clinical need, and selectthe most appropriate specialist or facility to providethe care required; while the receipt of a validreferral by the organisation allows care planning tobegin and streamlines the access process for theconsumer / patient.The nature of the organisation and the sector of thehealth service in which it functions will determine atwhich point(s) in the care journey prioritisation willoccur. Organisations should have a system or systemsof prioritisation in place that, wherever possible, aredeveloped in partnership with key referrers, that arebased upon documented processes, and whose aimis to ensure not only that those in greatest need obtaincare as soon as practicable, but also that all thoseaccessing the organisation receive appropriate andtimely care.Prompt points¼¼¼¼¼¼¼¼How does the organisation prioritiseconsumer / patient care? At what point(s)in the care journey does this occur?What staff members are responsible forprioritising care?What documentation is available to demonstrateappropriate prioritisation has taken place?How does the organisation evaluate itsprioritisation processes? What changes havebeen made as the result of such an evaluation?Inclusion / exclusion criteriaInclusion and exclusion criteria are the conditions thatdetermine eligibility or ineligibility for services providedby a healthcare organisation. They should be formallydocumented. The public hospital system operateswithin a philosophy of universal inclusion, meaningthat consumers / patients should achieve accessregardless of the nature or severity of their healthcareneeds or their personal status or circumstances.Financial considerations should not deny access totreatment in a public hospital or other public facility.The basis for, and implementation of, exclusion criteriawill vary according to the nature, sector and location ofthe organisation. However, when drafting such criteriathe needs and the wellbeing of the consumer / patientmust at all times be the overriding consideration. It isalso imperative that the organisation makes it clear tothe consumer / patient that any decision to exclude isnot made on a personal basis, but is made to avoidproviding inappropriate care, in an inappropriatesetting; or that it is due to other external factors,such as funding conditions. In excluding consumers/ patients, the organisation has a duty of care to, at aminimum, provide advice as to an alternative point ofcare, or to re-direct the consumer / patient either backto the referrer or to another appropriate clinician or120 The ACHS EQuIP5 Guide Book 1 Accreditation, Standards and Guidelines Clinical Function

service. In some circumstances, an assisted referralto another organisation or service provider maybe required.Prompt points¼¼Does the organisation have exclusion criteria?On what basis were they implemented?While organisations should avoid duplication whereverpossible, it must be understood, and explainedto the consumer / patient, that there are certaincircumstances in which repetition of questioning isa deliberate and necessary safety precaution. Thisincludes such aspects of care as consent, consumer /patient identification, and blood and blood componentmanagement, which are discussed within Criteria 1.1.3,1.5.6 and 1.5.5, respectively.¼¼How does the organisation assistexcluded consumers / patients to receiveappropriate care?Prompt pointsAdmissionIn the first instance, admission refers to theadministrative process by which an individual’s detailsare entered into the organisation’s systems so that thecare journey may begin. However, it is important torecognise that, depending upon the nature and sectorof the organisation, admission does not necessarilyrequire the provision of accommodation, or access to aspecific facility.Furthermore, the consumer / patient may not need toattend the facility in order to be admitted; while theorganisation’s duty of care towards the consumer /patient may begin before there is any direct contact.In private hospitals, admission generally occurs whenthe consumer / patient attends at an appointed time.The process may need to incorporate approval fromrelevant private insurers and/or the confirmation ofalternative payment options. Conversely, when aconsumer / patient self-presents at an Accident &Emergency Department, access may or may notbe followed by admission. Triage will determine theorganisation’s course of action, including prioritisationof care and admission where appropriate. However, theorganisation’s duty of care commences at the momentof presentation. Organisations should ensure that thereis policy that outlines when a consumer / patient isconsidered to have been admitted to the health serviceand when the duty of care commences.Organisations will have procedures in placeto facilitate admission, which should includedissemination of information to all necessary partieswhile respecting the consumer / patient’s right toprivacy and confidentiality. It is important that theorganisation consider the process of admission fromthe perspective of the consumer / patient and makeimprovements as required. Repeated requests for thesame information and duplication of forms can makeadmission unnecessarily frustrating and tiresome.¼¼When, in this organisation, is a consumer /patient considered to be ‘admitted’? Must aconsumer / patient attend at the organisationto be admitted? Must he or she be admitted toreceive a service?¼¼¼¼How does the organisation avoid duplicationof information collection upon consumer /patient admission?How is consumer / patient satisfaction withadmission processes determined? How oftenis this done?Continuity of careIn order to ensure continuity of care, the organisationmust have integrated processes that allow thecollection, dissemination and transfer of all necessaryinformation between all necessary parties. 6 Continuityof care requires that each clinician who sees aconsumer / patient in a multidisciplinary environmentis aware of what is known about the consumer /patient and of what actions have been taken by others.Continuity of care will help to ensure that:• diagnostic tests and imaging are not repeated• significant medical history is not omitted• there is an accurate history, particularly in regardsto allergic reactions and medication complications• medications or other therapies that failed toproduce a desired response are not repeated• clinicians do not need to rely on recollections ofconsumers / patients, their families and/or carers,which may be unreliable.October 2010 121

Section 5Standards, criteria, elements and guidelinesStandard 1.2: Consumers / patients / communities have accessto health services and care appropriate to their needsCriterion 1.2.2Access and admission / entry to the systemof care is prioritised according to healthcareneeds. (continued)Well-managed continuity of care also provides forthe transfer of information between the organisationand those outside of the organisation also involved inthe provision of care. 7 When a consumer / patient isreferred, the details provided should be incorporatedinto the health record, to ensure that it reaches allclinicians involved in the episode of care. This is alsothe case where an internal referral occurs within amultidisciplinary facility. Similarly, there is a need forthe organisation to have processes for the provisionof information concerning the care episode to relevantexternal clinicians.The organisation should regularly evaluate itsapproach to continuity of care, and seek feedbackfrom those providing / receiving referrals, in orderto gauge their satisfaction with the organisation’sadmission processes and transfer of information.Prompt pointsEvidence commonly presentedConsider whether the following willhelp to address criterion 1.2.2¼¼¼¼¼¼Policies on triagePolicies on prioritisationAdmission policy, including the documentedeligibility criteria¼¼Referral information for ineligible consumers /patients in line with criteria¼¼¼¼¼¼¼¼¼¼ICU access policyTheatre listsEvaluated data from waiting listsResults of patient satisfaction surveyswhich have included questions on theadmission processResults of referrer satisfaction surveys onthe admission process and the transferof information¼¼¼¼¼¼What are the organisation’s actions uponreceiving a referral?How does the organisation ensure the transferof all relevant information when arranging thetransfer of a consumer / patient to anotherhealthcare facility?How does the organisation ensure the referralis actioned in a timely manner?122 The ACHS EQuIP5 Guide Book 1 Accreditation, Standards and Guidelines Clinical Function

Performance measurementThis criterion states that: “Access and admission / entry to the system of care is prioritised according to healthcareneeds”. While providing access to health care, the organisation must have processes in place to determine theeligibility of consumers / patients, and the conditions under which they might be excluded; and to ensure that theprovision of care is prioritised according to clinical need. The organisation should also have systems for facilitatingcontinuity of care via its admission process, and the transfer of information between referrers and providers.Some common suggested performance measures are as follows:Number of consumers / patients waiting more than X weeks for urgent surgeryTotal number of consumers / patients booked for urgent surgeryComment: organisation to define ‘X’ and category of surgeryNumber of consumers / patients waiting more than X weeks for elective surgeryTotal number of consumers / patients booked for elective surgeryComment: organisation to define ‘X’ and category of surgeryNumber of new consumers / patients waiting more than X weeks for service appointment from date of requestTotal number of consumers / patients booked for a specific service appointmentComment: organisation to define ‘X’; service appointments include outpatient services,allied health and medical services.Number of consumers / patients having procedures cancelled by the hospital on the day of surgery dueto unavailability of beds / theatre closureTotal number of consumers / patients booked for a procedureComment: it is recommended that the reasons for cancellation be collectedNumber of consumers / patients waiting more than X days between initial referral contact and assessmentor first serviceTotal number of consumers / patients admitted to the serviceComment: organisation to define ‘X’Number of referrers satisfied with the organisation’s processes and timeliness for transfer of informationTotal number of referrers surveyedOctober 2010 123

Section 5Standards, criteria, elements and guidelinesStandard 1.2: Consumers / patients / communities have accessto health services and care appropriate to their needsCriterion 1.2.2Access and admission / entry to the system of care is prioritised according to healthcare needs.(continued)Number of consumers / patients satisfied with the organisation’s admission processesTotal number of consumers / patients surveyedNumber of consumers / patients transferred / referred / advised of options following exclusionTotal number of consumers / patients excludedReferences1. Australasian College for Emergency Medicine (ACEM).Access block and overcrowding in Emergency Departments.Melbourne VIC; ACEM; 2004.2. Services for Australian Rural and Remote Allied Health(SARRAH). Prioritisation and demand management.Accessed from http://www.sarrahtraining.com.au/ on31 August 2010.3. Ben-Tovim DI, Dougherty ML, O’Connell TJ and McGrathKM. Patient journeys: the process of clinical redesign.Med J Aust 2008; 188(6): S14–S17.4. Australian Department of Health and Ageing (DoHA).The state of our public hospitals: June 2010 report.Canberra ACT; DoHA; 2010.5. Ben-Tovim DI, Bassham JE, Bennett DM et al. Redesigningcare at the Flinders Medical Centre: clinical processredesign using “lean thinking”. Med J Aust 2008;188(6 suppl): S27–S31.6. National E-Health Transition Authority (NEHTA). The NEHTAcontinuity of care program is a national initiative enablingefficient transfer of information between clinicians to improvethe transfer of patient care. Continuity of Care Bull 2010;1: 1–2.7. Pelletier D, Duffield C and Donoghue J. Documentation andthe transfer of clinical information in two aged care settings.Aust J Adv Nurs 2005; 22(4): 40–45.Further readingClinical Excellence Commission (CEC). Improving patientaccess to acute care services: A practical toolkit for use in publichospitals. Sydney NSW; CEC. Accessed from http://www.cec.health.nsw.gov.au/pdf/toolkit.pdf on 6 September 2010.124 The ACHS EQuIP5 Guide Book 1 Accreditation, Standards and Guidelines Clinical Function

Section 5Standards, criteria,elements and guidelines1.3 Appropriateness StandardThe standard is:Appropriate care and services are provided toconsumers / patients.The intent of the appropriateness standard andcriterion is to ensure that consumers / patients receiveappropriate and necessary care, interventionsand services.There is one criterion in this standard. This is:1.3.1 Health care and services are appropriate anddelivered in the most appropriate setting.Appropriateness is doing the right treatment,intervention or service in the right way andeffectiveness is the extent to which thosetreatments, interventions or services achieve thedesired outcomes.October 2010 125

Section 5Standards, criteria, elements and guidelinesStandard 1.3: Appropriate care and services are providedto consumers / patientsCriterion LA – Awareness SA – ImplementationLA plus the followingCriterion 1.3.1Health care and servicesare appropriate anddelivered in the mostappropriate setting.a) Documented processesexist on how the organisationassesses the appropriatenessof care.b) Policy / guidelines exist on howto assess the appropriatenessof the setting in which careis provided.c) Clinical guidelines areused to guide appropriatecare delivery.a) The organisation has a strategyto ensure the appropriate useof interventions and services.b) Service planning includesan evaluation of theappropriateness of theservices to be provided.c) The organisation collects asuite of key indicators relatingto appropriateness of care.IntentIn health care, appropriateness is about doing whatis necessary, and not doing what is not necessary.Appropriate care is reflected in positive careoutcomes, and in the extent to which the consumer /patient’s needs and wants are met.The intent of this criterion is to ensure that consumers /patients receive appropriate and necessarycare, interventions and services in the mostappropriate setting.Relationships of 1.3.1 with other criteriaAppropriateness should be evident throughout thejourney of care (Standard 1.1). The processes ofaccess and admission and the use of inclusion andexclusion criteria (Criterion 1.2.2) will ensure thatcare is delivered in the most appropriate setting.Assessment (Criterion 1.1.1) and care planning(Criterion 1.1.2) will determine what is appropriate forthe consumer / patient; while the care subsequentlygiven will be not only appropriate, but delivered inthe most effective way (Criterion 1.4.1) by clinicianswho are credentialled and performing within theirdefined scope of practice (Criterion 3.1.3). Appropriatecare will be reflected in positive health outcomes(Criterion 1.1.4).Research can help to determine the appropriatenessof specific health interventions (Criterion 2.5.1),while quality improvement programs may assistin promoting adherence to best-practice clinicalguidelines and broaden the delivery of appropriatecare (Criterion 2.1.1).Ensuring appropriateness of care is an aspect of theorganisation’s integrated risk management framework(Criterion 2.1.2). Inappropriate care, or care deliveredin inappropriate settings, may lead to incidents(Criterion 2.1.3) and complaints (Criterion 2.1.4).Appropriateness of careAppropriateness is the degree to which service isconsistent with a consumer / patient’s expressedrequirements and is provided in accordance withcurrent best practice. 1 It refers to the relative weightof the benefits and harms of a medical or surgicalintervention. An appropriate procedure is one inwhich the expected health benefit (e.g. increasedlife expectancy, relief of pain, reduction in anxiety,improved functional capacity) exceeds the expectednegative consequences (e.g. mortality, morbidity,anxiety, pain, time lost from work) by a sufficientlywide margin that the procedure is worth carrying out,exclusive of cost. 2126 The ACHS EQuIP5 Guide Book 1 Accreditation, Standards and Guidelines Clinical Function

MA – EvaluationSA plus the followinga) The system for assessingthe appropriateness of careand services is evaluated byclinicians and management,and improved as required.b) Healthcare providers, includingclinicians and managers and/orconsumers, are involved in theevaluation of appropriatenessof care.c) Indicators for appropriatenessof care and services areevaluated and improvementsare made as required.EA – ExcellenceMA plus the followinga) The system for ensuringappropriateness of care iscompared externally andimprovements are made toensure better practice.and/orb) The organisation publishescomparative datademonstrating improvementsin appropriateness.and/orc) The organisation researchesthe appropriateness ofparticular interventions andacts on results.OA – LeadershipEA plus the followinga) The organisation demonstratesit is a leader in providingappropriate care and servicesin the appropriate setting.Inappropriate care can result from either:• underuse, such as the failure to provide a servicewhich has a benefit that is greater than the risk• overuse, when a health service is provided eventhough the risk outweighs the benefit.The question of appropriateness of care is applicable toall healthcare settings and modes of service delivery.There are three levels of appropriateness:• The national level• The organisation level• The clinician level.National level – This level encompasses work thathas been done by medical, nursing and alliedhealth professional bodies, jurisdictions, and otherindustry bodies in relation to appropriateness. Forexample, the National Health and Medical ResearchCouncil (NHMRC) has developed guidelines for theappropriate use of blood transfusions 3 , with which mosthealth services comply.Organisation level – This level should be the focus ofthe appropriateness criterion for both organisationsand surveyors when assessing and reviewingappropriateness.An organisation is responsible for ensuring that thereis a process for determining the appropriatenessof treatments, interventions and services, and thestrategy for accomplishing this should be availableto relevant staff.Systems that may support the assessment andevaluation of appropriateness include the credentiallingand scope of clinical practice system, peer reviewmeetings and/or clinical audit reviews. As the deliveryof appropriate care is dependent upon many factors,aspects to consider include:• What is the size of the organisation?• Are clinicians with expertise in undertakingspecific procedures available? Are they correctlycredentialled with the necessary scope ofpractice? What supervision is available?• What facilities and resources are required toensure that care is appropriate? For example,plant and equipment, emergency department,inpatient care?• What backup is available if required, such asintensive care or a senior consultant?• What corporate and support structures andsystems are in place, such as clinical governanceor quality improvement mechanisms, clinical auditsor a credentialling system?October 2010 127

Section 5Standards, criteria, elements and guidelinesStandard 1.3: Appropriate care and services are providedto consumers / patientsCriterion 1.3.1Health care and services are appropriateand delivered in the most appropriate setting.(continued)Many services already use inclusion andexclusion criteria to enable the appropriateadmission of consumers / patients to their service.Examples include:• admission to a day surgery or children for surgerywhere there are no dedicated facilities, as outlinedby the Australian and New Zealand College ofAnaesthetists 4, 5 in their professional standardsand The Royal Australian College of PhysiciansStandards for the care of children and adolescentsin health services, 6 or• admission to a post traumatic stress disordertreatment program as outlined by the AustralianCentre for Post Traumatic Mental Health or therelevant Workers Compensation system.Further information on inclusion and exclusion criteriais available in criterion 1.2.2.Serious issues are also raised about whetherorganisations should provide services that areconsidered in the literature to be of little benefit,unnecessary or inappropriate, simply because theconsumer / patient has requested it.Many thousands of interventions are provided toconsumers / patients in Australian health servicesevery day. The challenge is to ensure that as many ofthose interventions as possible are needed and aregoing to provide benefit to the consumer / patient.There is a strong correlation between the effectivenessand the appropriateness of an intervention.Organisations should also take into account anyresearch or quality improvement work beingundertaken that specifically relates to appropriate useof interventions. For example, a healthcare organisationmay undertake research on how to improve adherenceto scientific evidence and clinical practice guidelinesto reduce variation in the management of consumers /patients with the same clinical condition.Prompt pointsClinician level – The clinician is responsible fordetermining the most appropriate test, procedureor intervention for a consumer / patient, and fordiscussing the appropriateness with the consumer /patient and then documenting this discussion in thehealth record. Appropriate care or treatment should bebased on established and accepted standards, suchas evidence-based clinical guidelines or the treatmentprotocols used in oncology, electroconvulsive therapy 7and the treatment of adults with acute stress disorderand post traumatic stress disorder. 8¼¼¼¼¼¼What policies address appropriatenessof services? Are there policies aboutappropriateness of settings?How does the organisation access evidencebasedguidelines? How are these madeavailable to relevant staff?Do service planning documents addressappropriateness? What evaluation of thesedocuments has occurred?Treatments for similar conditions may vary accordingto the consumer / patient needs and this may take intoaccount factors such as:• allergies or adverse reactions• preference for treatment at home or ina medical facility• a choice between aggressive treatmentversus palliative care• elective versus emergency procedures• the stage of the disease process or severityof injury• cultural influences and religious beliefs.An appropriate settingThe appropriateness of the setting in which care isprovided is determined by matching consumer / patientneeds for treatment with the setting in which it shouldbe provided; this may vary from individual to individual.This aspect is closely related to the processes ofcredentialling and defining clinicians’ scope ofpractice, as addressed within Criterion 3.1.3.Appropriate services can be provided in inappropriatesettings. For example, major surgery should not beundertaken in an environment where senior consultantand/or potential intensive care back up is unavailable,or too far away. An individual recently diagnosedwith diabetes will require several interventions, but inmost cases it will not be necessary for these servicesto be provided as an inpatient. They should moreappropriately be provided as ambulatory services.128 The ACHS EQuIP5 Guide Book 1 Accreditation, Standards and Guidelines Clinical Function

Co-location of children and adolescents with adults inhealth services is a common practice. Organisationsshould consider the medical and psychosocial needsof children and adolescents as different from thoseof adults when allocating beds / wards. The RoyalAustralian College of Physicians has developedStandards for the care of children and adolescents inhealth servicesI 9 , available at: http://www.racp.edu.au/page/policy-and-advocacy/paediatrics-and-childhealth.The goal of the standards is to ensure thatchildren and adolescents attending health servicesreceive quality care in an environment that is safe andappropriate for their age and stage of development.As health care is increasingly being delivered outsideof the inpatient setting, consideration should alwaysbe given to the most appropriate setting for theprovision of care. Support for self management ofchronic conditions is most appropriately deliveredin ambulatory care or community settings, with thepotential for some aspects to be provided in a sportingfacility, such as a gym or hydrotherapy pool, underthe supervision of allied health professionals. Runningregular allied health clinics located, and in partnershipwith a local Aboriginal and Torres Strait Islandercooperative, can increase the access to physiotherapyor other allied health treatments by Aboriginal andTorres Strait Islander consumers / patients.When either the appropriateness of a setting or of theintervention is considered 10 , it is assumed that servicesare provided in a high quality, safe and technicallycorrect manner. However, in the case of inappropriatehealthcare delivery, the setting and service should beconsidered separately. A service that is inappropriatefor a specific type of consumer / patient should not beprovided in any setting. If the service is appropriate butthe setting is inappropriate, the care could be providedin an alternative setting.When considering care settings, the assessment ofappropriateness will depend on the availability ofalternative settings, such as moving new mothersto hotel rooms 11 , or delivering intravenous antibiotictreatment for an acute but stable condition via aHospital In The Home program if the home environmentis assessed as suitable.Prompt points¼¼¼¼What processes are used to evaluatethe appropriateness of setting for theorganisations procedures?How is appropriateness of setting includedwhen any proposed change to a clinical serviceis assessed for feasibility?Assessing appropriatenessAppropriateness of the service can be examined onan individual consumer / patient basis or by taking anorganisational approach.Appropriate care for a consumer / patient isconsidered to be relevant to their needs and basedon established standards. The questions to be askedcould be:• Is the treatment / intervention / service basedon established standards?• Is the treatment / intervention / service providedrelevant to this consumer / patient’s needs?The approach that considers the appropriatenessof the care or service provided to an individualunderpins clinical peer review activities, where careprovided to an individual is compared against anormative standard of care. This may be documentedin several ways including a clinical pathway, and/oragainst intervention / care selection criteria. Basedon the best available evidence, a list of criteria canbe developed to determine when it is appropriateto use a certain intervention. This will provide moreassurance to the consumer / patient, the organisationand the funders of health care that those interventionsrecommended are only undertaken in the mostappropriate circumstances. Examples of proceduresthat should be used only when determined to beappropriate are hysterectomies in young women, andtonsillectomies.October 2010 129

Section 5Standards, criteria, elements and guidelinesStandard 1.3: Appropriate care and services are providedto consumers / patientsCriterion 1.3.1Health care and services are appropriateand delivered in the most appropriate setting.(continued)When using admission rates to improve theappropriateness of care it should be borne inmind that:• the rates need to be focused on a specificadmission type or procedure group• determining the ‘right rate’ is extremelycomplex and is not necessary to improve theappropriateness of care• there may be advantages in comparing data withhigh-rate, median-rate and low-rate organisations• active participation by clinicians at the local level inidentifying relevant local factors and implementingstrategies is essential. The importance of involvingat least one locally recognised leading cliniciancannot be over-emphasised• no single technique will be effective in allinstances, and a combination of techniques willbe required.When an organisation reviews the appropriateness ofits service provision, variations between consumers /patients may be considered and hints gainedfrom statistical analysis. However, while review ofsuch analysis may identify variations in utilisationpatterns, alone this will not allow conclusions to bemade regarding the appropriateness of the servicesprovided. If variations are found, analysis of thereasons for the differences will be required.Evidence of inappropriate care can be seen in datathat would indicate either overuse or underuse ofservices. The ability to determine and identify whichcare is overused and which is underused is essential.Incident management data can also be utilised toassess appropriateness of care.The National Institute of Clinical Studies has identifieda series of interventions that, despite evidence of theireffectiveness, are inconsistently actioned by Australianhealthcare providers. 12 It may be feasible to assesswhether and how these interventions are used bythe organisation. Information on these interventions isavailable at: http://www.nhmrc.gov.au/nics/material_resources/resources/identifying_barriers.htmExamining admission rates for particular conditionsand rates of particular interventions (relative utilisationrates) may give an organisation some idea of theappropriateness of those admissions and interventions.Large variations in admission rates or relativeutilisation rates over time or between departmentsor facilities are signals of inconsistencies in thefactors affecting admission and intervention use.These signals could identify opportunities to achievebetter health outcomes for individual consumers /patients through quality improvement processes andadopting best practice. Where variations are seen,the healthcare organisation has a responsibility toexamine the reasons for the variation and improveappropriateness of care where necessary.Health services will need to identify a suite ofperformance indicators that are relevant to the servicesthey provide. Performance indicators may be, but arenot always, clinical; financial outcomes may also berelevant in a few limited circumstances. While the bestindicators show changes in outcome, many outcomesare based on multiple inputs, making it difficult todetermine the driver for the changes observed. Inthese cases, indicators that demonstrate a processhas been followed may be more useful.Further benefit will be gained from indicators ifthere are opportunities for comparison with similarhealth services, which may create opportunities toconsider appropriateness of care through evaluationof the data. Further review with input from staffoperating the relevant service(s) will be needed todetermine sources of variation and whether thereare opportunities for positive change. There areseveral well-documented methods for examining andmaintaining, or increasing the level of, appropriatenessand progressively reducing inappropriate care.Clinical information in the health record canbe reviewed to determine the indicators for theinterventions and any relevant risk factors orco-existing illnesses. To assess the appropriatenessof the setting, the health record may be reviewed todetermine the severity of the illnesses and the intensityof services needed to care for the consumer / patient.Where sample sizes are large enough, consumers /patients experiencing a similar intervention andmatched by severity of illness or other risk factors,could be compared between settings. This techniquecan be very useful when the intervention involvesvariations in education / training, such as betweenindividuals newly diagnosed with Type 2 diabetestrained in diabetes management in a large groupworkshop, and those given personal consultationswith different professionals.130 The ACHS EQuIP5 Guide Book 1 Accreditation, Standards and Guidelines Clinical Function

Prompt points¼¼¼¼¼¼What indicators are used to evaluate theappropriateness of care?How are clinicians involved in the evaluationof appropriateness of care? What other staffmembers are involved?How are consumers involved in the evaluationof appropriateness?Evidence commonly presentedConsider whether the following willhelp to address criterion 1.3.1¼¼¼¼¼¼¼¼¼¼¼¼¼¼¼¼¼¼¼¼¼¼¼¼¼¼Policies, guidelines and proceduresAdherence to by-lawsEvidence of the use of criteria ofappropriateness, such as Criteria ofAppropriateness of Blood Transfusions(NHMRC guidelines)Evidence of the use of analysis of indicatorsof appropriatenessClinical service plansDemographic / population studies and dataOrganisational profileConsumer / patient pathways / care plansContracts with other service providers suchas Home and Community Care (HACC)Operational planNew interventions policyStaffing levels and skill mixEducationOctober 2010 131

Section 5Standards, criteria, elements and guidelinesStandard 1.3: Appropriate care and services are providedto consumers / patientsCriterion 1.3.1Health care and services are appropriate and delivered in the most appropriate setting.(continued)Performance measurementThis criterion states that: “Health care and services are appropriate and delivered in the most appropriate setting”.The organisation should have policy, by-laws, guidelines and/or procedures in place to ensure that consumers /patients receive appropriate care in the most appropriate setting, while avoiding wherever possible, inappropriatecare in an inappropriate setting. It should be recognised that the organisation itself is not always the mostappropriate setting for consumer / patient care.Some common suggested performance measures are as follows:Note: Utilisation rates for surgical, medication or diagnostic interventions are useful indicators for monitoringcompliance with published best-practice guidelines. Rates may be determined using data based onICD-10-AM, Medicare Benefits Schedule or Diagnostic Related Group codes.The National Institute of Clinical Studies (NICS) has identified a number of areas where clinical practice does notalways reflect the best evidence. Change in these areas is likely to result in more appropriate care. Organisationsshould consider whether monitoring their performance in these areas would promote more appropriate care.For more information, see: National Institute of Clinical Studies (NICS). Evidence-Practice Gaps Report: A reviewof developments: 2004–2007. Vol. 1. Canberra ACT; National Health and Medical Research Council; 2008.This document can be accessed from the NICS website: http://www.nhmrc.gov.au/nics/index.htmNumber of admissions for selected potentially preventable hospitalisationsTotal number of admissionsComment: e.g. diabetes / asthma; ‘preventable hospitalisation’ to be defined by the organisationNumber of provided services with identified / documented criteria of appropriatenessTotal number of provided services in a particular organisation / in a particular locationComment: consider the blood NHMRC guidelines as an example. Organisational policy may identifycriteria of appropriateness for a particular interventionNumber of smokers / non-smokers who presented for screening chest x-raysTotal number of chest x-raysNumber of consumers / patients receiving treatment from the service for a common cold or acute bronchitiswho are prescribed antibioticsTotal number of consumers / patients receiving treatment from the service for a common cold and / oracute bronchitis132 The ACHS EQuIP5 Guide Book 1 Accreditation, Standards and Guidelines Clinical Function

Number of consumers / patients undergoing postoperative colorectal cancer surveillance who undergo acolonoscopy for surveillance within 3 yearsTotal number of consumers / patients undergoing postoperative colorectal cancer surveillanceNumber of consumers / patients prescribed contraindicated medicationTotal number of prescriptionsNumber of clinical interventions that varied from clinical guidelines / best-practice protocols withoutdocumented rationalisation for variationTotal number of health records auditedReferences1. International Society for Quality in Health Care (ISQua).The ISQua surveyor training standards programme.Dublin IRL; ISQua; 2009.2. Brook RH, Chassin MR, Fink A et al. A method for thedetailed assessment of the appropriateness of medicaltechnologies. Int J Technol Assess Health Care 1986(Reprint 1991); 2(1): 53-63.3. National Health and Medical Research Council (NHMRC)and Australasian Society of Blood Transfusion (ASBT).Clinical practice guidelines on the use of blood components.Canberra ACT; NHMRC & ASBT; 2001.4. Australian & New Zealand College of Anaesthetists(ANZCA). PS29: Statement of anaesthesia care of childrenin healthcare facilities without dedicated paediatric facilities.Sydney NSW; ANZCA; 2008.5. Australian & New Zealand College of Anaesthetists(ANZCA). PS15: Recommendations for the perioperativecare of patients selected for day surgery. Sydney NSW;ANZCA; 2006.6. Royal Australasian College of Physicians (RACP). Standardsfor the care of children and adolescents in health services.Sydney NSW; RACP; 2008.7. Royal Australian and New Zealand College of Psychiatrists(RANZCP). Clinical Memorandum #12: Guidelines onthe administration of electroconvulsive therapy (ECT).Melbourne VIC; RANZCP; Revised 2007.8. Australian Centre for Post-traumatic Mental Health.Australian guidelines for the treatment of adults withacute stress disorder and post-traumatic stress disorder.Melbourne VIC; National Health and Medical ResearchCouncil (NHMRC); 2007.9. Royal Australasian College of Physicians (RACP). Standardsfor the care of children and adolescents in health services.Sydney NSW; RACP; 2008.10. Hunter DJ. Measuring the appropriateness of hospital use.Can Med Assoc J 1997; 154(3): 901–902.11. Benson K. Suite deal for new mums. Sydney Morning Herald,Sydney NSW; Fairfax; 9 October 2008.12. National Institute of Clinical Studies. Identifying barriersto evidence uptake. Melbourne VIC; NICS; 2006.October 2010 133

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Section 5Standards, criteria,elements and guidelines1.4 Effectiveness StandardThe standard is:The organisation provides care and services thatachieve effective outcomes.The intent of the Effectiveness standard and criterionis three fold. It is to ensure that:• healthcare organisations use interventionsthat have been proven to be effective• all other care, services and interventionsare based on the best available evidence• care is provided in the most effectiveway possible.There is one criterion in this standard. This is:1.4.1 Care and services are planned, developedand delivered based on the best availableevidence and in the most effective way.Appropriateness is doing the right treatment,intervention or service in the right way andeffectiveness is the extent to which thosetreatments, interventions or services achieve thedesired outcomes.October 2010 135

Section 5Standards, criteria, elements and guidelinesStandard 1.4: The organisation provides care and servicesthat achieve effective outcomesCriterion LA – Awareness SA – ImplementationLA plus the followingCriterion 1.4.1Care and services areplanned, developed anddelivered based on thebest available evidence andin the most effective way.a) Documented processes existfor implementing best availableevidence into clinical practice.b) Policy / guidelines exist onhow to manage and minimiserisk to consumers / patientsaccommodated outside thespecialty ward area.a) The organisation supportshealthcare providers in theimplementation of evidencebasedcare.b) Care process mapping isdocumented and undertakenby a multidisciplinary teamwhen applicable.c) Policy and proceduresare implemented for themanagement of consumers /patients accommodatedoutside the specialty wardarea to ensure care is safeand effective.IntentThe intent of the Effectiveness standard and criterion isthree-fold. It is to ensure that:• healthcare organisations use, as first line,interventions that have been proven to be effective• all other care, services and interventions arebased on current best available evidence• care is provided in the most effective way possible(as confirmed by evaluation).Relationships of 1.4.1 with other criteriaThe effectiveness of health care is significantlyconnected with all aspects of the care journey(Standard 1.1). Care planning and delivery(Criterion 1.1.2), consumer / patient access(Criterion 1.2.2) and processes for ongoing care(Criterion 1.1.6) will all impact upon effectiveness,which is closely associated with, but distinctfrom, appropriateness. While appropriate care(Criterion 1.3.1) relates to providing the right treatment,intervention or service in the right way, effectivenessaddresses the extent to which those treatments,interventions or services achieve desired outcomes.Effectiveness of care should be evident whenevaluating outcomes of clinical care (Criterion 1.1.4).Evidence-based care should be embedded in theorganisation’s policies and procedures (Criterion3.1.5). Planning, development and delivery of effectivecare based upon the best available evidence isan aspect of the organisation’s integrated riskmanagement framework (Criterion 2.1.2), and failuresin this area may lead to incidents (Criterion 2.1.3) andcomplaints (Criterion 2.1.4).Implementing evidence-based practiceThe effectiveness of health care relates to theextent to which a treatment, intervention or serviceachieves the desired outcome, and follows on fromthe appropriateness of that treatment, interventionor service.In 2009, the National Health Performance Framework, 1designed for measuring health system performance,was updated. Effectiveness was identified as one ofthe six key domains of health system performance,with the other domains being safety, responsiveness,continuity of care, accessibility, and efficiencyand sustainability.136 The ACHS EQuIP5 Guide Book 1 Accreditation, Standards and Guidelines Clinical Function

MA – EvaluationSA plus the followinga) Indicators are used to evaluatethe use of evidence-basedcare and improvements aremade as required.b) Processes for ensuring the useof effective care, services andpractice are evaluated andimproved as required.c) Processes for managingconsumers / patientsaccommodated outside thespecialty ward are evaluatedand improved as required.EA – ExcellenceMA plus the followinga) The system for ensuring theuse of effective practice iscompared externally andimprovements are made toensure better practice.and/orb) The organisation benchmarksidentified key careprocesses and outcomeswith like organisations, andimprovements are made toensure better practice.and/orc) The organisation undertakesresearch into the effectivenessof interventions and servicesand the adoption of evidenceinto practice.OA – LeadershipEA plus the followinga) The organisation demonstratesit is a leader in effective,evidence-based care.In this context, effectiveness is defined as: care /intervention / action that is relevant to the consumer /patient’s needs and based on establishedstandards. Care, intervention or action achievesthe desired outcome.Organisations should consider the following questions 2 :• What is the right thing to do?• Did we do the right thing? (appropriateness)• Did we do the right thing 100% right?(effectiveness)There is evidence available to inform healthcareorganisations of the strategies and methods that canbe used to provide the most effective care, servicesand interventions.This standard and criterion require healthcareorganisations to focus on three key strategiesunderpinned by evidence demonstrating a contributionto more effective care and service delivery.They are:• using interventions / treatments that aredetermined to be most effective• using evidence in the development and deliveryof care and services and in the development andimplementation of policy and other practices• mapping and documenting key processes toensure that they will be undertaken in a consistentmanner in order to minimise variation.In the current healthcare environment, clinicians andmanagers can no longer rely solely on experience,rationale and opinion-based processes. Healthcareorganisations need to be sure that all policydevelopment, care processes and services are basedon the best available evidence.October 2010 137

Section 5Standards, criteria, elements and guidelinesStandard 1.4: The organisation provides care and servicesthat achieve effective outcomesCriterion 1.4.1Care and services are planned, developedand delivered based on the best availableevidence and in the most effective way.(continued)Policy should be in place that clearly describes how toidentify, access, critically select, implement, monitorand review the application of current, relevant bestpractice for all clinical practice that is provided bythe healthcare organisation. Clear processes andprocedures that guide the introduction and ongoingutilisation of evidence-based guidelines supportclinicians in putting such guidelines into practice.Regular review of this approach enables evaluationof the currency, relevance and effectiveness of suchpractice and provides opportunities to measure theeffectiveness of, and potentially revise, care provided.Clinical practice guidelines should be used wheneveravailable, and organisations should ensure that suchclinical practice guidelines are current. Best practicecan only be based on the best, currently availableevidence, as practices that are considered to bebest at one point in time can become redundant ifthe evidence changes as a result of advances inresearch. The National Health and Medical ResearchCouncil (NHMRC) has launched a national ClinicalPractice Guidelines Portal that provides links to currentAustralian guidelines developed by governments,professional colleges, specialty societies and nongovernmentagencies. These can be accessed at:http://www.clinicalguidelines.gov.auThe National Institute of Clinical Studies (NICS) inAustralia has also published several reports 3,4,5 thatraise awareness of, and review, the gaps between whatis known from the best available research and what isactually done in current daily practice over time. Thelatest report looks at the evidence, data on currentpractice and new policies and initiatives, and providesan update for each of the following identified evidencepracticegaps 5 :• advising on smoking cessation• advising on smoking cessation in pregnancy• screening for lung cancer with chest X-rays• preventing stroke in consumers / patients withatrial fibrillation• using ACE inhibitor and beta-blocker therapiesin heart failure• measuring glycated haemoglobin in diabetesmanagement• prescribing antibiotics for upper respiratorytract infections and acute bronchitis• preventing venous thromboembolism inhospitalised patients• preparing for elective colorectal surgery• using colonoscopy in colorectal cancer surgeryfollow-up• managing acute and cancer pain in hospitalisedconsumers / patients.Different interventions are more relevant in differenthealthcare settings. The listing of these areas in whichthere is an identified evidence-based practice gap isnot intended to suggest that all health services needto provide all identified initiatives to help close thegaps. Health services need to assess which of these,and any other proven interventions, are appropriate totheir case mix and how they will ensure their consistentuse in all relevant circumstances. Just as importantas increasing the uptake of beneficial forms of careis the removal of harmful or ineffective practices, andprocesses to guide this should also be in place.Prompt points¼¼¼¼¼¼What is the process for appraising andimplementing best available evidenceinto clinical practice?What methods are used to supportand encourage the implementation ofevidence-based care?How are these evaluated? What improvementshave been made from this evaluation?Key care processes mappedand recorded by a teamOrganisations need to be assured that clinicalteams are examining the evidence available whendetermining care plans and clinical pathways. It isrecognised that some proven interventions may becost-prohibitive and that not all proven interventionswill necessarily be available for use in all relevantcircumstances, such as new drugs that are not yeton the Pharmaceutical Benefits Scheme. Further,implementation may be dependent on many externalfactors, for example, government purchasing policiesand practices, corporate office policies, etc.138 The ACHS EQuIP5 Guide Book 1 Accreditation, Standards and Guidelines Clinical Function

The best way for healthcare organisations to ensurethat they provide care and services in the mosteffective way is to:• understand their most common careprocesses, including the admission andpre-operative processes• document the best way to carry outthose processes• put mechanisms in place to ensure that allwho are involved understand and carry out theprocess in this expected way.It is not expected that a care map or processflow chart will suit all consumers / patients with aparticular condition. It can be expected, however, thatapproximately 80% of individuals with a particularcondition will require the same components of care.Examination of the variation from this pathway shouldlead to improvements.In larger organisations, the purpose of processredesign is to achieve effective care from a consumer /patient perspective. This means identifying wheredelays, unnecessary steps or potential threats are builtinto the process and then redesigning the processto remove them, thus improving the quality of care.Typical steps in such a process might include:• mapping the existing care process(sometimes described as the ‘as is’ stage)• analysing where problems exist in that processand questioning why each step is done, by whom,where, in what sequence, and whether there is abetter way• imagining what an ‘ideal’ process might look like• identifying practical changes to the currentprocess to make it closer to the ideal process• testing these changes and evaluating whether theyresult in improvement. 6This process of review or redesign may result in aclinical pathway or care pathway, however named. Suchdocuments ensure that all steps in the process that areundertaken are necessary, that all multidisciplinary careproviders are aware of all necessary steps, and that noessential steps are forgotten.Prompt points¼¼¼¼How are key care processes identified andmapped? Who is involved?How are they evaluated? What improvementshave resulted from evaluation?Evidence-based treatment outsidethe specialty wardA consumer / patient accommodated outside thespecialty ward area is one who is being treatedin an area of the health service that normallytreats a different case mix. A consumer / patientaccommodated outside the specialty ward area maybe known as a ‘home-ward outlier’. For example, aconsumer / patient with a medical condition such asdiabetes may be admitted to a surgical ward becauseof a shortage of available beds. Where a child isadmitted to a non-paediatric ward, organisationsshould refer to the Standards for the care of childrenand adolescents in health services 7 that have beendeveloped for use in the Australian healthcaresystem. The goal of these standards is to ensure thatchildren and adolescents attending health servicesreceive quality care in an environment that is safe andappropriate for their age and stage of development,and organisations should refer to these where bothchildren / adolescents and adults are cared for.The Standards are relevant to all areas of the healthservice, including inpatient wards, intensive care units,emergency departments, day-care facilities, surgeryand recovery, outpatients, ambulatory care andcommunity health centres. The Standards are availablefrom: http://www.racp.edu.au/page/child-adolIt may be considered that a consumer / patient whosuffers from dementia is a ‘home-ward outlier’ in anyenvironment, especially if they are the only consumer /patient in that area suffering from dementia. In a dayprocedure centre, a consumer / patient undergoingorthopaedic surgery who is added to the end of anophthalmic surgical list is also a ‘home-ward outlier’consumer / patient.Consumers / patients accommodated outside thespecialty ward area are at greater risk of beingforgotten or receiving the wrong treatment and/ormedications, and of increased length of stay andincreased morbidity.In addition, signs of deterioration in a consumer /patient accommodated outside the home ward areoften missed, as the staff may be less familiar withthe condition for which the consumer / patient isbeing treated. 8Organisations must consider how to manage the risk ofconsumers / patients who have requirements beyondthe familiar expertise of the care unit. The processshould direct how staff manage the challenges of highconsumer / patient load and consumers / patients withcomplex disorders that require multidisciplinary input.October 2010 139

Section 5Standards, criteria, elements and guidelinesStandard 1.4: The organisation provides care and servicesthat achieve effective outcomesCriterion 1.4.1Care and services are planned, developedand delivered based on the best availableevidence and in the most effective way.(continued)Evidence commonly presentedConsider whether the following willhelp to address criterion 1.4.1¼¼Collection of clinical indicator dataPrompt points¼¼¼¼¼¼How does the organisation manageconsumers / patients accommodated outsidethe home-ward area?What methods have been used to evaluatethese processes?What changes have been made to theprocesses following evaluation?¼¼¼¼¼¼¼¼¼¼¼¼¼¼¼¼Changes in clinical indicators collectedEvidence-based policies, and clinicalpractice guidelinesIdentification of common care processesof principal conditions treatedProcesses to access information onnon-principal conditions treatedConsumer / patient feedbackInformation available on the use of clinicalpathways / care mapsAudits of clinical pathways/care mapsReview of unplanned readmissionsPerformance measurementThis criterion states that: “Care and services are planned, developed and delivered based on the best availableevidence and in the most effective way”. Organisations should be able to demonstrate that they deliver effectivecare based upon current, best-practice evidence. In assessing the effectiveness of care, organisations should askthe question, Did we do the right thing 100% right?Some common suggested performance measures are as follows:Note: Clinical indicators may be used as supporting evidence for this criterion. Please refer to the Clinical IndicatorSummary Guide on the ACHS website, http://www.achs.org.auNumber of unplanned re-presentations for a particular service within X days of dischargeTotal number of consumers / patients receiving a particular serviceComment: organisation to define ‘X’ in the context of the specific serviceNumber of clinical practice guidelines with evidence-based referencesTotal number of clinical practice guidelinesComment: consider policies and procedures as well as clinical practice guidelines140 The ACHS EQuIP5 Guide Book 1 Accreditation, Standards and Guidelines Clinical Function

Number of clinical care processes with documented stepsTotal number of clinical care processes in an organisation / service unitComment: an example of ‘documented steps’ is a flow chartNumber of children for whom a medication prescription was written but a current weight was not recordedTotal number of children receiving a medication prescriptionNumber of consumers / patients who have had a stroke and are commenced on a clinical pathway on admissionTotal number of consumers / patients who have had a strokeNumber of consumers / patients presenting with acute asthma who have a documented, completed, earlymanagement pathway or care plan in the health recordTotal number of consumers / patients with acute asthmaNumber of consumers / patients commencing haemodialysis with appropriate vascular accessTotal number of consumers / patients commencing haemodialysisComment: organisation to define ‘appropriate vascular access and timing of acute deterioration forwhich venous catheters may be considered appropriate’ based on their consumer / patientpool and surgical approach.Number of consumers / patients with osteoporosis-related fractures discharged on a preventative regimenTotal number of consumers / patients with osteoporosis-related fracturesComment: a ‘preventative regime’ may include, but does not imply, prescription medicationNumber of consumers / patients on in vitro fertilisation with documented recommended intake of folatein the periconceptual periodTotal number of consumers / patients on in vitro fertilisation treatmentOctober 2010 141

Section 5Standards, criteria, elements and guidelinesStandard 1.4: The organisation provides care and servicesthat achieve effective outcomesCriterion 1.4.1Care and services are planned, developed and delivered based on the best available evidenceand in the most effective way. (continued)Number of women receiving postnatal care provided with documented advice about placing infantson their backsTotal number of women receiving postnatal careNumber of consumers / patients with schizophrenia on atypical antipsychoticsTotal number of consumers / patients with schizophreniaNumber of consumers / patients with schizophrenia on more than one regular antipsychotic agentTotal number of consumers / patients with schizophreniaComment: measure of polypharmacyNumber of consumers / patients aged over 65 years prescribed regular benzodiazepines for more than 4 weeksTotal number of consumers / patients aged over 65 years prescribed regular benzodiazepinesReferences1. National Health Information Standards and StatisticsCommittee (NHISSC). National health performanceframework. 2nd edn. Canberra ACT; AIHW; 2009.2. Leape LL. Patient safety: What have we learned? Where arewe going? 4th Australasian Conference on Safety andQuality in Health Care. Melbourne VIC; 21–23 August 2006.3. National Institute of Clinical Studies (NICS). Evidencepracticegaps report. Vol. 2. Melbourne VIC; NICS; 2005.4. National Institute of Clinical Studies (NICS). Evidencepracticegaps report. Vol. 1. Melbourne VIC; NICS; 2003.5. Ireland P and National Institute of Clinical Studies (NICS).Evidence practice gaps report. A review of developments:2004–2007. Melbourne VIC; NICS; 2008.6. Locock L. Healthcare redesign: meaning, origins,application. Qual Saf Health Care 2003; 12(1): 53–58.7. Royal Australasian College of Physicians (RACP). Standardsfor the care of children and adolescents in health services.Sydney NSW; RACP; 2008.8. Garling P, SC. Final report of the special commissionof inquiry: Acute care services in NSW public hospitals.Sydney; NSW Special Commission of Inquiry; 2008.142 The ACHS EQuIP5 Guide Book 1 Accreditation, Standards and Guidelines Clinical Function

Section 5Standards, criteria,elements and guidelines1.5 Safety StandardThe standard is:The organisation provides safe care and services.This standard should be read in conjunction withcriteria 1.1.5 clinical handover / discharge / transferof care, 2.1.2 risk management, 2.1.3 incidentmanagement, 2.1.4 complaints management and3.2.5 security management.A degree of flexibility is provided in this standard.Some of the criteria will be more relevant to somehealthcare organisations than to others. The flexibilityin these criteria is explained in the guidelines undereach criterion. Organisations should determine thelevel of achievement required in each of these criteria.Further, organisations should determine thoseissues that do pose the biggest safety risks in theirorganisations. These should be managed effectivelyunder an alternative criterion, for example the riskmanagement criterion or the security managementcriterion for the management of aggression in mentalhealth services.The intent of this standard is to ensure that healthcareorganisations focus efforts on reducing harm toconsumers / patients and staff. This standard expectsthat organisations will develop a system for reducingthe incidence of harm, specifically the most commoncauses of harm in Western health systems. They are:• medication errors• healthcare acquired infections• breakdowns in skin integrity• falls• errors in the management of blood products• patient identification errors• malnutrition.There are seven criteria in this standard. They are:1.5.1 Medications are managed to ensure safe andeffective consumer / patient outcomes.1.5.2 The infection control system supports safepractice and ensures a safe environment forconsumers / patients and healthcare workers.1.5.3 The incidence and impact of breaksin skin integrity, pressure ulcersand other non-surgical wounds areminimised through wound prevention andmanagement programs.1.5.4 The incidence of falls and fall injuries isminimised through a falls managementprogram.1.5.5 The system to manage sample collection,blood, blood components / blood productsand patient blood management ensures safeand appropriate practice.1.5.6 The organisation ensures that the correctconsumer / patient receives the correctprocedure on the correct site.1.5.7 The organisation ensures that the nutritionalneeds of consumers / patients are met.Healthcare organisations should recognise thatensuring safety for both consumers / patients and allstaff requires a far broader focus than the seven issuescovered by this standard, and that efforts to improvesafety within an organisation should therefore extendbeyond these seven criteria. Potential for consumer /patient harm should be identified and prevented, withbarriers built into the system, making it resilient to theimpact of errors. Opportunities for staff harm should bemanaged in the same way.Several aspects of safety are dealt with in other EQuIPstandards and criteria. These include:• Standard 1.1 Continuity of care• Criterion 2.1.2 the risk management criterion,which provides the basis of an effective safetysystem• Criterion 2.1.3 the incident management criterion,which provides the cornerstone to any goodconsumer / patient safety system• Criterion 2.2.3 Performance review• Criterion 2.2.4 Staff education• Criterion 2.3.3 Data and information use• Criterion 3.1.2 External service providers• Criterion 3.1.3 Credentialling and defining thescope of clinical practice.October 2010 143

Section 5Standards, criteria, elements and guidelinesStandard 1.5: The organisation provides safe care and servicesCriterion LA – Awareness SA – ImplementationLA plus the followingCriterion 1.5.1Medications are managedto ensure safe andeffective consumer /patient outcomes.This is amandatorycriteriona) There is policy / guidelinesfor medication managementthat is consistent with theAustralian PharmaceuticalAdvisory Council (APAC)guidelines together withjurisdictional legislation.b) A multidisciplinary bodyoversees the managementof medication safety.c) Healthcare providers haveaccess to published guidelinesfor medication management.d) A standardised list ofapproved abbreviations formedications is used throughoutthe organisation.e) Medication risks are identified,evaluated and acted uponwith particular focus on highrisk medications.a) Clinical staff are providedwith orientation and ongoingeducation on the policy andprocedures of safe medicationmanagement.b) Procedures are implementedto reduce the risk and numberof medication errors.c) Medication documentationis standardised across theorganisation.d) There is a system to reportmedication errors, near missesand adverse drug reactionsand this is linked to the incidentmanagement system.e) The orientation system isupdated when new risksare identified.f) There is pharmacy involvementin the storage, transport anddistribution system.g) A system is implemented toensure medication review ofindividual consumers / patients.h) Consumers / patients andcarers are educated aboutprescribed medications toencourage ongoing safe use ofmedications and complianceafter discharge.IntentSafe, high quality care and effective consumer / patientoutcomes depend upon the correct management ofmedications. The intent of this criterion is to ensure thatmedications are managed to:• reduce the incidence of error in the prescription,dispensing and administration of medications toconsumers / patients• reduce the harm caused to consumers / patients inhealthcare organisations by medication errors.Relationships of 1.5.1 with other criteriaMedications and their management are relevantthroughout the care journey of the consumer /patient (Standard 1.1). Medication management is animportant aspect of the organisation’s integrated riskmanagement framework (Criterion 2.1.2), and errorsin this area may result in incidents, including sentinelevents (Criterion 2.1.3), which may lead to complaints(Criterion 2.1.4).144 The ACHS EQuIP5 Guide Book 1 Accreditation, Standards and Guidelines Clinical Function

MA – EvaluationSA plus the followingEA – ExcellenceMA plus the followingOA – LeadershipEA plus the followinga) The system for safe medicationmanagement is evaluated andimproved as required.b) Medication errors, near missesand adverse drug reactionsare reported, analysed andtrended, and further strategiesto reduce medication incidentsare implemented.c) Medication storage, distributionand transport processesare evaluated and improvedas required.a) The organisation comparesmedication managementsystems and medication errordata internally and externallyand improvements are madeto ensure better practice.and/orb) The organisation implementsevidence-based advancedsystems for medicationmanagement.and/orc) The organisation conductsresearch and developsinnovative methods to improvemedication management.a) The organisation demonstratesit is a leader in medicationmanagement.Planning for medication safetyThis criterion relates to all healthcare organisations thatprescribe, dispense and/or administer medications.Support service providers will need to consider themedications prescribed by other services whenassessing their consumers / patients.The use of medication remains the most commonintervention in health care. Medicine misuse, underuse,overuse and adverse reactions annually result in anestimated 140,000 hospital admissions in Australia 1 ;up to 75% of these adverse drug events are potentiallypreventable. 2Medication management policies and proceduresshould be based on quality use of medicinesprinciples as developed by the National PrescribingService (NPS) as part of the Australian NationalMedicines Policy. 3 Quality Use of Medicines (QUM)has a consumer focus and is based on three simpleprinciples:• select appropriate therapeutic management option(not always pharmaceutical)• choose suitable medications• use medications safely and effectively.October 2010 145

Most State / Territory health departments have alsodeveloped policies and procedures assisting ordirecting staff in decision making on high-risk, highcostand controversial drugs and conditions. 12 TheSociety of Hospital Pharmacists (SHPA) developed aspecific process for evaluating drug use (DUE) in ahospital setting. The SHPA Standards of Practice forDrug Use Evaluation in Australian Hospitals providesa useful starting point for continuously improving theuse of specific medications and adopts a continuousquality improvement approach to evaluating currentdrug use and then making changes to improve howmedications are used. 13Prompt points¼¼¼¼How are staff introduced to the standardisedlist of abbreviations and trained in its use?How does the organisation monitor healthrecords to ensure that entries followstandards for medication recording?When inconsistencies / problems are detectedthrough incidents or audits of consumer /patient records, what action(s) are taken?Prompt points¼¼¼¼How do healthcare professionals accessmedication information when working atthe organisation?What medication reference sources areavailable to healthcare professionals? Who isresponsible for ensuring that the information /editions are regularly updated?Standardised medication recordingThe Australian Commission on Safety and Qualityin Health Care (the Commission) has identifiedmedication safety as one of their priority areasand offers information and resources 14 to assistorganisations to reduce error and harm frommedications. Included in the Commission’srecommendations is the use of a common medicationchart 15 across all health services in Australia. 16Healthcare organisations are encouraged to implementa common chart when possible.In addition, the Commission has developedrecommendations regarding the standardisation oflanguage, including abbreviations used in medicationprescribing, that have been adopted by someorganisations and State / Territory health departments 17to avoid identified sources of error. Further informationand access to these resources is at: http://www.safetyandquality.gov.au/internet/safety/publishing.nsf/Content/PriorityProgram-06Medication risk managementand error reportingA healthcare organisation is responsible for ensuringthat it has a culture for medication management andreporting systems that enables the identification andnotification of as many medication errors, near missesand adverse drug events and/or reactions as possible.This is essential if potential risks are to be identified,evaluated and acted upon. Incident reports providevaluable information about incidents and near misses,however additional systems should be in place togather information about adverse drug events. Theseinclude health record reviews, audits, reviews of theliterature and various reports.High-risk medications often have a small therapeuticrange, for example anticoagulants, particularlywarfarin, intravenous potassium and insulin. Othermedications can pose a high risk due to the possibilityof them being transcribed incorrectly, such asproducts with sound-alike names 18 or brand names thatinclude numbers. Some packaging or the medicationsthemselves can be similar in appearance.Prompt points¼¼¼¼What medication risks or potential risks havebeen identified at the organisation? Whatactions have been taken to minimise risksassociated with the use of these medications?What system is used to track incidents / nearmisses at this organisation? How are thoserelated to medication management differentiatedfrom other types of incidents? Based onmonitoring across the organisation, haveany causative issues been identified? Whatactions have been taken to reduce the risk ofmedication incidents?October 2010 147

Section 5Standards, criteria, elements and guidelinesStandard 1.5: The organisation provides safe care and servicesCriterion 1.5.1Medications are managed to ensure safeand effective consumer / patient outcomes.(continued)Staff educationClinical pharmacology and medication managementare areas that are constantly changing as newmedications and treatment modalities becomeavailable. Ongoing education and training inpharmacology for all staff involved in prescribing,dispensing and administering medications is essential.Staff new to the organisation should be oriented to themedication records used, systems of clinical handoverand to equipment used for medication delivery,including devices such as infusion pumps. ‘Hands on’practice will improve efficiency and may reduce error.Strategies for identifying potential medication riskshould rely on:• external information (for example, the NationalPrescribing Service (NPS) promotes quality use ofmedicines through newsletters such as AustralianPrescriber, RADAR, Prescribing Practice Reviewand Nurses Update, and State / Territory healthdepartments publish alerts following investigationsof serious incidents)• the organisation’s own incident monitoringprocesses, which may identify local issues.Prompt points¼¼¼¼How is medication management integratedinto clinical staff orientation programs? Howare any organisation- or ward-specific aspectsof medication recording and clinical riskmanagement addressed during orientation?How does orientation differ for Visiting MedicalOfficers compared to employed clinical staff?How are medication-related areas requiringadditional training / education identified in newlyappointed staff? Is medication managementincluded in ongoing performance evaluation?Storage, transport and distributionStorage, transport and distribution refer to themanner in which medications are stored and themovement of pharmaceutical products around thehealthcare organisation.The Society of Hospital Pharmacists (SHPA) hasdeveloped Standards of Practice for the Distributionof Medications in Australian Hospitals 19 to assist inensuring the right consumer / patient receives the rightmedicine, in the right presentation, that will deliver theprescribed treatment in the right dose at the right timewith the least potential for error, at the lowest cost.These Standards of Practice provide information onpackaging and labelling of medications, as well as thetypes of areas that need to be considered for storageof medications outside of the pharmacy. This includessecurity of medications, as well as refrigeration wherenecessary and systems to maintain and monitorcold chain.Cold chain and security / access requirements applyto all lockers and fridges in which medications arestored on site. It includes the wards, emergencydepartments, surgeries and the centralised drugpurchasing, distribution and storage system. However,this criterion does not address the transport chainsused to supply organisations with products; this isaddressed within criterion 3.1.4, which deals withexternal service provision.The storage, distribution and transport system should:• comply with all legislative requirements• provide medicines to consumers / patientsin a timely manner• carry the lowest possible risk of error• minimise the cost of medicine storage,distribution and use• minimise wastage• provide data on medicine utilisation, preferablyto the level of the individual consumer / patient• identify unusual medicine usage patterns.148 The ACHS EQuIP5 Guide Book 1 Accreditation, Standards and Guidelines Clinical Function

Prompt points¼¼¼¼¼¼¼¼What pharmacy staff (if any) are employedby the organisation? What roles do pharmacystaff undertake in the storage, transportand distribution of medications around theorganisation?Who / what committee is involved in theevaluation of medication storage, distributionand transport processes?What has been discovered as a result ofevaluating these processes? Have anyimprovements been made to the system?How does the organisation know that medicinesare being distributed accurately, appropriately,efficiently and cost-effectively?Consumer / patient medicationreview and educationAustralian clinical pharmacy practice standardsdescribe goals and procedures for ten activities aimedat optimising the use of medicines and consumer /patient outcomes. They are:• accurate medication history• assessment of current medication management• clinical review• decision to prescribe a medicine• therapeutic drug monitoring• ward round participation• provision of medicines information tohealth professionals• provision of medicines informationto consumers / patients• information for ongoing care• adverse drug reaction management.It is not expected that all organisations will haveaccess to a clinical pharmacist, however a pharmacistprovides specific pharmaceutical expertise to help tomaximise medicine efficacy and minimise medicinetoxicity in individual consumers / patients. Includingpharmacists as part of the clinical team may help toreduce medication errors.In the absence of a pharmacist, other healthcareprofessionals should undertake the medication review.The review should evaluate a consumer / patient’scurrent medication 8 as soon as practicable afteradmission with a view to:• identifying the appropriateness and effectivenessof current medication, rationalising currentmedications if appropriate• paying particular attention to any problemsassociated with current drug therapy includingany possible relationship with currentmedical condition• documenting allergies and any previous adversedrug reactions.Wherever appropriate, consultation should occur withthe consumer / patient’s primary practitioner.Consumers / patients can benefit from the NPSinitiated,consumer-focused program that aims toprovide information about medicines and to reinforcethe importance of consumers / patients working withtheir healthcare providers. 20Prompt points¼¼¼¼Who undertakes medication reviews in theorganisation? How are consumers / patientsrequiring medication reviews identified and thereview scheduled?How are consumers / patients educated abouttheir medications before discharge? How is theeffectiveness of this process assessed?To further assist safe use of medicines, in 2004Australian Health Ministers called for everypublic organisation to have in place a process ofpharmaceutical review of medication prescribing,dispensing, administration and documentingprocesses for the use of medicines. Organisationsshould strive to follow these directives, which wouldgreatly benefit medication management.October 2010 149

Section 5Standards, criteria, elements and guidelinesStandard 1.5: The organisation provides safe care and servicesCriterion 1.5.1Medications are managed to ensure safeand effective consumer / patient outcomes.(continued)Evidence commonly presentedConsider whether the following willhelp to address criterion 1.5.1¼¼¼¼¼¼¼¼¼¼¼¼¼¼Audits of:––medication error rates––adverse reaction rates––prescriptions––compliance with medicationsPolicies, including reference to APACMedication chart reviewMedicines reconciliation procedures oraudit of activityStandard list of abbreviationsEvidence of pharmacy or pharmacistinvolvement in the distribution systemHealth record reviewPerformance measurementThis criterion states that: “Medications are managed to ensure safe and effective consumer / patient outcomes”.The organisation should be able to demonstrate that it has processes in place aimed at reducing the incidenceof error in the prescribing, dispensing and administering of medications, and to reduce harm caused to theconsumer / patient as a result of such errors.Indicators have a useful role in medication safety as near misses and sentinel events can play a significant role inalerting risky practices. Frequently reported risk or error without harm should be investigated fully. It provides anopportunity to avert catastrophic harm.Because the administration of medicines is so frequent in a hospital setting, variations in indicators offer statisticalevidence that has potential for interesting and insightful investigation. Results can be compared over time andagainst other organisations. After ensuring that differences are not the result of variation in definitions or countingpractices, variations in consumer / patient pool and practices may be considered and risky practices avoided.Some common suggested performance measures are as follows:Number of reported near misses that are medication incidentsTotal number of near misses150 The ACHS EQuIP5 Guide Book 1 Accreditation, Standards and Guidelines Clinical Function

Number of notified incidents that are medication incidentsTotal number of notified incidentsNumber of notified medication incidents associated with an adverse eventTotal number of notified medication incidentsNumber of medication incidents which were reviewed and where the recommendations were implementedTotal number of notified medication incidentsNumber of medication charts with illegible writingTotal number of medication charts auditedComment: for instance, the pharmacist does not know what to dispenseNumber of consumers / patients who have received information about their medicationTotal number of consumers / patients prescribed medicationNumber of consumers / patients satisfied with information received about their medicationsTotal number of consumers / patients surveyedNumber of consumers / patients who are satisfied with postoperative pain controlTotal number of consumers / patients surveyedNumber of consumers / patients who have received written information about facility-initiated drugs thatare to be continued post-dischargeTotal number of consumers / patients prescribed facility-initiated drugs that are to be continuedpost-dischargeOctober 2010 151

Section 5Standards, criteria, elements and guidelinesStandard 1.5: The organisation provides safe care and servicesCriterion 1.5.1Medications are managed to ensure safe and effective consumer / patient outcomes. (continued)Number of consumers / patients who experience morbidity as a result of a preventable adverse drug eventTotal number of consumers / patients who experience morbidityNumber of consumers / patients who did not bring their medicationTotal number of consumers / patients admittedComment: this could be due to different reasons such as that the consumer / patient had not beeninformed or forgotNumber of newly admitted consumers / patients that had a medication reconciliation completed within 24 hoursTotal number of consumers / patients admittedNumber of consumers / patients with a length of stay greater than X days who are reviewed by a clinicalpharmacistTotal number of consumers / patients with a length of stay greater than X daysComment: organisation to define ‘X’; not all organisations have access to a clinical pharmacist;a medication review may be undertaken by another appropriate meansNumber of elective procedures delayed or cancelled due to medication issuesTotal number of elective procedures delayed or cancelledComment: e.g. consumer / patient taking inappropriate medicationNumber of ‘at-risk’ consumers / patients recommended for a Home Medicines Reviewin a community-based health settingTotal number of consumers / patients ‘at-risk’ of medication misadventure in a community-basedhealth setting152 The ACHS EQuIP5 Guide Book 1 Accreditation, Standards and Guidelines Clinical Function

References1. Stowasser DA, Allison YM and O’Leary KM. Understandingthe medicines management pathway. J Pharm Pract Res2004; 34(4): 293-296.2. Runciman WB, Roughead EE, Semple SJ and Adams RJ.Adverse drug events and medication errors in Australia.Int J Qual Health Care 2003; 15(Suppl 1): i49-i59.3. Commonwealth of Australia. National strategy for qualityuse of medicines. Canberra ACT; Commonwealth ofAustralia; 2002.4. Leach H. National inpatient medication chartimplementation. J Pharm Pract Res 2006; 36(1): 1-2.5. UK National Health Service (NHS). The ‘how to’ guide forreducing harm from high risk medicines. In: Clarke J (ed).Patient Safety First Campaign. London UK; NHS; 2008.6. Rodriguez EM and Hickey K. A multi-vendor approach torestructuring medication management systems. PharmacyPurchasing and Products 2008; January: 14-15. Accessedfrom http://www.pppmag.com/documents/V5N1/p14_16.pdfon 1 September 2010.7. Westbrook J, Woods A, Rob M et al. Association ofinterruptions with an increased risk and severity ofmedication administration errors. Arch Intern Med 2010;170(8): 683-690.8. Australian Pharmaceutical Advisory Council (APAC).Guiding principles to achieve continuity in medicationmanagement. Canberra ACT; APAC; 2005.9. Australian Pharmaceutical Advisory Council (APAC).Guiding principles for medication management inthe community. Canberra ACT; Commonwealth ofAustralia; 2006.10. Queensland Health. Medication management manual.In: Lynne T (ed). Brisbane; Qld Health; 2003.11. Australian Pharmaceutical Advisory Council (APAC).Guidelines for medication management in residential agedcare facilities. 3rd edn. Canberra ACT; APAC; 2002.12. WA Therapeutic Advisory Group (WATAG). Publicationsand guidelines. Perth WA; WATAG. Accessed fromhttp://www.watag.org.au/watag/publications.cfm#guidelineson 1 March 2010.13. Society for Hospital Pharmacists of Australia (SHPA)Committee of Speciality Practice in Clinical Pharmacy.Guidelines for self-administration of medication in hospitalsand residential care facilities. J Pharm Pract Res 2002;32(4): 324-325.14. Dearne K. Toolkit to reduce hospital dispensingerrors. The Australian, Canberra ACT; News Limited;1 September 2009: 31.15. Australian Commission on Safety and Quality in HealthCare (ACSQHC). National inpatient medication chart.Sydney NSW; ACSQHC. Accessed from http://www.safetyandquality.gov.au/internet/safety/publishing.nsf/content/NIMC_001 on 8 January 2010.16. Australian Health Ministers’ Conference. Joint communiqué:Health ministers agree to reform agenda. CanberraACT; Australian Council for Safety and Quality in HealthCare; 2004.17. WA Department of Health. Operational Directive:Standardisation of terminology, abbreviations and symbolsin the prescribing and administration of medicines.Perth; WA Health; 2009.18. Joint Commission on Accreditation of HealthcareOrganisation (JCAHO), Joint Commission International andWHO Collaborating Centre for Patient Safety Solutions.Look-alike, sound-alike medication names. Patient SafSolns 2007. 1(Solution 1): 1–4. Accessed from http://www.health.vic.gov.au/qum/downloads/sound_alike.pdf on25 February 2010.19. Society for Hospital Pharmacists of Australia (SHPA).Standards of practice for the distribution of medicinesin Australian hospitals. J Pharm Pract Res 2006; 36(2):143-149.20. National Prescribing Service (NPS). Information forconsumers, and information for health professionals. SydneyNSW; NPS. Accessed from http://www.nps.org.au/# on14 October 2009.October 2010 153

Section 5Standards, criteria, elements and guidelinesStandard 1.5: The organisation provides safe care and servicesCriterion LA – Awareness SA – ImplementationLA plus the followingCriterion 1.5.2The infection control systemsupports safe practice andensures a safe environmentfor consumers / patientsand healthcare workers.This is amandatorycriteriona) There is an infectioncontrol policy / guidelines,including notifiable diseases,sterilisation and reprocessingwhere applicable, that isreferenced to:(i) Australian standards(ii) jurisdictional legislation(iii) codes of practice(iv) industry guidelines.b) The infection controlmanagement plan is approved,supported and resourced bythe organisation’s executive.c) There is policy / guidelines forfood handling that includesstorage, preparation anddistribution in accordancewith jurisdictional regulationsand/or standards.d) There is policy / guidelines forthe collection of dirty linen,management, transport andstorage of clean linen withinthe healthcare facility.e) Healthcare providers areeducated and informationis available on the risksof infection includingtheir responsibilities inpreventing infection.f) Healthcare providers aresupplied with equipment andan environment that enablesthem to implement the infectioncontrol policy / guidelines.g) External service providers,students, carers andvisitors are advised of theorganisation’s infectioncontrol requirements.a) The infection controlmanagement plan is reviewedand adequate resourcesare provided to ensureimplementation of the planand related policies.b) Infection prevention strategiesare integrated into all stagesof healthcare planning,including health facilityplanning, constructionand/or refurbishment.c) There is a documentedprogram of continuouseducation for staff aboutinfection control issues.d) A standardised hand hygieneobservation assessmenttool is used throughoutthe organisation.e) The infection control systemincludes isolation andcontainment of infectionswhen required.f) Policy / guidelines for collectionof dirty linen, management,transport and storage of cleanlinen are implemented withinthe health facility.g) A system is implemented forappropriate use of antibioticsand antimicrobials.h) An effective surveillancesystem is implementedto monitor healthcareassociated infections.i) The infection controlsystem ensures effectivecommunication of infectionrisks and management toconsumers / patients andtheir carers.154 The ACHS EQuIP5 Guide Book 1 Accreditation, Standards and Guidelines Clinical Function

MA – EvaluationSA plus the followinga) The infection control systemis evaluated and improvedas required.b) The system for thereprocessing of medicaldevices demonstrablycomplies with:(i) Australian Standards(ii) jurisdictional requirementsc) Hand hygiene practices areevaluated and improvedas required.d) The appropriate use ofantibiotics and antimicrobialsis evaluated and improvedas required.EA – ExcellenceMA plus the followinga) Performance indicators forthe infection control systemare compared with internaland external systems, andimprovements are made toensure better practice.and/orb) The organisation communicatesresults of its performance inits infection control publicly toinform consumers / patients,colleagues and peers.and/orc) The organisation undertakesresearch in areas of infectioncontrol and utilises results toimprove clinical practice.and/ord) The organisation demonstratesinnovation in its infectioncontrol program.OA – LeadershipEA plus the followinga) The organisation demonstratesit is a leader in infectioncontrol systems.October 2010 155

Section 5Standards, criteria, elements and guidelinesStandard 1.5: The organisation provides safe care and servicesCriterion 1.5.2The infection control system supports safepractice and ensures a safe environment forconsumers / patients and healthcare workers.(continued)IntentThe intent of this criterion is to ensure that, wheneverpossible, infections are prevented from occurringin health services; and that where prevention is notpossible, infections are managed effectively.Relationships of 1.5.2 with other criteriaStrategies to address the risk of infection inhealthcare settings should be an aspect of theorganisation’s maintenance of a safe environmentfor its consumers / patients and staff (Standard 3.2).Facility design, cleaning protocols (Criterion 3.2.2)and waste management systems (Criterion 3.2.3) mayimpact upon the control of infection.The organisation will help to protect staff via itsimmunisation program (Criterion 2.2.5). Wheresterilisation is outsourced to an external serviceprovider (Criterion 3.1.4), processes must ensure thequality of the service. Infection presents a significantchallenge to the provision of safe care and services(Standard 1.5). Appropriate care delivered in the mostappropriate setting will help to reduce the incidenceof infection (Criterion 1.3.1). The organisation mustaddress infection control through its integrated riskmanagement framework (Criterion 2.1.2), and failure todo so effectively may lead to incidents (Criterion 2.1.3)and complaints (Criterion 2.1.4).Infection prevention and controlInfection control in healthcare organisations is akey area for safe practice. Because of the nature ofhealth care, consumers / patients and staff can besources and recipients of infection. Infections can betransmitted from person to person or may be sourcedfrom the environment, including from consumer /patient care equipment. Consumers / patients, staffand any visitors to the facility may be a source or thereceiver of infection-causing organisms.Adopting evidence-based, quality infection controlmeasures can potentially prevent many instances ofinfection, and minimise the risk of others 1, 2 .Standard precautions should be used routinely andextended when there are additional risks. 3 Standardprecautions include:• hand hygiene and respiratory etiquette• use of personal protective equipment(aprons, gowns, face and eye protection, gloves,footwear, etc.)• handling and disposing of sharps, including theremoval and disposal of scalpel blades fromscalpel handles, according to AS/NZS 3825:1998Procedures and devices for the removal anddisposal of scalpel blades from scalpel handles• decontamination of the physical environment,including consumer / patient care equipment• reprocessing of instruments and othermedical devices• management of blood and body substance spills.Additional precautions should be undertaken whenstaff know or suspect a specific infectious agent.These can be initiated while confirmation by testingis pending. Appropriate responses, includingduration of response 3 and management of anyimmunocompromised consumers / patients 3 , willvary depending on the infectious agent and its modeof transmission.Management supportAn outline of the overall infection control (IC)strategy should be documented in an IC plan ormanual. In addition to adopting legislated andpolicy processes, the strategy has to respond to theunique circumstances of the organisation, such as itsphysical features, climate, casemix, procedural andservice profile, its staffing and visitors. The manualshould include a risk management plan that coversmanagement of infection outbreaks, a funding modelfor the program’s areas of activity and a descriptionof resources necessary to implement and sustainthese activities. 4The infection control management plan (ICMP) outlinesthe program structure, overall aims and objectives, theassociated quality management activities, programevaluation criteria and timeframes for review. 5 Thedocument should identify:• who is at risk and from what• the hazards involved• the procedures for minimising risk• appropriate measures for infection control, basedon standard precautions and, when required,additional precautions.156 The ACHS EQuIP5 Guide Book 1 Accreditation, Standards and Guidelines Clinical Function

The plan should address the governance of infectioncontrol – including articulation with other committeesand structures (internal and external). 5 The plan shouldbe reviewed regularly 5 and updated accordingly.Prompt points¼¼¼¼¼¼What groups or persons play key roles inexecuting the infection control plan? Who isultimately responsible for issues relating toinfection control?How is the Board or General Manager involvedin infection control planning? Who is responsiblefor budgeting and signing off on budgets thatarise from the infection control plan?What actions have been taken in the past2 years to improve infection control at theorganisation? How will the effectiveness ofthe change(s) be monitored?Facility design, renovationsand refurbishmentAll areas of a healthcare facility should be designed,constructed, furnished and equipped to minimisethe risk of transmission of infection. In particular, thedesign and layout of the facility should assist theapplication of standard and additional precautionsby the staff.In any modification to the healthcare environment,such as renovations, aim to reduce:• airborne transmission• surface contamination and transmission• water-borne contamination and transmissionof infection.Where consultant planners have been appointed todesign or renovate a facility, the briefing documentswill list healthcare requirements; infection controlissues must be clearly stated. The infection controlofficer should be accessible during design. ManyStates / Territories have formal guidelines to facilitate6, 7, 8building planningRenovations in an existing facility may involverelocating staff and consumers / patients, alteredaccess, different supply procedures and/or thepresence of additional people (architects, consultants,tradesmen). All of these may compromise pre-existingphysical features of a building that limit the spreadof infection.Prompt points¼¼¼¼What building design features currentlymake infection control challenging for thisorganisation? What potential is there to makephysical changes to improve these features?What practices have been adopted to reducethe risks associated with these features?How is the infection control manager or aknowledgeable IC consultant involved in anyplanning for a new health facility design or forchanges to existing buildings?Policy and processOrganisations should have infection control policiesas an aspect of the Infection Control ManagementPlan / Infection Control Manual. Policy and particularlyprocedures should be based upon the organisation’sservices, licences and risks, and therefore be bothrelevant and achievable. Policy and proceduresshould address all legislated requirements, includeperformance standards, and be based on existingjurisdictional directives, such as notifiable diseaseidentification and reporting, guidelines andAustralian standards.Policy should also address cleaning of the environmentin which health care is provided, single use itemsand reprocessing of sterile instruments.Sterilisation and reprocessing should be directlyaddressed in the infection control manual. Purchasedsterile disposables should comply with specificationsin Therapeutic Goods Orders issued under theCommonwealth Therapeutic Goods Act 1989;examples include gloves for different purposes,suture materials, and packaging of blood andblood components.Policy should also address risks to employees frominfection within the workplace, such as:• protection from, and response to, needlestickinjuries and other blood exposure 9• testing for previous exposure / carrier statusfor some specific diseases 9• immunisation requirements - auditing, provisionand recording – based on workplace riskcategorisation9, 10• education and training in relation to infection risks.October 2010 157

Section 5Standards, criteria, elements and guidelinesStandard 1.5: The organisation provides safe care and servicesCriterion 1.5.2The infection control system supports safepractice and ensures a safe environment forconsumers / patients and healthcare workers.(continued)Organisations should be aware of relevant standardsin regard to food safety, cleaning and laundry, andhow and when external service providers may enterpatient areas. Consideration of infection controlissues should also be made in care situations wherevisiting hairdressers, podiatrists and companionanimals, etc., attend.Staff working in informal settings or a setting that maybe considered to be low risk, such as office-basedpractices, community settings or long-term careestablishments with a home-like atmosphere, shouldbe provided with the same hand hygiene facilities,protective clothing and protective equipment as staffworking in larger healthcare settings. Waste should bedisposed of in accordance with Australian standards inany healthcare setting.Prompt points¼¼¼¼What legislation, regulations or codes of practiceinfluence policies operating in the organisation?How does the organisation monitor compliancewith infection control procedures? Hasmonitoring identified any areas requiring furtheraction? What actions were proposed, and whathas been their impact?Antibiotics and antimicrobialsAustralia has a growing problem with multiresistantbacterial pathogens. Initially this was focused inhospitals, however resistance in the community isalso rising. 11Inappropriate use of antimicrobials leads to 11 :• the emergence of resistant bacteria• an increase in the risk of consumer / patient harmfrom side effects• infection with multiresistant bacteria (such asStaphylococcus aureus (MRSA) or vancomycinresistantenterococci (VRE) or Clostridium difficile)• unnecessary costs.The Australian Commission on Safety and Qualityin Health Care (the Commission) includes antibioticstewardship in their multifaceted, multidisciplinaryapproach to preventing emergence of antimicrobialresistance and decreasing preventable healthcareassociatedinfections.Stewardship programs aim to change antibioticprescribing behaviour to reduce unnecessary useand promote the choice of agents less likely toselect resistant bacteria, in line with guidelines anddemonstrated patterns of antibiotic resistance.Guidelines should be available on the use ofprophylactic antimicrobials, covering high-risk classesof consumers / patients and specific procedures, andcases where staff experience occupational exposureto blood.Further information can be found on the Commission’swebsite at: http://www.safetyandquality.gov.au/internet/safety/publishing.nsf/Content/PriorityProgram-03_Antimicrobial-SsPrompt points¼¼¼¼¼¼¼¼What, if any, antibiotic prophylaxis isused for procedures at the organisation?Who is responsible for prescribing the drug?And its provision?How is antibiotic prescribing monitored?How is the Quality Use of Medicines (QUM)promoted, particularly in relation to antibiotics?What actions have been taken to limit theuse of broad spectrum antimicrobials inthe organisation?Infectious diseaseGuidance should be available for staff on managinghighly infectious diseases and recommendations forisolation. Many respiratory infections have the potentialfor rapid, epidemic spread. Infection managementprocedures for a wide range of diseases are availablevia State / Territory governments. 12Planning should focus on control of infection through 13 :• elimination of potential exposures, e.g. restrictedentry for workers and visitors who are sick• engineering controls, e.g. partitioning triageareas, isolation rooms, closed suctioning systemson airways of intubated consumers / patients,limiting movement of consumers / patients fordiagnostic procedures158 The ACHS EQuIP5 Guide Book 1 Accreditation, Standards and Guidelines Clinical Function

• administrative controls, e.g. vaccination, surfacedisinfection, managing consumer / patient flow,hand hygiene / cough etiquette• personal protective equipment, e.g. surgicalmasks, respirators, goggles• additional precautions tailored to the specificinfectious agent and its mode of transmission.Prompt points¼¼¼¼¼¼How do clinical staff access information andforms for the notification of infectious disease?What actions can be taken to gain pathology,microbiological or diagnostic imagingresults sooner when an infectious disease issuspected?How are infectious consumers / patients whomay spread infection through aerosols ordroplets managed in the organisation whenadmitted as an inpatient? e.g. during the swineflu outbreaks or annual influenza season?Healthcare-associated infectionsCare in a health facility should not provide greaterrisks to the consumer / patient than the risksassociated with the reason for admission to a facility.Healthcare-associated infections can be seriousand life-threatening. Care workers and equipmentcan be vectors for the transmission of a number ofpathogens. Managing infections through antibiotics,rather than preventing infections, has contributed togrowing resistance 14 in some bacteria, particularlyStaphylococcus aureus and Escherichia coli.Clostridium difficile also presents unique challenges,particularly in environments where antibioticsare used. 15In today’s care environment, inpatients will be exposedto a series of care providers, any of whom mighttransfer infection. Only through disciplined behavioursby all care providers, supported by visitors andother staff, will healthcare-associated infections beeffectively prevented.Prompt points¼¼¼¼How are levels of healthcare-associatedinfection (HAI) monitored and tracked over timein the facility? If a rise in incidence of HAIs weredetected, how and by whom would the problembe investigated?What is the most problematic resistantmicro-organism for the organisation? Whatnon-antibiotic-based approaches have beentaken to manage the spread or increasingresistance of this organism?Device reprocessingAS 4187:2003 Cleaning, disinfecting and sterilisingreusable medical and surgical instruments andequipment, and maintenance of associatedenvironments in health care facilities should bereferred to when developing policy and the infectioncontrol management plan. In many States / Territories,compliance with this standard is legislated, usuallywithin the professional practice acts for doctors andother procedural practitioners (e.g. NSW MedicalPractice Regulation 2008).There should be a process to ensure that thesterilising facility is alerted to instruments andassociated materials used on consumers / patientswith suspected or confirmed tuberculosis, measles,Creutzfeldt-Jakob disease or other conditions requiringadditional precautions.Designated personnel with skills, training andexperience are responsible for the reprocessing ofmedical devices. Maintaining surgical asepsis relieson correct cleaning. The quality of cleaning shouldbe monitored by an approved person to ensure thatstandards are maintained at all times. Where waterquality is ‘hard’, appropriate cleaning products anddisinfectants should be selected. 16When sterilising is outsourced, there should be amechanism for monitoring any breaks in due process,keeping an overall record and reporting back to thesupplier. Examples might include incomplete sealingof sterile packaging or inadequate cleaning.October 2010 159

Section 5Standards, criteria, elements and guidelinesStandard 1.5: The organisation provides safe care and servicesCriterion 1.5.2The infection control system supports safepractice and ensures a safe environment forconsumers / patients and healthcare workers.(continued)Prompt pointsThe Australian National Hand Hygiene Initiative(NHHI) draws upon the WHO program. There isextensive information on implementation and planningfor hand hygiene promotion activities and alsodetailed information on auditing compliance with anorganisation’s program. 18 Education program materials,auditor training and forms for auditing (audit formsand coding sheets) are available online from:http://www.hha.org.au/ForHealthcareWorkers.aspx.¼¼¼¼How does the organisation ensure that thereare appropriately trained personnel supervisingsterilising in the CSSD and at other sites wheresterilising occurs?How are endoscopes reprocessed?Does this process comply with all legislation?What precautions have been taken to ensurethat reprocessing will not cause delaysfor physicians?A key requirement of the NHHI is placement of alcoholbasedhand rub / gels / foams at the point of consumer/ patient care, such as at the foot of the bed, to facilitatecompliance with hand hygiene.Prompt points¼¼What measures have been taken to provideclinicians with easy access to hand hygienebetween every consumer / patient?Hand hygieneCorrect hand hygiene limits the transmission ofmicro-organisms by a healthcare worker:• from one site on a consumer / patient’s bodyto another body site• from one consumer / patient to another• from the environment or healthcare equipmentto a consumer / patient.Non-procedural facilities and departments should alsopromote and practise good hand hygiene. Prolongedserious illness may impair the immune response ofconsumers / patients, increasing their vulnerabilityto infection.In 2009, the World Health Organization (WHO)released findings of their evidence- and performancebasedresearch aimed to improve hand hygiene inhealth care. This formed the basis for their guidelineson hand hygiene 17 , which under leadership from theCommission on Safety and Quality in Health Care havenow been adopted throughout Australia.¼¼¼¼How is hand hygiene compliance monitoredin the facility? What are the target levels forcompliance, and how close is the organisationcoming to achieving these levels?How would an individual clinician whodemonstrated poor adherence to hand hygienebe managed by the organisation?Linen managementLinen management is outsourced by many healthcarefacilities. The selection of appropriate external serviceproviders and the contractual agreement process isaddressed within criterion 3.1.4.Linen management refers to the role of the organisationin coordinating the collection of dirty linen, its transferto the laundry or to an external contractor, and howclean linen is stored, distributed and managed withinthe healthcare facility. The separation of clean linenfrom dirty linen should be maintained at all times.Organisations, and individual departments 19 , shouldhave clear procedures on how linen is to be managed.Staff should be trained in, or at least familiar with, theseprocedures and their purpose. Each ward will requireits own regular, yet flexible, schedules for changingbeds to minimise the risks associated with infectedlinen while responding to consumer / patient, nursingand physician needs. Consideration should also begiven to the loads in skips, so that over-filling doesnot occur.160 The ACHS EQuIP5 Guide Book 1 Accreditation, Standards and Guidelines Clinical Function

Prompt points¼¼How do management procedures ensurethat linen does not become a vector fortransmission of infection? Who is responsiblefor monitoring compliance?Food handlingFood can be a source of toxins and micro-organismsand there are clear guidelines and legislation forthe storage, preparation and distribution of food. 24Reheating frozen and other pre-prepared foods is arisk factor in the spread of enteric diseases that can belife threatening for consumers / patients who are weakand/or immunosuppressed.Family members may seek to bring food to thehealthcare organisation for cultural reasons,dietary preferences or as a reward or enticement.Organisations should have procedures to managethese situations and should brief family members. 20‘Nil by mouth’ signage should also be explained.Safety in storage and reheating of food is important;wherever possible, organisations should assist inproviding refrigeration designated for food storageonly, and microwaves to ensure adequate reheating.Prompt points¼¼What actions ensure that food service doesnot become a source of illness in the facility?¼¼What actions are taken to protect consumers /patients from food-transmitted disease whenfood is brought from home?¼¼Is there a designated food storage refrigeratorand a safe means of reheating food?Education and information –staff, contractors, visitorsEducation and training in infection control, both internaland external to the organisation, should be current,documented and relevant to the organisation andstaff roles.Information provided to intending consumers / patientsand their carers should include details pertinent tothe infection control program. High dependency andintensive care units may limit attendances by numberof people or duration of visit.In situations where a consumer / patient is potentiallyinfectious, access and contact may also be restricted;the associated risks and actions should be explainedto a consumer / patient’s carers personally by ahealthcare professional.Hand hygiene, sharps management and respiratoryhygiene reminders are well-suited to signage, whichmay overcome cultural barriers using visual elements.More in-depth explanations of these and other infectioncontrol aspects of care may be covered by discussionsor in printed materials.Web-based information can be updated quickly andeasily, and disseminated widely. This is particularlyuseful for staff and/or the general public whenresponding to changing circumstances, such as duringan influenza outbreak or following an emergency suchas bushfires or floods.Contracts and negotiations with external serviceproviders should cover these contingencies to thesatisfaction of the organisation’s lawyers:• visits to the healthcare organisation site shouldfollow infection control procedures – hand hygiene,separation of infective materials from non-infective• regular service providers who visit the wardsor sterile areas (e.g. cleaners, food delivery)should be trained, preferably by an infectioncontrol person from the organisation, to followpreferred practice.A booklet or information sheet can be provided toindividual personnel by the organisation; this willformalise infection control as an issue that may affecttheir role.October 2010 161

Section 5Standards, criteria, elements and guidelinesStandard 1.5: The organisation provides safe care and servicesCriterion 1.5.2The infection control system supports safepractice and ensures a safe environment forconsumers / patients and healthcare workers.(continued)Evidence commonly presentedConsider whether the following willhelp to address criterion 1.5.2¼¼Infection control policiesPrompt points¼¼What information provided to consumers /patients covers infection control issues? Inhigh-risk areas such as intensive care, how arefamily members educated about the risks andtheir management?¼¼¼¼¼¼Which contracts with external service providersinclude reference to infection control risks?What infection control information is providedto students and volunteers prior to thembeginning a term of service?What is the response to outbreaks ofhealthcare-associated infections? How longis the response time? How is it evaluated andwhat are the results?¼¼¼¼¼¼¼¼¼¼¼¼¼¼¼¼¼¼Infection control systemsSterilising process monitoringMeeting minutesSupport servicesEvidence of staff immunisationSterilisation tracking systemsEvidence of advice given to external serviceproviders, students, carers and visitorsStaff trainingRisk assessment auditsPerformance measurementThis criterion states that: “The infection control system supports safe practice and ensures a safe environment forconsumers / patients and healthcare workers”. The organisation should be able to demonstrate that it has bestevidence-based processes in place to prevent healthcare-associated infection whenever possible, in consumers /patients and staff members alike, and to manage effectively any infections that do occur.Some common suggested performance measures are as follows:Number of clusters / trends of infections which are reviewed and followed upTotal number of clusters / trends of infectionsComment: e.g. an outbreak of gastroenteritisNumber of staff who attended annual infection control trainingTotal number of staff required to attend annual infection control trainingComment: it is suggested that organisations collect data on different staff groups such as cleaners,kitchen staff, nurses, etc.162 The ACHS EQuIP5 Guide Book 1 Accreditation, Standards and Guidelines Clinical Function

Number of consumers / patients whose prophylactic antibiotics were discontinued within 24 hoursafter surgery end timeTotal number of consumers / patients who received prophylactic antibiotics prior to surgeryNumber of percutaneous occupational exposures from recappingTotal number of needlestick injuriesNumber of body fluid exposuresTotal number of incidentsNumber of non-percutaneous occupational exposuresTotal number of occupational exposuresNumber of consumers / patients who received antimicrobial prophylaxisTotal number of consumers / patients for whom antimicrobial prophylaxis was indicatedComment: it is recommended that consumers / patients receive this within 1 hour prior to surgicalincision (or 2 hours if receiving vancomycin)October 2010 163

Section 5Standards, criteria, elements and guidelinesStandard 1.5: The organisation provides safe care and servicesCriterion 1.5.2The infection control system supports safepractice and ensures a safe environment forconsumers / patients and healthcare workers.(continued)References1. Gillespie EE, ten Berk de Boer FJ, Stuart RL et al.A sustained reduction in the transmission of methicillinresistant Staphylococcus aureus in an intensive care unitCrit Care Resusc 2007; 9(2): 161-165.2. Herzer KR and Seshamani M. A success story in health carein America: Eliminating infections and saving lives. KeystoneUSA; Michigan Health & Hospital Association and JohnsHopkins University; 2009.3. National Health and Medical Research Council (NHMRC).Australian guidelines for the prevention and controlof infection in healthcare. Canberra ACT; AustralianGovernment; 2010. Accessed 15 October 2010 fromhttp://www.nhmrc.gov.au/node/302904. Tropea J, Brand CA and Roberts C. A national stakeholderreview of Australian infection control programs: the scopeof practice of the infection control professional. MelbourneVIC; Australian Commission on Safety and Quality in HealthCare; 2008.5. Queensland Communicable Diseases Unit. Infection controlguidelines – extract. 2nd edn. Brisbane; QueenslandHealth; 2001.6. Health Projects International. Design guidelines forhospitals and day procedure centres. Melbourne;Victorian Department of Human Services; 2005.7. Health Department of WA, Facilities & Assets Branch.Guidelines for the construction, establishment andmaintenance of private hospital and day procedure facilities.3rd edn. Perth; WA Health; 1998.8. AHIA (formerly Health Capital and Asset ManagementConsortium) and UNSW Centre for Health AssetsAustralasia. Australasian Health Facility Guidelines(AusHFG). Sydney; UNSW. Accessed from http://www.healthfacilityguidelines.com.au/guidelines.htmon 11 December 2009.9. Communicable Diseases Network Australia. Guidelines formanaging blood-borne virus infection in health care workers.Canberra ACT; Commonwealth Department of Health andAged Care; 2005.10. Australian Technical Advisory Group on Immunisation(ATAGI) and National Health and Medical Research Council(NHMRC). Australian Immunisation Handbook. CanberraACT; Australian Dept of Health and Ageing. Accessed fromhttp://www.health.gov.au/internet/immunise/publishing.nsf/Content/Handbook-home on 8 March 2010.11. Australian Commission on Safety and Quality in Health Care(ACSQHC). Windows into safety and quality in health care2009. Sydney NSW; ACSQHC; 2009.12. NSW Health. A-Z of Infectious diseases. Sydney; NSWHealth. Accessed from http://www.health.nsw.gov.au/publichealth/Infectious/a-z.asp on 10 March 2010.13. Centers for Disease Control and Prevention (CDC). Interimguidance on infection control measures for 2009 H1N1influenza in healthcare settings, including protection ofhealthcare personnel. Atlanta USA; US CDC. Accessed fromhttp://www.cdc.gov/h1n1flu/guidelines_infection_control.htmon 10 March 2010.14. Cars O, Diaz Högberg L, Murray M et al. Meeting thechallenge of antibiotic resistance. Br Med J 2008; 337:a1438.15. Kelly CP and LaMont JT. Clostridium difficile — More difficultthan ever. N Engl J Med 2008; 359(18): 1932-1940.16. Centre for Healthcare Related Infection Surveillance andProtection (CHRISP). Disinfection and sterilization infectioncontrol guidelines. Extract from Queensland Health infectioncontrol guidelines. Brisbane; Qld Health; 2006.17. World Alliance for Patient Safety. WHO guidelines onhand hygiene in health care. Geneva, CH; World HealthOrganization; 2009.18. Hand Hygiene Australia. 5 Moments for hand hygiene. In:Grayson ML, Russo P et al. (eds). Sydney NSW; AustralianCommission on Safety and Quality in Health Care; 2009.19. NSW Health. Infection control policy. Sydney;NSW Health; 2007.20. Children’s Hospital Westmead (CHW). A handbookfor families. Sydney NSW; CHW; 2005.Relevant Australian StandardsHospital acquired infectionsHB 260:2003 Hospital acquired infections –Engineering down the risk.GlovesAS/NZS 4011:1997/Amdt 1-1998 Single-use examination gloves –specification.AS/NZS 4179:1997/Amdt 1-1998 Single-use sterile surgicalrubber gloves – specification.164 The ACHS EQuIP5 Guide Book 1 Accreditation, Standards and Guidelines Clinical Function

MasksAS/NZS 4381:2002 Single-use face masks for use in health care.Second edn.AS/NZS 1716:2003/Amdt 1-2005 Respiratory protective devices.Sixth edn.AS/NZS 1715:2009 Selection, use and maintenance of respiratoryprotective equipment. Fifth edn.Eyewear / gogglesAS/NZS 4381:2002 Single-use face masks for use in health care.Second edn.GownsAS 3789.2:1991/Amdt 1-1992 Textiles for health care facilities andinstitutions. Part 2: Theatre linen and pre-packs.AS 3789.3:1994 Textiles for health care facilities and institutions –Apparel for operating theatre staff.Handling and disposing of sharpsAS 4031:1992/Amdt 1-1996 Non-reusable containers for thecollection of sharp medical items used in health care areas.AS/NZS 4261:1994/Amdt 1-1997 Reusable containers forthe collection of sharp items used in human and animalmedical applications.AS/NZS 3825:1998 Procedures and devices for the removal anddisposal of scalpel blades from scalpel handles.Processing of instruments and equipmentAS 1079.1:1993 Packaging of items (sterile) for patient care– Selection of packaging materials for goods undergoingsterilization. Second edn.AS 1410:2003 Sterilizers—Steam—Pre-vacuum. Fourth edn.AS 2182:1998 Sterilizers—Steam—Benchtop. Fourth edn.AS 2192:2002 Sterilizers—Steam—Downward-displacement.Third edn.AS 2437:1987/Amdt 1-1988 Flusher/sanitizers for bed pansand urine bottles. Second edn.AS 2487:2002 Dry heat sterilizers. Second edn.AS 2514:1999 Drying cabinets for medical equipment.Second edn.AS 2773.1:1998 Ultrasonic cleaners for health care facilities.Part 1: Non-portable. Second edn.AS 2773.2:1999 Ultrasonic cleaners for health care facilities.Part 2: Benchtop.AS 2774:1985 Drying cabinets for respiratory apparatus.AS 2945(Int):2002 Batch-type washer/disinfectors for health carefacilities. Revised second edn.AS 3836:1998 Rack conveyor washers for health care facilities.AS/NZS 4146:2000 Laundry practice.AS/NZS 4187:2003 Cleaning, disinfecting and sterilizingreusable medical and surgical instruments and equipment, andmaintenance of associated environments in health care facilities.AS/NZS 4815:2006 Office-based health care facilities—Reprocessing of reusable medical and surgical instruments andequipment, and maintenance of the associated environment.Second edn.Facility designHB 260:2003 Hospital acquired infections – Engineering downthe risk.AS 1668.2:2002 (inc. Amdts 1 and 2) The use of ventilation andairconditioning in buildings – Ventilation design for indoor aircontaminant control.Waste disposalAS/NZS 3816:1998 Management of clinical and related wastes.HB 202:2000 A management system for clinical and relatedwastes—Guide to application clinical and related wastes.AS/NZS 3825:1998 Procedures and devices for the removal anddisposal of scalpel blades from scalpel handles.AS 4939:2001 Non-reusable personal use containers for thecollection and disposal of hypodermic needles and syringes.AS 4031:1992/Amdt 1-1996 Non-reusable containers for thecollection of sharp medical items used in health care areas.October 2010 165

Section 5Standards, criteria, elements and guidelinesStandard 1.5: The organisation provides safe care and servicesCriterion LA – Awareness SA – ImplementationLA plus the followingCriterion 1.5.3The incidence and impactof breaks in skin integrity,pressure ulcers and othernon‐surgical woundsare minimised throughwound prevention andmanagement programs.a) Policy / guidelines exist forthe maintenance of skinintegrity, and for managingpressure ulcers and othernon-surgical wounds.b) Healthcare providers usean evidence-based riskassessment process / tool toassess skin integrity.c) Strategies for the preventionof pressure ulcers andpreservation of skin integrityare evidence-based and reflectjurisdictional guidelines.d) Policy and procedures forthe management of woundsinclude consideration andstrategies for managing pain.a) Multidisciplinary woundprevention and managementprograms are implemented andadapted to local needs andhealthcare settings.b) Clinical staff are providedwith ongoing education on thepreservation of skin integrityand management of wounds.c) Risk assessment processesoccur on admission, attransitions of care, followingchanges in health status andprior to commencement ofhigh risk procedures.d) Wound documentationsystems are implemented thatsupport continuity of careand assessment of progresstowards goals.IntentThe intent of this criterion is to ensure that theoccurrence of healthcare-associated, non-surgicalbreaks in skin integrity is prevented whenever possibleand minimised at all times.This criterion is applicable to all organisations acrossthe spectrum of health care, as a break in skin integritycan occur as the result of health care itself, can affecta wide variety of consumers / patients (neonates, thefrail aged, the immobile and/or insensate, those withreduced sensory perception, individuals undergoinglengthy procedures), and can occur in all environmentsand situations involving bed care, the use ofsupport devices or physical interaction (emergencydepartments, wards, transport vehicles, operatingtheatres, day hospitals, community nursing).However, consumers / patients may present withcompromised skin in any healthcare setting.Assessment and management of pre-existing breaksin skin integrity must be built into the consumer /patient’s care plan whether or not it is the primarycause of his or her admission.Relationships of 1.5.3 with other criteriaThe process of health care itself may result in acompromise of skin integrity. It is therefore essentialthat the consumer / patient is assessed during eachphase of care (Criterion 1.1.1), and at each transfer ofcare (Criterion 1.1.5). When consumers / patients aremanaged in an inappropriate setting, it is more likelythat skin breaks will occur, or that a skin break will notbe detected (Criterion 1.3.1). An appropriate diet will166 The ACHS EQuIP5 Guide Book 1 Accreditation, Standards and Guidelines Clinical Function

MA – EvaluationSA plus the followingEA – ExcellenceMA plus the followingOA – LeadershipEA plus the followinga) Frameworks for skin integritypreservation and woundmanagement are evaluated andimproved as required.b) Education programs forclinical staff in skin integritypreservation and woundmanagement are evaluated andimproved as required.c) Rates of skin integrity breaks,including pressure ulcer rateswhere applicable, are trendedover time and improvementsare made to the preventionand management strategyas required.a) Skin integrity maintenance andwound management programsare compared with internaland external systems andimprovements are made toensure better practice.and/orb) Rates of skin integrity breaks,including pressure ulcerrates where applicable,are compared with internaland external systems andimprovements are made toensure better practice.and/orc) The organisation developspartnerships with otherstakeholders to facilitate woundprevention and managementacross the continuum of care.and/ord) The organisation undertakesresearch into skin integritymaintenance and/or woundmanagement.a) The organisation demonstratesit is a leader in skin integritymaintenance and woundmanagement.promote wound healing. Conversely, malnutrition isa risk factor for a loss of skin integrity, and moderateto high-risk consumers / patients should undergonutritional assessment (Criterion 1.5.7).Breaks in skin integrity are a risk that must be managedthroughout the health care process (Criterion 2.1.2),and when control processes fail, incidents andcomplaints may result (Criteria 2.1.3 and 2.1.4).Maintenance of skin integrity andmanagement of non-surgical woundsA wide variety of medical conditions can give rise to,or present as, a break in skin integrity. Consumers/ patients may be admitted with pre-existing acute /traumatic wounds, such as lacerations, abrasions,infections, abscesses or skin tears, or with chronicwounds such as ulcers, malignant or fungatingwounds, lymphoedema with ulceration, or woundswith osteomyelitis. Where any of these conditions exist,they must be assessed and managed.The focus of this criterion, however, is upon iatrogenicbreaks in skin integrity. The most recognised andstudied form of healthcare-associated skin break is thepressure ulcer, which is defined as any lesion causedby unrelieved pressure resulting in damage of the skinand underlying tissue. 1October 2010 167

Section 5Standards, criteria, elements and guidelinesStandard 1.5: The organisation provides safe care and servicesCriterion 1.5.3The incidence and impact of breaks inskin integrity, pressure ulcers and othernon-surgical wounds are minimised throughwound prevention and managementprograms. (continued)Pressure ulcers most commonly occur over bonyprominences. Skin tears, which result from friction and/or shearing, are common amongst the frail aged dueto the pathophysiology of older skin and the increasedincidence of falls and manual handling requirements. 2They can be caused by incorrect consumer / patienthandling in any healthcare setting. Urinary and/orfaecal incontinence can give rise to incontinenceassociateddermatitis, which is characterised by skininflammation manifested as redness with or withoutblistering, erosion, or loss of the skin barrier function,which occurs as a consequence of chronic or repeatedexposure of the skin to urine or faecal matter. 3Friction or tearing injuries may also result from theprolonged and/or inappropriate use of medical devicessuch as neck braces, casts, splints, prostheses,indwelling catheters and cannulae, and adhesive tape.In order to minimise and manage breaks in skinintegrity, organisations must have a skin integrity policythat is multidisciplinary in scope and based uponnational and State / Territory guidelines. The policyshould encompass:• risk assessment• wound documentation• care planning• pressure relief• appropriate equipment• staff education• consumer / patient and family education• auditing and reporting• appropriate referral to medical, nursingand allied health professionals.Prompt points¼¼¼¼¼¼What documentation (legislation, guidelines,current evidence) did the organisation drawupon when drafting its skin integrity policy?What departments / disciplines were consultedin the development of the organisation’s policy?What practical action(s) has the organisationtaken to reduce the incidence of iatrogenicwounds? How are improvements in thisarea determined?Identifying ‘at-risk’ consumers / patientsRisk assessment processes can include a rangeof screening and assessment tools that assist inidentifying ‘at-risk’ consumers / patients and shapingthe planning of their care. The same risk assessmenttool(s) should be used across the organisation.Documentation outlining the risk assessmentprocess should include the timing and frequencyof administration of the tool. It should also list anycomplicating factors that might alter a consumer /patient’s risk category. For example, while it isgenerally considered that a consumer / patient isat increased risk for the development of a pressureulcer if undergoing a procedure of 2.5 hours orlonger, a consumer / patient already in poor physicalcondition may be at increased risk from a muchshorter procedure.Risk assessments must not only be carried out upona consumer / patient’s admission, but following anychange in condition or transfer of care, and prior toany high-risk procedure. (NB: ‘high-risk’ refers to theindividual’s condition, not only to the procedure.)Ideally, implementation of wound prevention andmanagement strategies will result in an ongoingreduction in the incidence of healthcare-associatedwounds. Policies should be regularly reviewed,and improvements made with reference to currentevidence-based best practice.168 The ACHS EQuIP5 Guide Book 1 Accreditation, Standards and Guidelines Clinical Function

Prompt pointsPrompt points¼¼What pressure ulcer scoring system is usedin this organisation?¼¼How is pain assessed in consumers / patientswho are unable to describe their pain levels?¼¼How are consumers / patients assessed forthe risk of developing incontinence-associateddermatitis?¼¼How does the existing wound documentationsystem support continuity of care throughoutthe consumer / patient’s journey?¼¼¼¼¼¼At what points during the consumer / patient’scare journey are risk assessments carried out?How is the information gained from assessmenttranslated into the consumer / patient’scare plan?How is the information gained from assessmenttranslated into the consumer / patient’sdischarge plan?Wound managementThe primary focus of this criterion is on preventionof healthcare-associated skin breaks. However, ifconsumers / patients enter the healthcare system witha pre-existing wound, or if a wound subsequentlydevelops, it must be managed in the most effectiveway. An appropriate treatment regime mustencompass a pain management strategy. Certaincategories of consumers / patients, such as youngchildren or those suffering dementia, may be unable toprovide verbal information regarding their pain levels,and other forms of assessment must be employed. 4Conversely, it is recognised that in some consumers /patients the loss of, or reduction in, sensory perceptionmay play a significant role in the breakdown of skinintegrity and the development of wounds.All staff should be aware that monitoring andsurveillance must be ongoing with respect toconsumers / patients identified as being at riskof developing a break in skin integrity, and thatconsumer / patient management must continue acrossthe care continuum. Effective and successful consumer/ patient discharge will depend upon appropriatemeasures and equipment being in place, together withwritten and verbal information for consumers / patientsand carers about prevention and assessment.¼¼What information about maintenance of skinintegrity is provided for consumers / patientsand carers at the time of discharge?Staff educationOrganisations should ensure that all staff membersinvolved in assessment and management of skinintegrity have access to clinical expertise in woundmanagement and ongoing education where applicable.Education and information programs should bedeveloped and evaluated by a multidisciplinary team,and draw upon experience in wound managementfrom a variety of care situations, including aged care,spinal units, incontinence nursing, etc. The teamshould also include consumers / patients and theircarers, in order for the full spectrum of experience tobe represented. Education must be based upon thescreening and assessment tool(s) used organisationwide,in order to ensure consistency of assessment,and encompass the practical aspects of woundcare such as the correct use of pressure-relievingequipment and the positioning of consumers / patients.Related facets of the prevention of iatrogenic skinbreaks such as consideration of the most appropriatecleaning regimes for incontinent consumers / patients 5are also appropriate.Prompt points¼¼¼¼¼¼How often are wound management educationsessions held?Who participates in the organisation’seducation sessions?What role does management / administrationplay in wound care education?¼¼How often is the content of the educationprogram reviewed?October 2010 169

Section 5Standards, criteria, elements and guidelinesStandard 1.5: The organisation provides safe care and servicesCriterion 1.5.3The incidence and impact of breaks inskin integrity, pressure ulcers and othernon-surgical wounds are minimised throughwound prevention and managementprograms. (continued)Evidence commonly presentedConsider whether the following willhelp to address criterion 1.5.3¼¼¼¼¼¼¼¼¼¼¼¼¼¼Policies on admission of consumers / patientswith pre-existing woundsPolicy on management of consumers / patientsduring surgical proceduresHealthcare-associated woundmanagement systemsPressure area assessment tools, includingthe use of these in all areas of care suchas paediatrics, ICU, general surgical,medical wards, rehabilitation units,community-based servicesHealth record auditsEducation / information for staff andconsumers / patientsEquipment register170 The ACHS EQuIP5 Guide Book 1 Accreditation, Standards and Guidelines Clinical Function

Performance measurementThis criterion states that: “The incidence and impact of breaks in skin integrity, pressure ulcers and other nonsurgicalwounds are minimised through wound prevention and management programs”. The organisation shouldbe able to demonstrate that it has procedures in place to prevent the occurrence of iatrogenic wounds in theconsumer / patient wherever possible, and also to manage any breaks in skin integrity present upon admissionor that do subsequently develop. Improvements to the organisation’s rate of skin integrity maintenance can bedemonstrated via a quantitative expression of the collected data. Many of the guidelines listed at the end of thisdocument will provide direction in this respect.Some common suggested performance measures are as follows:Number of consumers / patients receiving skin integrity risk assessmentTotal number of consumers / patients admitted to a particular unit / ward / serviceNumber of ‘at-risk’ consumers / patients who develop a break in skin integrityTotal number of consumers / patients determined ‘at-risk’ of developing a break in skin integrityComment: the organisation should determine what constitutes ‘at-risk’Number of ‘at-risk’ consumers / patients who do not receive a risk assessment and develop a breakin skin integrityTotal number of ‘at-risk’ consumers / patients who do not receive a skin integrity risk assessmentNumber of consumers / patients who develop new stage 1 – 4 pressure ulcer as inpatientsTotal number of overnight bed daysNumber of consumers / patients developing stage 1 – 4 pressure ulcer without risk assessment documentationTotal number of consumers / patients developing stage 1 – 4 pressure ulcersNumber of consumers / patients admitted with stage 1 – 4 pressure ulcer who then develop more,or more severe, pressure ulcersTotal number of consumers / patients admitted with stage 1 – 4 pressure ulcersOctober 2010 171

Section 5Standards, criteria, elements and guidelinesStandard 1.5: The organisation provides safe care and servicesCriterion 1.5.3The incidence and impact of breaks inskin integrity, pressure ulcers and othernon-surgical wounds are minimised throughwound prevention and managementprograms. (continued)References1. NSW Health. Policy directive: clinical practices – pressureulcer prevention. Sydney; NSW Health; 2005.2. Carville K, Lewin G, Newall N et al. STAR: a consensus forskin tear classification. Prim Intent 2007; 15(1): 18-28.3. Gray M, Bliss D, Doughty D et al. Incontinence-associateddermatitis: a consensus. Wound Ostomy Cont Nurs 2007;34(1): 45-54.4. Herr K, Coyne P, Key T et al. Pain assessment in thenonverbal patient: position statement with clinical practicerecommendations. Pain Mgmt Nurs 2006; 7(2): 44-52.5. Ersser S, Getliffe K, Voegeli D and Regan S. A critical reviewof the inter-relationship between skin vulnerability andurinary incontinence and related nursing intervention.Int J Nurs Stud 2005; 42(7): 823-235.GuidelinesNational Pressure Ulcer Advisory Panel (NPUAP) and EuropeanPressure Ulcer Advisory Panel (EPUAP). Prevention of pressureulcers: quick reference guide. Washington DC; NPUAP.Accessed from http://www.epuap.org/guidelines/Final_Quick_Prevention.pdf on 10 September 2010.National Pressure Ulcer Advisory Panel (NPUAP) and EuropeanPressure Ulcer Advisory Panel (EPUAP). Treatment of pressureulcers: quick reference guide. Washington DC; NPUAP.Accessed from http://www.epuap.org/guidelines/Final_Quick_Treatment.pdf on 10 September 2010.Australian Wound Management Association (AMWA).Standards for wound management. Leederville WA; CambridgePublishing; 2010.Australian Wound Management Association (AMWA). ClinicalPractice Guidelines for the Prediction and Prevention of PressureUlcers. West Leederville WA; Cambridge Publishing; 2001.WA Department of Health, Silver Chain and Curtin University.Wounds west. Perth; Government of WA. Accessed fromhttp://www.health.wa.gov.au/WoundsWest/home/ on10 September 2010.Queensland Patient Safety Centre. Pressure ulcer preventionand management resource guidelines. Brisbane; QueenslandHealth; 2009.Joanna Briggs Institute. Pressure sores – Prevention of pressurerelated damage. Best Practice 2008; 12(2): 1-6.Victorian Department of Health. Pressure ulcers – including thePressure Ulcer Point Prevalence Surveys (PUPPS). Melbourne;Victorian Health. Accessed from http://www.health.vic.gov.au/pressureulcers/ on 30 April 2010.Further readingBaranoski S. Skin tears: Staying on guard against the enemyof frail skin. Nursing2010; 33: 14-21. Accessed from http://journals.lww.com/nursing/Fulltext/2003/10001/SKIN_TEARS__Staying_on_guard_against_the_enemy_of.5.aspx# on17 September 2010.Baranoski S. How to prevent and manage skin tears.Adv Skin Wound Care 2003; 16(5): 268-270.Carville K. Wound Care Manual, 5th edn. Perth WA; Silver ChainNursing Assn; 2005.WA Department of Health. Wounds prevalence survey2007; State-wide report overview. WoundsWest. Perth WA;Government of Western Australia; 2007.Joanna Briggs Institute. Topical skin care in aged care facilities.Best Practice 2007; 11(3): 1-4.Northern Sydney Central Coast Health Wound Care Committee2008. Skin Tears: A guide for patients and their carers. Sydney;NSW Health; 2009.Romanelli M, Clark M, Cherry G et al. (eds). Science and practiceof pressure ulcer management. London UK; Springer-Verlag;2006.Wound Ostomy and Continence Nurses Society (WOCN).Position paper on avoidable versus unavoidable pressure ulcers.Mt Laurel USA; WOCN Society. Accessed from http://www.wocn.org/About_Us/News/37/ on 8 June 2010.White W. Skin tears: a descriptive study of the opinions, clinicalpractice and knowledge base of RNs caring for the aged in highcare residential facilities. Prim Intent 2001; 9(4): 138-149.172 The ACHS EQuIP5 Guide Book 1 Accreditation, Standards and Guidelines Clinical Function

October 2010 173

Section 5Standards, criteria, elements and guidelinesStandard 1.5: The organisation provides safe care and servicesCriterion LA – Awareness SA – ImplementationLA plus the followingCriterion 1.5.4The incidence of fallsand fall injuries isminimised through a fallsmanagement program.a) Policy / guidelines exist forfalls management.b) Evidence-based fallsprevention information isprovided to staff througheducation programs andaccess to policy, proceduresand other relevant resources.c) Consumers / patients areassessed for risk of falls:(i) on admission(ii) following a changeof risk factor(iii) after a falland the level of risk isconveyed to the consumer /patient, carer and clinical team.d) Appropriate evidence-basedmultidisciplinary falls reductionstrategies are implementedaccording to identifiedrisk factors.e) Written and verbal fallsprevention information isprovided for consumers /patients and carers.f) Consumers / patients andwhere appropriate their carers,are involved in their fallsprevention / management plan.a) The risk assessment andfalls policy / guidelines areimplemented across theorganisation.b) Staff are educated on falls, andon falls injury risk assessment,prevention and management,and staff are trained in use offalls prevention equipment.c) An individualised fallsprevention plan addressesthe falls risk factors identifiedduring assessment.d) Falls and fall injury preventionequipment is available forconsumers / patients followingappropriate education andtraining for use.e) Falls risk is considered aspart of discharge planning for‘at risk’ consumers / patients.f) A system to report fallsincidents is implementedand reflects jurisdictionalrequirements.174 The ACHS EQuIP5 Guide Book 1 Accreditation, Standards and Guidelines Clinical Function

MA – EvaluationSA plus the followinga) The falls and fall injuryprevention and managementeducation program provided tostaff and consumers / patientsis evaluated and improvedas required.b) Effectiveness of individual fallsprevention management plansis reviewed and evaluated.c) Falls and fall injury data areanalysed and tracked overtime and improvements aremade to the falls preventionand management strategyas required.EA – ExcellenceMA plus the followinga) Falls data managementprograms are compared withinternal and external systemsand improvements are madeto ensure better practice.and/orb) The organisation developspartnerships with otherstakeholders to facilitatefalls prevention across thecontinuum of care.and/orc) The organisation undertakesresearch into falls and fallinjury prevention.OA – LeadershipEA plus the followinga) The organisation demonstratesit is a leader in the areas of fallsprevention and management.October 2010 175

Section 5Standards, criteria, elements and guidelinesStandard 1.5: The organisation provides safe care and servicesCriterion 1.5.4The incidence of falls and fall injuries isminimised through a falls managementprogram. (continued)IntentFalls-related injury is a leading cause of morbidity andmortality amongst older Australians. The intent of thiscriterion is to:• whenever possible, prevent falls from occurring• minimise injury from those falls that could notbe prevented.Relationships of 1.5.4 with other criteriaThe risk of a fall should be considered throughout allphases of the care journey (Standard 1.1). In particular,falls risk should be included as part of the consumer /patient assessment process (Criterion 1.1.1). Falls canbe reviewed in the evaluation of a consumer / patient’scare (1.1.4), and the ongoing risk of falls consideredin clinical handover (Criterion 1.1.6) and planning fortransfer of care or discharge (Criterion 1.1.5).Building arrangements and the equipment used at afacility can impact on the type, severity and numberof falls (Criterion 3.2.2), and addressing this issue isan aspect of the organisation’s safety managementsystem (Criterion 3.2.1). Falls within a facility are asignificant healthcare incident (Criterion 2.1.3), whichmust be managed within the organisation’s integratedrisk management framework (Criterion 2.1.2).Policy and processFalls prevention requires a multifactorial approachto achieve the following objectives 1 :• to identify consumers / patients at high riskof falling• to take precautions appropriate to individualconsumers / patients to reduce falls• to take precautions to minimise injuries fromfalls that cannot be prevented• to respond to immediate injuries and assistconsumers / patients to gain strength andconfidence following a fall.The possibility of a fall and the potential need forassistance post-fall is relevant for every healthcareorganisation, including day procedure centres andcommunity health centres. However, the focus will varybetween organisations and wards.Policies and guidelines for falls prevention for the wholeorganisation should include:• roles and responsibilities• education for consumers / patients and staff• available equipment• risk assessment of consumers / patients onadmission or when changes occur in theirhealth status• environmental hazards and plans to minimisetheir impact• post-falls responses• falls reduction strategies• standard reporting systems• falls data, event monitoring and their review.There is now significant evidence-based informationfrom Australia and overseas that is useful in planningpolicy and procedures, and in daily managementof the ward / facility. The Australian Commission onSafety and Quality in Health Care’s Guidelines forpreventing falls and harm from falls in older people isa comprehensive evidence-based resource 1 that canguide organisations in the creation and implementationof their falls management plan. It includes a descriptionof tools that have been developed for assessing andresponding to falls risk in different healthcare settings.Regardless of the tool(s) selected, organisationsshould have procedures describing responses thatmay be appropriate for consumers / patients withdifferent levels of risk.Policies and procedures should reflect currentknowledge, be carried through to operationalresponses, and be accessible to all staff involved intheir implementation.Because risk factors for falls are often multifactorial,it is important to identify contributing factors to anyincident. A suggested minimum dataset for recognisingareas to focus improvement of care is: 1• What risk factors for falls and injury were present?• What was the activity at the time of the fall?• Has the consumer / patient had a fallsrisk assessment?• What was the mechanism of the fall?• What interventions were in place at thetime of the fall?• Was it a confirmed or suspected fall?176 The ACHS EQuIP5 Guide Book 1 Accreditation, Standards and Guidelines Clinical Function

Prompt points¼¼¼¼¼¼What issues are covered by this organisation’sfalls policy?Has the organisation undertaken a riskassessment for falls? What consumer / patientor procedural characteristics (duration of care,anaesthetics or psychoactive medications)present the greatest challenges for theorganisation in relation to falls?Based on tracking data, how effective hasthe organisation’s policy / guideline beenin combating falls? What changes havebeen introduced in response to analysisof falls data? Have the changes made anymeasurable difference?Individual risk assessment and planningThere is a danger in assuming that falls risk is limited tothe frail aged; it is possible for young and relatively fitpeople to suffer isolated falls due to trip hazards, lightheadednessor temporary confusion in the face of anacute illness or medication. Individual risk assessmentshould take into account the specific circumstances ofeach consumer / patient episode of care.Many risk factors for falling in a healthcare setting havebeen identified. 1,2 These include:• intrinsic factors: such as a previous fall,postural instability / muscle weakness, cognitiveimpairment, delirium, disturbed behaviour, urinaryfrequency, incontinence, postural hypotension,some medications and/or visual impairment• extrinsic factors: particularly a hospitalisationof more than 18 days• environmental factors: most falls happen aroundthe bedside and in the bathroom, and at timeswhen there is less observation, such as outsidevisiting hours, when showering, and at meal times.A falls assessment will focus on the consumer /patient’s intrinsic risk factors. In individual wardsor facilities, the relative importance of different riskfactors will vary based on the characteristics of theirconsumers / patients and the environment; this shouldbe reflected in the management of assessment anddischarge planning. Risk assessment documentsshould be easily accessible to all staff and there shouldbe communication with the consumer / patient and anycarers about the proposed measures to mitigate risk.To draw conclusions about the effectiveness ofindividual management plans, good record keeping isneeded. Organisations should ensure that records arekept together and all events are reported and followedup through the incident management system.Reviewing the effectiveness of individual managementplans could involve:• recording consumers / patients’ falls during theirstay with consideration of pre-identified riskfactors at time of discharge• retrospective audits of consumer / patient healthrecords in the light of the risk assessment plan• including a falls risk management question insatisfaction surveys.Prompt points¼¼¼¼What proportion of consumers / patientshave a full risk assessment for falls followingpreliminary screening at the time of admission?For consumers / patients who have longer terminpatient care, how frequently are these updatedin response to changes in a falls risk factor?At what stage of an admission is falls riskdiscussed with consumers / patients and/ortheir carers? Who has these conversations?(Responses to this question should varybetween wards or departments.) What role canthe consumers / patients and their carers playin managing falls risk?¼¼What actions are taken to assist consumers /patients identified to be at risk of fallingfollowing discharge?¼¼How is the effectiveness of falls prevention andmanagement planning evaluated?Organisational risk assessmentand reportingThe Australian Commission on Safety and Quality inHealth Care has prepared an implementation guidebased on their best-practice guidelines for preventingfalls and harm from falls in older people. 3 Theproposed implementation process for a falls preventionprogram includes consideration of risk factors, andthe guide provides templates for planning a fallsmanagement program. 3 There are now evidencebasedreviews that collate information on the efficacyof falls prevention. The evidence is described in theCommission’s best practice guidelines for preventingfalls and harm from falls in older people. 1October 2010 177

Section 5Standards, criteria, elements and guidelinesStandard 1.5: The organisation provides safe care and servicesCriterion 1.5.4The incidence of falls and fall injuries isminimised through a falls managementprogram. (continued)Falls are included as a ‘category’ for describingincidents in most State / Territory health departmentincident report programs.Prompt points¼¼¼¼¼¼What falls reduction strategies have beenimplemented to alleviate falls risk factors? Havethey had an impact on the number or severity offalls, or made it easier to prevent people falling?How do staff access policy and proceduredocuments on falls? How are new stafffamiliarised with the facility’s falls managementprogram? What communication vehicles areused to update ‘frontline’ staff about newevidence in relation to falls?What incident reporting system is used torecord falls at this facility? Who is responsiblefor following up and investigating incidents thatinvolve falls?Equipment to reduce fallsActivity is central to recovery and return to thecommunity after hospitalisation. Efforts to maintain andimprove mobility of consumers / patients are importantdespite the risks involved. Reminders in a healthcareorganisation’s entry brochure that consumers / patientsbring spectacles and mobility aids can reduce theneed for their provision in the facility.If a need for equipment is identified, the organisationshould provide access through its own reserves,purchase by families, or hiring and lease schemes.Where available, multidisciplinary care that includesrehabilitation specialists, occupational therapists,physiotherapists and other allied health and ancillaryservices as appropriate may provide informationand improve access. A review of footwear may alsoassist consumers / patients to manage risk duringtheir rehabilitation. Under other circumstances, it isimportant that staff have access to relevant contactnumbers to facilitate consumers / patients gainingappropriate equipment for inpatient use and at time ofdischarge. Examples of contacts that might be relevantare hiring services for walking frames and rollators,suppliers of wheelchairs and other equipment andhome modification consultants or services.Hip protectors, and in the longer term, medicationto promote bone strength, for example Vitamin D,calcium and osteoporosis drugs, may be protectivefor consumers / patients who do fall. Assessment ofwhether these measures would benefit a consumer /patient should be followed up by a clinician.In some instances, equipment can be the cause ofthe fall. Equipment stored just out of reach, the wrongequipment supplied and insufficient education on theuse of it should be avoided.The placement of walking aids, call buttons and mealtrays can also cause falls. Cleaners and other relevantstaff should be educated about returning equipmentto its former position when it is moved for cleaning orconsumer / patient access. In addition, spills, clutterand the placement of furniture can contribute to a fall.Prompt points¼¼¼¼¼¼What equipment is used within the facilityto reduce the risk of falls while (ideally)encouraging mobility? Is there any trainingon falls prevention or the effective use ofmobility supports for consumers / patientsrequiring them?Are hip protectors used for high-riskconsumers / patients who are likely to fall?How are consumers / patients selected for hipprotector use?What arrangements does the organisationhave to assist consumers / patients at riskof falls to access appropriate equipmentfollowing discharge?Education – internal and externalAll staff should be aware of universal strategies for fallsprevention in their setting, for example the appropriatesupervision of consumers / patients, and understandwhich consumers / patients are at increased risk inorder to prevent falls.178 The ACHS EQuIP5 Guide Book 1 Accreditation, Standards and Guidelines Clinical Function

Education should include:• training in understanding risk factors andprevention and management strategies (genericand sector / profession specific)• understanding the use of the organisation’sselected assessment materials in various contextswith particular consumers / patients. It is alsoimportant that consumers / patients and theircarers / visitors understand the potential risk fromfalls and the actions being taken to prevent a falloccurring while consumers / patients are within ahealthcare facility.Ideally, all consumers / patients at risk of falling wouldbe regularly checked by staff and offered assistance. 4The term used for regular, proactive checks by nursesof consumers / patients in wards of a healthcare facilityis ‘rounding’. The goal is to reduce the need for weakconsumers / patients to attempt unassisted travel bypre-empting their need to go to the bathroom or seeka drink.Training in protective OH&S strategies and in the useof lifting equipment is important. Repositioning andtransferring consumers / patients are associated withthe majority of manual handling incidents. 5 Obeseconsumers / patients 6 who are at risk of falling presenteven greater challenges to staff.Education programs are now routinely evaluatedin most organisations. Regardless of whether fallstraining for staff, volunteers and consumers / patientsis provided by internal educators or by externalcontractors, nursing staff and others who arefamiliar with the specific issues should be involvedin evaluating the program and its provision, ideallyagainst some predetermined goals.Prompt points¼¼What information is provided to consumers /patients to assist them (and their carers) tobetter manage falls risk – in the facility, andwhen they return home?¼¼¼¼¼¼¼¼How do clinical staff access information aboutfalls prevention?Is rounding used in the inpatient wards? If so,has rounding had any impact on the numbersor severity of falls?What training programs are available tostaff to improve their knowledge of falls riskassessment, prevention and management?How are new staff members familiarised withthe falls prevention equipment used in theorganisation? What efforts are made to ensurestaff members do not injure themselves throughtheir efforts to prevent consumers / patientsfrom falling?How are any falls education programsmonitored? When staff attend training byan external provider, how is the value ofthis training to the staff member and to theorganisation assessed?Evidence commonly presentedConsider whether the following willhelp to address criterion 1.5.4¼¼¼¼¼¼¼¼¼¼¼¼¼¼Falls prevention and management policiesHealth record auditsFalls risk assessments and action plansFalls data and outcomes arising from theirevaluation / reviewInvestigation / follow-up of a serious falls eventSignage, providing information on reductionof falls for consumers / patients, carers andother visitorsConsumer / patient information sheetsOctober 2010 179

Section 5Standards, criteria, elements and guidelinesStandard 1.5: The organisation provides safe care and servicesCriterion 1.5.4The incidence of falls and fall injuries is minimised through a falls management program.(continued)Performance measurementThis criterion states that: “The incidence of falls and fall injuries is minimised through a falls management program”.The organisation should be able to demonstrate policy, procedures and education aimed at minimising consumer /patient falls and falls injury during an episode of care, and assisting consumers / patients and their carers tomanage falls risk following discharge.Some common suggested performance measures are as follows:Number of consumers / patients who suffer or experience slips, trips and fallsTotal number of overnight bed daysNumber of consumers / patients experiencing two or more fallsTotal number of consumers / patients who experience a fallNumber of consumers / patients aged over 65 years who fallTotal number of overnight bed days of consumers / patients aged 65 years and olderNumber of consumers / patients with a documented falls risk assessmentTotal number of consumers / patients admitted to a particular unit / wardNumber of consumers / patients who fall following an intra-organisational incident of aggressionTotal number of consumers / patients who fallNumber of ‘at-risk’ consumers / patients provided with injury prevention devicesTotal number of ‘at-risk’ consumers / patientsComment: the definition of ‘at-risk’ should be based upon categories of risk determined usingthe organisation’s falls risk assessment processes180 The ACHS EQuIP5 Guide Book 1 Accreditation, Standards and Guidelines Clinical Function

Number of ‘at-risk’ consumers / patients who fallTotal number of ‘at-risk’ consumers / patients as determined by a falls risk assessmentNumber of consumers / patients at high risk of a fall who are seen by at least one relevant clinician capableof influencing that riskTotal number of consumers / patients assessed as being at high risk of a fallComment: a ‘relevant clinician’ might be a physiotherapist, occupational therapist,continence nurse, etc.Follow-up falls assessments (in response to changes in consumer / patient condition)Number of changes to consumer / patient condition that meet organisation-defined conditionsfor a falls reassessmentComment: organisational procedures should state circumstances where a falls reassessmentis to be undertakenNumber of falls resulting in any injuryTotal number of fallsComment: it is recommended to collect the different types of injuriesReferences1. Australian Commission on Safety and Quality in Health Care(ACSQHC). Preventing falls and harm from falls in olderpeople: best practice guidelines for Australian hospitals.Sydney NSW; ACSQHC; 2009.2. National Ageing Research Institute and Centre for AppliedGerontology. An analysis of research on preventing fallsand falls injury in older people: community, residentialcare and hospital settings. Canberra ACT; AustralianGovernment; 2004.3. Australian Commission on Safety and Quality in Health Care(ACSQHC). Implementation guide for preventing falls andharm from falls in older people: Best practice guidelinesfor Australian hospitals and residential aged care facilities.Sydney NSW; ACSQHC; 2009.4. Szumlas S, Groszek J, Kitt S et al. Take a second glance:a novel approach to inpatient fall prevention. Joint Comm JQual & Patient Safety 2004; 30(6): 295-302.5. NSW Nurses Association and Workcover NSW.Manual handling guide for nurses. Sydney NSW;Workcover NSW; 1998.6. Australian Safety and Compensation Council (ASCC).Manual handling risks associated with the care, treatmentand transportation of bariatric (severely obese) patients inAustralia. Canberra ACT; ASCC; 2009.October 2010 181

Section 5Standards, criteria, elements and guidelinesStandard 1.5: The organisation provides safe care and servicesCriterion LA – Awareness SA – ImplementationLA plus the followingCriterion 1.5.5:The system tomanage samplecollection,blood, bloodcomponents /bloodproducts andpatient bloodmanagementensures safeand appropriatepractice.a) Policy exists for:(i) consumer / patient identification atthe time of sample collection(ii) completion of the request form, safecollection, identification and labellingof the consumer / patient sample(iii) prescription and documentation ofblood component / product therapy(iv) obtaining and documentinginformed consent(v) managing consumers / patientswho decline administration of bloodcomponents / products(vi) the timely availability andsafe administration of bloodcomponents / products(vii) monitoring and review of theappropriateness of bloodcomponent / product therapy(viii) consumer / patient blood managementincluding blood conservationstrategies and alternatives to bloodcomponent / product therapy(ix) reporting and management ofadverse effects of blood component /product therapy.b) Policy exists for the storage conditionsand transportation of samples and bloodcomponents / products and includes:(i) validating, monitoring and recordingof temperature for all blood fridges(ii) response to blood fridge alarms(iii) maintenance standards for allblood fridges(iv) delivery, placement and removal ofblood components / products fromany blood fridge / controlled storage(v) a documented audit trail.c) The sample collection and bloodcomponent / product management policyis compliant with:(i) jurisdictional legislation(ii) ANZSBT / ASTH / NBA / NHMRC /RCNA guidelines(iii) Australian standards(iv) ARCBS Circular of Information(v) NPACC requirements(vi) NATA requirementsas appropriate.a) The sample, blood component / productmanagement system ensures:(i) verification of consumer / patientidentification at the time ofsample collection(ii) timely and safe collectionand labelling of samples(iii) documented indication andprescription for blood components(iv) the consumer / patient and careris informed of the risks, benefitsand appropriateness of the bloodcomponent / product for their clinicalsituation and consents to administration(v) timely availability of bloodcomponents / products(vi) verification of correct consumer /patient and component / productand safe administration of bloodcomponents / products(vii) adverse events and near misses arereported and linked to the incidentmanagement system.b) The system for the safe transportationand storage of samples and bloodcomponents / products includes:(i) a blood components / productsinventory register(ii) allocated responsibilities forresponding to storage alarms andtaking corrective action(iii) documentation accompanying samplesand blood components / products(iv) labels being checked each time thecomponent / product is handled(v) policy for monitoring blood componentusage and wastage.c) Relevant staff are provided with orientationand education on procedures for safesample and blood component / productmanagement, which include:(i) consumer / patient identification andsample collection(ii) storage and transportation of samplesand blood components / products(iii) blood component / product therapyprescription and safe administration(iv) recognition, management and reportingof adverse effects of blood component /product therapy.182 The ACHS EQuIP5 Guide Book 1 Accreditation, Standards and Guidelines Clinical Function

MA – EvaluationSA plus the followingEA – ExcellenceMA plus the followingOA – LeadershipEA plus the followinga) All aspects of the sample andblood component managementsystems are monitored, evaluatedand trended, and improvementsare made as required.b) The staff orientation, trainingand competency program isevaluated and improvementsare made as required.c) Staff skills and competence aredefined, assessed, and evaluatedand improvements are madeas required.d) The system for transportationand storage of samples andblood components is evaluatedand improvements are madeas required.e) The blood components inventoryregister system is evaluatedand improvements are madeas required.f) Sample and blood component /product errors, near misses andadverse events are analysed andtrended and further strategiesto reduce sample and bloodcomponent incidents areimplemented.a) The systems for sample andblood component managementare compared with internaland external systems andimprovements are made toensure better practice.and/orb) The system for transportingand storage of samples andblood components / productsis compared with internaland external systems andimprovements are made toensure better practice.and/orc) The organisation undertakesresearch into blood component /product and consumer / patientblood management practices.a) The organisation demonstrates thatit is a leader in sample collection,blood, blood components / bloodproducts and consumer / patientblood management.October 2010 183

Section 5Standards, criteria, elements and guidelinesStandard 1.5: The organisation provides safe care and servicesCriterion 1.5.5:The system to manage sample collection,blood, blood components / blood productsand patient blood management ensures safeand appropriate practice. (continued)IntentThe intent of this criterion is to ensure that healthcareorganisations responsible for transfusing blood,blood components or blood products have effectivemanagement systems that promote safe andappropriate blood management.This criterion applies to all organisations that may beresponsible for transfusing blood or administeringany blood product or component, regardless of howinfrequently it occurs.This criterion is not applicable where organisations:• do not collect blood samples from consumers /patients for the purposes of transfusion of blood orblood products / components• do not store, transport or administer blood orblood products / components.Requirements for samples of blood, body fluids andtissues that are not related to blood transfusion areaddressed within criterion 1.5.6.In this criterion, the term ‘sample’ refers to bloodsamples collected from a consumer / patient to enablehuman-derived blood or blood component / producttransfusion, or for other blood grouping procedures,as per the National Pathology Accreditation AdvisoryCouncil (NPAAC) Requirements for TransfusionLaboratory Practice available at: http://www.ocs.gov.au/internet/main/publishing.nsf/Content/npaac-trans-2008-toc~npaac-trans-2008-1The term ‘blood’ has been used in this criterion todescribe homologous and autologous whole blood;‘blood component’ to describe fresh components (redcells, platelets, fresh frozen plasma, cryoprecipitate,cryodepleted plasma); and ‘blood product’ to describeplasma derivatives and recombinant products.The term ‘sampling’ has been used to describe thecollection of a blood sample from a consumer / patient.Relationships of 1.5.5 with other criteriaComplete and accurate patient identification, andthe matching of consumer / patient, sample, test andtest results, is critical for pathology sample collectionand also for administration of blood components /products (Criterion 1.5.6). Another vital aspect ofblood management is ensuring informed consentfor the transfusion is obtained prior to administeringany blood components / products (Criterion 1.1.3).Blood components / products may play a criticalrole in managing a deteriorating consumer / patient(Criterion 1.1.2).The administration of blood and blood components /products has associated risks (Criterion 2.1.2) that,if not managed correctly, are likely to lead to adverseand sentinel events (Criterion 2.1.3).External service providers such as private pathologyservices are frequently subcontracted to manageblood collection or inventory, and this arrangementmust be managed by the organisation (Criterion 3.1.4).Management systemThis criterion is based on the many evidence-basedstandards, guidelines and circulars that have beendeveloped in recent years by individuals, organisationsand associations and experts in the field of blood andblood component / product management and bloodcomponent therapy. These include:• Australian and New Zealand Society of BloodTransfusion (ANZSBT) 1,2 / Australasian Societyof Blood Transfusion 3• Australian Red Cross Blood Service (ARCBS) 4, 5• Royal College of Nursing Australia (RCNA) 2• National Health and Medical Research Council(NHMRC) 6• National Blood Authority. 7, 8The various standards, guidelines and circulars withwhich organisations should be compliant, are listed atthe end of this criterion in the references.Accreditation of laboratory processes is undertakenby the NPAAC and the National Association of TestingAuthorities (NATA).The management of samples, blood and bloodcomponents / products beyond the laboratory involves:• consumer / patient identification at all points alongthe process• correct labelling of consumer / patient samples• storage and transportation of samples, blood andblood components / products184 The ACHS EQuIP5 Guide Book 1 Accreditation, Standards and Guidelines Clinical Function

• appropriateness of blood component therapy• documentation of all aspects of the blood / bloodcomponent / product administration processincluding the reason for administration• appropriate training for sample collection and theadministration of blood components / products• competency assessment of staff directly involvedin sample collection, blood and blood component /product administration• consent for blood, blood component /product administration• governance• staff responsibility.Policies and procedures should be available toall staff. Issues that should be covered in policy /procedures include:• consumer / patient identification• the minimum information required (as astandardised data set) for samples and requestforms 2 , sampling and sample labelling• timeliness including handling of urgent requests• obtaining and documenting consent fortransfusion and procedures in the event of failureto gain consent for blood, blood component /product therapy• consumer / patient blood management• prescription, documentation, and administrationof blood and blood components / products• adverse event management.Healthcare facilities should have a local emergencyblood management plan in accordance withjurisdictional and National Blood Authorityrequirements. 8The identification of the consumer / patient and, whereapplicable, the blood component / product must beverified at every stage. Where possible, the consumer/ patient should be asked to state his/her full name anddate of birth. Policy should include the managementof unidentified consumers / patients. All consumers /patients, including any individual whose identity isunknown, should have a completed identification bandattached at all times. 1–3Consumers / patients should be informed of the risksof, benefits of and alternatives to blood transfusion,and the risks from non-administration. Informationbrochures on blood components / products should beprovided to consumers / patients and carers. 2, 9As a general principle, every effort should be madeto implement appropriate consumer / patient bloodmanagement. Strategies that should be considered,particularly when surgery is elective, include:• optimising consumer / patient haemoglobulinprior to surgery• correction of iron deficiency with parenteral andoral iron.Although the Australasian Society of Blood Transfusionhas prepared a guideline for autologous bloodcollection 3 in Australia, there are few circumstanceswhen autologous transfusion should be recommended;this is addressed by the Australian Red Cross BloodService (ARCBS) on their website: www.transfusion.10, 11com.au.Complete documentation of administration ofblood components / products should be kept inthe consumer / patient health record. This includesthe blood component / product compatibilityreport, forms used for prescription, observationstaken during administration, documentation of theadministration of blood components / products,management information including the managementof adverse effects, and a record of the component ordonation numbers.Clinical governance of blood samples and transfusionsis the responsibility of the Hospital TransfusionCommittee (HTC). Where there is no HTC or equivalentbody, discussion of transfusion-related issues shouldbe incorporated as a standing agenda item in meetingsof a committee appropriate to the organisation,such as a Hospital Management Committee orQuality Committee.Errors associated with samples may impact at anyphase of transfusion activity, leading to adverse events/ near misses. Data that track levels of use of bloodcomponents and blood products over time should beprovided to meetings of the HTC in a consistent formatfor its consideration.A range of approaches may be used to evaluate theblood component / product management system.Where the organisation has clear and detailedsystems for sample and blood component / productmanagement, review may involve an audit of activityagainst policy and protocols. There is a wide varietyof tools, including audit tools, available; the NationalBlood Authority has links to most under ‘Best PracticeTools’ at http://www.nba.gov.au/bptools/index.htmlOctober 2010 185

Section 5Standards, criteria, elements and guidelinesStandard 1.5: The organisation provides safe care and servicesCriterion 1.5.5:The system to manage sample collection,blood, blood components / blood productsand patient blood management ensures safeand appropriate practice. (continued)Laboratories and healthcare organisations shouldmonitor wastage of blood and blood components /products, and record reasons for discard. Reviewof this information will identify aspects of bloodmanagement that could be improved. For example,blood may have been discarded because it could notbe returned to inventory due to being stored in noncompliantrefrigerators. Waste linked to exceedingthe expiry date may indicate that excessive inventoryis being held.Massive transfusion can strain the inventories oforganisations and can deplete product. The ARCBSwebsite describes a range of responses to massivetransfusion including for emergency and electivesurgery settings. 12 Organisations should developpolicy and/or procedures to guide decision makingin response to massive transfusion that includesliaison with the appropriate supplier of bloodcomponents / products.Where private pathology companies are involved inblood sampling related to transfusion, the organisationshould include a set of key performance indicators(KPIs) in the service contract, to ensure that servicesand their delivery meet a predetermined standard.Prompt points¼¼¼¼¼¼Does the organisation’s policy address bloodconservation strategies and alternativesto transfusion?Does the organisation have a protocol formassive transfusion? If there is a protocol, howis compliance assessed?Does the organisation have a perioperativeblood management program? In the lead upto elective surgery, how does the organisationidentify consumers / patients who are anaemicor confirm that this check has been done by thereferring physician / surgeon?Safe transport and storageBlood components / products should be stored only indedicated, temperature-controlled blood transfusionrefrigerators in accordance with AS 3864:1997 Medicalrefrigeration equipment – for the storage of blood andblood products. 13The documented ‘audit trail’ should ensure that allblood components / products can be traced fromreceipt to recipient, or to final destination if notadministered. Where a health facility has a bloodrefrigerator that is not situated within the transfusionlaboratory (such as in operating rooms), the audit trailshould be maintained so that the delivery, placementand removal of blood components / products can betraced. The security of this area must be maintainedwhile also ensuring there is immediate access in anemergency. A register must be in the proximity of theblood refrigerator and correctly maintained.¼¼¼¼¼¼Does the organisation’s sample collectionpolicy address consumer / patient identificationand include the minimum data set required forlabelling and request forms?Does the organisation’s consent policyseparately address the administration of bloodcomponents / products? How does it coverrefusal of consent? Does the organisationalpolicy refer to potentially controversial situations,such as may occur when failing to transfusecould lead to death of a consumer / patient?What written information on transfusion isprovided for consumers / patients?Access for removal, collection, transport and deliveryof blood components / products should be restricted toauthorised staff members.There should be a backup procedure in place in caseof blood refrigerator failure that includes an alternativestorage site (e.g. at another nearby hospital) 2 and that:• can be locked if in an unsupervised area• is connected to emergency power… as well as resources to adequately storeblood components / products until transfer to thealternative site.186 The ACHS EQuIP5 Guide Book 1 Accreditation, Standards and Guidelines Clinical Function

Blood components / products (not for immediate use)should be stored and transported only in boxes /eskies validated satisfactory for this purpose with thevalidated time for satisfactory storage indicated onthe box / esky. Transfusion providers must record thetime when blood components / products were placedinto a box / esky, the time for which storage will besatisfactory, and indicate that the blood components /products should be returned to a blood transfusionrefrigerator if not used within that time.Prompt points¼¼¼¼¼¼¼¼¼¼How does the organisation’s policy addressallocated responsibilities and corrective actionsfor responding to storage alarms?Can the organisation demonstratea documented audit trail for bloodcomponents / products?Does the organisation have a blood refrigeratorlocated outside the transfusion / laboratoryservice (such as in the operating rooms)? Ifso, who is responsible for maintaining thisregister? How frequently is the register audited,and to whom are the results reported?How does the organisation’s policy addressremoval of blood components / productsfrom controlled refrigeration and transportrequirements / responsibilities?How does the organisation monitor bloodcomponent / product usage and wastage?Staff should be assessed as being competent to carryout the tasks they are performing. 2 All staff working inareas where blood components / products are handledor who may be questioned by consumers / patientsabout transfusions should have some knowledge ofthe organisation’s blood management systems andprocesses, and any related policies.Clinicians who will administer blood and bloodcomponents / products should be trained in the correctprocedures for transfusion, in the organisation’s sitesfor storage, correct use of forms and any uniqueprocedures. All staff who will administer bloodshould be competency-tested and the assessmentoutcome recorded on their personnel file. The trainingdatabase / register should nominate clinical andnon-clinical staff who need to maintain their training inblood management, and use this record to scheduleeducation, as discussed within criterion 2.2.4.There are numerous online sites that offer educationand training in aspects of blood transfusion, anexample of which is http://www.bloodsafelearning.org.au/ 14 The organisation can gain insight into theease of understanding, relevance and applicabilityof its education / training by surveying participantsabout their learning experience. It is imperativethat staff understand the information provided andits application.Prompt points¼¼Does the organisation’s policy address therequirement for education and training for newand existing staff?Education, training and assessmentEducation, training and assessment of competencein respect to consumer / patient identification,sample collection, blood and blood component /product policies and procedures, including collectionand transport, prescription, administration andmanagement of adverse events should be in placefor new staff, and regular updates for all staff shouldoccur at least biennially. The training may includemedical, nursing, midwifery and phlebotomy staff.Non-clinical ancillary staff, such as porters, orderliesand ward assistants, require training that covers thetransportation of blood. Training and competenceassessment records should be maintained.¼¼¼¼¼¼Does the training register / database specifystaff who require clinical and non-clinicaltraining in blood management? How does theorganisation use this database to schedule itseducation course(s) in blood management?Can the organisation demonstrate thateducation and training programs areregularly reviewed?How does the organisation track bloodmanagement education / training for its staff?October 2010 187

Section 5Standards, criteria, elements and guidelinesStandard 1.5: The organisation provides safe care and servicesCriterion 1.5.5:The system to manage sample collection,blood, blood components / blood productsand patient blood management ensures safeand appropriate practice. (continued)Errors, near misses and adverse eventsThe governing body is responsible for ensuring thatappropriate staff are informed of and follow policyand procedures for sample collection and bloodcomponent therapy and report all adverse events andnear misses relating to the blood component / productadministration process.Such incidents should be examined by the executivecommittee / HTC. Serious incidents require detailedreview. The incidence of near misses / less seriousadverse events, particularly when these cluster withan identifiable setting, timing or product type, shouldalso be examined. A nominated staff member shouldbe allocated responsibility for developing proceduresand coordinating training to respond to identifiedweaknesses in transfusion-related processes ortheir application.Prompt points¼¼¼¼¼¼How does the organisation’s policy address therequirements for reporting and review of nearmisses and adverse events?Does the organisation have a HTC / executivecommittee to monitor and respond totransfusion-related near misses / adverseevents? How are transfusion data and theactions taken in response to monitoring adverseevents and near misses communicated to thegoverning body?What training do transfusion and bloodmanagement staff receive in incident reporting?Do the staff have ready access to a computerlinked to the incident management system, oran alternative means of recording any adverseevents / near misses?Evidence commonly presentedConsider whether the following willhelp to address criterion 1.5.5:¼¼¼¼¼¼¼¼¼¼¼¼¼¼¼¼Policies and proceduresConsent and refusal processesInformation provided to consumers / patientsEvidence of compliance with policies andproceduresStaff education and training programs andrecordsResults of review of near misses and adverseeventsAudit / KPI dataEvaluation of systems188 The ACHS EQuIP5 Guide Book 1 Accreditation, Standards and Guidelines Clinical Function

Performance measurementThis criterion states that: “The system to manage sample collection, blood, blood components / blood productsand patient blood management ensures safe and appropriate practice”. Organisations responsible for transfusingblood, blood components or blood products should be able to demonstrate that they have in place effectivesystems that promote safe and appropriate blood management, including processes to manage issues of consentand programs for staff education.Some common suggested performance measures are as follows:Number of transfusion episodes where informed consumer / patient consent was documentedTotal number of transfusion episodes auditedNumber of transfused blood component episodes with documented evidence of two checking signaturesTotal number of transfused blood component episodes auditedNumber of episodes of transfused blood components / products with reason for transfusion documentedin health recordTotal number of transfused blood component / product episodes auditedComment: Reason for transfusion should be documented on both the request form and in thehealth recordNumber of pre-transfusion samples that do not meet requirements for labelling described in current clinicalpractice guidelines 6 / NPAAC* standards 15 labelling requirementsTotal number of pre-transfusion samples*National Pathology Accreditation Advisory CommitteeNumber of transfusion episodes in stable adults undertaken in accordance with current national clinical practiceguidelines 6 for the appropriate use of blood componentsTotal number of adult transfusion episodes auditedComment: Auditing to address this indicator requires good knowledge of the guidelines and sothis indicator should be calculated by trained staffOctober 2010 189

Section 5Standards, criteria, elements and guidelinesStandard 1.5: The organisation provides safe care and servicesCriterion 1.5.5:The system to manage sample collection, blood, blood components / blood products andpatient blood management ensures safe and appropriate practice. (continued)Number of consumers / patients who experienced a reaction that was reportedTotal number of consumers / patients who experienced a reactionComment: Calculating this indicator may require the matching of health record information to theincident management systemNumber of transfusion episodes in stable adults undertaken in accordance with current national clinical practiceguidelines 6 for the appropriate use of blood componentsTotal number of adult transfusion episodes auditedComment: Auditing to address this indicator requires good knowledge of the guidelines and sothis indicator should be calculated by trained staffNumber of administered blood components / products that have a unit / product number documented in theconsumer / patient’s health recordTotal number of blood component / product episodes auditedComment: This indicator might be calculated from health records updated over a specified time periodOR health records might be examined for blood component / product administration until atarget number of blood component / product administrations is reachedNumber of clinical staff required to manage blood transfusions whose education / competency testing is currentTotal number of clinical staff required to manage blood transfusions190 The ACHS EQuIP5 Guide Book 1 Accreditation, Standards and Guidelines Clinical Function

References1. Australian & New Zealand Society of Blood Transfusion.Guidelines for pretransfusion laboratory practice. 5th edn.Sydney NSW; ANZBT; 2007.2. Australian & New Zealand Society of Blood TransfusionInc. and Royal College of Nursing Australia. Guidelinesfor the administration of blood components. Sydney NSW;ANZBT; 2004.3. Australasian Society of Blood Transfusion. Guidelinesfor autologous blood collection. Topics in TransfusionMedicine 2002; 9(2): 1-54. Accessed from http://www.anzsbt.org.au/publications/documents/2002_Vol9_2.pdf on26 August 2010.4. Australian Red Cross Blood Service (ARCBS). Labeland component information. 4th edn. Melbourne VIC;ARCBS; 2008.5. Australian Red Cross Blood Service (ARCBS).Blood component information: Circular of information.An extension of blood component labels. Melbourne VIC;ARCBS; 2009.6. National Health and Medical Research Council (NHMRC).Clinical practice guidelines for the use of blood components.Canberra ACT; Australian Government. Accessed fromhttp://www.nhmrc.gov.au/publications/synopses/cp77syn.htm on 24 August 2010.7. National Blood Authority (NBA). Guidelines on theprophylactic use of Rh D immunoglobulin (anti-D) inobstetrics. Canberra ACT; National Health and MedicalResearch Council (NHMRC); 2003.8. National Blood Authority (NBA) and Australian HealthMinisters’ Conference. National blood supply contingencyplan (NBSCP): Australia’s response to blood shortages.Canberra ACT; Australian Government; 2008.9. National Health and Medical Research Council (NHMRC)and Australasian Society of Blood Transfusion (ASBT).Clinical practice guidelines on the use of blood components.Canberra ACT; NHMRC & ASBT; 2001.10. Australian Red Cross Blood Service (ARCBS). Transfusionmedicine manual: Autologous, allocated and directeddonations. All states; ARCBS. Accessed from http://www.manual.transfusion.com.au/Inventory-Management/Practice/Donations---specialised.aspx on 25 August 2010.11. Australian Red Cross Blood Service (ARCBS). Transfusionmedicine manual: Transfusion alternatives – techniquesfor minimising and avoiding allogeneic blood componenttherapy. Sydney NSW; ARCBS. Accessed from http://www.manual.transfusion.com.au/Transfusion-Clinical-Practice/Transfusion-Alternatives.aspx on 25 August 2010.12. Australian Red Cross Blood Service (ARCBS). Massivetransfusion: haemorrhage. Melbourne VIC; ARCBS.Accessed from http://www.manual.transfusion.com.au/Transfusion-Clinical-Practice/Disease-Therapeutics/Massive-Transfusion.aspx on 27 August 2010.13. AS 3864:1997 Medical refrigeration equipment—For the storage of blood and blood products. 2nd edn.14. SA Dept of Health. BloodSafe e-Learning Australia.Adelaide; SA Dept of Health. Accessed from https://www.bloodsafelearning.org.au/# on 24 August 2010.15. National Pathology Accreditation Advisory Council(NPAAC). Requirements for transfusion laboratory practice.Canberra ACT; NPAAC; 2008.October 2010 191

Section 5Standards, criteria, elements and guidelinesStandard 1.5: The organisation provides safe care and servicesCriterion LA – Awareness SA – ImplementationLA plus the followingCriterion 1.5.6The organisation ensuresthat the correct consumer /patient receives thecorrect procedure on thecorrect site.a) Policy and proceduresfor ensuring correct patient,correct procedure and correctsite identification prior toany clinical intervention areconsistent with internationaland jurisdictional policy /guidelines.b) Information on consumer /patient identification andcorrect procedure, correct sitepolicy / guidelines is providedto healthcare providers andto consumers / patientsand carers.a) The consumer / patientidentification and correctprocedure, correct site policy /guidelines and documentationare implemented throughoutthe organisation bystaff / teams involved inhealthcare interventions.b) Staff are educated on theconsumer / patient identificationand correct procedure, correctsite policy and procedures.c) Consumers / patients andcarers are involved in ensuringcorrect patient, correctprocedure and correct site.d) A system to report near missesand errors in consumer / patientidentification is implemented,and is linked to the incidentmanagement system.IntentThis criterion is relevant for all organisations thatundertake surgical and/or interventional procedures.It applies to all operative and other invasiveprocedures that could potentially expose consumers/ patients to harm, including procedures performed insettings outside operating theatres, administration ofmedications, transfusions and diagnostic testing.The intent of this criterion is to expand the use ofthe Correct Patient, Correct Site, Correct ProcedureProtocol into other therapeutic areas, ensuringconsumer / patient identification proceduresare implemented and adhered to throughoutthe organisation.Relationships of 1.5.6 with other criteriaSafe care and service provision (Standard 1.5)depends upon correct identification of the consumer /patient and correct documentation of the procedureand site. While these issues predominantly affectthe conduct of surgical and other interventionalprocedures, they also impact upon medicationmanagement (Criterion 1.5.1) and all aspects ofblood and blood component management (Criterion1.5.5). All documentation associated with correctidentification / site / procedure, including the issuing ofunique consumer / patient identifiers, will be recordedin the consumer / patient health record (Criterion 1.1.8).Systems for ensuring correct identification, correctsite and correct procedure are an aspect of theorganisation’s integrated risk management framework(Criterion 2.1.2). Failures in this area will lead toincidents, including adverse events and sentinel events(Criterion 2.1.3), and to complaints (Criterion 2.1.4).192 The ACHS EQuIP5 Guide Book 1 Accreditation, Standards and Guidelines Clinical Function

MA – EvaluationSA plus the followingEA – ExcellenceMA plus the followingOA – LeadershipEA plus the followinga) The organisation implementsstandard consumer / patientidentification processes thatcorrespond with nationalspecifications.b) Compliance with policy andprocedures on consumer /patient identification, correctprocedure and correct siteare evaluated, and improvedas required.c) Any confirmed incidentof wrong patient, wrongprocedure or wrong site isinvestigated, and strategiesimplemented as required.a) The organisation implementsevidence-based advancedsystems and technology toensure correct patient, correctprocedure and correct siteis achieved.and/orb) The organisation conductsresearch and developsinnovative methods toimprove correct consumer /patient identification, correctprocedure and correct site.a) The organisation demonstratesit is a leader in consumer /patient identification, ensuringthat the correct patient receivesthe correct procedure on thecorrect site.Policy and proceduresThe Surgical Safety Checklist expands on the UniversalProtocol for preventing wrong site, wrong procedureand wrong person surgery which was developed in theUSA 1 , endorsed by the former Australian Council forSafety and Quality in Health Care 2 and then adoptedby a number of Australian State health departments. 3, 4It is anticipated that organisations will adapt thesemaster checklists for the unique circumstancesunder which their organisation carries out surgicalprocedures, by adding more specific components.However, adaptations should not compromise theconsistency of the process or the team participationaspects of the checklists.A review of implementation of the Correct Patient,Correct Procedure, Correct Site protocol (based on theUniversal Protocol) in 2008 5 identified that two phasesof the process had the greatest variation betweensurgical teams: marking the site of the procedure andconducting the ‘team timeout’, that is, the mandatorysuspension of all activity in the operating or procedureroom prior to beginning the procedure, during which allnecessary checks are made.Organisational policy and associated protocols andprocedures should include:• to whom the policy pertains• the procedural steps to be taken• actions to be taken when there are discrepanciesor disagreements in variation at the timeout• actions to be taken in the event of a wrong patient,wrong procedure, wrong site incident• any exceptions to the use of the policy• dispute resolution procedures.In spite of the introduction of checklists during the pastdecade, wrong patient, wrong procedure, wrong side,wrong site incidents have continued to occur, and insurgical settings can have devastating implications 6–8for both consumer / patient and the care team.The Australian Commission on Safety and Qualityin Health Care (the Commission) reviewed sentinelevent data from public and private hospitals acrossAustralia and reported that for each of the three yearsreviewed, procedures involving the wrong consumer /patient or body part accounted for almost a third andsometimes up to two thirds of total sentinel events.October 2010 193

Section 5Standards, criteria, elements and guidelinesStandard 1.5: The organisation provides safe care and servicesCriterion 1.5.6The organisation ensures that the correctconsumer / patient receives the correctprocedure on the correct site. (continued)Based on a system for integrating definitions of sentinelevents nationally, 62% of sentinel events in publichospitals in 2006–07 involved procedures on thewrong consumer / patient or body part. 9Responsibility for ensuring correct patient / procedure /site verification rests with all team members. However,the person in charge of the interventional procedurecarries ultimate responsibility. 10In emergencies, the Royal Australasian College ofSurgeons suggests that all attempts should still bemade to identify the correct patient / procedure / site /side according to their principles, although it maynot be possible or appropriate to complete all thechecks. Any exceptions to the full protocol should bedocumented in the consumer / patient notes. 10Incorrect alignment of consumer / patient withprocedure is not restricted to operating theatres.The Commission has investigated the applicabilityof their Correct Patient, Correct Procedure, CorrectSite protocol in other procedural settings and hasdeveloped protocols for radiology, nuclear medicine,radiation therapy and oral surgery. 11 These protocolsare available from the Commission on request.They all follow a four-step model of:1. Verification of patient information2. Matching that information against the request form(or the consent form where appropriate)3. Timeout immediately prior to the procedure4. Post-procedure confirmation and documentation.The potentially harmful consequences of consumer /patient misidentification are not restricted to the realmof surgical and other such interventions, but must alsobe managed with respect to the use of medicationand the collection of blood, tissue or other biologicalsamples for cross-matching and/or pathologicaltesting. The correct management of blood and bloodcomponents and the organisation’s responsibilitiesin this area are described within criterion 1.5.5, andmedication management within criterion 1.5.1.In addition, the organisation must have policy andprocedures to ensure the correct matching ofconsumer / patient, sample and paperwork when notonly blood (‘wrong blood in tube’), but any body fluid,tissue sample or cells are collected for the purposeof pathological examination. The collection of biopsymaterial, which will involve an invasive procedure,should be undertaken following the same guidelines asany other surgical procedure, with the same crosscheckingof consumer / patient identification, site andside. When material is taken for diagnostic purposes,the organisation must also ensure that the correctexamination / testing of the material is carried out, andthat the results are assigned to the correct consumer /patient health record.Prompt points¼¼¼¼¼¼¼¼On what approach does the organisation baseits policy for ensuring correct procedure on thecorrect patient, and correct site? How does theorganisation ensure that there is a consistencyin the approach taken between differentsurgeries and surgical teams?Are similar, or other, procedures for checkingconsumer / patient and procedure used inany departments beyond surgery? How iscompliance with these systems monitored?How does the organisation ensure thatconsumer / patient, sample, paperwork andhealth record are correctly matched duringpathology testing?What indicators or other measures would alertthe organisation to failings of this system?Consumer / patient identification bandsWith consumers / patients and clinicians increasinglymoving between organisations and facilities, variationsin identification bands and the alert systems tied tothem can have serious implications for consumer /patient care. The Commission researched this issueand highlighted the need for a common identificationband, suggesting that the specifications of such aband be developed upon the following principles 16 :• All consumers / patients should wear someform of identification, and healthcare providersshould have policy in place that guides thisidentification process.• The primary purpose of an identification band orother identification mechanism is to identify theconsumer / patient wearing the band. The useof identification bands to signify clinical alertsis secondary.• It is up to the jurisdictions and other healthservice providers to determine how they meetthe specifications for identification bands.194 The ACHS EQuIP5 Guide Book 1 Accreditation, Standards and Guidelines Clinical Function

In June 2010, the Healthcare Identifiers Act (Cth) 12 waspassed. The Healthcare Identifiers Regulations 2010 13 ,which set out provisions relating to the assignment,collection, use, adoption and disclosure of healthcareidentifiers, are now in effect. Organisations shouldfamiliarise themselves with the requirements under thislegislation and move towards their implementation.Prompt points¼¼¼¼¼¼¼¼¼¼¼¼What changes have been made to theconsumer / patient identification bandsin your organisation to comply with thenational standards?What clinical alerts are used with theidentification banding system?To prevent confusion, how does the organisationensure consistency in the way that consumers /patients’ names are presented on the ID bandand the patient record, e.g. ordering of someAsian names?Are there any exceptions to the use of the bandson consumers / patients?What steps has the organisation taken toensure consumers / patients have only oneidentification number?Has the organisation integrated the new nationalhealth identifier system into their systems?Education – staff, consumers /patients, carersSystems developed to manage consumer / patientidentification and correct matching of procedures tothe consumer / patient all require compliance andconsistency to be effective. Healthcare organisationsmust ensure that agreed processes are carried out byall relevant staff in a consistent manner; this means thatpre-surgical checks are always undertaken and arecomplete and correct.Leadership from senior clinicians is importantfor embedding in the organisation a culture thatensures these checks are habitual, but do notbecome habituated.When ensuring correct patient / procedure / site /side, systems and processes should be executedand completed in a predictable sequence on everyoccasion. Understanding the reasons for the repetitionwill assist full cooperation from staff. Education aboutthe process and its details should aim to ensure thatitems are not omitted from a checklist or protocol.The repetition may be boring, but it ensures thatresponsibilities are clear and that nothing is omitted.Consistency in how the surgical site is marked is alsoimportant. There are concerns that the variabilityin types of marks used in Australia may lead toconfusion, particularly where staff move betweenoperating teams. 5 Agreement should be soughtabout the nature of this mark. The mark should bevisible in the procedural field when preparation anddraping is complete. As a minimum, procedures thatinvolve laterality (i.e. are not midline procedures),multiple structures (e.g. fingers) and spinal levelsmust be marked. Additional marking, including anyincision marking, remains at the discretion of theperson responsible for the procedure and cannotbe delegated to another person. There should be noabbreviating of ‘left’ and ‘right’.Consumers / patients, their families and carers canplay an important role in preventing mismatches. Byraising awareness of the potential problem, there maybe greater tolerance by consumers / patients of whatcan appear to be pointless and repetitive questioningfrom a series of healthcare providers, and a greaterwillingness to respond to variations in the questioning.Organisations should explain the identification processto consumers / patients and their carers on admission,and that the process will be repeated prior to anyintervention, to enable their active involvement in theidentification process.Focus points¼¼How does the organisation brief consumers /patients to prepare them for active collaborationin correct patient / procedure / site?¼¼¼¼How are staff members taught the organisation’sprocesses for correct patient / procedure / site?What is done to ensure that performance of theorganisation’s procedures is undertaken reliablyand in a consistent manner by surgical andother teams?October 2010 195

Section 5Standards, criteria, elements and guidelinesStandard 1.5: The organisation provides safe care and servicesCriterion 1.5.6The organisation ensures that the correctconsumer / patient receives the correctprocedure on the correct site. (continued)Risk management and reportingJurisdictional health department systems for trackingsentinel events, adverse events and near misses aimto identify contributing factors. There are differencesin the classification schemes used by each State andTerritory, but all will include the capacity to recordincorrect consumer / patient identification, incorrectprocedure or incorrect site. In fact, in a review ofsentinel events that occurred in 2004–05, undertakenby the Commission, 53 of 130 incidents meeting thedefinition of ‘sentinel event’ were procedures involvingthe wrong consumer / patient or body part. 14 Furtherinvestigation of these events suggested that the mostcommon contributing factors for procedures involvingthe wrong consumer / patient or body part were lackof, problems with, or breakdown in rules / policies /procedures (this applied in 36/53 cases), followed bylack of, problems with, or breakdown in information /documentation (applied in 17/53 cases), and lackof, problems with, or breakdown in communication(applied in 18/53 cases).Regardless of the system used for recording andtracking sentinel events, incidents and near missesassociated with wrong patient / procedure / sitehave not fallen in recent years. (However, it hasbeen suggested that this may be due to morecomplete reporting.)Prompt points¼¼¼¼How are incidents relating to incorrectconsumer / patient identification or incorrect sitefor a procedure recorded and tracked by theorganisation? How are they investigated?Have any actions been taken in response toinvestigations of incidents or near misses relatedto incorrect consumer / patient identification, ora procedure undertaken on the wrong patientor wrong site?Evidence commonly presentedConsider whether the following willhelp to address criterion 1.5.6¼¼¼¼¼¼¼¼¼¼Pre-operative policies and compliancewith national protocolStaff educationEvidence of compliance with policiesInformation provided to staff andconsumers / patientsResults of review of near misses andsentinel eventsPerformance measurementThis criterion states that: “The organisation ensures that the correct consumer / patient receives the correctprocedure on the correct site”. Effective systems for consumer / patient identification and for determiningcorrect procedure, site and side are vital to the provision of safe, high quality care and the minimisation ofadverse events, including sentinel events. The organisation should be able to demonstrate that it has policy andprocesses to manage correct identification and matching of consumer / patient to intervention in all aspects of itsservice provision.Some common suggested performance measures are as follows:Number of incidents of wrong site surgeryTotal number of surgical cases196 The ACHS EQuIP5 Guide Book 1 Accreditation, Standards and Guidelines Clinical Function

Number of wrong patient, wrong procedure or wrong site incidents investigatedTotal number of wrong patient, wrong procedure or wrong site incidents reportedNumber of ‘wrong blood in tube’ (WBIT) incidents associated with sampling for blood / blood component /product administrationTotal number of transfusion specimensComment: this indicator may be collected by the pathology service and may be called a ‘mismatch’;from their whole organisation data; where relevant the service may be able to isolate thosespecimens relating to transfusionNumber of incidents involving mismatch of consumer / patient and pathology test / resultsTotal number of wrong patient, wrong procedure or wrong site incidents reportedNumber of incidents involving incorrect non-surgical procedures / testsTotal number of wrong patient, wrong procedure or wrong site incidents reportedComment: the organisation should determine service areas to examine, e.g. radiology, nuclear medicineReferences1. Joint Commission on Accreditation of HealthcareOrganizations (JCAHO). Facts about the Universal Protocol.Oakbrook Terrace USA; JCAHO. Accessed from http://www.jointcommission.org/PatientSafety/UniversalProtocol/up_facts.htm on 6 May 2010.2. Australian Council for Safety and Quality in Health Care.Ensuring correct patient, correct site, correct procedure.Canberra ACT; Australian Council for Safety and Qualityin Health Care; not dated.3. NSW Health. Correct patient, correct procedure and correctsite policy. Sydney; NSW Health; 2007.4. WA Council for Safety and Quality in Health Care, and WAOffice for Safety and Quality in Health Care. Correct patient,correct procedure and correct site policy and guidelines forWestern Australian health services. Perth WA; Departmentof Health; 2006.5. Australian Commission on Safety and Quality in Health Care(ACSQHC). Ensuring correct patient, correct site, correctprocedure protocol for surgery: Review of implementationand proposals for action. Sydney NSW; ACSQHC; 2008.6. Donnellan E. Hospital removed wrong kidney from child.Irish Times, Dublin IRE; 21 April 2008.7. Freyer FJ. Hospital fined in wrong-site surgery. ProvidenceIsland Journal, Rhode Island USA; 27 November 2007.8. Freyer FJ. Surgeon operates on wrong knee at MiriamHospital. Providence Island Journal, Rhode Island USA;20 September 2008.9. Australian Commission on Safety and Quality in Health Care(ACSQHC). Windows into safety and quality in health care,2008. Sydney NSW; ACSQHC; 2008.10. Royal Australasian College of Surgeons (RACS). RACSGuidelines for ensuring correct patient, correct side andcorrect site surgery. Melbourne VIC; RACS; 2009.11. Australian Commission on Safety and Quality in Health Care(ACSQHC). Ensuring correct patient, correct site and correctprocedure in radiology, nuclear medicine, radiation therapyand oral surgery. Fact Sheet. Sydney NSW; ACSQHC.12. Healthcare Identifiers Act 2010 (Cth).13. Healthcare Identifiers Regulations 2010 (Cth).14. Australian Institute for Health and Welfare (AIHW) andAustralian Commission on Safety and Quality in Health Care.Sentinel events in Australian public hospitals 2004–05.Canberra ACT; AIHW; 2007.October 2010 197

Section 5Standards, criteria, elements and guidelinesStandard 1.5: The organisation provides safe care and servicesCriterion LA – Awareness SA – ImplementationLA plus the followingCriterion 1.5.7The organisation ensuresthat the nutritional needsof consumers / patientsare met.a) Policy / guidelines exist forthe delivery of nutritional careconsistent with jurisdictionalguidelines.b) A multidisciplinary teamoversees the organisation’snutrition management strategyto ensure the provision offood and fluid to consumers /patients consistent with goodnutritional care.c) Relevant healthcare providersare educated, and aware oftheir role in delivering goodnutritional care and preventingmalnutrition.d) Relevant healthcare providersuse a validated nutrition riskscreening tool to assessconsumers / patients(i) on admission(ii) following a changeof health status(iii) weekly thereafter.e) Nutritional care is incorporatedinto the consumer / patientcare plan.a) The organisation has astrategic and coordinatedapproach to deliveringconsumer / patient-centrednutritional risk screening andcare for those with malnutrition.b) The nutrition policy / guidelinesare adapted to local needsand implemented acrossthe organisation.c) Roles and responsibilities ofrelevant healthcare providersin the delivery of the nutritionmanagement strategy areclearly defined.d) Food, fluid and nutritionalcare is considered as part ofan intervention and medicaltreatment plan.e) Referrals to nutrition-relatedservices occur in a timelymanner.IntentThe intent of this criterion is to ensure that thenutritional needs of consumers / patients are metduring their healthcare journey. Organisations havea responsibility to optimise the nutrition of theirconsumers / patients, so as to support wellbeing andrecovery, and to prevent malnutrition.A key focus of this criterion is on prevention ofmalnutrition whilst in the healthcare setting. However,if consumers / patients enter a healthcare organisationwith malnutrition, or it subsequently develops, it shouldbe managed as per established guidelines.As nutrition care can affect a wide variety ofconsumers / patients across the spectrum of healthcare, this criterion is applicable to all organisations,although there will be different degrees of involvementdepending on the nature of the organisation and thelength of consumer / patient stay.Relationships of 1.5.7 with other criteriaGood nutrition is essential to the wellbeing andrecovery of the consumer / patient, and to ensure thatthe length of stay is not unnecessarily lengthened.Nutritional needs should be determined duringassessment (Criterion 1.1.1), and nutrition care shouldbe planned and delivered (Criterion 1.1.2). Goodnutrition is an aspect of appropriate (Criterion 1.3.1)and effective (Criterion 1.4.1) care delivery, and integralin promoting resistance to infection (Criterion 1.5.2)198 The ACHS EQuIP5 Guide Book 1 Accreditation, Standards and Guidelines Clinical Function

MA – EvaluationSA plus the followingEA – ExcellenceMA plus the followingOA – LeadershipEA plus the followinga) Nutritional care is evaluatedand improved as required.b) Education programs onnutritional care and malnutritionare evaluated and improvedas required.c) Reporting of incidentscontributing to deterioration inconsumer / patient nutritionalstatus is analysed and trended,and improvements are made tothe nutritional policy / guidelineas required.a) The organisation comparesnutrition management systemsdata internally and externallyand improvements are madeto ensure better practice.and/orb) The organisation communicatesresults of its performancein nutrition management toinform consumers / patients,colleagues and peers.and/orc) The organisation undertakesresearch into nutritional carein healthcare settings and actson the results.a) The organisation demonstratesit is a leader in strategies toensure that the nutritionalneeds of consumers / patientsare met.and skin integrity (Criterion 1.5.3). The organisationmust also consider the dietary requirements ofconsumers / patients with diverse needs and fromdiverse backgrounds (Criterion 1.6.3).Preventing malnutrition in the healthcare setting isan aspect of the organisation’s management of risk(Criterion 2.1.2). The development of malnutritionin a consumer / patient is a reportable incident(Criterion 2.1.3) that should be investigated.DefinitionsNutrition care is a coordinated multidisciplinaryapproach to the provision of nutrition that adapts to theconsumer / patient’s individual needs and preferencesthroughout the healthcare journey. This encompassesall aspects of the nutrition continuum of care fromnutrition assessment and intervention, includingaccess to safe, acceptable and appropriate foodservices, nutrition supplements and/or enteral andparenteral nutrition. 1Nutritional status is the state of a person’s health inrelation to the consumption and utilisation of nutrientsfor energy, metabolism, normal organ function, healingand immune function. 2, 3October 2010 199

Section 5Standards, criteria, elements and guidelinesStandard 1.5: The organisation provides safe care and servicesCriterion 1.5.7The organisation ensures that the nutritionalneeds of consumers / patients are met.(continued)Malnutrition is defined as “a state of nutrition in whicha deficiency or excess (or imbalance) of energy,protein, and other nutrients causes measurableadverse effects on tissue / body form (body shape,size and composition) and function and clinicaloutcome”. 4Artificial nutrition support is the administration ofspecially formulated liquid nutrients, either orally(oral nutrition support), through a tube directly into thegastrointestinal tract (enteral nutrition), or into a vein(parenteral nutrition). 5Nutrition screening describes the process ofidentifying individuals with characteristics commonlyassociated with nutrition problems who may requirecomprehensive nutrition assessment and may benefitfrom nutrition intervention. 1, 4Nutrition assessment is a comprehensive approachto gathering pertinent data in order to define nutritionalstatus and identify nutrition-related problems. Theassessment often includes consumer / patienthistory, medical diagnosis and treatment plan,nutrition and medication histories, nutrition-relatedphysical examination including anthropometry,nutritional biochemistry, psychological, social, andenvironmental aspects. 1, 4Nutrition policy / guidelinesOrganisations should have a nutrition policy aimedat optimising nutrition for wellbeing, recovery andpreventing malnutrition.The prevalence of malnutrition in adults in hospitalsis reported in international and Australian studiesto be in the order of 10-60%. 6 A number of studiesshow deterioration in nutritional status in consumers /patients over the course of hospitalisation. 7 Theprimary cause of malnutrition in developed countries isdisease, due to associated factors including anorexia,dysphagia, malabsorption and increased nutrientrequirements. Inadequate intake, due to the provisionof inadequate quantities of suitable food or difficultieswith eating, compounds these effects. The majorityof authors describing malnutrition in institutionalsettings cite a lack of awareness and recognition ofthe problem, resulting in a lack of activities to identify,prevent and treat malnutrition. 8–10 Recent Australianstudies found that a majority of consumers / patientsassessed as malnourished had not been previouslyidentified, and as such, were not receiving anyspecialised nutrition care. 10–14Malnutrition is recognised as having seriousimplications for health and recovery from illness orsurgery through effects on skeletal and somatic musclefunction, gastrointestinal function, immune function andwound healing. 15, 16 These functional changes impact onthe incidence of complications and on clinical outcome(morbidity and mortality), which in turn have majorimplications for length of hospital stay, readmission,15, 16quality of life, convalescence and healthcare costs.The organisation’s nutrition policy should bemultidisciplinary in scope and based on national andState / Territory guidelines. Policy should address all ofthe following key elements of nutrition care:• governance• risk screening, assessment, care planning,monitoring and discharge planning• planning and provision of food, fluids, andnutritional supplements• mealtime environment and assistance to eatand drink• consumer / patient information and communication• education and training for staff.Prompt points¼¼¼¼¼¼What documentation (legislation, guidelines,current evidence) did the organisation drawupon when drafting its nutrition policy?What departments / disciplines were consultedin the development of the organisation’s policy?What evidence is there of implementation of thepolicy within the organisation?Nutrition management strategyQuality management relates to the implementationof a nutrition management / malnutrition preventionand management strategy, based on the elementswithin the nutrition care policy, and development ofa quality improvement program. Depending on thesize of the organisation, a governance committee orresponsible person should be appointed to oversee theimplementation of this strategy. Dietitians are key staff200 The ACHS EQuIP5 Guide Book 1 Accreditation, Standards and Guidelines Clinical Function

in the development of policy and processes related tonutrition care, but delivering high quality nutrition careto customers / patients is a complex task involvingmany different processes and staff groups. Roles andresponsibilities of staff need to be clearly defined andagreed and regularly reviewed.In smaller organisations, where dietitians are notretained, organisations should draw upon currentevidence when developing nutrition managementpolicy / guidelines and procedures.A nutrition management strategy should be adopted byall sections of the organisation to ensure appropriateidentification and actions are taken for all consumers /patients. A systematic approach should includeprocesses that ensure strategies are undertakento maintain nutritional status / prevent malnutrition /manage malnutrition. 17 Strategies include:• nutrition risk screening on admission and atagreed and documented intervals during stay• a documented nutrition care plan, includingcurrent weight and target weight• access to safe, acceptable and appropriatefood service• meal / menu planning to suit the healthservice population, and individual consumer /patient needs• a mealtime environment conducive to eating• provision of timely assistance to eat• monitoring of consumer / patient food intakeand nutritional status• referral to other health professionalswhere required• implementation of artificial nutrition supporttherapy when oral intake is inadequate, as peragreed procedures• nutrition care discharge planning andongoing care• identified roles and responsibilities of staff withrespect to nutrition care of consumers / patients• multidisciplinary staff education• consumer / patient and family education• audit and reporting.Prompt points¼¼¼¼¼¼¼¼¼¼¼¼¼¼What evidence is there of a multidisciplinarynutrition management strategy?Where appropriate, are incidents related tonutrition reported, analysed, trended and usedto improve quality procedures?Are there identified roles and responsibilitiesfor staff related to nutrition care?How does the organisation ensure thatconsumers / patients receive adequateassistance to eat?Is there a procedure / guideline related toimplementation of artificial nutrition?How is a consumer / patient’s nutritional statusassessed and monitored during care delivery?Does the presentation of information in theconsumer / patient health record make it easyto detect a deteriorating consumer / patient?Individual nutrition screening,assessment and careNutrition risk screeningNutrition risk screening is a critical first step toquickly identify those persons who may be at riskof poor nutrition. Where such a risk is determined,appropriate nutrition care should be implemented,which may include a more comprehensive assessmentof nutritional status. There are several simple nutritionscreening tools which have been validated for usein different settings. 4 The choice of screening tooldepends on the population group and organisationalprocesses. Nutrition risk screening can be performedby staff who come into contact with consumers /patients, such as nursing staff, medical staff, or directlyby consumers / patients or carers themselves.Nutrition care plans‘At-risk’ consumers / patients should have adocumented nutrition care plan. Nutrition care plansshould be determined based on individual nutrition riskand/or a more comprehensive nutritional assessment.Nutrition care planning should be developed inconsultation with dietitians, either individually for theconsumer / patient or through agreed processes suchas flowcharts or standards.October 2010 201

Section 5Standards, criteria, elements and guidelinesStandard 1.5: The organisation provides safe care and servicesCriterion 1.5.7The organisation ensures that the nutritionalneeds of consumers / patients are met.(continued)Nutrition assessment should include:• the condition of the consumer / patient’smouth and teeth• use of, and condition of dentures• capacity to swallow effectively• ability to open packages• ability to self feed• diet requirements, such as vegan / vegetarian• cultural requirements, such as halal orkosher meals.Where a consumer / patient is admitted for simplesurgical work with short length of stay, it is sufficientto have light diet or full ward diet documented on theclinical pathway / nursing care plan.Provision of nutrition careIn order to enable consumers / patients to maintainor restore nutritional status, the meal service shouldbe provided on a flexible basis along with practical,consumer / patient-focused support and assistance.Consumers / patients with a loss of appetite may beunable to manage standard size meals and may needto be tempted with small attractive meals and frequentnourishing snacks and drinks. Help needs to beavailable to those who have difficulty choosing from themenu, opening portion-control food packaging, cuttingup their food and/or feeding themselves. The eatingenvironment should be pleasant and encouraging,with minimal disruptions.Some consumers / patients cannot manage adequatenutrition orally and require artificial nutrition. Thereshould be established guidelines from which clinicalteams can consider the appropriateness of artificialnutrition for individual consumers / patients. Artificialnutrition should be overseen by a dietician.Evaluation of nutrition careThe consumer / patient’s nutrition care should beevaluated on a regular basis, as determined in thenutrition care plan and modified as necessary toensure meeting the goals of optimising nutrition.Consumer / patient / carer educationConsumers / patients should be provided withinformation related to the importance of nutritionfor recovery, the food / meal service system, andif necessary, assisted to understand the value ofartificial nutrition in maintaining nutritional status /managing malnutrition.Prompt points¼¼¼¼¼¼¼¼¼¼¼¼¼¼What nutrition screening processes are usedin the organisation? Who does this?Is there a process / protocol for managing‘at-risk’ consumers / patients?Where there is a documented nutritioncare plan, does it follow a consistentstructure / format?How is a consumer / patient’s nutritional statusassessed and monitored during care delivery?Does the presentation of information in theconsumer / patient health record make iteasy to detect deteriorating nutritional status,e.g. weight loss, poor oral intake?What evidence is there that food, fluid andnutrition care is considered as part of anintervention / medical treatment plan?How do audits demonstrate nutrition complianceor initiate activity to improve nutrition care?Staff educationEducation and training for staff should be developed,implemented and evaluated by a multidisciplinaryteam including consumers / patients. There shouldbe training and an increased awareness of:• the benefits of good nutrition care for recovery• the organisation’s nutrition care processes,including how the food / meal servicesystem operates• malnutrition and its adverse effects onconsumer / patient outcomes.This is essential for the success of optimising nutritioncare and reducing malnutrition prevalence.202 The ACHS EQuIP5 Guide Book 1 Accreditation, Standards and Guidelines Clinical Function

Training programs should be available for:• operational staff, including consumer / patientsupport and food service staff• medical staff• nursing staff• other allied health• administrative staff.Prompt points¼¼What nutrition education programs are therewithin the organisation and who are theyaimed at?Evidence commonly presentedConsider whether the following will helpto address criterion 1.5.7¼¼¼¼¼¼¼¼¼¼Nutrition care governance structurePolicy and processes related to nutrition careMonitoring and audit of results e.g. % ofconsumer / patients weighed, % of consumer /patients screened; % of consumers / patientswith appropriate nutrition careEducation and information for staff andconsumer / patientConsumer / patient food service developed withmultidisciplinary team to meet the consumer /patient population needsPerformance measurementThis criterion states that: “The organisation ensures that the nutritional needs of consumers / patients are met”.The focus of this criterion is upon the prevention of malnutrition within the healthcare setting; and upon correctresponses to malnutrition when it is detected or developed. The organisation should be able to demonstrate thatit has policy, procedures and education programs that support a multidisciplinary approach to nutrition care forconsumers / patients.Some common suggested performance measures are as follows:Number of consumers / patients receiving nutrition risk screeningTotal number of consumers / patients admitted to a particular unit / wardNumber of consumers / patients receiving nutrition risk screening weekly who were not ‘at-risk’ on admissionTotal number of consumers / patients with a length of stay greater than seven days in a particular unit / wardwho were not ‘at-risk’ of malnutrition on admissionNumber of consumers / patients identified as malnourishedTotal number of consumers / patients admitted to a particular unit / wardOctober 2010 203

Section 5Standards, criteria, elements and guidelinesStandard 1.5: The organisation provides safe care and servicesCriterion 1.5.7The organisation ensures that the nutritional needs of consumers / patients are met. (continued)Number of consumers / patients identified as malnourishedTotal number of consumers / patients admitted to a particular unit / ward that were not identified asmalnourished on admissionNumber of consumers / patients receiving appropriate nutritional careTotal number of consumers / patients admitted to a particular unit / wardComment: the organisation should determine what constitutes ‘appropriate nutritional care’Number of consumers / patients who were diagnosed as malnourished or ‘at-risk’ of malnutrition receivingappropriate nutritional careTotal number of consumers / patients who were diagnosed as malnourished or ‘at-risk’ of malnutritionin a particular unit / wardComment: the organisation should determine what constitutes ‘appropriate nutritional care’; theorganisation should determine what constitutes ‘at-risk’; examples of consumers / patientsat risk of malnutrition include the frail aged or those with physical limitations, such as of theupper limb(s) or spineNumber of consumers / patients referred to a dietitianTotal number of consumers / patients admitted to a particular unit / ward204 The ACHS EQuIP5 Guide Book 1 Accreditation, Standards and Guidelines Clinical Function

References1. American Dietetic Association. Identifying patientsat risk: ADA’s definitions for nutrition screening andnutrition assessment. Council on Practice (COP) QualityManagement Committee. J Am Diet Assoc 1994; 94(8):838-839.2. National Cancer Institute. Dictionary of cancer terms.Bethesda USA: National Cancer Institute. Accessed fromhttp://www.cancer.gov/dictionary/ on 31 August 2010.3. Detsky A, McLaughlin J, Baker J et al. What is subjectiveglobal assessment of nutritional status? J Parenter EnteralNutr 1987; 11(1): 8-13.4. Dietitians Association of Australia. Evidence based practiceguidelines for the nutritional management of malnutrition inadult patients across the continuum of care. Nutr Diet 2009;66(Suppl.): S1-S34.5. Council of Europe. Resolution ResAP(2003)3 on food andnutritional care in hospitals. Strasbourg FR; Committee ofMinisters. Accessed from https://wcd.coe.int/ViewDoc.jsp?id=85747 on 24 July 2010.6. Stratton R, Green CJ and Elia M. Disease-relatedmalnutrition: an evidence-based approach to treatment.1st edn. Wallingford UK; Cabi Publishing; 2003.7. Braunschweig C, Gomez S and Sheean P. Impact ofdeclines in nutritional status on outcomes in adult patientshospitalized for more than 7 days. J Am Diet Assoc 2000;100(11): 1316-1322.8. Cornish CA and Kennedy NP. Protein-energy malnutrition inhospital in-patients. Br J Nutr 2000; 83: 575-591.9. Kondrup J, Johansen N, Plum L et al. Incidence of nutritionalrisk and causes of inadequate nutritional care in hospitals.Clin Nutr 2002; 21(6): 461-468.10. Gaskill D, Black L, Isenring E et al. Malnutrition prevalenceand nutrition issues in residential aged care facilities.Australasian J Ageing 2008; 27(4): 189-194.11. Banks M, Ash S, Bauer J and Gaskill D. Prevalence ofmalnutrition in adults in Queensland public hospitals andresidential aged care facilities. Nutr Diet 2007; 64(3):172-178.12. Middleton M, Nazarenko G, Nivison-Smith I and SmerdelyP. Prevalence of malnutrition and 12-month incidence ofmortality in two Sydney teaching hospitals. Int Med J 2001;31(8): 455-461.13. Lazarus C and Hamlyn J. Prevalence and documentationof malnutrition in hospitals: A case study in a large privatehospital setting. Nutr Diet 2005; 62(1): 41-47.14. Banks M. Malnutrition and its consequences: an opportunitycost saving for Australian healthcare. Nutr Diet 2009;66(Suppl.): A23.15. Isabel M, Correia T and Waitzberg DL. The impact ofmalnutrition on morbidity, mortality, length of hospital stayand costs evaluated through a multivariate model analysis.Clin Nutr 2003; 22(3): 235-239.16. Green C. Existence, causes and consequences of diseaserelatedmalnutrition in the hospital and the community andclinical and financial benefits of nutritional intervention.Clin Nutr 1999; 18(Supp 2): 3-28.17. Elia M. The Malnutrition Advisory Group consensusguidelines for the detection and management of malnutritionin the community. Nutr Bull 2001; 26: 81-83.Relevant standardsBankhead R, Boullata J, Brantley S et al. A.S.P.E.N. Enteralnutrition practice recommendations. J Parenter Enteral Nutr2009; 33: 122.Dietitians Association of Australia. Evidence based practiceguidelines for the nutritional management of malnutrition inadult patients across the continuum of care. Nutr Diet 2009;66(Suppl.): S1-S34.NHS Quality Improvement Scotland. Food, Fluid and NutritionalCare. Edinburgh UK; NHS. Accessed from http://www.nhshealthquality.org/nhsqis/1015.html on 8 September 2010.State-based menu standardsand policy documentsNSW Department of Ageing, Disability and Home Care (DADHC).Policy document: Ensuring good nutrition. Sydney; DADHC.NSW Greater Metropolitan Clinical Taskforce. Nutrition standardsfor adult in-patients in NSW hospitals. Sydney; NSW Health; 2010.Sydney South West Area Health Service (SSWAHS). Food andnutrition. Policy SSW_PD2009_030. Sydney; NSW Health; 2009.Victorian Department of Human Services. Nutrition standardsfor menu items in Victorian hospitals and residential aged carefacilities. Melbourne VIC; DHS; 2009.October 2010 205

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Section 5Standards, criteria,elements and guidelines1.6 Consumer Focus StandardThe standard is:The governing body is committed to consumerparticipation.The intent of this standard and criteria is to promoteconsumer participation and the need to involveconsumers / patients in their health care and ensuretheir rights, responsibilities and needs are met.This standard has three criteria. They are:1.6.1 Consumers / patients, carers and thecommunity participate in the planning,delivery and evaluation of the health service.1.6.2 Consumers / patients are informed of theirrights and responsibilities.1.6.3 The organisation meets the needs ofconsumers / patients and carers with diverseneeds and from diverse backgrounds.Consumers are people who directly or indirectlymake use of health services 1 , and includes carers, asupport person or a representative of organisationsof consumers.The term consumer incorporates women, men, peoplefrom diverse cultural experiences, including Aboriginaland Torres Strait Islander people, class positions andsocial circumstances, sexual orientations, health andillness conditions.1. Australian Commission on Safety and Quality in Health Care. Windows into safety and quality in health care 2008. Sydney NSW;ACSQHC; 2008.October 2010 207

Section 5Standards, criteria, elements and guidelinesStandard 1.6: The governing body is committed to consumer participationCriterion LA – Awareness SA – ImplementationLA plus the followingCriterion 1.6.1Consumers / patients,carers and the communityparticipate in the planning,delivery and evaluationof the health service.a) Management’s commitmentto consumer / patient, carerand community participation isdemonstrable.b) The organisation has identifiedits community and mainconsumer groups.c) The organisation has policy /guidelines that addressconsumer / patient, carer andcommunity participation anda documented process tomanage this.d) Consumers / patients, carersand the community are advisedof the organisation’s codeof conduct.a) Consumers and consumergroups are consulted abouteffective ways of participatingwith the organisation andpartnerships are established.b) Relevant staff are trainedin how to implement andevaluate consumer / patient,carer and community groupparticipation strategies.c) Consumers / patients and,when relevant, carers areinvolved in policy / guidelinedevelopment and healthservices planning.d) Consumers / patients and,when relevant, carers signconfidentiality agreementswhen appointed to committees,and as otherwise appropriate.e) The organisation implementsrelevant training for interestedconsumers / patientsand carers.IntentThe intent of this criterion is to ensure thatorganisations recognise, and act upon, the importanceof consumer / patient, carer and communityparticipation in health care. This participation rangesfrom inclusion of consumers / patients and, whereappropriate, their carers in decisions about care,through to community involvement in policy decisions.Relationships of 1.6.1 with other criteriaAn important aspect of participation of consumers /patients, their carers and the wider community in theplanning, delivery and evaluation of the health serviceis the involvement of consumers / patients and, whereappropriate, carers in planning and delivery of care(Criterion 1.1.2); and the provision of appropriateinformation to the community by the organisation(Criterion 1.2.1). In collaborating with consumers /patients, their carers and the community, organisationsshould display an understanding of the diverse needsand diverse backgrounds of the population it serves(Criterion 1.6.3).208 The ACHS EQuIP5 Guide Book 1 Accreditation, Standards and Guidelines Clinical Function

MA – EvaluationSA plus the followingEA – ExcellenceMA plus the followingOA – LeadershipEA plus the followinga) The consumer / patient andcarer participation programis evaluated and consumers /patients and carers areinvolved in this evaluationand improvements are madeas required.b) Feedback on consumer /patient and carer participationis provided to the communityand the organisation.a) Consumer / patient, carerand community groupparticipation is comparedwith other organisations andimprovements are made toensure better practice.and/orb) Consumers / patients andcarers participate in thedevelopment and evaluationof existing or new services.a) The organisation demonstratesit is a leader in consumer /patient, carer and communityparticipation.Understanding consumers andthe communityAt both Federal and State / Territory levels, there is acommitment in Australia to consumer / patient, carerand community participation in health care. Within theorganisation, this commitment should be integrated intothe operation at three key levels 1 :• at the level of management, with a focus upon thedecision makers, and how participation can bepromoted and increased• at the program or development level, with staffdeveloping and providing information, care,treatment and research with consumers / patients,carers and the community• at the level of individual care, with the consumer /patient and, where appropriate, his or her carer(s)being actively involved in the planning anddelivery of care.Within the scope of this criterion, a consumer is definedas someone who makes either direct or indirectuse of health services – that is, current or potentialusers of the health system, and/or their carer(s). 2, 3The definition is wide-ranging, encompassing bothconsumers with specific health needs, or who may atsome time have them, and those who have a generalinterest in the health system and health funding. Manyconsumers also have an indirect influence upon thehealth system in the capacity of taxpayers. A careris not necessarily a family member, but anyonewho gives unpaid, informal care to an individualin need of assistance because of their physical ormental condition. 4 Within this criterion, a carer is alsoa consumer.October 2010 209

Section 5Standards, criteria, elements and guidelinesStandard 1.6: The governing body is committed to consumer participationCriterion 1.6.1Consumers / patients, carers and thecommunity participate in the planning,delivery and evaluation of the health service.(continued)A community is a group of people who share acommon interest or background (e.g. cultural, social,political, economic, health), which may also be, but isnot necessarily, geographic. 5 An individual consumerwill belong to a number of different communities,while any community will be made up of consumers.The community from which a healthcare organisationattracts participating consumers may be thecommunity at large, that is, they may be members ofthe general population with an interest in health care;or it may be the specific community needing healthcare and served by the organisation.For a private hospital, the community will consistof their visiting medical officers (VMOs) and theconsumers / patients who use their services.Although VMOs are in these circumstances regardedas members of the organisation’s ‘community’,the feedback offered by such individuals, theorganisation’s response to it, and the processes bywhich this happens, necessarily differ from situationsinvolving members of the public.A healthcare organisation offering specialist caremay provide a narrow range of services, but to a verydiverse set of consumers / patients.Before initiating consumer participation, it is vital thatorganisations understand the nature of the communityconcerned, which will vary greatly according to theorganisation’s size, location, purpose, and whetherit is public or private. A large public hospital mayinteract with a community consisting of many differentgroups that:• are culturally and linguistically diverse,including Aboriginal and Torres Strait Islanders• have a wide range of special needs• may be socially disadvantaged or marginalised• are, or are not, represented by advocates.While a healthcare organisation, especially oneservicing an extensive community, is not expectedto be aware of every individual group within thatcommunity, it is nevertheless essential that it havea good understanding of those likely to require orhave an interest in its services. Thorough consumer /patient data collection and the use of internal surveysare essential. Organisations should also enter intopartnerships with various community and advocacyassociations, and make use of their accumulatedknowledge bases. However, it is also important thatcertain groups are not overlooked because of theabsence of a public ‘voice’ or formal associations:individuals with a language or communication barrier,or marginalised consumers such as the homeless ordisenfranchised, often lack recognition.Prompt points¼¼¼¼How does the organisation demonstrate itscommitment to consumer / patient, carer andcommunity participation in health care?How does the organisation ensure that it hasidentified the various groups that make upthe community it services?Policies and participationOrganisations must develop policy / guidelines thataddress consumer / patient, carer and communityparticipation in their planning and delivery of care,which should draw upon those issued by Federal andrelevant State / Territory bodies. The basic frameworkfor community participation, which must be addressedwithin organisational policy / guidelines, consists of:• informing the community• listening to the community• responding to the community• involving the community.Consumer participation in health care has the ultimategoal of improving outcomes by giving the communitywhat it wants and needs. There are many ways inwhich consumers / patients, carers and the communitycan participate in the planning, delivery and evaluationof the services provided by the organisation, and theprocesses may be formal or informal depending uponthe size and the nature of the organisation. Someavenues of participation are:• unsolicited feedback (complaints, praise)• solicited feedback (surveys)• individual care planning (decision making in care,consumer / patient-centred planning)• group care planning (education sessions,consumer / patient and carer support groups)• consultation (focus / interest groups, publicmeetings, discussion papers for reaction)210 The ACHS EQuIP5 Guide Book 1 Accreditation, Standards and Guidelines Clinical Function

• partnerships (Quality Improvement committees,advocacy groups, community advisorycommittees, consumer and carer committees,research committees)• decision making (policy forums, governancestructures).One of the major ways that an organisation canshape its approach to consumer / patient, carer andcommunity participation is by asking its communitywhat opportunities and avenues to participation itwants. By soliciting feedback and suggestions viainternal surveys, by the use of flyers and advertising,by entering into partnerships and discussions withcommunity, advocacy and welfare groups and byemploying other means of communication such asa website, the organisation will come to a betterunderstanding of the most appropriate ways toinvolve consumers in its processes. Similarly, oncethose processes are in place, organisations canuse the same pathways to inform the communityof what it is doing and of how to participate. Boththe means by which organisations decide uponwhich participation strategies to implement and theprocesses by which they are implemented should bethoroughly documented.Prompt points¼¼¼¼¼¼¼¼¼¼How does the organisation decide whatparticipation strategies to implement?By what means does the organisation solicitfeedback and suggestions from the community?Does the organisation have consumers onany of its committees? On which committees?How did those consumers become membersof the committees?With what special interest or professional groupshas the organisation entered into partnership?What training and education is provided forstaff involved with consumer / patient, carerand community participation?Legal responsibilities,recruitment and trainingSome forms of consumer participation are quiteinformal, such as completion of surveys andinvolvement in focus groups. Others are legislativelygoverned and the processes by which the organisationmeets its obligations in this respect should beaddressed within its policy / guidelines. The specificrequirements will vary from jurisdiction to jurisdictionand region to region. For example, in Victoria theestablishment of community advisory committees bythe Metropolitan Health Service Boards is mandatory. 6When planning to include consumers on formalcommittees such as consumer advisory committees,Quality Improvement committees or research ethicscommittees, there are several steps that should befollowed. 7 The committee should already have adescription of its role, its terms of reference, and itsintended contribution to the broader functioning ofthe organisation. A recruitment notice, somewhatlike a position description, should then be drafted,outlining the consumer’s role on the committee andany desirable attributes / experiences, and includingsuch details as the frequency and length of meetings.Organisations should encourage applicants fromdiverse backgrounds and with special needs.To this end, the application process should bestraightforward, and any resources subsequentlyrequired for participation, for example, transport forsomeone with a disability, if required, or catering forany special dietary requirements, should be allocated.The recruitment notice and any other relevantinformation, such as an application form, should bemade available via the organisation’s normal channelsfor dissemination of consumer information, as well asvia broader means such as advertising.Training should be provided where appropriate toinform and support consumer representatives and tomake their participation as meaningful as possible.Consumers should be mentored and supported by astaff member or experienced consumer member ofthe committee when they first take up a position.¼¼¼¼By what means does the organisation gatherfeedback on its consumer participationprogram? How does it respond to this feedback?What are some of the organisation’s positiveoutcomes from consumer participation?To whom did the organisation disseminateinformation of these outcomes?October 2010 211

Section 5Standards, criteria, elements and guidelinesStandard 1.6: The governing body is committed to consumer participationCriterion 1.6.1Consumers / patients, carers and thecommunity participate in the planning,delivery and evaluation of the health service.(continued)Prompt points¼¼¼¼¼¼On how many different committees within theorganisation do consumers participate? Howmany of these are advisory, and how manydecision making?How does the organisation recruit consumers?How does it encourage participation bypeople from diverse backgrounds and withspecial needs?What skills does the organisation requirefrom its consumers? What training does theorganisation provide for consumers prior totheir taking up a committee role?Evidence commonly presentedConsider whether the following willhelp to address criterion 1.6.1¼¼¼¼¼¼¼¼¼¼¼¼¼¼Inclusion of a consumer participation programin the organisation’s strategic planPolicies enabling and governingconsumer participationEvidence of consumer participationon committeesTerms of reference for the relevant committees,and minutes of their meetingsEvidence of consumer and stafftraining / educationEvidence of feedback / news of positiveoutcomes / quality improvements from consumerparticipation e.g. websites, newslettersFeedback from selected consumerrepresentatives on their role and achievements212 The ACHS EQuIP5 Guide Book 1 Accreditation, Standards and Guidelines Clinical Function

Performance measurementThis criterion states that: “Consumers / patients, carers and the community participate in the planning, delivery andevaluation of the health service”. The organisation should be able to demonstrate that it encourages and facilitatescommunity participation in all aspects of its service provision, from the level of individual care planning through topolicy decision making.Some common suggested performance measures are as follows:Number of consumers / patients who have been invited to participate in surveys in a given time periodTotal number of consumers / patients seen / admitted in a given time periodNumber of organisational committees with consumer representation / involvementTotal number of organisational committeesNumber of Quality Improvement projects with consumer participationTotal number of QI projectsNumber of staff who have attended education / training sessions regarding consumer participationTotal number of staff invited to attend education / training sessions regarding consumer participationNumber of committees within the health service that have held community consultation sessionsfor which proceedings have been documentedTotal number of committees within the health service that have held community consultation sessionsOctober 2010 213

Section 5Standards, criteria, elements and guidelinesStandard 1.6: The governing body is committed to consumer participationCriterion 1.6.1Consumers / patients, carers and thecommunity participate in the planning,delivery and evaluation of the health service.(continued)References1. Rural and Regional Health and Aged Care Services Division.Doing it with us, not for us: Strategic direction 2010–13.Melbourne; Victorian Department of Health; 2009.2. Gregory J. Consumer engagement in Australian healthpolicy: Final report of the AIHPS research project.Melbourne VIC; Australian Institute of Health Policy Studies(AIHPS); 2008.3. SA Health. Consumer and community participation policydirective. Adelaide SA; Government of South Australia; 2009.4. Sydney West Area Health Service. Consumer, carer andcommunity participation policy. Sydney; NSW Health 2008.5. National Health and Medical Research Council (NHMRC).A model framework for consumer and communityparticipation in health and medical research. Canberra ACT;Australian Government; 2004.6. Victorian Department of Human Services (DHS). CommunityAdvisory Committee guidelines: Non-statutory guidelines formetropolitan health services. Melbourne VIC; DHS; 2000.7. Health Issues Centre. Getting started: Involving consumerson committees. Melbourne VIC; La Trobe University; 2008.Guidelines and toolkitsHealth Issues Centre. Recommended suite of consumer, carerand community participation standards for Victorian public healthservices; final report. Melbourne VIC; La Trobe University; 2009.Health Consumers Queensland. Your voice in health: Strategicplan 2008-2010. Brisbane; Queensland Health; 2008.Domiciliary Care SA. Bringing care home: consumer participationstrategy. Norwood SA; Government of South Australia 2007.South Australian Community Health Research Unit (SACHRU).Community participation evaluation tool. Adelaide SA; FlindersUniversity; 2009.National Health and Medical Research Council (NHMRC).Resource pack for consumer and community participationin health and medical research. Canberra ACT;Australian Government; 2004.Victorian Rural and Regional Health and Aged Care ServicesDivision. Participation indicators. Melbourne VIC; Department ofHuman Services (DHS), Victorian Government; 2005.Consumer and Community Participation Program. Consumerand community participation toolkit. Brisbane; QueenslandHealth; 2002.National Resource Centre for Consumer Participation in Health.An introduction to consumer participation: Fact Sheet 1.Melbourne VIC; La Trobe University; 2002.SA Health. Community and consumer participation: principles.Adelaide SA; Government of South Australia. Accessed fromhttp://www.safetyandquality.sa.gov.au/Default.aspx?tabid=105on 10 September 2010.SA Health. Consumer and community participation guideline.Adelaide SA; Government of South Australia; 2006.Further readingHealth Issues Centre and Northern Health CommunityParticipation Program. Good practice in consumer, carerand community participation from Victorian health services:Case study. Community Participation Week. Melbourne VIC;La Trobe University; 2009.Australian Council for Safety and Quality in Health Care.Partnerships for health in action: Promoting consumerand community involvement in health care improvement.Canberra ACT; Australian Government; 2005.Consumer and Community Participation Implementation Groupand NSW Health. Partners in health. Sharing information andmaking decisions together. Sydney; NSW Government; 2001.Sydney West Area Health Service. Consumer and communityengagement framework for Sydney West Area Health Service.Penrith; NSW Health; 2007Gregory J. A framework of consumer engagement in Australianhealth policy. Health Issues 2007; 91(Winter): 22-27.Bruce N. Facilitating consumer participation: Lessons to belearnt from breast health consumers? Health Issues 2007;91(Winter): 16-18.Lloyd C, Tse S and Deane FP. Community participation and socialinclusion: How practitioners can make a difference. Australiane-Journal for the Advancement of Mental Health (AeJAMH)2006; 5(3): 1-10. Accessed from http://www.qldalliance.org.au/resources/items/2009/09/294410-upload-00001.pdf on10 September 2010.Mooney GH and Blackwell SH. Whose health service is itanyway? Community values in healthcare. Med J Aust 2004;180(2): 76-78.214 The ACHS EQuIP5 Guide Book 1 Accreditation, Standards and Guidelines Clinical Function

October 2010 215

Section 5Standards, criteria, elements and guidelinesStandard 1.6: The governing body is committed to consumer participationCriterion LA – Awareness SA – ImplementationLA plus the followingCriterion 1.6.2Consumers / patients areinformed of their rightsand responsibilities.a) A consumer / patientrights and responsibilitiesdocument exists.b) A confidentiality and privacypolicy / guideline is in place.c) The organisation providesinformation on how consumers /patients and carers whenrelevant, can access advocacyand support services.d) The procedure for consumeraccess to their healthrecords is documented andcommunicated to consumers /patients and when appropriate,their carers.a) Consumers / patients andwhen appropriate, carersreceive a copy of the rightsand responsibilities document.b) Staff discuss rights andresponsibilities with theconsumer / patient and whenappropriate, their carer.c) The organisation implementspolicy and proceduresto ensure that personalhealth-related information ismanaged in accordance withjurisdictional privacy legislation.d) Staff and volunteers signconfidentiality agreements.IntentThe intent of this criterion is to assist health serviceorganisations in meeting their responsibilities to informconsumers / patients of both their rights and theirresponsibilities, in order to achieve the best possiblehealth outcomes.While the focus of this criterion is upon the rights andresponsibilities of the consumer / patient, organisationsmust be aware that in most instances these rights andresponsibilities will extend to family members and/orcarers involved in a given episode of care, in particularthe rights governing communication, participation andthe right to comment upon any aspect of the healthcareexperience. This awareness should be demonstratedthroughout the organisation’s policies and procedures.Relationships of 1.6.2 with other criteriaAmong the rights of the consumer / patient are theright to collaborate in the planning and delivery ofcare (Criterion 1.1.2), to give informed consent to thatcare (Criterion 1.1.3) and, when required, to haveinformation provided to them in different formats(e.g. in Braille or verbally) or in a language other thanEnglish, in printed form or via a trained interpreter(Criterion 1.6.3). Every consumer / patient has theright to access his or her health record (Criteria 1.1.8and 2.3.1). Failure of the organisation to meet itsobligations with respect to consumer / patient rightsmay lead to incidents (Criterion 2.1.3) and complaints(Criterion 2.1.4).Consumer / patient rights andresponsibilitiesWithin this criterion, the term consumer refers both toany individual receiving care within the organisation,and to any family member, carer or other supportperson with an interest and/or a role in that individual’scare. Rights are what the consumer / patient is entitledto demand from his or her healthcare provider andhealth service organisation, and what the provider and/or organisation is obligated to provide to the consumer/ patient and, when appropriate, to his or her carer.Responsibilities are obligations placed on theconsumer / patient when he or she accesses ahealth service, which are usually defined in terms ofhonesty, compliance and conduct, and which facilitatethe healthcare provider and/or the health serviceorganisation’s provision of safe, high quality health care.216 The ACHS EQuIP5 Guide Book 1 Accreditation, Standards and Guidelines Clinical Function

MA – EvaluationSA plus the followinga) The system to informconsumer / patient rightsand responsibilities isevaluated, and improvementsto documents and practicesare made as required.EA – ExcellenceMA plus the followinga) Documents and practices forconsumer / patient rights andresponsibilities are comparedwith external systems, andimprovements are made toensure better practice.and/orb) The organisation demonstratesthat consumers / patientsexercise their rightsand understand theirresponsibilities.OA – LeadershipEA plus the followinga) The organisation demonstratesit is a leader in ensuringconsumers / patients andcarers are informed of theirrights and responsibilities.The Australian Charter of Healthcare Rights 1 wasdeveloped by the Australian Commission on Safety andQuality in Health Care (the Commission) and endorsedby all Health Ministers for use in Australia in 2008. TheCharter summarises the basic rights that consumers /patients are entitled to receive when accessing healthservices, as well as outlining the responsibilities of theconsumer / patient while receiving health care. The aimof the Charter is to provide a framework for the creationof a genuine partnership between consumers / patientsand healthcare providers, in order to achieve the bestpossible health outcomes.The Charter has three guiding principles 1 :1. Everyone has the right to be able to access healthcare and this right is essential for the Charterto be meaningful.2. The Australian Government commits tointernational agreements about human rightswhich recognise everyone’s right to have thehighest possible standard of physical and mentalhealth care.3. Australia is a society made up of people withdifferent cultures and ways of life, and the Charteracknowledges and respects these differences.It is applicable to all health settings anywhere inAustralia, including:• public hospitals• private hospitals• multipurpose services• general practices• specialist rooms• day procedure facilities• community health services• private allied health facilities• all sites of domiciliary care.The Charter summarises the basic rights thatconsumers / patients are entitled to receive whenaccessing healthcare services. These rights are:1. Access2. Safety3. Respect4. Communication5. Participation6. Privacy7. Comment.October 2010 217

Section 5Standards, criteria, elements and guidelinesStandard 1.6: The governing body is committed to consumer participationCriterion 1.6.2Consumers / patients are informed of theirrights and responsibilities. (continued)Implementation of the Australian Charter of HealthcareRights is mandated at a State / Territory level, andorganisations should adopt the Commission’s Charterin toto if they do not have their own Charter of Rights,or make certain that any existing Charter of Rights isin alignment with the official document. Organisationsmust also have policy / guidelines in place to ensurethat the rights and responsibilities of consumers /patients are recognised, that all relevant informationis conveyed to consumers / patients in a timely andappropriate manner, and that consumers / patients aregiven all necessary assistance in the exercise of theirrights. Some State / Territory policies may go furtherand/or into more detail than the Commission’s Charter,and organisations must comply with all relevantlegislative requirements. Information on the AustralianCharter of Healthcare Rights, as well as variousrelated brochures, posters and information sheets,are available on the Commission’s website(http://www.safetyandquality.gov.au/).The organisation must be aware of, and make provisionfor, those circumstances under which the rights of theconsumer / patient are transferred to a family memberor carer, for example, in the event that the consumer /patient is a minor, or is in an insensate condition.Conversely, there are circumstances under which therights of the consumer / patient and/or their carer(s)are superseded by the requirements of legislation,including under various provisions of the Mental HealthAct. The organisation must ensure that it is aware ofall such legislative responsibilities that apply withinits jurisdiction.Prompt points¼¼Does the organisation have its own Charterof Rights, or has it implemented the AustralianCharter of Healthcare Rights? If it has its ownCharter, how has it ensured that it aligns withall aspects of the Australian Charter?Informing consumers / patients oftheir rights and responsibilitiesInforming consumers / patients of their rightsand responsibilities is one of the organisation’sown responsibilities. A copy or a summary of theorganisation’s Charter of Rights should be displayedat reception, in waiting areas, and in consultingrooms and wards. A copy should be included in anyinformation packs sent to elective consumers / patientsprior to admission, and given to anyone receivingdomiciliary care on the first visit. Where relevant,information about the Charter and its provisionsshould be displayed upon the organisation’s website.Translated copies of the Charter should be madeavailable, in a range of languages drawn from theorganisation’s knowledge of the community it serves,and in Braille and/or audio-format where appropriate;many of these are available to download from theCommission’s website. Consumers / patients shouldalso be made aware that professional interpreters areavailable to help with understanding the organisation’sCharter, and of how to access this service if it isrequired or desired.To support open, respectful and transparentcommunication, the organisation must ensure thatstaff are well-versed in the provisions of its Charter ofRights, aware that they must be prepared to discussrights and responsibilities with consumers / patients,be able and willing to answer any questions thatarise, and facilitate consumer / patient access tointerpreters and/or advocates as required or desired.The provision of information via documentation anddirect explanation should be noted in the consumer/ patient’s health record. The consumer / patient’sunderstanding of the information can be determinedduring discussion, or via survey.There are various ways in which the organisationcan educate and train its staff in the practicalimplementation of its Charter of Rights. A copy ofthe organisation’s Charter should be included in theemployment package for new staff, and sessions onthe implications and content of such a Charter shouldbe included in orientation and ‘refresher’ educationcourses for all staff.¼¼¼¼How is the Charter of Healthcare Rightsreferenced in the organisation’s policies andprocedures, and its management of complaints?What other policies / guidelines, if any, havebeen drawn upon in the organisation’s draftingof its rights and responsibilities documentation?Dissemination of information about the organisation’sCharter of Rights and the rights and responsibilities ofthe consumer / patient should not be confined to theorganisation itself. The Charter and related documentscan be distributed via existing partnerships withcommunity and advocacy groups, and also suppliedto related health facilities such as nursing homes andhostels. The provisions of the Charter could also bemade the topic of community education sessions orfocus groups.218 The ACHS EQuIP5 Guide Book 1 Accreditation, Standards and Guidelines Clinical Function

Prompt pointsPrompt points¼¼Where is the organisation’s Charter of Rightsdisplayed within the organisation? Into howmany different languages has it been translated?¼¼How does the organisation make consumers /patients aware of the availability ofadvocacy services?¼¼When does the organisation provideconsumers / patients with information abouttheir rights and responsibilities? In what form(s)is this information provided?¼¼What changes, if any, have been made tothe provision of information about advocacyservices as a result of consumer feedback?¼¼¼¼¼¼How does the organisation ensure that its staffare able to answer questions about and discussthe provisions of its Charter of Rights?How does the organisation inform its communityof the rights and responsibilities of theconsumer / patient?From whom does the organisation seekfeedback about its provision of information aboutconsumer / patient rights and responsibilities?How is this feedback documented? How isit used?Consumer / patient accessto health recordsThe right of the consumer / patient to access his or herown health record is guaranteed under the AustralianCharter of Healthcare Rights 1 , the National PrivacyPrinciples 2 and privacy legislation 3 . The organisationmust develop a process by which the consumer /patient can obtain this access, and the details of thisprocess should be documented and made availableto the consumer / patient in a range of formatsand languages, and via the use of an interpreterif necessary.Consumer / patient advocacyIt is the right of the consumer / patient to accessadvocacy services if required or desired, and thisshould be clearly stated within the organisation’srights and responsibilities documentation; separateinformation pamphlets should also be provided.Organisations are not themselves required to provideadvocacy services, but they must assist the accessingof such support services by consumers / patients byadvising that these services are available if neededthrough relevant support agencies, such as cancer,mental health or multicultural groups, as well as variousconsumer groups in each State / Territory. Informationon local advocacy services and how to contact themby telephone or via the internet should be provided,and the process should be facilitated by interpretersif necessary.Organisations should regularly evaluate the meansby which they provide information about advocacyservices and consumer / patient satisfaction withthe process. Seeking feedback from consumers /patients, their family members and/or carers will allowimprovements to be made as required.Prompt points¼¼How would a consumer / patient obtainaccess to his or her health record? How is thisinformation provided to the consumer / patient?Privacy and confidentialityThe consumer / patient’s right to privacy, and to havepersonal disclosures and medical information handledwith strict confidentiality, is fundamental to health careand one of the basic rights mandated in the AustralianCharter of Healthcare Rights. There is an expectationwithin the community that personal health informationwill be treated with the utmost care, and this duty tomaintain confidentiality is underpinned by legal andprofessional standards.October 2010 219

Section 5Standards, criteria, elements and guidelinesStandard 1.6: The governing body is committed to consumer participationCriterion 1.6.2Consumers / patients are informed of theirrights and responsibilities. (continued)Organisations must have privacy and confidentialitypolicy / guidelines in place that meet the demandsof all relevant legislation, codes of professionalethics, and accepted standards. This documentationshould specify under what circumstances personalinformation will be shared, by whom and with whom.All staff, including volunteers, who work within thehealth system are in a position of trust, where theymay gain access to personal health information thatis confidential. Staff must be educated about theorganisation’s privacy and confidentiality policy /guidelines, and sign confidentiality agreements oncommencement of employment. At a State / Territorylevel, legislation allows for the fining and/or dismissalof health service employees who breach consumer /patient confidentiality.Prompt pointsEvidence commonly presentedConsider whether the following willhelp to address criterion 1.6.2¼¼¼¼¼¼¼¼¼¼Consumer / patient rights and responsibilitiesdocument / pamphlet, in a range ofappropriate languagesStaff education and training programson the provisions of the Charter andtheir implementationDocumented process for access to healthrecords for consumers / patientsEvidence of dissemination of information onconsumer / patient rights and responsibilitiesoutside the organisationDocumented improvements made to thesystems for disseminating information onconsumer / patient rights and responsibilities¼¼¼¼What legislation / standards / codes hasthe organisation drawn upon in drafting andimplementing its policy / guidelines for mattersof privacy and confidentiality?How are staff made aware of the termsof the privacy and confidentiality policy /guidelines? When are staff confidentialityagreements signed?220 The ACHS EQuIP5 Guide Book 1 Accreditation, Standards and Guidelines Clinical Function

Performance measurementThis criterion states that: “Consumers / patients are informed of their rights and responsibilities”. The organisationshould be able to demonstrate that it has a Charter of Rights in alignment with the Australian Charter of HealthcareRights, that it educates and trains its staff to understand and to discuss all aspects of its Charter with consumers /patients, and that it provides consumers / patients and its community with information about, and facilitates theunderstanding of, its Charter.Some common suggested performance measures are as follows:Number of consumers / patients who have received information about their rights and responsibilitiesin a given time periodTotal number of consumers / patients seen in a given time periodNumber of consumers / patients who have received information about their rights and responsibilitiesin an appropriate language or formatTotal number of consumers / patients who have received information about their rights and responsibilitiesNumber of consumers / patient receiving a direct explanation of their rights and responsibilities,as noted in their health recordsTotal number of health records auditedNumber of consumers / patients who can explain their rights and responsibilitiesTotal number of consumers / patients surveyedNumber of long-term consumers / patients receiving a review of rights and responsibilities every X monthsTotal number of long-term consumers / patientsComment: organisation to define ‘X’ and ‘long-term’References1. Australian Commission on Safety and Quality in HealthCare (ACSQHC). Australian charter of healthcare rights(for consumers). Sydney NSW; ACSQHC; 2008.2. Office of the Federal Privacy Commissioner. National privacyprinciples. Information sheet. Canberra ACT; Office of thePrivacy Commissioner; 2008.3. Australian Law Reform Commission (ALRC). For yourinformation: Australian privacy law and practice.ALRC Report 108. Sydney NSW; ALRC; 2008.Further readingAustralian Commission on Safety and Quality in Health Care(ACSQHC). Australian charter of healthcare rights publications.Sydney NSW; ACSQHC. Accessed from http://www.health.gov.au/internet/safety/publishing.nsf/Content/com-pubs_ACHR on15 September 2010.World Health Organization (WHO), Genomic Resource Centre.Patients’ rights. Geneva CH; WHO. Accessed from http://www.who.int/genomics/public/patientrights/en/ on 12 November 2009.Victorian Department of Human Services (DHS), Homeand Community Care Program (HACC). Your rights andresponsibilities as a HACC service user. Melbourne VIC;DHS; 2009.October 2010 221

Section 5Standards, criteria, elements and guidelinesStandard 1.6: The governing body is committed to consumer participationCriterion LA – Awareness SA – ImplementationLA plus the followingCriterion 1.6.3The organisation meetsthe needs of consumers /patients and carers withdiverse needs and fromdiverse backgrounds.a) The organisation identifiesthe diverse needs anddiverse backgrounds of itsconsumers / patients and theircarers, to improve its culturalcompetence, awarenessand safety.b) Policy / guidelines are writtento ensure that services areprovided appropriate toconsumers / patients andcarers with diverse needs andfrom diverse backgrounds.c) The organisation meetslegislative requirements thatare relevant to consumers /patients and carers withdiverse needs and fromdiverse backgrounds.a) The organisation collectsdemographic data in relationto the diverse populationit serves.b) Staff are informed about andhave access to informationand resources regardingconsumers / patients andcarers with diverse needs andfrom diverse backgrounds.c) Staff are provided with theopportunity for training toenhance their skills in planningand delivery of appropriateservices to consumers / patientsand carers with diverse needsand from diverse backgrounds.d) Food, services, care andconsideration for spiritualneeds are provided in amanner that is appropriateto consumers / patients withdiverse needs and fromdiverse backgrounds.e) Translated information isdeveloped appropriateto the diverse needs anddiverse backgrounds ofconsumers / patients.f) Trained interpretersare available and staff /consumers / patients areinformed of the availability.222 The ACHS EQuIP5 Guide Book 1 Accreditation, Standards and Guidelines Clinical Function

MA – EvaluationSA plus the followinga) The organisation demonstratespartnerships with relevant localorganisations, to support thediverse needs and diversebackgrounds of consumers /patients and their carers.b) Data on utilisation of theservice by people with diverseneeds and from diversebackgrounds are collected,and maintained to monitoraccess, which is improvedas required.c) The organisation evaluateswhether consumers / patientsand their carers’ diverse needsare met, and strategies forimprovement are implementedas required.EA – ExcellenceMA plus the followinga) Where indicated, theorganisation demonstratesactive partnerships withrelevant Aboriginal and TorresStrait Islander communitiesto support the developmentof culturally appropriate andresponsive services.and/orb) Performance indicators fordiverse needs and diversebackgrounds are measured,and compared internally andexternally, and improvementsare made to ensure betterpractice.and/orc) The organisation developsinnovative processes forservice delivery, consultationand participation, to meetrequirements of consumers /patients with diverse needsand from diverse backgrounds.OA – LeadershipEA plus the followinga) The organisation demonstratesit is a leader in its systemsfor participation strategiesfor consumers / patients andcarers with diverse needs andfrom diverse backgrounds.October 2010 223

Section 5Standards, criteria, elements and guidelinesStandard 1.6: The governing body is committed to consumer participationCriterion 1.6.3The organisation meets the needs ofconsumers / patients and carers with diverseneeds and from diverse backgrounds.(continued)IntentThe Australian population is comprised of manydiverse groups, whose needs must be met during thedelivery of health care. The intent of this criterion isto ensure that the organisation fulfils its obligation toprovide for the diversity of the community it serves.Relationships of 1.6.3 with other criteriaThe organisation’s responsibility to provide care andservices to those consumers / patients with diverseneeds, and from diverse backgrounds, must bemet in terms of both its physical environment andits communication. Consumers / patients and, insome cases, their carers must be able to accessthe organisation, and be able to locate the requiredservices (Criterion 3.2.2). They must understand theirrights and responsibilities (Criterion 1.6.2), understandand give informed consent to their treatment(Criterion 1.1.3) and, where appropriate, participate inthe planning and delivery of their care (Criterion 1.1.2).The organisation, in turn, must understand thecommunity that it is servicing, and supply all necessaryinformation about its services (Criterion 1.2.1).Policies and proceduresEqual opportunity and freedom from discriminationon the basis of age, race, religion, gender, sexualorientation and disability are legislatively governed inAustralia at both Federal and State / Territory levels.Within the healthcare system, this translates to anobligation to create an environment where recognitionof diversity is embedded within the culture of theorganisation and where all consumers / patients,whatever their individual circumstances, receiveequality of care.Diversity is a broad concept that includes allAustralians. It refers to the various qualities that definethe individual and exist across society as a whole.It includes characteristics or factors such as age,race, ethnicity, language, gender, sexual orientation,religion, beliefs, family and/or social structure, andability, including disability; as well as socio-economiclevel, educational attainment, personality, marital andparental status, general life and work experience, andstatus within the general community.Recognising that each person is a unique and complexbeing is integral to understanding and respondingeffectively to healthcare needs at an individual, familyor community level.Cultural and linguistic diversity (CALD) pertains tothe breadth of cultural and/or linguistic affiliation(s)held by individuals within the community, by virtue oftheir place of birth, ancestry, ethnic origin, religion,preferred language or language(s) spoken at home,or because of their parents’ identification on asimilar basis. 1 It is the organisation’s responsibilityto develop policy and procedures that fulfil therelevant legislative requirements, and that recogniseand provide for the physical, mental, cultural and/orlinguistic needs of the consumers / patients accessingits services.Organisations should develop policies andprocedures to address:• understanding people and their needs• understanding and analysing changingdemographics• encouraging consumer / patient participationin decision making• providing relevant and accessible information• developing an appropriately trained workforce• meeting the specific needs of differentcommunities.Prompt points¼¼What legislation did the organisation referencewhen developing its policies / procedures fordelivering health care to those consumers /patients from diverse backgrounds and withdiverse needs?Creating and maintaining a culturallycompetent workplaceCultural competence refers to the processes andpractices implemented by an organisation thatfoster inclusiveness and establish the progressionof learning about diversity and differences and theirimpact on the way services are delivered, received,accessed and promoted. In the context of health care,cultural competence focuses on the capacity of theorganisation to improve health and wellbeing for theindividual and the community by integrating cultureinto the delivery of health services. 2 The organisationshould strive for the creation of a culturally competentworking environment, with culture being integrated224 The ACHS EQuIP5 Guide Book 1 Accreditation, Standards and Guidelines Clinical Function

into the delivery of health services so as to improvehealth and wellbeing for both the individual and thecommunity. 2 In pursuing this aim, it is important torecognise that staff members will bring their ownculture to any clinical encounter, and that the healthsystem itself, as an institution, also has a culture of itsown. Reflection on practice and upon one’s own cultureis an inherent element of cultural competence.Some cultural groups may have different healthneeds than others, such as Aboriginal and TorresStrait Islander people. ‘Closing the Gaps’ is a strategythat aims to reduce indigenous disadvantage withrespect to life expectancy, child mortality, access toearly childhood education, educational achievementand employment outcomes; it was endorsed by theAustralian Government in March 2008. There are anumber of tools and information on how healthcareorganisations can address these issues, available athttp://www.healthinfonet.ecu.edu.au/closing-the-gap,as well as a number of other websites.Those individuals whose personal condition or situationmakes it difficult for them fully to participate in theirown health care are said to have special needs.The personal condition or situation may be:• poor literacy, whether from a non-Englishspeaking background or not• affected by trauma• affected by medication / drugs• age (either very young or very old / frail)• a disability.There are many different types of disability. A disabilitycan be caused by a genetic condition, an illness or anaccident, and may mean that the individual in questionhas special needs. 3 Disability may include:• intellectual disability• physical disability• sensory disability• acquired brain injury• neurological impairment• mental illness• dual disability / co-morbidity (i.e. one of the aboveand a psychiatric disability), also known as dualdiagnosis; this often refers to a person with amental illness and a drug or alcohol addiction• disabilities that are unrelated to ageing• any combination of the above.Communication with people with some disabilitiesmay be difficult. Alternative modes of communicationmay need to be sought for those with vision, speech,language, hearing and cognitive impairments. Careshould be taken to focus on the consumer / patient’soverall health, and not just on factors relating totheir disability.Apart from providing a formal interpretation service,the organisation should encourage, and provide theresources and time for staff to undergo further trainingin order to enhance their ability to provide care for adiverse consumer / patient base. Furthermore, theorganisation may wish to consider the recruitmentof bilingual staff, which should also be done withreference to the community demographic, with the goalto facilitate effective and responsive care.Prompt points¼¼¼¼How does the organisation foster a greatercultural awareness and better provision ofservices for culturally and linguistically diverseconsumers / patients by its staff?How does the organisation facilitatecommunication with special needsconsumers / patients?Meeting the needs of diverseconsumers / patientsCulturally and linguistically diverse communities makeup a significant proportion of the Australian population.Nevertheless, certain barriers exist that may interferewith the provision of health care to the members ofthese communities. 4 These barriers include:• different culturally-based concepts of health andillness, which may affect the understanding oftreatment and the impact of compliance• a lack of familiarity with the Australian healthsystem, which may be very different from healthservices in the country of origin• a lack of understanding of consumer / patientrights and responsibilities• a lack of proficiency in the English language,which impacts on the ability to access andcommunicate with health service providers• a lack of confidence, which may hinder effectiveparticipation in healthcare planning and evaluationOctober 2010 225

Section 5Standards, criteria, elements and guidelinesStandard 1.6: The governing body is committed to consumer participationCriterion 1.6.3The organisation meets the needs ofconsumers / patients and carers with diverseneeds and from diverse backgrounds.(continued)• language and cultural barriers, which may preventthe understanding required for informed consentto medical / surgical procedures, and which haveserious medico-legal implications• serious ongoing physical and mental healthissues as a result of past trauma, including torture,refugee experiences and/or confinement toprisons or camps.Accurate and suitably detailed communication betweenproviders and consumers / patients is fundamental toquality health care. Various options exist for providingculturally and linguistically diverse consumers / patientswith the required information. Fact sheets in a varietyof languages are a first step towards the provisionof all relevant documents. The languages into whichthe text is translated should reflect the demographicserved by the organisation. Where the organisationprovides services upon a referral basis, broad-basedsocial statistics may be used to guide the developmentof the fact sheets, which should be re-evaluated andre-issued over time according to data collected withinthe organisation. The text of the fact sheets shouldbe supported where appropriate by diagrams andschematics, for the benefit of those with deficienciesin language skills. Consumers / patients and familiesfrom relevant culturally and linguistically diversegroups should be involved in the development of allsuch materials.The provision of an interpreter service promotesaccess to health services and information for peoplewith limited English proficiency and for the hearingimpaired.The use of interpreters in health care ismandated at a State / Territory level; they are tobe used in all situations where communication isessential, including admission, consent, assessment,counselling, discharge, explanation of treatment,associated risks and side effects, health education andmedical research, and day-only surgery. 5 Interpretersmay also assist with meeting the spiritual needs of theconsumer / patient. Organisations should not rely uponfamily members or other non-professional individuals tofacilitate communication with consumers / patients witha limited proficiency in English or a hearing impairment,but should arrange for access to accreditedinterpreters who are trained in medical terminology andissues of confidentiality.All people, regardless of religious, faith or culturalbackground, may have pastoral and spiritual needs.As contemporary Australia is multicultural andmultifaith, the organisation should have policy andprocedures in place regarding spiritual and pastoralcare, and provide consumers / patients with accessto the appropriate services.Prompt points¼¼How does the organisation identify the differentgroups (CALD and/or special needs) for which itneeds to provide targeted services?¼¼How are CALD and special needs consumers /patients involved in the decision making process?¼¼¼¼¼¼¼¼How many different language groups areserviced by the organisation’s interpreterservice? How did the organisation determineto provide support in these languages?How often does the organisation reassess thedemographic of the community that it serves?How is this carried out?How does the organisation determine whetherthe services it provides for its CALD and specialneeds consumers / patients are appropriate?With what community groups does theorganisation interact in order to best meetthe needs of its CALD and special needsconsumers / patients?Evidence commonly presentedConsider whether the following willhelp to address criterion 1.6.3¼¼¼¼¼¼¼¼¼¼¼¼¼¼¼¼¼¼Policy that fulfils legislative requirementsStaff training programsPre-admission informationDisability and multicultural signageAvailability of information in non-Englishlanguages / English for the hearing-impairedEvidence of access and use of interpreterservices by consumers / patientsEvaluation of interpreter servicesEvaluation of demographic informationEvidence of community partnerships226 The ACHS EQuIP5 Guide Book 1 Accreditation, Standards and Guidelines Clinical Function

Performance measurementThis criterion states that: “The organisation meets the needs of consumers / patients and carers with diverse needsand from diverse backgrounds”. Healthcare facilities must be able to understand and to meet the diverse needsof the communities they serve. Organisations should be able to demonstrate their knowledge of their community,however defined, and that they are able to fulfil the healthcare and communication needs of the diverse groupsthat make up their community.Some common suggested performance measures are:Number of staff who have participated in cultural awareness trainingTotal number of staff invited to participate in cultural awareness trainingComment: it is recommended that data for different staff groups be collectedNumber of FTE indigenous and/or multicultural staff employed in the organisationTotal number of FTE staff employed in the organisationComment: FTE = full time equivalentNumber of CALD consumers / patients accessing interpretive services (printed, verbal)Total number of CALD consumers / patientsComment: CALD = culturally and linguistically diverseNumber of languages used in community resourcesTotal number of CALD groups accessing the serviceNumber of special needs consumers / patient admitted to or seen by the organisationTotal number of consumers / patients admitted to or seen by the organisationNumber of consumers / patients from specific CALD and/or special needs groupsTarget benchmark for consumers / patients from specific CALD and/or special needs groupsComment: ‘target benchmark’ is the number of consumers / patients that the organisation was requiredto service, or the target that the organisation hopes to achieveOctober 2010 227

Section 5Standards, criteria, elements and guidelinesStandard 1.6: The governing body is committed to consumer participationCriterion 1.6.3The organisation meets the needs ofconsumers / patients and carers with diverseneeds and from diverse backgrounds.(continued)References1. Ethnic Disability Advocacy Centre (EDAC). Nationaldisability strategy: focusing on CALD people withdisabilities. Perth WA; EDAC; 2008.2. Stewart S. Cultural competence in health care. Sydney NSW;Diversity Health Institute, SWAHS; 2006.3. Victorian Department of Human Services. Statedisability plan 2002–2012: Part 1. Melbourne;Victorian Government; 2002.4. Centre for Culture Ethnicity and Health (CEH).Consumer participation and culturally and linguisticallydiverse communities. Melbourne VIC; CEH; 2005.5. NSW Health. Policy Directive: Interpreters – standardprocedures for working with health care interpreters.Sydney; NSW Health; 2006.228 The ACHS EQuIP5 Guide Book 1 Accreditation, Standards and Guidelines Clinical Function

Section 6GlossaryDefinitions in this glossary are for use in the context of the ACHS EQuIP5 standards,criteria, elements and guidelines.accessaccessibilityaccountabilityaccreditationadvance care plan /directiveAC60: AdvancedCompletion in 60 dayssurveythe various pathways and processes via which the consumer / patient may enterthe health system and obtain required servicesthe ability of consumers / patients or potential consumers / patients to obtain requiredor available services when needed within an appropriate time 1responsibility and requirement to answer for tasks or activities. This responsibilitymay not be delegated and should be transparent 1a public recognition by a healthcare accreditation body of the achievement ofaccreditation standards by a healthcare organisation, demonstrated through anindependent external peer assessment of that organisation’s level of performancein relation to the standards 1instructions that consent to, or refuse, the future use of specified medical treatments.It becomes effective in situations where the consumer / patient no longer has thecapacity to make treatment decisions 2in the context of EQuIP5:an opportunity for an organisation to promptly address outstanding issues to achievean acceptable level of performance within 60 days from an EQuIP survey date.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 criteriaadmission 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 3 ; in some contexts,the term ‘registration’ may be used rather than admission. The point at whichadmission is considered to have occurred, and the processes by which it happens,vary considerably according to the nature of an organisation.In the first instance, admission refers to the administrative process by which anindividual’s details are entered into the organisation’s systems so that the carejourney may begin. However, it is important to recognise that, depending upon thenature and sector of the organisation, admission does not necessarily require theprovision of accommodation, or access to a specific facility.adverse eventan incident that results in harm to a consumer / patient, where harm includes disease,injury, suffering, disability and death 4adverse reaction unexpected harm arising from a justified treatment 5agreementanalysisa mutually agreed arrangement describing the scope for cooperative venturesbetween parties and documenting relevant responsibilitiespresentation of the essential features into simple elements, such as a summary,outline or identification of the essence of an issueantimicrobial a chemical substance that inhibits or destroys bacteria, fungi or parasites. 4These include antibiotics, antivirals and disinfectantsappropriateservice that is consistent with a consumer / patient’s expressed requirements andis provided in accordance with current best practice 1in the context of EQuIP5: is suitable, or fitting, to doOctober 2010 229

Section 6Glossaryappropriatenessartificial nutritionalsupportas requiredassessment‘at-risk’ consumer /patientAustralian standardsbenchmarkingbest practicebloodblood componentblood productsdoing what is necessary, and not doing what is not necessary. Occurs whenconsumers / patients receive appropriate and necessary care, interventions andservices in the most appropriate settingparenteral and/or enteral nutrition therapy 6(parenteral nutrition: intravenous administration of nutrients into a central orperipheral vein. Enteral nutrition: feeding provided through the gastrointestinal tractvia a tube, catheter, or stoma that delivers nutrients distal to the oral cavity) 6when required by obligationa process by which the characteristics and needs of consumers / patients, groups orsituations are evaluated or determined so that they can be addressed. Assessmentforms the basis of a plan for services or action. 1 While assessment may be knownby different names and occurs in a broad variety of contexts, such as triage in anemergency department, comprehensive assessment by an Aged Care AssessmentService, or screening and intake by a community health or outreach service, theprocess remains consistent and as defined abovea consumer / patient characterised by a high risk or susceptibility to a disease 7or event, e.g. fallsnational standards developed by Standards Australiathe continuous measurement of a process, product, or service compared to those ofthe toughest competitor, to those considered industry leaders, or to similar activitiesin the organisation, in order to find and implement ways to improve it. One of thefoundations of both total quality management and continuous quality improvement.Internal benchmarking occurs when similar processes within the same organisationare compared. Competitive benchmarking occurs when an organisation's processesare compared with best practices within the industry. Functional benchmarkingrefers to benchmarking a similar function or process, such as scheduling, inanother industry 6an approach that has been shown to produce superior results, selected by asystematic process, and judged as exemplary, or demonstrated as successful.It is then adapted to fit a particular organisation 1homologous and autologous whole blood, blood including red blood cells, platelets,fresh frozen plasma, cryoprecipitate and cryo-depleted plasma 4fresh blood components including red cells, platelets, fresh frozen plasma,cryoprecipitate and cryodepleted plasma 8plasma derivatives and recombinant productsbusiness plan the current action plan for achieving organisation goals 1by-lawscarbon emissionsrules, regulations or legislation adopted by the organisation for the regulation ofboth its internal and external affairsgenerally an abbreviation of emissions of greenhouse gases. Greenhouse gases area number of different gases that all have the ability to influence the global energybalance of the Earth; the greenhouse effect 9230 The ACHS EQuIP5 Guide Book 1 Accreditation, Standards and Guidelines Clinical Function

care plancarers / support personsthe documentation of items agreed to in a care planning process. This should include:• date of development• participants in development of care plan• consumer / patient-stated and agreed issues or problems• consumer / patient-stated and agreed goals• agreed actions and the name of 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 10people who provide unpaid care and support to family members and friends whohave a disability, mental illness, chronic condition, terminal illness or who are frail. 11Carers include parents and guardians caring for children 4 .in the context of EQuIP5:a carer / support person is any person elected by a consumer / patient to accompanyor assist the consumer / patient during an episode of carechange managementclinical auditclinical classificationclinical governanceclinical handoverclinical indicatorclinical pathwaythe process of managing the effective implementation of organisational strategies,ensuring that permanent changes in goals, behaviours, relationships, processesand systems are achieved to the organisation’s advantage. It is the key competencerequired for managing all strategic initiativesa systematic independent examination and review to determine whether actualactivities and results comply with planned arrangements 1the process of translating data, such as for diseases, conditions, injuries andinterventions, from a consumer / patient record into a coded format using a relevantclassification systemthe system by which the governing body, managers and clinicians shareresponsibility and are held accountable for consumer / patient care, minimising risksto consumers / patients and for continuously monitoring and improving the quality ofclinical care 12the transfer of professional responsibility and accountability for some or all aspects ofcare for a consumer / patient, or group of consumers / patients, to another person orprofessional group on a temporary or permanent basis. 4, 13 The efficient and effectivetransfer of high quality clinical information from one healthcare provider to anotherfacilitates safe transfer of care 14a 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 rateof occurrence of an event and are used to assess, compare and determine thepotential to improve care. They assist in assessing whether or not a standard inconsumer / patient care is being met by indicating potential problems that mightneed addressing 15sometimes called a care map, a consumer / patient management tool that organises,sequences and times the major care activities and interventions of the entireinterdisciplinary team for a consumer / patient with a particular diagnosis or need fora procedure 16October 2010 231

Section 6Glossarycliniciancode of practicea healthcare provider, trained as a health professional. Clinicians include registeredand non-registered practitioners, or a team of health professionals providing healthcare who spend the majority of their time providing direct clinical care. 4 The termencompasses medical practitioners, nurses, dentists, paramedics and alliedhealth professionals such as physiotherapists, occupational therapists, speechpathologists, dieticians, radiographers, social workers, psychologists, pharmacistsand all others in active clinical practice 17 , but excludes clinicians-in-training and juniorpractitioners who must work under supervision 18a published document that sets out commonly agreed sets of guidelines andinforms all parties of responsibilities and expectations under the code. Codes ofpractice can be 19 :• voluntary agreements where a group of companies or an industry sector agreeto abide by a particular code• quasi-regulation where the code may be developed by industry in cooperationwith government• co-regulation where the code describes required performance or behaviour, orspecifies acceptable means of meeting broader performance-based obligations,and where there are penalties for non-compliance with the codecommunitycompetencecomplaintconditional surveya 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 20a guarantee that an individual’s knowledge and skills are appropriate to theservice provided and an assurance that the knowledge and skill levels areregularly evaluated 1expression of a problem, an issue, or dissatisfaction with services that may beverbal or in writing 1in the context of EQuIP5:an additional survey that is undertaken one year following an Organisation-WideSurvey or a Periodic Review, during which issues were identified as needing to beaddressed rapidly. A recommendation for a Conditional Survey is made for issues forwhich a 60-day framework is too short to achieve the level of change required, andprovides the organisation with an opportunity to address issues that require sometime and resources in order to achieve an acceptable level of performance.A Conditional Survey may be offered to an organisation in up to two criteria in orderto address:• High Priority Recommendations (HPRs), and/or• an SA rating in mandatory criteriaIn addition, a Conditional Survey may be offered to an organisation in order to address:confidentialityconsent, informed• LA/SA ratings in from six to eleven non-mandatory criteriaguaranteed limits on the use and distribution of information collected from individualsor organisations 1a process of communication between a consumer / patient and his or her medicalofficer that results in the consumer / patient’s authorisation or agreement to undergoa specific medical intervention. This communication should ensure the consumer /patient has an understanding of all the available options and the expected outcomessuch as the success rate and/or side effects for each option 4232 The ACHS EQuIP5 Guide Book 1 Accreditation, Standards and Guidelines Clinical Function

consent,acknowledgement ofconsumer / patientconsumer / patientparticipationcontinuity of carecontractcoordinatecorporate governancecredentiallingcredentialsin the absence of a completed consent form, an acknowledgement of consent formshould be present in the health record, signed by the consumer / patient and, whenappropriate, the treating physician, stating that the proposed treatment, the benefitsand risks and any costs involved have been explained to the consumer / patienta person, however titled, who makes either direct or indirect use of health services;that is, a current or potential user of the health system, and/or their carer(s). 21, 22 Thisencompasses consumers / patients receiving health care from a clinician 4 , those withspecific health needs, or who may at some time have them, and those who have ageneral interest in the health system and health funding. Many consumers / patientsalso have an indirect influence upon the health system in the capacity of taxpayersthe process of involving consumers / patients and the community meaningfullyin decision making about their own health care, health service planning, policydevelopment, setting of priorities and quality issues in the delivery of services 23the ability to provide uninterrupted, coordinated care or services across programs,practitioners, organisations and levels over time 20a mutual agreement between two or more competent parties that creates a legallysupportable obligation to do or not do something specifiedto bring together in a common, ordered and harmonious action or effortthe processes by which the organisation is directed, controlled and held to account.It encompasses the systems, processes and arrangements by which authority,accountability, stewardship, leadership, direction and control are exercised inan organisation. 24 It influences how objectives are set and achieved, how risk ismonitored and assessed and how performance is optimised 25the formal process used to verify the qualifications, experience, professional standingand other relevant professional attributes of clinicians for the purpose of forming aview about their competence, performance and professional suitability to providesafe, high quality healthcare services within specific organisational environments 26documentation that an individual’s knowledge, skills, competence and qualificationscomply with specific requirements 1criteria specific steps to be taken or activities to be done, to reach a decision or a standard 1cultural competenceculture, organisationaldatadata collectiondata integritydata securitythe processes and practices implemented by an organisation that fosterinclusiveness and establish the progression of learning about diversity anddifferences, and their impact on the way services are delivered, received, accessedand promoted. In the context of health care, cultural competence focuses on thecapacity of the organisation to improve health and wellbeing for the individual andthe community by integrating culture into the delivery of health services 27the prevailing pattern of beliefs, attitudes, values and behaviours withinan organisation 28unorganised facts from which information can be generateda store of data captured in an organised way for a specific defined purposeaccuracy, consistency and completeness of dataprotection of data from intentional or unintentional destruction, modificationor disclosureOctober 2010 233

Section 6Glossarydefining the scope ofclinical practicedelegationdeteriorating consumer /patientdisaster recoverydischarge / transferof caredocument control systemdiverse backgrounddiverse needseducationeffectiveeffectivenessthe process that follows on from the credentialling of medical practitioners and otherclinicians, which involves delineating the extent of, and limits to, an individual’s clinicalpractice within a particular organisation, based on that individual’s credentials,competence, performance and professional suitability, and the needs and the26, 29capability of the organisation to support the individual’s scope of clinical practicethe devolution of authority appropriate to individual roles and responsibilities withinan organisation for the operation of clinical and non-clinical services. A formaldelegation system ensures that clear lines of accountability exist, particularly wheretemporary delegations are enacteda consumer / patient whose physiological condition is deteriorating. May applyto any consumers / patients receiving medical, surgical, maternity or mentalhealth care and is determined by observing and documenting changes in theirclinical circumstances. This includes both the absolute change in physiologicalmeasurements and abnormal observations, as well as the rate of change over timefor an individual 30a disaster recovery strategy is a set of pre-determined procedures that provides forsubstitute operations and a quick return to normal after any disruptionthe release of a consumer / patient from care 7 or movement of a consumer / patientfrom one setting of care to another 31a planned system for controlling the release, change and use of importantdocuments within an organisation, particularly policies and procedures. The systemrequires each document to have a unique identification, and to show dates of issue,updates and authorisation. Issue of documents in the organisation is controlled andall copies of all documents are readily traceable and obtainable 32the breadth of social, economic and cultural factors that influence an individualconsumer / patient’s experience and perspective. This encompasses culturally and/or linguistically diverse backgroundsthe range of consumer / patient needs that may be found within the community thatan organisation serves, and which may form a barrier to health care if not addressedby the organisation in meeting its duty of care. Such needs may be cultural, physical,linguistic, economic or health-status relatedsystematic instruction and learning activities to develop or bring about change inknowledge, attitudes, values or skills 1producing the desired resultcare, intervention or action that is relevant to the consumer / patient’s needs andbased on established standards. This care, intervention or action achieves thedesired outcome 20efficiency achieving desired results with the most cost-effective use of resources 20electronic recordselementsa record on electronic storage media that is produced, communicated, maintainedand/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 33in the context of EQuIP5:elements identify what should be in place to achieve the criterion at a certain ratinglevel: a description of what is required to achieve the criterion. These provideprompts for improvement and best practice234 The ACHS EQuIP5 Guide Book 1 Accreditation, Standards and Guidelines Clinical Function

employee assistanceprogramentryend-of-life careenvironmentalsustainabilityerrorethicsevaluationevidenceevidence-basedexternal entityexternally basedreferencesfeedbackflexible work practicesa proven strategy for assisting employees and their families with personal and workrelatedproblems, difficulties and concerns which they may experience from time totime and which can affect work performancea process by which a consumer / patient comes into a healthcare organisation toreceive healthcare servicesa quality management approach that evaluates the individual holistic needs of aconsumer / patient, his or her family and/or carers, and coordinates appropriate careat the end of life. It recognises the interdependent physical, social, emotional, culturaland spiritual aspects of care and includes the combination of broad health andcommunity services that care for a person at the end of his or her life 34development that meets the needs of the present without compromising the abilityof future generations to meet their own needs. The ability to maintain the balancebetween resources, such as water, timber and solar energy, and living organisms35, 36such as humans, animals and plantsunintentionally being wrong in conduct or judgement. Errors may occur by doingthe wrong thing (commission) or by failing to do the right thing (omission) 37acknowledged set of principles which guide professional and moral conductassessment of the degree of success in meeting the goals and expected results(outcomes) of the organisation, services, program or consumers / patients 1data and information used to make decisions. Evidence can be derived fromresearch, experimental learning, indicator data, and evaluations. Evidence is usedin a systematic way to evaluate options and make decisions 1the use of systematically reviewed appraised clinical research findings to aid thedelivery of optimum clinical care to consumers / patients 38 ; the transfer of knowledgefrom research into healthcare practicea body / establishment external to the organisationreference and research information generated outside the organisation, such asjournals, internet information, research databases, library resources, etc.a communication from a consumer / patient relaying how delivered products,services and information compare with consumer / patient expectationsworking arrangements that assist employees to meet personal responsibilities,such as caring for a child or other family member. These may include 39 :• changes in hours of work• changes in patterns of work• changes in location of workfollow-up processes and actions taken after a service has been completed 1formalised follow-upgovernancegoverning bodydocumented processes and actions taken after a service has been completedthe set of relationships and responsibilities established by a healthcare organisationbetween its executive, workforce and stakeholders (including consumers). Itincorporates the set of processes, customs, policy directives, laws, and conventionsaffecting the way a healthcare organisation is directed, administered or controlled.Governance arrangements specify the mechanisms for monitoring performance 4a body that carries legal accountability and/or scope of organisational responsibilityfor the services provided, such as an individual owner or a group of seniormanagers, a governing body of directors, a board, a group of senior managersand/or a chief executive appointed by a government agencyOctober 2010 235

Section 6Glossaryguidelineshealthcare-associatedinfectionshealthcare providerhealth priority areashealth recordhealth workforceHigh PriorityRecommendation (HPR)home ward outlierconsumer / patientiatrogenicICD – 10 – AMincidentinclude(s)indicatorprinciples guiding or directing action. 1 Clinical practice guidelines are systematicallydeveloped statements to assist practitioner and consumer / patient decisions aboutappropriate health care for specific circumstances. 40 Guidelines in the EQuIP5 Guideprovide essential information for the achievement of the EQuIP5 standardsinfections acquired in healthcare facilities (nosocomial infections) and infections thatoccur as a result of healthcare interventions (iatrogenic infections), and which maymanifest after people leave the healthcare facility 41a team or individuals who, in cooperation with the consumer / patient, assumeresponsibility for all aspects of an episode of care in response to the diagnosis andneeds of the consumer / patientidentified health areas which contribute significantly to the burden of illness andinjury, which have potential for health gains and reduction in the burden of disease.These priorities sit under the overarching framework of the National ChronicDisease Strategy 42–44term used to describe many types of data and reports about a consumer / patientstored in different media 45the workforce that provides health care to consumers / patients; ranging fromworkers with no formal qualifications providing support services in home-basedsettings through to highly qualified specialists working in technology intensivesuper-acute hospital settingsin the context of EQuIP5:a recommendation where there is an area of high risk identified by the surveyingteam when:• consumer / patient care is compromised, and/or• the safety of consumers / patients and/or staff is jeopardisedThe HPR is a trigger for the organisation to address the issue either at anAC60 or at a Conditional Surveya consumer / patient who is being treated in an area of the organisation that normallytreats a different casemix, for example, a consumer / patient with a medical conditionsuch as diabetes who may be admitted to a surgical ward due to a lack of availablemedical bedsarising from or associated with health care rather than an underlying diseaseor injury 37a system of codes, from a set of defined categories, which are used to categoriseactivity in a consistent and systemised way: the International Classification ofDiseases, 10th Revision, Australian modificationan event or circumstance which could have or did lead to unintended and/orunnecessary harm to a person, and/or complaint, loss or damage 4a list that provides examples and is not limitingperformance measurement tool, screen or flag that is used as a guide to monitor,evaluate, and improve the quality of services. Indicators relate to structure, processand outcomes 1236 The ACHS EQuIP5 Guide Book 1 Accreditation, Standards and Guidelines Clinical Function

infection controlmanagement planinformation managementinformation privacyinformation systeminformation technology(IT)integrated governanceintegrity, dataa documented plan that outlines the structure of an infection control program, itsoverall aims and objectives, associated quality management activities, programevaluation criteria and timeframes for review. 46 The document should address thegovernance of infection control and identify:• who is at risk and from what• the hazards involved• the procedures for minimising risk• appropriate measures for infection control, based on standard precautions andwhen required, additional precautionsthe process of planning, organising, analysing and controlling data and information.The management of information applies to both computer-based and manual systemsthe right of a person to control the use and disclosure of information that reveals hisor her identity, health information or health statusa system that provides access to information using hardware, software, supplies,policies, procedures and peoplemechanical and electronic devices designed for the collection, storage,manipulation, presentation and dissemination of informationan additional approach that aims to strengthen and streamline healthcareorganisation governance arrangements by focusing on quality 4 as the driver ofchange and placing clinical governance at the heart of governance arrangements.Considered a key building block of good governance in health care 47the characteristic of data and information being accurate and completeinteroperability the ability of information systems to reliably exchange information without error 33interventionIT cost managementIT securityIT systemleadershipany act performed to prevent harming of a consumer / patient or to improve themental, emotional or physical function of a consumer / patient 48a mechanism to manage IT costsa tangible set of physical and logical mechanisms used to protect information held inhard copy, computer systems and information, and telecommunication infrastructurefrom unauthorised accessa group of interacting, interrelated or interdependent elements forming or regardedas forming a collective entitythe 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 1legibility data or information that is decipherable or readable 16legislationmagnet hospitalmanagementthe body of laws made by Parliament. These consist of: acts of parliament;and regulations, ordinances and rules which are also called ‘subordinate’ or‘delegated’ legislation 49a term coined in the United States from research that sought to understand whycertain hospitals were able to attract and retain staffsetting targets or goals for the future through planning and budgeting, establishingprocesses for achieving those targets and allocating resources to accomplish thoseplans. Ensuring that plans are achieved by organising, staffing, controlling andproblem solving 1October 2010 237

Section 6Glossarymandatory criterionin the context of EQuIP5:one where it is considered that without Marked Achievement (evaluation), the qualityof care or the safety of people within the organisation could be at riskmalnutritionmanual handling / taskmedication errormedication managementmedico legalrequirementsmissionmonitormorbiditymortalitymultidisciplinaryNational ChronicDisease Strategya 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 50a task comprised wholly or partly by any activity requiring a person to use any partof their musculoskeletal system in performing their work. These tasks can include 51 :• lifting, lowering, pushing, pulling, carrying or otherwise moving, holding orrestraining any person, animal or item• repetitive actions• sustained work postures• exposure to vibrationany preventable event that may cause or lead to inappropriate medication use orconsumer / patient harm while the medication is in the control of the healthcareprofessional or consumer / patient 4the processes of dispensing, prescribing, storing, administering and monitoringthe effects of medicines 4requirements of or relating to both medicine and law 7a broad written statement in which an organisation states what it does and why itexists. The mission sets apart one organisation from another 1to 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 37a diseased state or symptom or the incidence of disease; the rate of sickness in aspecified community or group 7the number of deaths in a given time or place or the proportion of deaths to agiven population 7care or a service given with input from more than one discipline or professionthe overarching framework of national direction for improving chronic diseaseprevention and care across Australia. A nationally agreed agenda to encouragecoordinated action in response to the growing impact of chronic disease on thehealth of Australians and the healthcare system 42near miss an incident that did not cause harm, but had the potential to do so 4needsnon-clinical informationnon-surgical woundsphysical, mental, emotional, social or spiritual requirement for wellbeing. Needs may ormay not be perceived or expressed by those in need. They must be distinguished fromdemands, which are expressed desires, not necessarily needs 1information that is not direct, personal consumer / patient informationin the context of EQuIP5:wounds that may arise following admission to a health service and only whilst theconsumer / patient is admitted. This encompasses pressure ulcers, or ulcers thatmay develop by other means; skin tears, caused by friction and/or tearing; skininfections, etc. This does not include wounds that would be the purpose of theadmission, such as burns, wounds related to cancers, radiation injuries etc.238 The ACHS EQuIP5 Guide Book 1 Accreditation, Standards and Guidelines Clinical Function

nutrition carenutrition screeningnutrition assessmentobjectiveongoing careopen disclosureoperational planorganisationorientationoutcomepalliative care planpathwaypatient master indexperformance measurepersonal informationinterventions, monitoring, and evaluation designed to facilitate appropriate nutrient6, 52intake based upon the integration of information from the nutrition assessmentthe process of identifying consumers / patients with characteristics commonlyassociated with nutrition problems who may require comprehensive nutritionassessment and may benefit from nutrition intervention 50a comprehensive approach to gathering pertinent data in order to define nutritionalstatus and identify nutrition-related problems. The assessment often includesconsumer / patient history, medical diagnosis and treatment plan, nutritionand medication histories, and nutrition-related physical examination includinganthropometry, nutritional biochemistry, psychological, social, and environmentalaspects 50target that must be reached if the organisation is to achieve its goals. It is thetranslation of the goals into specific, concrete terms against which results canbe measured 1the active and supportive management of care for people with chronic orcomplex conditions as well as the process that follows an admission to ahealthcare organisationthe open discussion of incidents that resulted in harm to a consumer / patient whilereceiving health care. The criteria of open disclosure are an expression of regret, afactual explanation of what happened and the potential consequences, and the stepsbeing taken to manage the event and prevent recurrence 4a short-term plan that details how aspects of a strategic plan will be accomplishedall sites / locations under the governance of, and accountable to, the governingbody / owner(s) 1a formal process of informing and training staff on entry into a position ororganisation, covering the policies, processes and procedures applicable tothat healthcare organisation 4results that may or may not have been intended that occur as a result of a serviceor interventiona written statement developed for a consumer / patient who is suffering from alife-limiting illness, with little or no prospect of a cure, and for whom the primarytreatment goal is quality of life, which states the nursing and other interventions to beundertaken, the health outcomes to be achieved and the review of care which willoccur at regular intervals 53a multidisciplinary plan of care that commences before or on admission and finishesat dischargepermanent listing or register of health information held by an organisation onconsumers / patients who have received or are scheduled to receive services 4in the context of EQuIP5:suggested indicators at the end of each criterion in the Guide provided to assistorganisations to identify, or ‘flag’, an issue that may need further investigation andto assist in the evaluation of processes. These measures are distinct from clinicalindicators, available to organisations through the ACHS Clinical Indicator Programinformation or an opinion (including information or an opinion forming part of adatabase), whether true or not, and whether recorded in a material form or not, aboutan individual whose identity is apparent, or can reasonably be ascertained, from theinformation or opinion 54October 2010 239

Section 6Glossarypolicypressure ulcerprevention andmanagementprocedureprocesswritten statement(s) which acts as a guideline and reflects the position and values ofthe organisation on a given subject. 1 All procedures and protocols should be linkedto a policy statement 4a localised injury to the skin and/or underlying tissue, usually over a bonyprominence and caused by unrelieved pressure, friction or shear. Pressure ulcersoccur most commonly on the sacrum and heel but can develop anywhere on thebody. Pressure injury is a synonymous term for pressure ulcer 4a systematic approach adopted by all sections of an organisation to ensureappropriate identification and actions for consumers / patients at risk of an illnessor conditiona set of documented instructions conveying the approved and recommended stepsfor a particular act or sequence of actsa series of actions, changes or functions that bring about an end or a resultpsycho-social pertaining to a combination of psychological and social factors 48quality activitiesquality frameworkquality improvementactivities which measure performance, identify opportunities for improvement inthe delivery of care and service, and include actions and follow-upan overarching approach to quality improvement that promotes integration of riskmanagement with quality improvement strategies and informs decision makingand planning 55ongoing response to quality assessment data about a service in ways that improvethe processes by which services are provided to consumers / patients 1quality use of medicines the judicious, appropriate, safe and effective use of medicines 56recordsrecords managementrecord safetyall records within the organisation, clinical and non-clinicalfield of management responsible for the efficient and systematic control of thecreation, receipt, maintenance, use and disposition of records 57the physical safety of records such as from light, humidity, vermin, fire and moisturerecord storage the function of storing records for future retrieval and use 57recruitment and selection process used to attract, choose and appoint qualified staff 32referralrelevantresearchriskrisk managementthe process of directing or redirecting a consumer / patient to an appropriatespecialist or agency for definitive treatment 7in the context of EQuIP standards:when something is connected with a matter; when there is a logical connectionan active, diligent and systematic process of inquiry in order to discover, interpretor revise facts, events, behaviours, or theories, or to make practical applicationswith the help of such facts, laws or theoriesthe 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 termsof a combination of the consequences of an event and the associated likelihoodof occurrence 58coordinated activities to direct and control an organisation with regard to risk, suchas activities that identify, control and minimise threats to the ongoing efficiency,4, 58effectiveness and success of its operations to deliver desired outcomes240 The ACHS EQuIP5 Guide Book 1 Accreditation, Standards and Guidelines Clinical Function

isk managementframeworkroot cause analysis(RCA)samplesamplingscope of clinical practiceself identified Aboriginalor Torres Strait Islanderpersonsentinel eventservicesskillmixspecialty ward areastaffa set of components that provide the foundations and organisational arrangementsfor designing, implementing, monitoring, reviewing and continually improving riskmanagement throughout the organisation. The framework should be embeddedwithin the organisation's overall strategic and operational policies and practices 58a systematic process whereby the factors which contributed to an incidentare identified 37blood samples collected from a consumer / patient for purposes of blood orblood product / component transfusion / infusionthe collection of a sample from a consumer / patientthe extent of an individual medical practitioner’s clinical practice within a particularorganisation, based on the individual’s credentials, competence, performanceand professional suitability, and the needs and the capability of the organisation tosupport the medical practitioner’s scope of clinical practice. 59 This is delineated afterthe process of credentiallinga person of Aboriginal or Torres Strait Islander descent who identifies as anAboriginal or Torres Strait Islander and is accepted as such by the community inwhich he or she lives 60an unexpected occurrence involving death or serious physical or psychologicalinjury, 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 recurrencewould carry a significant chance of a serious adverse outcome. Such events signalthe need for immediate investigation and response 6products of the organisation delivered to consumers / patients, or units of theorganisation that deliver products to consumers / patients 1the mix of posts, grades or occupations within a unit / organisation. It may also referto the combinations of activities or skills needed for each job within the organisation 61in the context of EQuIP5:an area of an organisation that normally treats consumers / patients with a specificcasemix, for example, an orthopaedic ward, a paediatric ward, a maternity ward, etc.term which includes employed, visiting, sessional, contracted or volunteer personnelstakeholder individuals, organisations or groups that have an interest or share in services 1standardstatutory notificationsstatutory requirementsstrategic planstrategysurveillancesurveya desired and achievable level of performance against which actual performanceis measured 1any notification required by an act of parliamentany requirement laid down by an act of parliamenta formalised plan that establishes an organisation’s overall objectives and that seeksto position the organisation in terms of its environment 1a long-term plan of action designed to achieve a particular objectivethe ongoing, systematic collection, analysis and interpretation of health-related dataessential to the planning, implementation and evaluation of public health practice 62 ,closely integrated with the timely dissemination of these data to those responsiblefor prevention and control 63external peer review which measures the performance of the organisation againstan agreed set of standards 32October 2010 241

Section 6Glossarysystemtrackingtrainingthe resources, policies, processes and procedures that are organised, integrated,regulated and administered to accomplish an objective 4creating, capturing and maintaining information about the movement and useof records 57the development of practical skills that should be related to the professionaldevelopment needs of the individual and organisation and may be incorporated intoprofessional development programs 4unique identifier universal number or code that uniquely identifies a person or other discrete entity 33validationvaluesto make sound, ratify, confirm, substantiate or to give legal force to. Validity dealswith the relationship of the data obtained to the purpose for which it accomplishes,or measures what it seeks to measureprinciples and beliefs that guide an organisation and may involve social orethical issuesvision description of what the organisation would like to be 1waiting listwhen requiredwhere requireda register which contains essential details about consumers / patients who havebeen assessed as needing elective carerequired at the timerequired in certain circumstancesReferences1. International Society for Quality in Health Care (ISQua).The ISQua surveyor training standards programme.Dublin IRL; ISQua; 2009.2. NSW Health. Guidelines for end-of-life care and decisionmaking.Sydney; NSW Health; 2005.3. Queensland Health, Admitted Patient Data Collection(QHAPDC). Queensland Health Admission policy. AppendixF: Criteria for admission. Brisbane; Qld Health. Accessedfrom http://www.health.qld.gov.au/hic/qhapdc2006/Appendix_F.pdf on 20 August 2010.4. Australian Commission on Safety and Quality in HealthCare. Consultation paper on the draft National Safety andQuality Healthcare Standards, August 2010. Sydney NSW;ACSQHC; 2010.5. World Health Organization. Final technical report: Theconceptual framework for the International Classification forPatient Safety, Version 1.1. Geneva CH; WHO; 2009.6. Joint Commission on Accreditation of HealthcareOrganisations (JCAHO). Sentinel event glossary of terms.Oakbrook Terrace USA; JCAHO. Accessed from http://www.jointcommission.org/SentinelEvents/se_glossary.htm on9 September 2010.7. MedlinePlus Medical Dictionary. Medical Dictionary.Merriam-Webster. Accessed from http://www.merriamwebster.com/medlineplus/at%20riskon 12 August 2010.8. National Blood Authority (NBA). National haemovigilancedata dictionary: A guide for formatting haemovigilance datafor the Australian national haemovigilance data set. 3rd edn.Canberra ACT; NBA; 2010.9. Energy Australia. What are carbon emissions? In: Universityof Sydney Integrated Sustainability Analysis Group.Carbon emissions & you. Sydney NSW; Energy Australia.Accessed from http://www.energysave.energyaustralia.com.au/carbon_emissions__and__you/learn/4.0_key_questions/4.3_carbon_questions/4.4.1_what_are_carbon_emissions on 14 September 2010.10. Primary Care Partnerships Victoria. Victorian servicecoordination practice manual. Melbourne; VictorianDepartment of Human Services; 2009.11. Australian Commission on Safety and Quality in HealthCare (ACSQHC). Consultation Paper on the National Safetyand Quality Healthcare Standards (Draft). Sydney NSW;ACSQHC; 2009.12. Australian Council on Healthcare Standards (ACHS). Newsin brief: Clinical governance defined. ACHS News, 2004;12(Spring): 4.13. Australian Commission on Safety and Quality in Health Care(ACSQHC). Windows into safety and quality in health care2008. Sydney NSW; ACSQHC; 2008.14. Sydney South West Area Health Service. Guideline: clinicalhandover. Sydney; NSW Health; 2007.242 The ACHS EQuIP5 Guide Book 1 Accreditation, Standards and Guidelines Clinical Function

15. ACHS Performance and Outcomes Service. ACHSclinical indicator program information 2010. Sydney NSW;Australian Council on Healthcare Standards (ACHS); 2010.16. Abdelhak M, Grostick S, Hanken MA and Jacobs E. Healthinformation: Management of a strategic resource. 2nd edn.Philadelphia USA; Saunders; 2001.17. Frommer M, Heinke M and Barton M. Credentiallingof cancer clinicians: A guide for Australian healthcareorganisations. Sydney NSW; Cancer Council Australiaand the Australian Cancer Network; 2005.18. Australian Health Practitioner Regulation Agency (AHPRA).Registration process. Canberra ACT; AHPRA. Accessedfrom http://www.ahpra.gov.au/Registration/Registration-Process.aspx on 16 July 2010.19. South Australian Government and Northern TerritoryGovernment. Australian codes of practice database.Accessed from http://codes.bli.net.au/Codes.asp?Section=90 on 10 September 2010.20. National Health Information Standards and StatisticsCommittee (NHISSC). National health performanceframework. 2nd edn. Canberra ACT; AIHW; 2009.21. Gregory J. Consumer engagement in Australian healthpolicy: Final report of the AIHPS research project.Melbourne VIC; Australian Institute of Health Policy Studies(AIHPS); 2008.22. SA Health. Consumer and community participation policydirective. Adelaide; Government of South Australia; 2009.23. Austin Health. Consumer and community participation.Heidelberg VIC; Austin Health. Accessed from http://www.austin.org.au/Page.aspx?ID=138 on 9 June 2010.24. UK Department of Health. A first class service, quality in thenew NHS. London UK; National Health Service. Accessedfrom http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4006902on 1 September 2010.25. ASX Corporate Governance Council. Corporate governanceprinciples and recommendations. Sydney NSW; AustralianSecurities Exchange (ASX); 2007.26. Australian Council for Safety and Quality in Health Care.Standard for credentialling and defining scope of clinicalpractice. Canberra ACT; Australian Council for Safety andQuality in Health Care; 2004.27. Stewart S. Cultural competence in health care. Sydney NSW;Diversity Health Institute, SWAHS; 2006.28. Forster P. Queensland health systems review.Final report Brisbane; Queensland Govt; 2005.29. Royal Australasian College of Surgeons (RACS). Positionpaper: Appointments and credentialing committees thatdefine scope of practice. Melbourne VIC; RACS; 2009.30. Australian Commission on Safety and Quality in HealthCare (ACSQHC). National Consensus Statement: essentialelements for recognising and responding to clinicaldeterioration. Sydney NSW; ACSQHC; 2010.31. Ma E, Coleman E, Fish R et al. Quantifying posthospital caretransitions in older patients. J Am Med Dir Assoc 2004; 5(2):71-74.32. Shaw CD and ISQua toolkit working group. Toolkit foraccreditation programs: Some issues in the designand redesign of external health care assessment andimprovement systems. Melbourne VIC; ISQua; 2004.33. National E-Health Transition Authority (NEHTA).Acronyms, abbreviations & glossary of terms. Sydney NSW;NEHTA; 2005.34. Palliative Care Australia (PCA). Palliative care – Glossary ofterms. Melbourne VIC; PCA; 2008.35. Green Times, your online green journal and directory.Environmental sustainability. Sydney NSW; Sierra Marketing.Accessed from http://www.greentimes.com.au/glossary/categories/lifestyle/environmental-sustainability.html on14 September 2010.36. Qld Dept of Environment and Resource Management.Sustainability. Brisbane; Queensland Government.Accessed from http://www.derm.qld.gov.au/environmental_management/sustainability/ on 14 September 2010.37. Runciman WB. Shared meanings: preferred terms anddefinitions for safety and quality concepts. Med J Aust 2006;184(10 Suppl): S41-S43.38. Rosenberg W and Donald A. Evidence-based medicine: anapproach to clinical problem solving. BMJ 1995; 310(6987):1122-1126.39. Fair Work Australia and Fair Work Ombudsman. Fair workonline. Canberra ACT, Australian Government. Accessedfrom http://www.fairwork.gov.au/Pages/default.aspx on17 March 2010.40. Field MJ, Lohr KN and the Committee to Advise the PublicHealth Service on Clinical Practice Guidelines, Institute ofMedicine (eds). Clinical practice guidelines: Directions fora new program. Washington DC USA; National AcademiesPress; 1990.41. National Health and Medical Research Council (NHMRC).Australian guidelines for the prevention and control ofinfection in healthcare (Consultation Draft). Canberra ACT;Australian Government; 2010.42. National Health Priority Action Council (NHPAC). Nationalchronic disease strategy. Canberra ACT; Australian HealthMinisters’ Advisory Council (AHMAC); 2005.43. Australian Institute of Health & Welfare (AIHW). Chronicdisease: National chronic disease strategy. CanberraACT; AIHW. Accessed from http://www.health.gov.au/internet/main/publishing.nsf/Content/pq-ncds-strat on17 August 2010.44. Australian Institute of Health & Welfare (AIHW). NationalHealth Priority Area FAQs. Canberra ACT; AustralianGovernment. Accessed from http://www.aihw.gov.au/nhpa/faqs.cfm#NHPA_what on 10 September 2010.45. United Medical Protection (UMP). Medico-legal handbook:A guide to legal issues in medical practice. Sydney NSW;UMP; 2003.46. Queensland Communicable Diseases Unit. Infection controlguidelines – extract. 2nd edn. Brisbane; QueenslandHealth; 2001.October 2010 243

Section 6Glossary47. National Health Service (NHS). Integrated governancehandbook: A handbook for executives and non-executivesin healthcare organisations. London UK; Department ofHealth; 2006.48. Harris PG, Nagy S and Vardaxis N (eds). Mosby’s dictionaryof medicine, nursing and health professions. Sydney NSW;Mosby Elsevier; 2010.49. Law Reform Commission NSW (NSW LRC). DiscussionPaper 30 (1993) – Review of the Anti-Discrimination Act 1977(NSW). Lawlink NSW. Sydney NSW; NSW LRC. Accessedfrom http://www.lawlink.nsw.gov.au/lrc.nsf/pages/DP30TORon 16 September 2010.50. Dietitians Association of Australia. Evidence based practiceguidelines for the nutritional management of malnutrition inadult patients across the continuum of care. Nutr Diet 2009;66(Suppl.): S1-S34.51. Australian Safety and Compensation Council (ASCC).National standard for manual tasks. Canberra ACT;ASCC; 2007.52. American Society for Parenteral and Enteral Nutriton(ASPEN). Definition of terms. Silver Spring USA;ASPEN. Updated: November 2009. Accessed fromhttp://www.nutritioncare.org/lcontent.aspx?id=546on 14 September 2010.53. Palliative Care Australia (PCA). Standards for providingquality palliative care for all Australians. Canberra ACT;PCA; 2005.54. Privacy Act (1988)(Cth.)55. Australian Council on Healthcare Standards (ACHS). Riskmanagement and quality improvement handbook. SydneyNSW: ACHS; 2007. Accessed from http://www.achs.org.au/RiskMgmtQIHandbook/ on 27 July 2010.56. Australian Council for Safety and Quality in Health Care. Thenational strategy for quality use of medicines. Canberra ACT;Department of Health and Ageing; 2002.57. AS ISO 15489.1:2002 Records management: General.58. AS/NZS ISO 31000:2010 Risk management —Principles and guidelines.59. Queensland Health. Credentialing and defining the scopeof clinical practice for medical practitioners in Queensland:A policy and resource handbook. Brisbane; QueenslandGovernment; 2009.60. ‘The Commonwealth Definition’, High Court judgement in thecase of Commonwealth v Tasmania (1983) 46 ALR 625.61. Buchan J and Dal Poz MR. Skill mix in the health careworkforce: reviewing the evidence. Bull World Health Organ2002; 80: 575-580.62. World Health Organization (WHO). Public healthsurveillance. Geneva CH; WHO. Accessed from http://www.who.int/immunization_monitoring/burden/routine_surveillance/en/index.html on 2 September 2010.63. Thacker S and Berkelman R. Public health surveillancein the United States. Epidemiol Rev 1988; 10: 164-190.244 The ACHS EQuIP5 Guide Book 1 Accreditation, Standards and Guidelines Clinical Function

Section 6EQuIP5 AcronymsAACHSADGAECAHMCAHRQALARAANZCMHNANZICSANZSBTAPACARCBSASERNIP-SARPANSAAS/NZSBCCABGCCTVCEOCICIAPCJDCPDCPICQICPRCSMDDNADRGEEAEAPEDEEOEPAEQuIPAustralian Council on Healthcare StandardsAustralian Dangerous GoodsAnimal Ethics CommitteeAustralian Health Ministers’ ConferenceAgency for Healthcare Research and QualityAs Low As Reasonably PossibleAustralian and New Zealand College of Mental Health NursesAustralian and New Zealand Intensive Care SocietyAustralian and New Zealand Society of Blood TransfusionAustralian Pharmaceutical Advisory CouncilAustralian Red Cross Blood ServiceAustralian Safety and Efficacy Register of New Interventional Procedures–SurgicalAustralian Radiation Protection and Nuclear Safety AgencyAustralian and New Zealand StandardCoronary Artery Bypass Graft(s)Closed Circuit TelevisionChief Executive OfficerClinical IndicatorClinical Information Access ProgramCreutzfeldt-Jakob DiseaseContinuing Professional DevelopmentClinical Practice ImprovementContinuous Quality ImprovementCardiopulmonary ResuscitationCustomer Services ManagerDeoxyribonucleic AcidDiagnosis Related GroupExcellent Achievement (EQuIP Rating)Employee Assistance ProgramEmergency DepartmentEqual Employment OpportunitiesEnvironmental Protection AuthorityEvaluation and Quality Improvement ProgramOctober 2010 245

Section 6EQuIP5 AcronymsFFTEGg / LGPHHACCHbHIVHRECHRMHSANZII&CTICMPICUIMISOITJJMOKKPILLALMCAMMAMETMSDSNNANATANBANCDDDNEHTANFRNHMRCNHPANICSNOHSCFull Time EquivalentHaemoglobin is measured in grams (g) per litre (L)General PractitionerHealth and Ageing Home and Community CareHaemoglobinHuman Immunodeficiency VirusHuman Research Ethics CommitteeHuman Resources ManagementHaematology Society of Australia & New ZealandInformation and Communication TechnologyInfection Control Management PlanIntensive Care UnitInformation ManagementInternational Organization for StandardizationInformation TechnologyJunior Medical OfficerKey Performance IndicatorLittle Achievement (EQuIP Rating)Left Main Coronary ArteryMarked Achievement (EQuIP Rating)Medical Emergency TeamMaterial Safety Data SheetsNot ApplicableNational Association of Testing AuthoritiesNational Blood AuthorityNational Cardiovascular Disease and Diabetes RegisterNational E-Health Transition AuthorityNot For ResuscitationNational Health and Medical Research CouncilNational Health Priority AreasNational Institute of Clinical StudiesNational Occupational Health and Safety Commission246 The ACHS EQuIP5 Guide Book 1 Accreditation, Standards and Guidelines Clinical Function

NPAACNPPNPSNSQHS(STANDARDS)OOAOH&SOWSPPBSPDCAPDSAPOSPRQQAQIQUMRRACPRACSRANDRANZCARCARCBSRCNASSASHPASIDSTTQMUUCLAVVAVMOVTEWXYZWHONational Pathology Accreditation Advisory CouncilNational Privacy PrinciplesNational Prescribing ServiceNational Safety and Quality Health Service (Standards)Outstanding Achievement (EQuIP Rating)Occupational Health and SafetyOrganisation-Wide Survey (ACHS EQuIP survey)Pharmaceutical Benefits SchemePlan, Do, Check, ActPlan, Do, Study, ActPerformance Outcomes Service (ACHS)Periodic Review (ACHS EQuIP survey)Quality AssuranceQuality ImprovementQuality Use of MedicineRoyal Australasian College of PhysiciansRoyal Australasian College of SurgeonsCorporation, the name of which was derived from a contractionof the term research and developmentRoyal Australian and New Zealand College of AnaesthetistsRoot Cause AnalysisRed Cross Blood ServiceRoyal College of Nursing, AustraliaSome Achievement (EQuIP Rating)Society of Hospital Pharmacists of AustraliaSudden Infant Death SyndromeTotal Quality ManagementUniversity of California, Los AngelesVeterans’ AffairsVisiting Medical OfficerVenous ThromboembolismWorld Health OrganizationOctober 2010 247

248 The ACHS EQuIP5 Guide Book 1 Accreditation, Standards and Guidelines Clinical Function

Contact and InformationInquiries regarding EQuIP5, other ACHS accreditationprograms and program education and support,should be directed to:The Australian Council on Healthcare Standards (ACHS)5 Macarthur StreetUltimo NSW 2007Australia+61 2 9281 9955+61 2 9211 9633achs@achs.org.auwww.achs.org.au

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