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The ACHS EQuIP5 GUIDE Book 2 Accreditation, Standards and Guidelines Support and Corporate Functions Safety Quality Performance
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Page 1: Safety Quality Performance Version 2 · MA – evaluation. SA plus the following. eA – excellence. MA plus the following. oA – Leadership. EA plus the following. Criterion 2.1.1

strive for excellence | framework for maintaining quality care and service | focus on the customer | developing strong leadership | striving for best practice | standards | criterion | guidelines | safety, quality performance | strive for excellence | framework for maintaining quality care and service | focus on the customer | developing strong leadership | striving for best practice | standards | criterion | guidelines | safety, quality performance | strive for excellence | framework for maintaining quality care and service | focus on the customer | developing strong leadership | striving for best practice | standards | criterion | guidelines | safety, quality performance | strive for excellence | framework for maintaining quality care and service | focus on the customer | developing strong leadership | striving for best practice | standards | criterion | guidelines | safety, quality performance | strive for excellence | framework for maintaining quality care and service | focus on the customer | developing strong leadership | striving for best practice | standards | criterion | guidelines | safety, quality performance | strive for excellence | framework for maintaining quality care and service | focus on the customer | developing strong leadership | striving for best practice | standards | criterion | guidelines | safety, quality performance | strive for excellence | framework for maintaining quality care and service | focus on the customer | developing strong leadership | striving for best practice | standards | criterion | guidelines | safety, quality performance | strive for excellence | framework for maintaining quality care and service | focus on the customer | developing strong leadership | striving for best practice | standards | criterion | guidelines | safety, quality performance | strive for excellence | framework for maintaining quality care and service | focus on the customer | developing strong leadership | striving for best practice | standards | criterion | guidelines | safety, quality performance | strive for excellence | framework for maintaining quality care and service | focus on the customer | developing strong leadership | striving for best practice | standards | criterion | guidelines | safety, quality performance | strive for excellence | framework for maintaining quality care and service | focus on the customer | developing strong leadership | striving for best practice | standards | criterion | guidelines | safety, quality performance | strive for excellence | framework for maintaining quality care and service | focus on the customer | developing strong leadership | striving for best practice | standards | criterion | guidelines | safety, quality performance | strive for excellence | framework for maintaining quality care and service | focus on the customer | developing strong leadership | striving for best practice | standards | criterion | guidelines | safety, quality performance | strive for excellence | framework for maintaining quality care and service | focus on the customer | developing strong leadership | striving for best practice | standards | criterion | guidelines | safety, quality performance | strive for excellence | framework for maintaining quality care and service | focus on the customer | developing strong leadership | striving for best practice | standards | criterion | guidelines | safety, quality performance | strive

The ACHS EQuIP5 GUIDE

Book 2Accreditation, Standards and Guidelines

Support and Corporate Functions

Safety Quality Performance

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Version 2
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Page 2: Safety Quality Performance Version 2 · MA – evaluation. SA plus the following. eA – excellence. MA plus the following. oA – Leadership. EA plus the following. Criterion 2.1.1

The ACHS EQuIP5 Guide: Book 2 – Accreditation, Standards and Guidelines – Support and Corporate Functions

Published by The Australian Council on Healthcare Standards (ACHS)

Copies available from the ACHS Publications Service

Phone: +61 2 9281 9955 Fax: +61 2 9211 9633

Copyright © The Australian Council on Healthcare Standards (ACHS)

This work is copyright. Apart from any use as permitted under the Copyright Act 1968, no part may be reproduced by any process without prior written permission from The Australian Council on Healthcare Standards. Requests and enquiries concerning reproduction and rights should be addressed to the Chief Executive, The Australian Council on Healthcare Standards, 5 Macarthur Street, ULTIMO NSW 2007 Australia

Recommended citation: The Australian Council on Healthcare Standards (ACHS), The ACHS EQuIP5 Guide: Book 2 – Accreditation, Standards and Guidelines – Support and Corporate Functions. Sydney Australia; ACHS; 2010.

The EQuIP Guide: First published 1996 Second edition 1998 Second edition revised 1999 Third edition 2002 Fourth edition 2006 Fifth edition 2010

5th Edition ISBN-13: 978 1 921806 01 8 (paperback) ISBN-10: 1 921806 01 X (paperback) ISBN-13: 978 1 921806 03 2 (web) ISBN-10: 1 921806 03 6 (web)

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Fifth edition version 2 2011
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Page 3: Safety Quality Performance Version 2 · MA – evaluation. SA plus the following. eA – excellence. MA plus the following. oA – Leadership. EA plus the following. Criterion 2.1.1

October 2010  249

Contents

Foreword� 1

Introduction� 4

Section 1 ACHS�and�accreditation� 5

1.1 About the Australian Council on Healthcare Standards 5

1.2 What is accreditation? 6

Section 2 Overview�of�EQuIP� 7

2.1 The EQuIP cycle 7

2.2 What is EQuIP? 8

2.3 The self assessment 8

2.4 Organisation-Wide Survey (OWS) 8

2.5 Periodic Review (PR) 9

2.6 EQuIP membership 9

2.6.1� ACHS�EQuIP�Certification�Program� 9

Section 3 EQuIP�Surveys� 10

3.1 The EQuIP Self-Assessment process 10

3.1.1� �Benefits�and�objectives�of�the�self�assessment� 10

3.1.2� The�self-assessment�process� 10

3.1.3� �The�EQuIP�Self-Assessment�feedback�report� 11

3.1.4� �Changes�to�the�self-assessment�format�from�EQuIP�4�to�EQuIP5� 11

3.1.5� �Before�starting�a�Pre-Survey��Assessment� 11

3.2 Pre-Survey Assessment (PSA) 12

3.2.1� �How�to�start�a�PSA� 12

3.2.2� The�PSA�format� 12

3.2.3� �Points�to�remember�in��preparing�a�PSA� 15

3.2.4� �The�Electronic�Assessment��Tool�(EAT)� 15

3.3 EQuIP onsite surveys and processes 16

3.3.1� The�survey�schedule� 16

3.3.2� Additional�surveys� 17

3.3.3� �Getting�ready�for�the�survey�−��one�page�summaries� 18

3.3.4� Survey�timetables� 19

3.3.5� �Surveyors’�meeting�with�the�leadership�team� 20

3.3.6� The�survey�presentation� 20

3.3.7� The�survey�process� 20

3.3.8� Verification� 21

3.3.9� The�Summation�Conference� 21

3.4 EQuIP survey reports 22

3.4.1� How�to�use�the�survey�report� 22

3.4.2� �Public�release�of�accreditation��information� 22

3.5 Accreditation levels, survey recommendations and achievement ratings 23

3.5.1� Accreditation�outcomes� 23

3.5.2� Criterion�achievement�ratings� 23

3.5.3� Expectations�for�ratings� 25

3.5.4� �High�Priority�Recommendations��(HPRs)� 26

3.5.5� Achieving�accreditation� 27

3.5.6� Non-accreditation� 27

3.5.7� An�appeals�process� 27

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250  The ACHS EQuIP5 Guide  Book 2  Accreditation, Standards and Guidelines  Support and Corporate Functions

Contents

Section 4 How�to�use�this�EQuIP�Guide� 28

4.1 The EQuIP framework 28

4.2 Key changes in EQuIP5 29

4.2.1� EQuIP5�functions,�standards,�criteria�� 30

4.3 The criteria 32

4.3.1� Structure�of�the�criteria�(an�example)� 32

4.3.2� Mandatory�criteria� 34

4.3.3� Not�applicable�(NA)�criteria�/�elements� 34

4.4 Further information 34

4.4.1� �Aboriginal�and�Torres�Strait�Islander�people� 34

4.4.2� �Policies,�procedures,�protocols,�guidelines�and�by-laws� 35

4.4.3� Jurisdictions� 36

4.4.4� Performance�measures� 36

4.4.5� Clinical�indicators�� 37

4.4.6� �National�E-Health�Transition�Authority�(NEHTA)� 41

4.4.7� �National�Safety�and�Quality�Health�Service�Standards�(Australian�Commission�on�Safety�and�Quality�in�Health�Care)� 41

Section 5 Standards,�criteria,�elements�and�guidelines� 43

Book 1 Clinical Function (Standards 1.1 – 1.6) 43

Book 2 Support Function (Standards 2.1 – 2.5) 251

Corporate Function (Standards 3.1 – 3.2) 375

Section 6�

6.1 Glossary and Acronyms Glossary (Book 1) 229 Glossary (Book 2) 463

Acronyms (Book 1) 245 Acronyms (Book 2) 479

6.2 Acknowledgements (Book 2) 482

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October 2010  251

2.1�Quality�Improvement�and�Risk�Management�Standard

The�standard�is:�The governing body leads the organisation in its commitment to improving performance and ensures the effective management of corporate and clinical risks.

The�intent�of�this�standard�is�to�ensure�that�the�organisation:

• effectively�manages�all�corporate�and�clinical�risks�in�an�integrated�way�

• continuously�improves�all�aspects�of�the�organisation�and�the�services�that�the�organisation�provides.

There�are�four�criteria�in�this�standard.�They�are:

2.1.1 Theorganisation’scontinuous quality improvement system demonstratesitscommitmenttoimprovingtheoutcomesofcareandservicedelivery.

2.1.2 Theintegratedorganisation-widerisk management framework ensuresthatcorporate and clinical risksareidentified,minimisedandmanaged.

2.1.3 Healthcareincidentsaremanagedtoensureimprovementstothesystemsofcare.

2.1.4� �Healthcare�complaints and feedback�are�managed�to�ensure�improvements�to�the�systems�of�care.

Risk management�is�intended�to�reduce�the�threat�of�activities�and�processes�going�wrong.�Quality�Improvement�is�the�action�taken�throughout�the�organisation�to�increase�the�effectiveness�of�activities�and�processes�to�provide�added�benefits�to�the�organisation�and�consumers�/�patients.�While�risk�management�and�quality�management�are�distinct�functions,�a�quality�and�risk�management�continuum�exists.�Quality�and�risk�management�programs�must�work�together�to�achieve�organisational�goals�and�quality�outcomes.�Incident and complaints management�is�one�strategy�available�to�healthcare�organisations�for�identifying,�analysing�and�treating�risks.

seCtion 5Standards, criteria, elements and guidelines

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seCtion 5Standards, criteria, elements and guidelinesstandard 2.1:�The�governing�body�leads�the�organisation�in�its�commitment�to�improving�performance�and�ensures�the�effective�management�of�corporate�and�clinical�risks

252  The ACHS EQuIP5 Guide  Book 2  Accreditation, Standards and Guidelines  Support and Corporate Functions

IntentThe�intent�of�this�criterion�is�to�ensure�that�all�healthcare�organisations�understand�the�importance�of�the�development�of�an�improvement�culture�and�system,�and�are�able�to�demonstrate�their�commitment�to�continuous�quality�improvement�in�all�aspects�of�care�and�service�delivery.

Relationships of 2.1.1 with other criteriaThis�guideline�should�be�read�in�conjunction�with�all�other�criteria.

Organisational commitmentTo�be�effective,�quality�improvement�must�be�fundamental�to�the�way�the�organisation�thinks�about�what�it�does.�It�should�be�embedded�within�the�organisation’s�philosophy,�practices�and�business�processes,�rather�than�viewed�or�practised�as�an�independent�activity.

It�is�important�that�every�employee�is�engaged�in�improvement�efforts�that�are�relevant�and�important�for�their�work.�Organisations�should�build�in�time�for�staff�to�participate�in�quality�improvement�(QI)�as�part�of�their�daily�work,�and�provide�the�necessary�training,�resources,�flexibility�and�authority�for�staff�to�test�processes�and�make�improvements.1

Without�physician�involvement�in�the�process�and�a�focus�on�consumer�/�patient�care,�quality�management�in�clinical�settings�will�remain�difficult�to�achieve.2�Many�doctors�have�clearly�become�leaders�in�this�area.�However,�some�doctors�see�themselves�as�working�for�consumers�/�patients,�and�struggle�to�expand�to�their�‘parallel’�role�in�working�for�an�organisation.3�Clinical�leadership,�arising�from�the�governing�body,�is�needed�if�quality�management�is�to�operate�effectively�amid�the�complexities�of�a�healthcare�environment.

Leadership�faces�two�challenges�in�implementing�quality�improvement�continuously�over�time4:

• When�a�quality�program�is�introduced,�the�major�challenges�will�arise�from�building�the�participatory�review�process�that�is�part�of�quality�improvement.�However,�early�in�a�quality�program,�big�improvements�are�likely�to�be�possible�by�correcting�existing�problems�and�then�by�introducing�preventative�measures.�

• As�the�program�matures,�and�systems�become�established,�recurring�problems�will�gradually�be�resolved�and�areas�of�high�risk�will�be�identified�and�may�be�mitigated.�The�challenge�now�is�to�lift�the�bar�repeatedly�to�generate�further�improvement.�Leadership�remains�imperative,�because�without�ongoing�commitment�there�is�a�tendency�to�forget�the�effort�needed�to�maintain�

Criterion LA – Awareness sA – implementationLA plus the following

MA – evaluationSA plus the following

eA – excellenceMA plus the following

oA – LeadershipEA plus the following

Criterion 2.1.1

Theorganisation’scontinuousqualityimprovementsystemdemonstratesitscommitmenttoimprovingtheoutcomesofcareandservicedelivery.

this is a mandatory criterion

a)� The�governing�body�is�committed�to�continuous�quality�improvement.

b)� A�framework�for�continuous�quality�improvement�exists.�

a)� Quality�improvement�is�planned,�continuous�and�linked�to�the�risk�management�system,�education,�and�the�strategic�plan.

b)� Staff�are�supported�and�participate�in�ongoing�improvement�in�care�and�service�delivery.

c)� Leaders�in�quality�improvement�are�identified�and�developed�across�the�organisation,�and�supported�to�drive�improvement.

a)� The�effectiveness�of�the�improvement�framework�and�its�component�activities�is�evaluated�and�improved�as�required.

b)� Qualitative�and�quantitative�data�are�collected,�analysed�and�used�to�plan�and�drive�improvement.

c)� Clinicians�are�involved�in�the�evaluation�of�the�quality�improvement�system.

a)� Comparison�occurs�with�internal�and�external�systems,�and�improvements�to�practices�and�systems�are�made�to�ensure�better�practice.

and/or

b)� The�evaluation�of�the�effectiveness�of�improvement�activities�demonstrates�excellence�in�improvement�processes.

a)� The�organisation�demonstrates�that�it�is�a�leader�in�continuous�quality�improvement.

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October 2010  253

current�levels�of�performance.�This�ongoing�effort�requires�an�embedded�culture�of�striving�for�excellence,�which�is�challenging�to�maintain,�particularly�if�staff�turnover�is�high.�Leadership�is�fundamental�to�building�such�a�culture.

A�‘commitment’�to�quality�improvement�within�the�governing�body�may�appear�somewhat�intangible,�yet�there�are�many�ways�that�an�organisation�can�demonstrate�this.�Consider:�

• the�use�of�key�quality�indicators�by�the�governing�body�within�their�regular�meeting�structure

• inclusion�of�quality�improvement�in�the�strategic�plan

• key�staff�appointments�

• budgetary�decisions

• ways�that�the�organisation�uses�an�accreditation�framework�in�planning�(EQuIP�or�other)

• the�governing�body’s�response�to�ACHS�surveyors’�or�other�external�consultants’�recommendations�

• interactions�with�organisational�councils,�committees,�or�commissions�responsible�for�monitoring�and�ensuring�the�effectiveness�of�quality�improvement�efforts

• participation�by�members�of�the�governing�body�and�support�for�organisational�staff�involvement�in�external�quality�activities,�such�as�training�programs,�EQuIP�surveying,�voluntary�reporting�of�performance�data�to�external�organisations,�training�programs�with�a�quality�focus,�presentations�of�QI�project�outcomes�at�conferences,�etc.

• using�any�(public)�performance�reports�as�opportunities�to�identify�deficiencies�and�improve�care,�health�outcomes,�and�consumer�/�patient�satisfaction.�Performance�reports�may�include�coroner’s�reports,�the�findings�of�a�Royal�/�Special�Commission,�indicator�reports,�consumer�/�patient�survey�or�focus�group�reports.

Prompt points

¼ How does the governing body demonstrate its commitment to continuous quality improvement within the organisation?

¼ How does the governing body monitor and motivate quality improvement efforts and actions within the organisation?

Criterion LA – Awareness sA – implementationLA plus the following

MA – evaluationSA plus the following

eA – excellenceMA plus the following

oA – LeadershipEA plus the following

Criterion 2.1.1

Theorganisation’scontinuousqualityimprovementsystemdemonstratesitscommitmenttoimprovingtheoutcomesofcareandservicedelivery.

this is a mandatory criterion

a)� The�governing�body�is�committed�to�continuous�quality�improvement.

b)� A�framework�for�continuous�quality�improvement�exists.�

a)� Quality�improvement�is�planned,�continuous�and�linked�to�the�risk�management�system,�education,�and�the�strategic�plan.

b)� Staff�are�supported�and�participate�in�ongoing�improvement�in�care�and�service�delivery.

c)� Leaders�in�quality�improvement�are�identified�and�developed�across�the�organisation,�and�supported�to�drive�improvement.

a)� The�effectiveness�of�the�improvement�framework�and�its�component�activities�is�evaluated�and�improved�as�required.

b)� Qualitative�and�quantitative�data�are�collected,�analysed�and�used�to�plan�and�drive�improvement.

c)� Clinicians�are�involved�in�the�evaluation�of�the�quality�improvement�system.

a)� Comparison�occurs�with�internal�and�external�systems,�and�improvements�to�practices�and�systems�are�made�to�ensure�better�practice.

and/or

b)� The�evaluation�of�the�effectiveness�of�improvement�activities�demonstrates�excellence�in�improvement�processes.

a)� The�organisation�demonstrates�that�it�is�a�leader�in�continuous�quality�improvement.

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seCtion 5Standards, criteria, elements and guidelinesstandard 2.1:�The�governing�body�leads�the�organisation�in�its�commitment�to�improving�performance�and�ensures�the�effective�management�of�corporate�and�clinical�risks

254  The ACHS EQuIP5 Guide  Book 2  Accreditation, Standards and Guidelines  Support and Corporate Functions

Criterion 2.1.1

Theorganisation’scontinuousqualityimprovementsystemdemonstratesitscommitmenttoimprovingtheoutcomesofcareandservicedelivery.�(continued)

Quality framework, integration and use of data to drive improvement Implementing�processes�that�assist�an�organisation�to�become�a�safe�and�accountable�healthcare�environment�for�consumers�/�patients�and�healthcare�providers�requires�attention�to�systems�and�the�analysis�of�collected�data.

Quality�improvement�and�the�management�of�risks�in�health�care�should�be�part�of�both�strategic�and�operational�planning�in�every�area�and�service�of�healthcare�delivery.�Risk�management�and�quality�improvement�should�be�considered�when�determining�clinical�practice,�equipment�design�and�procurement,�personnel�management�and�financial�planning.5

There�are�some�essentials�that�characterise�a�quality�improvement�program�irrespective�of�the�QI�framework�used�by�the�organisation,�its�size,�type�or�complexity.�It�would�be�expected�that:

• staff�members�accountable�for�taking�action�are�identified�and�informed

• risk�management�and�consumer�/�patient�safety�are�considered�in�all�decision�making

• improvement�teams�are�multidisciplinary

• quality�activities�are�informed�by�appropriate�data�collection

• staff�are�familiar�with�quality�objectives�and�processes,�ideally�through�formal�training,�but�in�the�absence�of�this,�through�orientation�and�mentoring

• there�are�channels�through�which�concerns�about�quality�of�care�and/or�processes�can�be�directed�

• nationally�identified�and�jurisdictional�goals�for�the�healthcare�system�are�considered�and�integrated�into�planning.

Quality�improvement�has�been�widely�integrated�into�Australian�health�care�since�the�1980s.�

Quality�improvement�and�risk�management�systems�are�directed�to�apply�a�structured�framework�for�identification,�analysis,�action,�monitoring�and�review�for�risks,�problems�and/or�opportunities.�Communication�and�consultation�with�stakeholders�are�critical�for�these�processes�to�work�effectively.�

EQuIP�has�been�developed�as�a�framework�for�assessing�organisational�performance�against�wide-reaching�standards�and�criteria.�Member�organisations�may�choose�to�structure�their�QI�activities�around�the�same�framework.�However,�although�the�EQuIP�elements�reflect�the�maturation�of�QI�processes�(awareness��implementation��evaluation�and�further�improvement��excellence��outstanding�achievement),�this�alone�will�not�provide�the�tools�to�undertake�a�QI�project�in�an�area�of�concern.�

ACHS�has�developed�the�RiskManagementandQualityImprovementHandbook5�to�support�members�in�implementing�QI�and�risk�management�within�their�organisation.�The�Guide�is�available�to�members�at�http://www.achs.org.au/RiskMgmtQIHandbook/.�The�handbook�will�introduce�the�many�tools,�skills,�principles�and�frameworks�available�to�conduct�effective�quality�improvement�projects.�

An�organisation�may�be�able�to�show�that�the�words�‘quality�improvement’�appear�within�planning�documents�or�educational�programs.�However,�a�higher�level�of�evidence�would�demonstrate�how�the�quality�system�was�used�to�respond�to�an�issue,�by�investigating�risks�and�mitigating�their�impact.�For�example,�staff�who�undertake�activities�where�there�are�potential�risks�may�benefit�from�an�alternative�approach,�and�this�might�require�education�or�further�training.�If�an�identified�high-risk�practice�were�in�widespread�use,�the�organisation�should�have�structured�processes�to�communicate�the�proposed�solution,�train�staff�in�adopting�the�new�or�altered�practice�and�monitor�the�outcome�of�the�change.

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October 2010  255

Evaluating�the�improvement�framework�itself�will�rely�on�a�more�qualitative�examination�undertaken�at�more�than�one�level.�Assuming�the�framework�is�being�widely�used,�consider�whether:

• it�is�used�to�tackle�performance�questions.�If�not,�potential�reasons�may�arise�from�organisational�culture.�Changing�culture�may�be�essential,�but�this�is�likely�to�be�a�long-term�issue�for�senior�managers.�In�the�meantime,�actions�taken�by�the�quality�team�might�reduce�the�impact�of�identifiable�factors�such�as�inadequate�leadership,�inadequate�time�or�resources,�failure�to�gain�multidisciplinary�attendance�at�meetings,�or�to�achieve�outcomes�from�meetings.�

• the�organisation’s�improvement�framework�and�processes�work�effectively�across�different�types�of�quality�issues.�If�not,�organisations�should�consider�the�circumstances�and�reasons�why�the�framework�has�not�been�effective.�Have�any�changes�been�made�in�process,�personnel�or�resources�to�refine�the�improvement�framework�and�its�operations?

• the�actions�taken�as�part�of�a�QI�project�are�followed�up,�measured,�further�refined,�and�the�outcomes�communicated�to�management.�Where�positive�outcomes�have�been�achieved,�has�the�organisation�initiated�the�same�changes�more�broadly,�or�reported�the�outcome�to�similar�organisations�through�a�presentation,�conference�or�journal?

• the�strengths�and�weaknesses�of�the�organisation’s�approach�to�quality�improvement�are�known.�Has�the�organisation’s�framework�been�compared�to�systems�and�processes�used�by�other�similar�organisations?�

Prompt points

¼ Describe how quality improvement activities are initiated, organised and coordinated. Is there a central framework or committee to coordinate this activity? If so, what roles are played by the component parts?

¼ Describe the links between QI activity and the strategic plan? What links tie QI activity to risk management? When QI activity suggests the need for education, are there any links that would facilitate the provision of training?

¼ What processes / measures are used to monitor the quality of service provision?

¼ How is the QI system itself evaluated and improved?

QI leadership, participation and supportLeaders�are�not�always�‘titled’�personnel�filling�prominent�roles.�Quality�may�be�the�responsibility�of�a�person�with�the�title,�‘Quality�Manager’,�but�achieving�consumer�/�patient�care�that�is�safe�and�excellent�is�the�responsibility�of�all�clinical�personnel,�irrespective�of�their�position�in�an�organisational�hierarchy.�Guiding�genuine�change�in�consumer�/�patient�care�will�require�support�and�commitment�from�people�working�at�an�operational�level.

Among�physicians,�there�are�those�who�have�earned�the�respect�of�their�peers�and�can�influence�others.6�Gaining�‘buy�in’�from�opinion�leaders�will�help�to�build�up�the�momentum�for�change.�Middle�managers�are�key�in�disseminating�and�building�a�quality�conscious�culture.7�They�can�translate�strategy-level�goals�into�actionable�improvement�at�the�department�or�unit�level,�engage�staff�in�safety�and�quality�improvement�efforts,�help�determine�which�care�processes�need�to�be�improved�and�how,�and�establish�processes�for�spreading�and�sustaining�improvement�over�time.7

Organisational�support�may�be�overt�or�be�built�into�a�supportive�culture.�Organisations�and�managers�can�support�identified�leaders�by:

• formally�providing�time�for�the�management�/�coordination�of�QI�teams�/�projects�that�have�been�formally�recognised�by�management

• providing�space�(on�websites,�noticeboards,�etc.)�and�leadership�support�for�any�notices�or�project�recruitment�efforts�associated�with�quality�projects

• recognising�QI�activity�and�outcomes�in�staff�performance�reviews

• supporting�further�education�in�quality�and�leadership�through�conference�attendance,�local�workshops�or�funding�to�support�further�education

• supporting�promotion�of�successful�projects�at�conferences�and�awards

• formally�acknowledging�teams�and�their�leaders�in�newsletters,�staff�meetings,�and�in�other�ways.

The�governing�body�and�senior�management�are�responsible�for�providing�support�for�clinical�staff�to�make�and�execute�good�decisions�and�improve�healthcare�performance.8�Staff,�consumers�and�other�stakeholders�should�be�informed�about,�and�actively�involved�in,�the�organisation’s�safety�and�quality�issues�and�improvement�initiatives.9�

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seCtion 5Standards, criteria, elements and guidelinesstandard 2.1:�The�governing�body�leads�the�organisation�in�its�commitment�to�improving�performance�and�ensures�the�effective�management�of�corporate�and�clinical�risks

256  The ACHS EQuIP5 Guide  Book 2  Accreditation, Standards and Guidelines  Support and Corporate Functions

Criterion 2.1.1

Theorganisation’scontinuousqualityimprovementsystemdemonstratesitscommitmenttoimprovingtheoutcomesofcareandservicedelivery.�(continued)

Review�of�the�quality�improvement�system�needs�to�include�clinicians�from�the�range�of�professional�areas�because:

• diverse�training,�consumer�/�patient�pools�and�roles�in�care�bring�different�perspectives�to�problem�solving

• QI�plans�to�resolve�an�identified�issue�may�impact�other�areas�of�care�–�the�web�of�professional�and�systems�linkages�that�facilitate�care�can�be�extensive�and�complex�

• from�the�perspective�of�the�consumer�/�patient,�the�clinicians�are�the�‘public�face’�of�the�organisation.

Most�organisations�have�teams�or�committees�of�clinicians�that�meet�to�consider�outcomes�of�clinical�care.�Where�a�clinician�expresses�concern�about�a�gap�between�desired�outcomes�and�measured�behaviours�or�effects,�there�is�reason�for�further�investigation.�Awareness�of�gaps�may�come�from�internal�or�external�sources,�including:

• complaints�from�consumers�/�patients�

• data�on�incident�types�and�distribution�

• an�internal�review�following�a�serious�incident�or�near�miss�

• external�reviews�such�as�Royal�Commissions,�coroners’�reports�or�ACHS�surveys,�or�clinical�indicator�data.�

The�involvement�of�clinicians2�in�such�investigation�management�and�risk�mitigation�is�central�to�successful�quality�improvement�programs.�Wolff�and�Taylor�have�developed�a�checklist�for�engaging�doctors�in�quality�improvement�and�consumer�/�patient�safety�programs�that�might�provide�some�useful�focus�points�to�improve�engagement�and�participation.2�

Prompt points

¼ How does the organisation develop clinicians who will understand and lead in quality improvement?

¼ How does the organisation support its staff to participate in continuous quality improvement?

¼ What role do clinicians, particularly medical staff, play in quality improvement within the organisation? How are the outcomes of quality improvement reported back to the clinicians?

Evidence commonly presented

Consider whether the following will help to address criterion 2.1.1

¼ Quality council / QI committee / improvement team membership that includes governing body leadership and participation

¼ Governing body agenda and minutes with reports of improvements, clinical and non-clinical performance, sponsoring of key improvement activities

¼ Strategic and operational plans, budgets that include quality improvement

¼ Governing body endorsement of framework for quality improvement

¼ Continuous quality improvement plans, frameworks such as philosophy, policy, improvement processes, performance targets, links to incidents, complaints, risks, education, planning

¼ Strategies for supporting staff to be leaders / participants in improvement activities

¼ By-laws, appointment criteria, position descriptions that include quality improvement responsibilities

¼ System for prioritising improvements to address high-risk, high-volume issues

¼ Reports of quantitative and qualitative performance data, clinical and non-clinical, and communication and distribution channels

¼ Minutes of meetings that discuss and action data

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October 2010  257

¼ A list of improvements, clinical and non-clinical

¼ Evaluation of the improvement activities – impact on the consumer / patient, organisation performance targets, cost versus benefit

¼ Evaluation of governing body, management and staff participation such as membership of project teams, number of activities

¼ Evaluation of the continuous quality improvement framework such as understanding and knowledge of the philosophy, policy, improvement processes, performance targets; improvements addressing high-risk, high-volume services; costs versus benefits

¼ Benchmarking activities, improved practices and systems assessment of organisational culture for quality improvement

Performance measurementThis�criterion�states�that:�“The�organisation’s�continuous�quality�improvement�system�demonstrates�its�commitment�to�improving�the�outcomes�of�care�and�service�delivery”.�The�organisation�should�be�able�to�demonstrate�that�a�framework�for�continuous�quality�improvement�is�embedded�in�all�aspects�of�its�operation,�and�that�its�quality�improvement�activities�contribute�to�better�service�provision�for�its�community,�and�better�health�outcomes.

Some�common�suggested�performance�measures�are�as�follows:

Number�of�quality�improvement�activities�that�partially�/�fully�achieve�stated�objectives

Total number of quality improvement activities

Comment:measurableobjectivesandatimeframeshouldbeincludedinQIprojectplansattimeofapprovalbymanagement

Number�of�quality�improvement�meetings�with�executive�/�senior�management�representation�

Total number of quality improvement meetings

Comment:organisationtodefine‘executive/seniormanager’

Number�of�consumers�/�patients�involved�in�formal�quality�improvement�activities

Total number of persons involved in formal quality improvement activities

Comment:organisationtodefine‘involvement’

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seCtion 5Standards, criteria, elements and guidelinesstandard 2.1:�The�governing�body�leads�the�organisation�in�its�commitment�to�improving�performance�and�ensures�the�effective�management�of�corporate�and�clinical�risks

258  The ACHS EQuIP5 Guide  Book 2  Accreditation, Standards and Guidelines  Support and Corporate Functions

Criterion 2.1.1

Theorganisation’scontinuousqualityimprovementsystemdemonstratesitscommitmenttoimprovingtheoutcomesofcareandservicedelivery.�(continued)

Number�of�quality�improvement�activities�/�projects�for�which�outcomes�are�currently�monitored��for�the�purposes�of�further�improvement

Total number of quality improvement activities / projects

Number�of�quality�improvement�outcomes�communicated�to�staff�members�not�directly�involved��in�the�quality�activity

Total number of quality improvement activities

Number�of�quality�improvement�activities�formally�acknowledged�by�the�health�service�executive

Total number of quality improvement activities

Comment:dependingontheorganisationanditsgovernance,‘formallyacknowledged’mightinvolvemanagementsignoffonanactivityorareporttoameetingofgoverningbodyorexecutiveteam

Number�of�minutes�of�executive�and�governing�body�meetings�that�record�recommendations�/�outcomes�about�quality�improvement�activities

Total number of executive / governing body meetings held

Number�of�improvements�implemented�in�risk�priority�areas

Total number of potential improvements identified in risk priority areas

Comment:riskpriorityareastobedeterminedbytheorganisation;forexample,riskpriorityareascouldincludeseverityassessmentcode(SAC)1and2,orequivalent

Number�of�clinical�indicators�that�are�better�than�the�national�peer�group�aggregate�rate

Total number of clinical indicators collected by the organisation

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October 2010  259

References1.� Riley�WJ,�Parsons�HM,�Duffy�GL�etal.�Realizing�

transformational�change�through�quality�improvement�in�public�health.�JPublicHealthManagPract�2010;�16(1):�72-78.

2.� Wolff�AM�and�Taylor�SA.�Enhancingpatientcare:Apracticalguidetoimprovingqualityandsafetyinhospitals.�Sydney�NSW;�MJA�books;�2009.

3.� Runciman�B,�Merry�A�and�Walton�M.�Safetyandethicsinhealthcare:aguidetogettingitright.�Aldershot�UK;�Ashgate�Publishing�Limited;�2007.

4.� Bishop�A�and�Dougherty�R.Implementingcontinuousqualityimprovementatthehealthcareproviderlevel.Lexington�USA;�Dougherty�Management�Associates;�2004.

5.� Australian�Council�on�Healthcare�Standards�(ACHS).�Riskmanagementandqualityimprovementhandbook.�Sydney�NSW:�ACHS;�2007.�Accessed�from�http://www.achs.org.au/RiskMgmtQIHandbook/�on�27�July�2010.

6.� Reinertsen�J,�Bisognano�M�and�Pugh�M.�Sevenleadershipleveragepointsfororganization-levelimprovementinhealthcare.InnovationSeries.�2nd�edn.�Cambridge�USA;�Institute�for�Healthcare�Improvement�(IHI);�2008.

7.� Federico�F�and�Bonacum�D.�Strengthening�the�core:�Middle�managers�play�a�vital�role�in�improving�safety.�HealthcExec2010; Jan/Feb: 68-70.

8.� Balding�C.�From�quality�assurance�to�clinical�governance.�AustHealthRev�2008;�32(3):�382-391.

9.� Victorian�Quality�Council.�Thehealthcareboard’sroleinclinicalgovernance.Melbourne�VIC;�Dept�of�Human�Services;�2004.

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seCtion 5Standards, criteria, elements and guidelinesstandard 2.1:�The�governing�body�leads�the�organisation�in�its�commitment�to�improving�performance�and�ensures�the�effective�management�of�corporate�and�clinical�risks

260  The ACHS EQuIP5 Guide  Book 2  Accreditation, Standards and Guidelines  Support and Corporate Functions

Criterion LA – Awareness sA – implementationLA plus the following

MA – evaluationSA plus the following

eA – excellenceMA plus the following

oA – LeadershipEA plus the following

Criterion 2.1.2

Theintegratedorganisation-wideriskmanagementframeworkensuresthatcorporateandclinicalrisksareidentified,minimisedandmanaged.

this is a mandatory criterion

a)� There�is�an�organisation-wide�risk�management�policy�/�guideline�for�corporate�and�clinical�risks�that�identifies�specific�strategies�for�managing�risks�and�is�available�to�clinicians,�managers�and�other�staff.

b)� Clinicians,�managers�and�other�staff�are�informed�about�their�responsibilities�for�identifying�and�managing�risks.

a)� There�is�integration�between�quality�improvement,�risk�management�and�strategic�planning�within�the�organisation.

b)� An�integrated,�organisation-wide�risk�management�framework�addressing�corporate�and�clinical�risks�is�developed,�documented�and�implemented.

c)� Systems�are�implemented�to�ensure�clinicians,�managers�and�staff�can�initiate�action�to�prevent�and/or�reduce�the�impact�of�risks.

d)� A�risk�management�approach�is�used�when�considering�and�developing�new�and�modified�services.

a)� The�corporate�and�clinical�risk�management�framework�is�evaluated�and�improved�as�required.

b)� Risk�identification�and�risk�analysis�are�undertaken�using�qualitative�and�quantitative�data.

c)� Data�from�risk�management�processes�are�provided�to�clinicians,�managers�and�other�staff�and�improvements�to�care�and�services�are�planned�and�implemented.

a)� Components�of�the�risk�management�framework�are�compared�with�internal�and�external�systems�and�improvements�are�made�to�ensure�better�practice.

and/or

b)� Evaluation�of�the�risk�management�framework�demonstrates�that�risk�management�is�effective�and�risks�are�minimised.

a)� The�organisation�demonstrates�that�it�is�a�leader�in�corporate�and�clinical�risk�management.

IntentAll�activities�of�all�organisations�involve�risk�that�must�be�managed.�This�is�particularly�true�of�healthcare�organisations,�where�in�addition�to�the�degree�of�risk�inherent�to�the�provision�of�care�there�is�community�expectation�of�safety.�The�intent�of�this�criterion�is�to�ensure�that�the�organisation�identifies,�minimises�and�manages�its�corporate�and�clinical�risks�via�an�integrated,�organisation-wide�risk�management�framework.

Relationships of 2.1.2 with other criteriaThis�guideline�should�be�read�in�conjunction�with�all�other�criteria.

Strategic planning, governance and risk managementRisk�is�defined�as�the�effect�of�uncertainty�on�objectives.1�A�healthcare�organisation’s�objectives�have�different�aspects,�such�as�clinical,�financial,�health�and�safety�or�environmental,�and�they�apply�at�the�strategic,�organisation-wide,�unit,�project�and�process�levels.�In�the�context�of�risk,�uncertainty�is�defined�as�“the�state,�even�partial,�of�deficiency�of�information�related�to�understanding�or�knowledge�of�an�event,�its�consequence,�or�likelihood”.1�Any�deviation�from�the�expected�can�result�in�a�positive�and/or�negative�effect.�Therefore,�any�type�of�risk,�whatever�its�nature,�may�have�either�(or�both)�positive�or�negative�consequences.

Strategic�planning�is�a�continuous�and�systematic�process�whereby�decisions�are�made�by�an�organisation�about�intended�future�outcomes,�how�outcomes�are�to�be�accomplished,�and�how�success�is�measured�and�evaluated.2�A�strategic�plan�should�include�a�mission�statement,�objectives,�goals,�and�an�action�plan.3�Governance�may�be�viewed�as�a�‘guidance�system’�for�the�achievement�of�an�organisation’s�planned�objectives,�as�defined�within�its�

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October 2010  261

Criterion LA – Awareness sA – implementationLA plus the following

MA – evaluationSA plus the following

eA – excellenceMA plus the following

oA – LeadershipEA plus the following

Criterion 2.1.2

Theintegratedorganisation-wideriskmanagementframeworkensuresthatcorporateandclinicalrisksareidentified,minimisedandmanaged.

this is a mandatory criterion

a)� There�is�an�organisation-wide�risk�management�policy�/�guideline�for�corporate�and�clinical�risks�that�identifies�specific�strategies�for�managing�risks�and�is�available�to�clinicians,�managers�and�other�staff.

b)� Clinicians,�managers�and�other�staff�are�informed�about�their�responsibilities�for�identifying�and�managing�risks.

a)� There�is�integration�between�quality�improvement,�risk�management�and�strategic�planning�within�the�organisation.

b)� An�integrated,�organisation-wide�risk�management�framework�addressing�corporate�and�clinical�risks�is�developed,�documented�and�implemented.

c)� Systems�are�implemented�to�ensure�clinicians,�managers�and�staff�can�initiate�action�to�prevent�and/or�reduce�the�impact�of�risks.

d)� A�risk�management�approach�is�used�when�considering�and�developing�new�and�modified�services.

a)� The�corporate�and�clinical�risk�management�framework�is�evaluated�and�improved�as�required.

b)� Risk�identification�and�risk�analysis�are�undertaken�using�qualitative�and�quantitative�data.

c)� Data�from�risk�management�processes�are�provided�to�clinicians,�managers�and�other�staff�and�improvements�to�care�and�services�are�planned�and�implemented.

a)� Components�of�the�risk�management�framework�are�compared�with�internal�and�external�systems�and�improvements�are�made�to�ensure�better�practice.

and/or

b)� Evaluation�of�the�risk�management�framework�demonstrates�that�risk�management�is�effective�and�risks�are�minimised.

a)� The�organisation�demonstrates�that�it�is�a�leader�in�corporate�and�clinical�risk�management.

strategic�plan.�Risk�management�is�an�integral�aspect�of�governance,�inasmuch�as�all�objectives,�whether�corporate�or�clinical,�will�contain�an�element�of�risk,�which�must�be�effectively�managed�via�strategies�and�controls,�in�order�for�those�objectives�to�be�achieved.4

Risk�management�is�a�coordinated�activity�that�directs�and�controls�the�organisation�with�regard�to�risk,�while�a�risk�management�framework�is�the�systematic�application�of�management�policies,�procedures�and�practices�to�the�activities�of�communicating,�consulting,�establishing�the�context,�and�identifying,�analysing,�evaluating,�treating,�monitoring�and�reviewing�risk.1�By�associating�the�management�of�risk�with�all�objectives,�of�all�kinds�and�at�all�organisational�levels,�it�becomes�fully�integrated�as�an�organisation-wide�system,�or�risk�management�framework.�This�framework�in�turn�ensures�that�information�about�risk�derived�from�the�risk�management�process�is�satisfactorily�reported�and�used�as�the�basis�for�future�decision�making�and�accountability.1�The�risk�management�framework�should�link�to�strategic�and�business�planning�and�support�assessment�of�new�and/or�altered�services.

For�risk�management�to�be�effective�it�should1:

• create�and�protect�value�by�contributing�to�the�demonstrable�achievement�of�objectives,�and�improvement�of�performance

• be�an�integral�part�of�all�organisational�processes

• be�a�part�of�decision�making

• explicitly�address�uncertainty

• be�systematic,�structured�and�timely

• be�based�on�the�best�available�information

• be�tailored�to�the�organisation

• take�human�and�cultural�factors�into�account

• be�transparent�and�inclusive

• facilitate�continual�improvement�of�the�organisation.

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seCtion 5Standards, criteria, elements and guidelinesstandard 2.1:�The�governing�body�leads�the�organisation�in�its�commitment�to�improving�performance�and�ensures�the�effective�management�of�corporate�and�clinical�risks

262  The ACHS EQuIP5 Guide  Book 2  Accreditation, Standards and Guidelines  Support and Corporate Functions

Criterion 2.1.2

Theintegratedorganisation-wideriskmanagementframeworkensuresthatcorporateandclinicalrisksareidentified,minimisedandmanaged.�(continued)

Risk�management�systems�aim�to�support:

• achievement�of�the�organisation’s�strategic�goals

• protection�of�organisational�assets�(financial�and�physical)

• protection�of�human,�and�intangible,�resources�and�property

• prevention�of�injury�to�consumers�/�patients,�employees,�volunteers�and�visitors

• reduction�or�mitigation�of�loss.

Within�the�health�system,�an�integrated�strategy�will�include�the�management�of�both�corporate�and�clinical�risk;�not�only�consumer�/�patient-�and�staff-related�clinical�risk,�but�also�financial,�human�resources,�occupational�health�and�safety,�environmental�and�asset-related�risk.�All�such�risks�must�be�identified�and�integrated�with�the�quality�improvement�system.�

Corporate�risk�management�strategies�may�include:

• audit�processes

• human�resources�planning

• political�risk�management

• implementation�of�financial�management�systems

• fraud�minimisation�schemes

• occupational�health�and�safety�strategies

• effective�use�of�feedback�from�consumers�/�patients�and�staff

• staff�education�and�training�programs

• recruitment�and�retention�strategies

• staff�performance�review�and�development.

Clinical�risk�management�strategies�may�include:

• clinical�audit�processes

• superior�review,�peer�review�and�peer�supervision

• credentialling�and�defining�the�scope�of�clinical�practice�for�all�clinicians�(discussed�within�criterion�3.1.3)

• implementation�of�an�incident�management�system�that�includes�management�of�adverse�and�sentinel�events�(discussed�within�criterion�2.1.3)

• retrospective�consumer�/�patient�health�record�reviews

• effective�use�of�clinical�indicators

• mortality�and�morbidity�reviews

• performance�review�and�professional�development.

No�one�strategy�is�ideal�for�managing�all�risks.�In�order�to�be�effective,�organisations�should�undertake�to�implement�a�‘suite’�of�the�above-mentioned�risk�management�strategies�in�accordance�with�the�size�of�the�organisation�and�the�scope�of�the�services�provided.�As�part�of�this�process,�organisations�should�establish�policy�/�guidelines�and�a�system�that:

• identifies

• analyses

• evaluates

• treats

• continuously�monitors�and�reviews

• communicates

...�all�corporate�and�clinical�risks�that�occur,�or�that�have�the�potential�to�occur,�in�a�healthcare�organisation,�as�well�as�delineating�the�specific�strategies�for�managing�these�risks.

A�governing�body-endorsed�policy�/�guideline�should�be�implemented�that�confirms�the�organisation’s�commitment�to�the�management�of�risk,�defines�its�risk�management�framework,�and�describes�its�principles,�processes�and�specific�strategies�for�achieving�its�objectives,�and�the�responsibility�of�all�staff�for�their�implementation.�This�policy�/�guideline�must�be�made�available�to�all�clinicians,�managers�and�other�staff.

Prompt points

¼ How often is the organisation’s risk management framework evaluated and, if necessary, improved? What prompts this re-evaluation?

¼ What processes does the organisation use to consult with its stakeholders about the management of risk?

¼ How is the organisation’s risk management policy / guideline made available to staff?

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October 2010  263

Staff responsibility and involvement in risk managementAll�staff�at�all�levels�have�a�role�to�play�in�the�organisation’s�management�of�risk.�This�accountability�should�be�made�explicit�within�position�descriptions5,�and�discussed�during�performance�reviews.6�Staff�should�be�informed�during�orientation�of�the�organisation’s�processes�for�risk�management,�and�further�educated�according�to�their�role�within�the�organisation�as�to�their�specific�responsibility�for�identifying,�evaluating�and/or�mitigating�risk,�and�the�steps�by�which�any�individual�can�initiate�action�in�order�to�prevent�and/or�reduce�the�impact�of�risks.�It�should�be�emphasised�that�staff�responsibility�extends�to�all�categories�of�risk,�not�clinical�risk�alone.�The�integration�between�quality�and�risk�should�be�made�evident,�with�discussion�of�matters�that�were�initially�raised�as�risk�issues,�but�which�through�proper�management�led�to�improvement�activities�or�to�enhanced�consumer�/�patient�outcomes.�Evaluation�of�the�effectiveness�of�orientation�and�education�programs�should�be�undertaken�to�ensure�that�staff�understand�the�risk�management�framework�and�their�position�within�it,�and�improvements�made�as�required.�The�organisation�should�strive�to�create�a�culture�wherein�active�involvement�of�staff�in�the�risk�management�process�is�encouraged�and�supported.

Clinician�engagement�is�critical�to�the�effective�management�of�clinical�risk.�Involvement�of�clinicians�in�risk�management�programs�should�be�considered�during�credentialling�and�defining�the�scope�of�clinical�practice.�Other�forums�for�clinician�participation,�according�to�the�size�and�scope�of�the�organisation,�may�be�Medical�Advisory�Committees�(MAC)�or�specialist�groups.�Data�from�risk�management�processes�should�be�provided�to�all�relevant�staff,�and�used�as�the�basis�for�improvements�to�care�planning�and�services.

Prompt points

¼ How does the organisation inform and educate its staff about their responsibilities in risk management? How does it determine whether these processes are effective?

¼ What does the organisation do to encourage staff to participate in risk management?

¼ What resources does the organisation provide to facilitate clinician engagement in clinical risk management?

¼ How does the organisation distribute the data gathered from risk management processes? How does it determine to whom the data should be provided?

¼ How does the organisation ensure that necessary changes identified during the risk management process are implemented?

Risk management of new / altered servicesOne�of�the�most�important�aspects�of�an�organisation’s�risk�management�framework�is�the�assessment�of�a�proposed�new�or�modified�service,�for�example,�a�change�to�an�existing�procedure,�or�the�introduction�of�a�new�drug�or�diagnostic�test.7�The�implementation�of�new�or�modified�clinical�interventions�is�governed�at�a�State�/�Territory�level,�and�these�policies�take�a�risk�management�approach�to�the�process,�with�a�view�to�reducing�or�preventing�adverse�events.�The�process�by�which�an�assessment�of�a�new�intervention�is�made,�and�the�identity�of�those�responsible�for�carrying�it�out,�should�be�clearly�delineated�within�the�organisation’s�risk�management�policy�/�guideline;�it�will�also�comprise�an�aspect�of�the�organisation’s�policy�/�guideline�for�managing�credentialling�and�defining�the�scope�of�clinical�practice8,�as�discussed�within�criterion�3.1.3.�The�Royal�Australasian�College�of�Surgeons,�through�its�Research,�Audit�and�Academic�Surgery�Division,�has�issuedGeneralGuidelinesforAssessing,Approving&IntroducingNewSurgicalProceduresintoaHospitalorHealthService7,�which�where�appropriate�should�direct�the�organisation’s�risk�management�of�the�introduction�of�new�surgical�procedures.�The�risk�management�process�for�a�new�or�modified�service�should�consider�its�clinical�effectiveness�and�the�potential�advantages�to�the�consumer�/�patient;�any�known�risks�and�possible�management�strategies�for�them;�how�the�consumer�/�patient�will�be�informed�of�the�advantages�and�risks;�education�and�training�of�staff;�and�costs�and�cost�benefits.9�Upon�introduction,�the�service�must�be�carefully�monitored�and�reviewed,�and�the�gathered�data�used�to�evaluate�and�improve�or�eliminate�it.

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seCtion 5Standards, criteria, elements and guidelinesstandard 2.1:�The�governing�body�leads�the�organisation�in�its�commitment�to�improving�performance�and�ensures�the�effective�management�of�corporate�and�clinical�risks

264  The ACHS EQuIP5 Guide  Book 2  Accreditation, Standards and Guidelines  Support and Corporate Functions

Criterion 2.1.2

Theintegratedorganisation-wideriskmanagementframeworkensuresthatcorporateandclinicalrisksareidentified,minimisedandmanaged.�(continued)

Prompt points

¼ What policy / guidelines were consulted in the development of the organisation’s process for managing risk in the introduction of a new or modified service?

¼ How does the organisation assess the effectiveness and safety of a new or modified service?

Evidence commonly presented

Consider whether the following will help to address criterion 2.1.2

¼ Organisation-wide risk management policy / guideline and procedures, endorsed by the governing body, that guide staff in the management and prevention of corporate and clinical risks, and that links with the quality improvement system

¼ Strategic, operational and business plans that consider risks

¼ Minutes of governing body, Medical Advisory Committee, medical staff council and staff meetings where risk issues were reported and actioned

¼ Budget allocation for risk management

¼ Tools for identifying and analysing risks

¼ Quantitative and qualitative data on identified risks such as incidents, Root Cause Analysis findings, clinical outcomes, staff injuries and budget variances

¼ Reports of the data on risks and on the communication and distribution channels used to reach relevant staff

¼ Improvements resulting from the analyses of risks

¼ By-laws, appointment criteria and position descriptions that include risk management responsibilities

¼ Clinician engagement in clinical risk management as an aspect of credentialling and defining the scope of clinical practice

¼ Evaluation of clinician, management and staff understanding of the risk management system

¼ Evaluation of the risk management system – policy, risk identification, system for managing and preventing risks, communication of data on risks, use of data, high-risk, high-volume activities identified and improved, cost versus benefit

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October 2010  265

Performance measurementThis�criterion�states�that:�“The�integrated�organisation-wide�risk�management�framework�ensures�that�corporate�and�clinical�risks�are�identified,�minimised�and�managed”.�The�organisation�should�be�able�to�demonstrate�its�commitment�to�the�creation�of�a�culture�in�which�risk�management�is�recognised�as�the�responsibility�of�all�staff,�where�all�aspects�of�the�risk�management�system�are�regularly�evaluated�and�improved�where�necessary,�and�in�which�the�management�of�risk�is�an�aspect�of�the�organisation’s�continuous�quality�improvement�system.�

Some�common�suggested�performance�measures�are�as�follows:

Number�of�improvements�implemented�in�risk�priority�areas

Total number of potential improvements identified in risk priority areas

Comment:riskpriorityareastobedeterminedbytheorganisation;forexample,riskpriorityareascouldincludeseverityassessmentcode(SAC)1and2ratedrisks,orequivalent

Number�of�risk�management�goals�/�targets�met

Total number of risk management goals / targets

Number�of�clinical�indicators�that�are�better�than�the�national�peer�group�aggregate�rate

Total number of clinical indicators collected by the organisation

Number�of�new�interventions�and�treatments�introduced�into�the�organisation

Total number of new interventions and treatments subjected to risk assessment

Number�of�clinicians�actively�engaged�in�clinical�risk�management

Total number of clinicians

Number�of�reviewed�health�records�that�identified�a�preventable�adverse�event

Total number of health records reviewed

Number�of�internal�reviews�of�coroner�cases�/�findings�that�related�to�the�organisation

Total number of cases referred to the coroner

Comment:internalreviewiswheretheorganisationformallyreviewsfindingsrelatedtotheorganisationfromcasesthathavebeenreferredtothecoroner

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seCtion 5Standards, criteria, elements and guidelinesstandard 2.1:�The�governing�body�leads�the�organisation�in�its�commitment�to�improving�performance�and�ensures�the�effective�management�of�corporate�and�clinical�risks

266  The ACHS EQuIP5 Guide  Book 2  Accreditation, Standards and Guidelines  Support and Corporate Functions

Criterion 2.1.2

Theintegratedorganisation-wideriskmanagementframeworkensuresthatcorporateandclinicalrisksareidentified,minimisedandmanaged.�(continued)

References1.� AS/NZS�ISO�31000:2010�Riskmanagement–Principlesand

guidelines.

2.� Blackerby�Associates.Learnmoreaboutstrategicplanninginthenot-for-profitandgovernmentsector.�Phoenix�USA.�Accessed�from�http://www.blackerbyassoc.com/SPDefine.html�on�11�August�2010.

3.� Special�Libraries�Association.�Strategicplanninghandbook.�Alexandria�USA;�Special�Libraries�Assoc;�2009.

4.� Dahms�T.�Part�1:�Risk�management�and�corporate�governance:�are�they�the�same?�RiskMagazine2008�(23�January).�Accessed�from�http://www.riskmanagementmagazine.com.au�on�11�August�2010.

5.� Rural�Infection�Control�Practitioners�(RICPRAC).�Infectionpreventionandcontrolmanual:section10.1riskmanagement.�3rd�edn.�Melbourne;�Victorian�Dept�of�Health;�2008.

6.� Maddock�A.�Risk�management�in�practice:�ERM�in�health�care.�RiskMagazine�2006�(14�September).�Accessed�from�http://www.riskmanagementmagazine.com.au�on�11�August�2010.

7.� Royal�Australasian�College�of�Surgeons�(RACS)�and�ASERNIP-S.�Generalguidelinesforassessing,approving&introducingnewproceduresintoahospitalorhealthservice.Stepney�SA;�RACS;�2008.

8.� Australian�Council�for�Safety�and�Quality�in�Health�Care.�Standardforcredentiallinganddefiningscopeofclinicalpractice.Canberra�ACT;�Australian�Council�for�Safety�and�Quality�in�Health�Care;�2004.

9.� Sweeney�J�and�Cimoni�M.�Introducinganewprocedureusingaclinicalgovernanceframework:independentuseofnasendoscopytoassessandmanageswallowingandvoicedisorders.Austin�Health;�Melbourne�VIC;�2005.�Accessed�from�http://www.sapmea.asn.au/conventions/alliedhealth/presentations/Sweeney,%20Joanne%20ah145.ppt�on�12�August�2010.

GuidelinesStandards�Australia.�HB�254-2005:2005�Handbook:Governance,riskmanagementandcontrolassurance.

North�Coast�Area�Health�Service,�NSW�Health.�AnewdirectionfortheNorthCoast:Healthservicesstrategicplan.Towards2010.Lismore;�NSW�Health;�2007.

Further readingDahms�T.�Part�2:�Risk�management�and�corporate�governance:�are�they�the�same?�RiskMagazine2008�(14�February).�Accessed�from�http://www.riskmanagementmagazine.com.au�on�11�August�2010.

Langley�A.�What�does�it�mean�when�the�risk�assessment�says�4.73�x�10-5?�NSWPublicHealthBulletin�2003;�14(8):�166-167.

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seCtion 5Standards, criteria, elements and guidelinesstandard 2.1:�The�governing�body�leads�the�organisation�in�its�commitment�to�improving�performance�and�ensures�the�effective�management�of�corporate�and�clinical�risks

268  The ACHS EQuIP5 Guide  Book 2  Accreditation, Standards and Guidelines  Support and Corporate Functions

IntentThe�intent�of�this�criterion�is�to�ensure�that�organisations�have�in�place�effective�systems�for�the�management�of�healthcare�incidents�and�near�misses�as�and�when�they�occur,�so�that�their�causes�may�be�investigated�and�improvements�made�to�processes�and�cultures�in�order�to�prevent�recurrence.

Relationships of 2.1.3 with other criteriaManagement�of�healthcare�incidents�is�a�vital�component�of�the�provision�of�safe�care�and�services�(Standard�1.5)�and�of�the�organisation’s�commitment�to�quality�improvement�(Criterion�2.1.1).�The�organisation’s�risk�management�framework�must�include�processes�for�investigating�and�minimising�the�occurrence�of�incidents�(Criterion�2.1.2),�which�may�employ�an�Information�Technology�system�by�which�incident�data�can�be�recorded�and�analysed�(Criterion�2.3.3).�Failure�to�manage�incidents�correctly�may�lead�to�complaints�(Criterion�2.1.4).�The�management�of�incidents�is�an�aspect�of�the�rights�of�the�consumer�/�patient�(Criterion�1.6.2),�which�include�the�right�to�provide�feedback�and/or�to�lodge�a�formal�complaint,�and�to�have�the�issues�raised�thereby�investigated�and�resolved;�and�the�right�to�privacy�and�confidentiality�throughout�the�management�of�incidents.

Criterion LA – Awareness sA – implementationLA plus the following

MA – evaluationSA plus the following

eA – excellenceMA plus the following

oA – LeadershipEA plus the following

Criterion 2.1.3

Healthcareincidentsaremanagedtoensureimprovementstothesystemsofcare.

this is a mandatory criterion

a)� The�organisation�has�a�process�to�effectively�identify�and�manage�incidents�in�an�integrated�manner,�including�serious�incidents.

b)� The�organisation�is�aware�of�the�principles�for�open�disclosure.

c)� Incident�management�and�open�disclosure�policy�/�guidelines�exist�and�are�communicated�to�staff.

d)� Consumers�/�patients�are�provided�with�information�about�incident�management�processes.

a)� Incidents�are�systematically�managed�in�accordance�with�jurisdictional�policy�/�legislation�and�Australian�standards�including:

� (i)� identification

� (ii)� review

� (iii)� action�on�incidents

� (iv)� communication�

� (v)� �levels�of�responsibility�for�incident�management

� (vi)� �support�for�consumers�/�patients�and�staff�involved�in�incidents

� (vii)� �in-depth�investigations�for�serious�incidents�/�sentinel�events.

b)� Clinicians,�managers�and�staff�are�orientated�/�trained�in�incident�management�and�open�disclosure.

a)� The�incident�management�system�is�evaluated�and�improved�as�required.

b)� The�principles�of�open�disclosure�are�evident�in�the�system�to�manage�incidents.

c)� Incidents�are�trended,�risks�are�identified,�and�improvements�are�made�as�required.

d)� Improvement�strategies�are�evaluated,�communicated�and�implemented�across�the�organisation�to�ensure�the�organisation�is�providing�safe�practice�and�a�safe�environment.

e)� The�support�provided�for�consumers�/�patients�and�staff�involved�in�incidents�is�evaluated,�and�improved�as�required.

a)� The�incident�management�system�is�compared�with�external�systems,�and�improvements�are�made�to�ensure�better�practice.

and/or

b)� The�national�open�disclosure�standard�is�fully�implemented�and�evaluated,�and�improvements�are�made�as�required.�

and/or

c)� Incident�data�is�compared�internally�and�externally�and�improvements�are�made�to�ensure�better�practice.

and/or

d)� Lessons�learned�from�investigations�of�incidents�/�sentinel�events�are�provided�to�other�healthcare�organisations.

and/or

e)� The�organisation�undertakes�research�into�incident�management�and�acts�on�the�results.

a)� The�organisation�demonstrates�it�is�a�leader�in�incident�management�systems�and�processes.

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October 2010  269

Management of incidentsA�degree�of�risk�is�an�inherent�component�of�the�provision�of�healthcare,�and�organisations�must�recognise�and�admit�this�while�striving�at�all�times�to�reduce�that�risk.1�The�right�of�the�consumer�/�patient�to�safe,�high�quality�health�care�is�fundamental,�and�a�vital�aspect�of�the�provision�of�safe�services�is�the�management�of�incidents.�Incidents,�including�near�misses,�must�be�identified,�reported�and�investigated,�and�all�appropriate�steps�taken�in�order�to�prevent�their�recurrence.�The�processes�for�the�management�of�clinical�incidents�are�mandated�at�a�State�/�Territory�level,�and�it�is�the�responsibility�of�the�organisation�to�ensure�that�its�systems�meet�the�requirements�of�the�relevant�legislation�and�Australian�standards.

An�incident�is�an�event�or�circumstance�that�results�in,�or�could�have�resulted�in,�unintended�or�unnecessary�harm�to�a�person�and/or�a�complaint,�loss�or�damage,�while�a�near�miss�is�an�incident�that�did�not�cause�harm,�loss�or�damage,�but�had�the�potential�to�do�so.2

An�integrated�incident�management�system�must�have�the�capacity�to�record,�examine�and�respond�to�a�diverse�range�of�real�and�potential�outcomes.�Incident�management�itself�is�a�multistep�process,�involving:

• identification�of�incidents,�including�near�misses

• notification�of�identified�incidents�via�the�organisation’s�reporting�system

• prioritisation,�to�ensure�that�a�standardised,�objective�measure�of�severity�is�allocated�to�each�incident

Criterion LA – Awareness sA – implementationLA plus the following

MA – evaluationSA plus the following

eA – excellenceMA plus the following

oA – LeadershipEA plus the following

Criterion 2.1.3

Healthcareincidentsaremanagedtoensureimprovementstothesystemsofcare.

this is a mandatory criterion

a)� The�organisation�has�a�process�to�effectively�identify�and�manage�incidents�in�an�integrated�manner,�including�serious�incidents.

b)� The�organisation�is�aware�of�the�principles�for�open�disclosure.

c)� Incident�management�and�open�disclosure�policy�/�guidelines�exist�and�are�communicated�to�staff.

d)� Consumers�/�patients�are�provided�with�information�about�incident�management�processes.

a)� Incidents�are�systematically�managed�in�accordance�with�jurisdictional�policy�/�legislation�and�Australian�standards�including:

� (i)� identification

� (ii)� review

� (iii)� action�on�incidents

� (iv)� communication�

� (v)� �levels�of�responsibility�for�incident�management

� (vi)� �support�for�consumers�/�patients�and�staff�involved�in�incidents

� (vii)� �in-depth�investigations�for�serious�incidents�/�sentinel�events.

b)� Clinicians,�managers�and�staff�are�orientated�/�trained�in�incident�management�and�open�disclosure.

a)� The�incident�management�system�is�evaluated�and�improved�as�required.

b)� The�principles�of�open�disclosure�are�evident�in�the�system�to�manage�incidents.

c)� Incidents�are�trended,�risks�are�identified,�and�improvements�are�made�as�required.

d)� Improvement�strategies�are�evaluated,�communicated�and�implemented�across�the�organisation�to�ensure�the�organisation�is�providing�safe�practice�and�a�safe�environment.

e)� The�support�provided�for�consumers�/�patients�and�staff�involved�in�incidents�is�evaluated,�and�improved�as�required.

a)� The�incident�management�system�is�compared�with�external�systems,�and�improvements�are�made�to�ensure�better�practice.

and/or

b)� The�national�open�disclosure�standard�is�fully�implemented�and�evaluated,�and�improvements�are�made�as�required.�

and/or

c)� Incident�data�is�compared�internally�and�externally�and�improvements�are�made�to�ensure�better�practice.

and/or

d)� Lessons�learned�from�investigations�of�incidents�/�sentinel�events�are�provided�to�other�healthcare�organisations.

and/or

e)� The�organisation�undertakes�research�into�incident�management�and�acts�on�the�results.

a)� The�organisation�demonstrates�it�is�a�leader�in�incident�management�systems�and�processes.

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seCtion 5Standards, criteria, elements and guidelinesstandard 2.1:�The�governing�body�leads�the�organisation�in�its�commitment�to�improving�performance�and�ensures�the�effective�management�of�corporate�and�clinical�risks

270  The ACHS EQuIP5 Guide  Book 2  Accreditation, Standards and Guidelines  Support and Corporate Functions

Criterion 2.1.3

Healthcareincidentsaremanagedtoensureimprovementstothesystemsofcare.(continued)

• investigation�by�the�designated�internal�and,�where�appropriate,�external�authorities

• classification,�which�is�defined�as�the�process�of�capturing�relevant�information�to�ensure�that�the�nature�of�the�incident�is�completely�documented�and�understood

• analysisandaction,to�understand�how�and�why�the�incident�occurred,�and�to�identify�ways�of�preventing�a�recurrence

• feedback,�which�should�include�the�changes�made,�and�the�improvements�achieved�as�a�result�of�the�changes.

Prompt points

¼ What legislation and policies did the organisation draw upon in shaping its incident management policy?

¼ What system of incident reporting does the organisation use?

¼ How does the organisation actively promote incident reporting by staff? How is feedback provided to staff?

¼ Within the organisation, who is responsible for incident investigation?

¼ What changes have been made to the organisation’s systems and processes as a result of incident investigation?

¼ Who is responsible for evaluating the organisation’s system of incident management? How often does this happen? Have any changes been made to the system as a result of this evaluation?

¼ How does the organisation communicate the outcomes of incident investigation to staff? How does it ensure that this communication is effective?

Sentinel events and open disclosureNot�all�incidents�that�occur�during�health�care�cause�harm,�or�could�have�caused�harm,�to�the�consumer�/�patient�involved.�Incidents�that�do�are�known�as�adverse�events.�A�sentinel�event�is�a�rare�but�extremely�serious�form�of�adverse�event,�wherein�the�process�of�health�care�itself�is�unexpectedly�and�unintentionally�responsible�for�harm�to,�or�the�death�of,�a�consumer�/�patient.�In�2003,�the�former�Australian�Council�for�Safety�and�Quality�in�Health�Care,�in�collaboration�with�jurisdictional�authorities,�developed�a�national�list�of�core�sentinel�events3,�which�now�forms�the�basis�of�mandatory�sentinel�event�reporting�by�jurisdictions.�The�national�list�is�as�follows:

1.� Procedures�involving�the�wrong�patient�or�body�part

2.� Suicide�of�a�patient�in�an�in-patient�unit

3.� Retained�instruments�or�other�material�after�surgery�requiring�re-operation�or�further�surgical�procedure

4.� Intravascular�gas�embolism�resulting�in�death�or�neurological�damage

5.� Haemolytic�blood�transfusion�reaction�resulting�from�ABO�incompatibility

6.� Medication�error�leading�to�the�death�of�a�patient�reasonably�believed�to�be�due�to�incorrect�administration�of�drugs

7.� Maternal�death�or�serious�morbidity�associated�with�labour�or�delivery

8.� Infant�discharged�to�the�wrong�family

Some�jurisdictions�have�added�further�categories�to�the�list.�For�example,�the�2008–2009�Sentinel�Event�Report�from�Western�Australia�indicated�that�the�majority�of�sentinel�events�reported�during�that�period�fell�into�the�additional�“other�adverse�event”�category.4

Open�disclosure�is�the�frank�and�transparent�discussion�of�incidents�that�result�in�harm�to�a�consumer�/�patient�while�receiving�health�care.�In�2003,�the�former�ACSQHC�published�theOpenDisclosureStandard:anationalstandardforopencommunicationinpublicandprivatehospitals,followinganadverseeventinhealthcare.1�The�principles�of�open�disclosure�are:

1.� Openness�and�timeliness�of�communication

2.� Acknowledgement�of�the�event

3.� An�expression�of�regret

4.� Recognition�of�the�reasonable�expectations�of�patients�and�their�support�persons

5.� Staff�support

6.� Integrated�risk�management�and�systems�improvement

7.� Good�governance

8.� Confidentiality

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October 2010  271

Consumers�/�patients�should�be�informed�about�the�organisation’s�incident�management�processes,�as�well�as�be�notified�about�how�to�contact�support�personnel�such�as�advocates�or�translators.�The�provision�of�feedback�and/or�the�lodging�of�a�formal�complaint�is�one�of�the�consumer�/�patient’s�fundamental�healthcare�rights.�Complaints�investigation�is�an�important�aspect�of�an�integrated�risk�management�system,�as�consumer�/�patient�complaints�provide�an�alternative�viewpoint�on�the�circumstances�under�which�a�particular�incident�occurred,�and�can�also�serve�as�a�‘flag’�for�unreported�incidents.�

The�provision�of�feedback�to�consumers�/�patients�involved�in�an�incident�should�be�timely,�and�updates�should�be�given�throughout�the�investigation,�rather�than�a�final�‘report’�at�the�conclusion�of�what�may�be�a�lengthy�process.�There�should�also�be�reassurance�that�the�consumer�/�patient’s�right�to�privacy�and�the�confidentiality�of�the�health�record�will�be�respected�throughout�the�investigative�process.�If�the�consumer�/�patient’s�care�plan�changes�as�the�result�of�an�adverse�event,�the�new�plan�should�be�developed�in�consultation�with�the�consumer�/�patient�and,�where�appropriate,�his�or�her�carer.

To�be�successful,�the�organisation’s�management�of�open�disclosure�must�also�include�the�provision�of�all�necessary�staff�support,�including�professional�counselling.�Involvement�in�an�adverse�event�can�be�devastating�for�healthcare�providers,�and�organisations�should�work�towards�creating�a�system�that,�while�ensuring�appropriate�accountability,�is�non-punitive,�and�where�the�goal�is�not�the�assignment�of�blame�but�the�improvement�of�processes.�

Prompt points

¼ How are the principles of open disclosure evident in the organisation’s system of incident management?

¼ How does the organisation educate and train staff in the principles and practices of open disclosure? How often are these programs evaluated?

¼ How are adverse events investigated within the organisation? Who is involved in the investigation?

¼ How are consumers / patients provided with information about incident management and complaints?

¼ What support services does the organisation provide for staff involved in an adverse event?

¼ How does the organisation ensure that the support services it provides for consumers / patients and staff involved in an adverse event are appropriate? Who is responsible for evaluating these services? What improvements have been made to these services as a result of their evaluation? – and if none, why not?

Evidence commonly presented

Consider whether the following will help to address criterion 2.1.3

¼ Incident management systems

¼ Policies and procedures, including:

– incidents – open disclosure – how incident management is addressed

during orientation ¼ Participation in programs such as the Australian

Incident Monitoring System (AIMS) or the Incident Information Management System (IIMS)

¼ Evidence of the integration of complaints and feedback in the incident management system

¼ Evidence of staff education and training in incident management and incident reporting

¼ Evidence of staff training in the principles and practice of open disclosure

¼ Evidence of feedback sought from consumers / patients and staff regarding open disclosure support services

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seCtion 5Standards, criteria, elements and guidelinesstandard 2.1:�The�governing�body�leads�the�organisation�in�its�commitment�to�improving�performance�and�ensures�the�effective�management�of�corporate�and�clinical�risks

272  The ACHS EQuIP5 Guide  Book 2  Accreditation, Standards and Guidelines  Support and Corporate Functions

Criterion 2.1.3

Healthcareincidentsaremanagedtoensureimprovementstothesystemsofcare.(continued)

Performance measurementThis�criterion�states�that:�“Healthcare�incidents�are�managed�to�ensure�improvements�to�the�systems�of�care”.�Effective�processes�for�investigating�incidents�and�for�making�improvements�to�the�organisation’s�systems�and�processes�as�a�result�are�vital�to�the�provision�of�safe,�high�quality�health�care.�The�organisation�should�be�able�to�demonstrate�that�it�works�to�create�a�culture�in�which�staff�are�encouraged�to�report�incidents,�and�where�incident�reporting�provides�the�basis�for�improvement�of�services�and�processes.

Some�common�suggested�performance�measures�are�as�follows:

Number�of�near�misses�reported

Total number of incidents reported

Number�of�incident�investigations�instigated�by�a�complaint�from�a�consumer�/�patient

Total number of incidents reported

Number�of�incidents�reported�at�each�designated�level�of�severity

Total number of incidents reported

Comment:treateachSACorequivalentasaseparatenumerator

Number�of�sentinel�events�for�which�a�Root�Cause�Analysis�has�been�completed

Total number of sentinel events

Number�of�Root�Cause�Analyses�completed�within�the�required�timeframe

Total number of Root Cause Analyses

Number�of�Root�Cause�Analysis�recommendations�implemented

Total number of Root Cause Analysis recommendations

Number�of�improvements�implemented�from�Root�Cause�Analysis�investigations�that�have�been�sustained�12�months�post-implementation

Total number of improvements from Root Cause Analysis investigations 12 months or more ago

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October 2010  273

References1.� Australian�Council�for�Safety�and�Quality�in�Health�Care.�

Opendisclosurestandard:anationalstandardforopencommunicationinpublicandprivatehospitals,followinganadverseeventinhealthcare.Canberra�ACT;�Australian�Council�for�Safety�and�Quality�in�Health�Care;�2003.

2.� Runciman�WB.�Shared�meanings:�preferred�terms�and�definitions�for�safety�and�quality�concepts.�MedJAust2006;�184(10�Suppl):�S41-S43.

3.� Australian�Council�for�Safety�and�Quality�in�Health�Care.�Factsheet:sentinelevents.Canberra�ACT;�Australian�Council�for�Safety�and�Quality�in�Health�Care;�2005.

4.� WA�Department�of�Health.�DeliveringsaferhealthcareinWesternAustralia:WAsentineleventreport2008–2009.Perth;�WA�Dept�of�Health;�2009.

GuidelinesAS/NZS�ISO�31000:2010�Riskmanagement–Principlesandguidelines.

Taylor-Adams�S�and�Vincent�C.�Systems�analysis�of�clinical�incidents:�The�London�protocol.ClinRisk�2004;�10(6):�211-220.

Committee�on�the�Financial�Aspects�of�Corporate�Governance�and�Gee�and�Co�Ltd.�Financialaspectsofcorporategovernance.�London�UK;�Committee�on�the�Financial�Aspects�of�Corporate�Governance;�1992.

NSW�Health.�Easyguidetoclinicalincidentmanagement.Sydney;�NSW�Health.�Accessed�from�http://www.health.nsw.gov.au/quality/incidentmgt/onlineguide/�on�19�August�2010.

NSW�Health.Easyguidetoclinicalpracticeimprovement–aguideforhealthcareprofessionals.�Sydney;�NSW�Health;�2002.

Further readingAustralian�Commission�on�Safety�and�Quality�in�Health�Care�(ACSQHC).�Windowsintosafetyandqualityinhealthcare2009.�Sydney�NSW;�ACSQHC;�2009.

Australian�Commission�on�Safety�and�Quality�in�Health�Care.�Windowsintosafetyandqualityinhealthcare2008.�Sydney�NSW;�ACSQHC;�2008.

NSW�Health�and�Clinical�Excellence�Commission�(CEC).�IncidentmanagementintheNSWpublichealthsystem–looking,learning,acting.July–December2008.Sydney�NSW;�CEC;�2009.

NSW�Health�and�Clinical�Excellence�Commission�(CEC).�Statewideimplementationofopendisclosure:Becauseit’stherightthingtodo.Sydney�NSW;�CEC.�Accessed�from�http://www.health.nsw.gov.au/resources/quality/opendisc/pdf/swide_implementation.pdf�on�19�August�2010.

Victorian�Rural�and�Regional�Health�and�Aged�Care�Services�Division.�Sentineleventprogram.Annualreport2007–08:Buildingfoundationstosupportpatientsafety.Melbourne;�Victorian�Dept�of�Human�Services�(DHS);�2008.

Hughes�C�and�Mackay�P.�Sea�change:�public�reporting�and�the�safety�and�quality�of�the�Australian�health�care�system.��MedJAust�2006;�184(10):�S44-S47.

Wilson�RM�and�van�der�Weyden�MB.�The�safety�of�Australian�healthcare:�10�years�after�QAHCS.MedJAust�2005;�182(6):�260-261.

Rosenthal�M.�Editorial:�The�role�of�information�in�reducing�medical�error.�MedJAust�2004;�181(1):�27-28.

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seCtion 5Standards, criteria, elements and guidelinesstandard 2.1:�The�governing�body�leads�the�organisation�in�its�commitment�to�improving�performance�and�ensures�the�effective�management�of�corporate�and�clinical�risks

274  The ACHS EQuIP5 Guide  Book 2  Accreditation, Standards and Guidelines  Support and Corporate Functions

Criterion LA – Awareness sA – implementationLA plus the following

MA – evaluationSA plus the following

eA – excellenceMA plus the following

oA – LeadershipEA plus the following

Criterion 2.1.4

Healthcare�complaints�and�feedback�are�managed�to�ensure�improvements�to�the�systems�of�care.

a)� The�organisation�has�a�process�for�managing�complaints�and�feedback,�that�is�communicated�to�staff.

b)� The�organisation�has�a�process�for�risk�rating�complaints.

c)� Consumers�/�patients�and�carers�are�informed�of�the�process�for�making�a�complaint�and�providing�feedback.

a)� Complaints�and�feedback�are�managed�in�accordance�with�jurisdictional�policy/�legislation�and�Australian�standards.

b)� The�complaint�management�system�includes:�

� (i)� �registration�of�the�complaint

� (ii)� �review,�including�formal�review�of�serious�complaints�

� (iii)� �response�in�a�timely�manner�

� (iv)� �support�and/or�advocacy�for�consumers�/�patients,�carers�and�staff�involved�in�complaints

� (v)� �communication�of�outcomes.

c)� Clinicians,�managers�and�staff�are�orientated�/�trained�in�complaint�management�and�open�disclosure.

d)� Staff�are�trained�in�relevant�methods�of�conflict�and�complaint�resolution.

e)� Feedback�about�care�and�service�is�communicated�to�staff,�consumers�/�patients�and�management.�

f)� There�is�a�system�to�implement�the�recommendations�from�reviews�of�serious�complaints.

a)� The�principles�of�open�disclosure�of�an�adverse�event�are�evident�in�the�system�to�manage�complaints.

b)� Consumers�/�patients�and�carers�are�involved�in�the�evaluation�of�the�complaint�management�process.

c)� Complaints�are�trended,�risks�are�identified,�and�improvements�are�made�as�required.

d)� The�support�and�access�to�advocacy�provided�for�consumers�/�patients,�carers�and�staff�involved�in�complaints�is�evaluated,�and�improved�as�required.

a)� The�complaint�and�feedback�management�system�is�compared�with�external�systems�and�improvements�are�made�to�ensure�better�practice.

and/or

b)� Complaint�data�are�compared�internally�and�externally,�and�improvements�are�made�to�ensure�better�practice.

and/or

c)� The�organisation�undertakes�research�into�complaint�management�and�acts�on�the�results.

a)� The�organisation�demonstrates�it�is�a�leader�in�complaints�and�feedback�management.

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October 2010  275

Criterion LA – Awareness sA – implementationLA plus the following

MA – evaluationSA plus the following

eA – excellenceMA plus the following

oA – LeadershipEA plus the following

Criterion 2.1.4

Healthcare�complaints�and�feedback�are�managed�to�ensure�improvements�to�the�systems�of�care.

a)� The�organisation�has�a�process�for�managing�complaints�and�feedback,�that�is�communicated�to�staff.

b)� The�organisation�has�a�process�for�risk�rating�complaints.

c)� Consumers�/�patients�and�carers�are�informed�of�the�process�for�making�a�complaint�and�providing�feedback.

a)� Complaints�and�feedback�are�managed�in�accordance�with�jurisdictional�policy/�legislation�and�Australian�standards.

b)� The�complaint�management�system�includes:�

� (i)� �registration�of�the�complaint

� (ii)� �review,�including�formal�review�of�serious�complaints�

� (iii)� �response�in�a�timely�manner�

� (iv)� �support�and/or�advocacy�for�consumers�/�patients,�carers�and�staff�involved�in�complaints

� (v)� �communication�of�outcomes.

c)� Clinicians,�managers�and�staff�are�orientated�/�trained�in�complaint�management�and�open�disclosure.

d)� Staff�are�trained�in�relevant�methods�of�conflict�and�complaint�resolution.

e)� Feedback�about�care�and�service�is�communicated�to�staff,�consumers�/�patients�and�management.�

f)� There�is�a�system�to�implement�the�recommendations�from�reviews�of�serious�complaints.

a)� The�principles�of�open�disclosure�of�an�adverse�event�are�evident�in�the�system�to�manage�complaints.

b)� Consumers�/�patients�and�carers�are�involved�in�the�evaluation�of�the�complaint�management�process.

c)� Complaints�are�trended,�risks�are�identified,�and�improvements�are�made�as�required.

d)� The�support�and�access�to�advocacy�provided�for�consumers�/�patients,�carers�and�staff�involved�in�complaints�is�evaluated,�and�improved�as�required.

a)� The�complaint�and�feedback�management�system�is�compared�with�external�systems�and�improvements�are�made�to�ensure�better�practice.

and/or

b)� Complaint�data�are�compared�internally�and�externally,�and�improvements�are�made�to�ensure�better�practice.

and/or

c)� The�organisation�undertakes�research�into�complaint�management�and�acts�on�the�results.

a)� The�organisation�demonstrates�it�is�a�leader�in�complaints�and�feedback�management.

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seCtion 5Standards, criteria, elements and guidelinesstandard 2.1:�The�governing�body�leads�the�organisation�in�its�commitment�to�improving�performance�and�ensures�the�effective�management�of�corporate�and�clinical�risks

276  The ACHS EQuIP5 Guide  Book 2  Accreditation, Standards and Guidelines  Support and Corporate Functions

Criterion 2.1.4

Healthcare�complaints�and�feedback�are�managed�to�ensure�improvements�to�the�systems�of�care.�(continued)

IntentFeedback�and�complaints�from�consumers�/�patients�provide�vital�data,�both�positive�and�negative,�about�the�organisation’s�systems�and�processes�and�its�provision�of�services.�The�intent�of�this�criterion�is�to�ensure�that�the�organisation�has�in�place�effective�systems�for�managing�consumer�/�patient�feedback�and�complaints,�so�that�the�information�provided�will�drive�meaningful�and�necessary�quality�improvement,�while�also�identifying�what�the�organisation�and�its�staff�does�well.

Relationships of 2.1.4 with other criteriaEffective�management�of�healthcare�complaints�and�feedback�is�an�important�aspect�of�the�organisation’s�provision�of�safe�care�and�services�(Standard�1.5)�and�of�its�commitment�to�quality�improvement�(Criterion�2.1.1).�Consumers�/�patients�are�encouraged�to�participate�actively�in�the�planning,�delivery�and�evaluation�of�health�care�(Criterion�1.6.1),�and�an�aspect�of�this�is�the�consumer�/�patient’s�right�to�provide�feedback�or�to�lodge�a�complaint�about�their�health�care,�and�to�have�appropriate�action�taken,�along�with�the�right�to�advocacy�services�and/or�other�support�if�desired�(1.6.2).�

The�process�of�consumer�/�patient�complaints�lodging�and�investigation�should�be�tied�into�the�system�of�incident�management�(Criterion�2.1.3)�within�the�organisation’s�integrated�risk�management�framework�(Criterion�2.1.2).�A�complaint�involving�an�adverse�event�should�be�managed�according�to�the�organisation’s�policy�/�guidelines�on�open�disclosure�(Criterion�2.1.3),�while�a�complaint�lodged�by�either�a�consumer�/�patient�or�another�staff�member�against�a�clinician�may�require�formal�investigation�by�the�relevant�professional�body�(Criterion�2.2.3),�and�impact�upon�credentialling�and�scope�of�practice�(Criterion�3.1.3).�The�organisation�will�have�policy�and�procedures�for�managing�staff�grievances�(Criterion�2.2.5).

Complaints managementA�complaint�is�an�expression�of�dissatisfaction�made�to�an�organisation,�related�to�its�products,�services�or�staff,�or�to�the�complaints-handling�process�itself,�where�a�response�or�resolution�is�explicitly�or�implicitly�expected.1�A�compliment�is�an�expression�or�implication�of�praise�or�satisfaction.2,�3�

In�2004,�the�former�Australian�Council�for�Safety�and�Quality�in�Health�Care�released�the�Better�PracticeGuidelinesonComplaintsManagementforHealthCareServices4,�with�the�stated�aims�of:

• improving�the�responsiveness�of�the�health�system�to�the�needs�and�concerns�of�consumers�/�patients

• placing�consumers�/�patients�at�the�centre�of�the�system�and�harnessing�their�experiences�to�drive�improvements

• helping�healthcare�professionals�to�understand�potential�problems�and�how�to�improve�their�service�to�the�public

• restoring�the�trust�of�consumers�/�patients�and�reducing�the�risk�of�litigation,�through�open�communication�and�a�commitment�to�learn�from�problems�and�prevent�their�recurrence

• promoting�better�complaints�management�practice�by�healthcare�services�and�improving�the�links�between�complaints�management�and�safety�and�quality�improvement.

The�provision�of�feedback�by�consumers�/�patients,�their�families�and/or�carers�can�offer�a�unique�perspective�on�consumer�and�community�needs5,�and�draw�attention�to�both�successes�and�flaws�in�the�systems,�processes�and�services�operating�within�organisations.�Valid�complaints,�properly�managed,�should�lead�to�the�consumer-driven�improvement�of�those�systems,�processes�and�services;�while�positive�feedback�and�compliments�provide�an�opportunity�to�highlight�the�achievements�of�the�organisation’s�operation�and,�in�particular,�its�staff.�

The�management�of�a�complaint�is�a�multistep�process.6�A�complaint�is:

• received�from�a�complainant�either�verbally,�in�writing�or�online

• registered�and�acknowledged,�a�formal�process�that�includes�the�complaint�being�entered�into�the�organisation’s�incident�management�system,�and�the�complainant�being�informed�that�this�has�been�done

• assessed,�an�initial�judgement�of�the�severity�of�the�incident

• investigated�by�the�relevant�internal�and/or�external�authorities

• analysed�and�reviewed�to�determine�the�appropriate�course�of�action

• responded�to,�with�the�recommendations�of�the�investigators�being�acted�upon

• resolved,�in�which,�in�the�event�of�a�valid�complaint,�formal�acknowledgement�is�made�to�the�complainant,�and�all�documentation�finalised.

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October 2010  277

Many�complaints�are�received�by�staff�in�a�spontaneous,�verbal�manner,�and�the�appropriate�response�may�include�an�acknowledgement�of�the�complainant’s�concern,�an�explanation�if�the�staff�member(s)�can�give�it,�a�note�of�the�complaint�made�in�the�health�record�of�the�consumer�/�patient�concerned,�facilitation�of�a�discussion�between�the�complainant�and�the�relevant�clinician(s),�an�apology�if�warranted,�and�the�provision�of�information�as�to�how�the�complaint�can�be�formally�lodged,�should�the�complainant�wish�to�proceed.�

There�should�be�a�single,�publicly�recognisable�point�of�contact�within�the�organisation�for�the�receipt�and�management�of�complaints,�and�the�name,�address,�telephone�number�and�website�details�of�the�designated�office�and/or�individual(s)�in�charge�of�the�process�should�be�provided�to�consumers�/�patients�and�their�carers.�The�size�and�nature�of�the�organisation�will�determine�the�number�and�identity�of�those�with�the�authority�to�assess�and�investigate�complaints;�larger�facilities�commonly�employ�professional�complaints�investigators.�

Prompt points

¼ What legislation and policies did the organisation draw upon in shaping its complaint management policy?

¼ How is the complaints management system tied into the organisation’s process for incident management? How are the principles of open disclosure evident within the system?

¼ Within the organisation, who is responsible for receiving complaints? – entering complaints into the incident management system? – investigating complaints?

¼ How does the organisation ensure that recommendations from the investigation of a complaint are implemented?

¼ What changes have been made to the organisation’s systems and processes as a result of complaints investigation?

¼ Who is responsible for evaluating the organisation’s system of complaints management? How often does this happen? Have any changes been made to the system as a result of this evaluation?

¼ How does the organisation communicate the outcomes of complaints investigation to staff? How does it ensure that this communication is effective?

Staff education, training and supportAlthough�the�organisation�will�have�in�place�processes�for�the�lodging�of�a�complaint,�and�designated�staff�to�receive,�report�and�investigate�complaints,�a�complaint�can�be�received�at�any�moment�by�anyone.�It�is�therefore�vital�that�the�organisation�educate�and�train�its�staff�in�the�appropriate�behaviour�and�responses.�With�the�right�approach,�many�complaints�may�be�resolved�without�the�need�for�formal�investigation.

Staff�should�be�made�aware�of�the�organisation’s�processes�for�complaints�management�at�orientation,�and�subsequently�at�regular�education�sessions.�‘Frontline’�staff,�who�are�in�direct�contact�with�consumers�/�patients,�their�families�and/or�their�carers,�are�most�likely�to�receive�a�spontaneous�complaint,�and�should�receive�formal�training�not�only�in�the�correct�procedure�for�reporting�a�complaint,�but�in�conflict�and�complaint�resolution.�Appropriate�training�courses�are�offered�by�the�various�State�/�Territory�health�departments.�Standards�Australia�also�offers�a�good�practice�guide�called�TheHowAndWhyOfComplaintsHandling7,�which�is�intended�to�assist�those�involved�in�complaints�handling,�and�should�be�referred�to�when�organisations�are�developing�or�reviewing�complaints�management�systems�and/or�training�programs.�

Prompt points

¼ What information about complaints management is provided to staff during orientation? How often are ‘refresher’ sessions in this information provided?

¼ What training does the organisation provide or facilitate to assist staff in the handling of complaints? For what staff is this training offered?

¼ How does the organisation provide feedback to staff concerning the outcomes of complaints investigation?

¼ What support services are available to staff affected by a complaint?

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seCtion 5Standards, criteria, elements and guidelinesstandard 2.1:�The�governing�body�leads�the�organisation�in�its�commitment�to�improving�performance�and�ensures�the�effective�management�of�corporate�and�clinical�risks

278  The ACHS EQuIP5 Guide  Book 2  Accreditation, Standards and Guidelines  Support and Corporate Functions

Criterion 2.1.4

Healthcare�complaints�and�feedback�are�managed�to�ensure�improvements�to�the�systems�of�care.�(continued)

Consumer awareness and supportThe�right�to�comment�about�any�aspect�of�their�experience�while�receiving�health�care�is�guaranteed�to�consumers�/�patients�under�the�Australian�Charter�Of�Healthcare�Rights8,�which�supports�the�view�that�all�participants�in�the�healthcare�system�benefit�from�processes�that�encourage�feedback�about�the�services�received�by�consumers�/�patients,�and�which�ensure�that�any�concerns�are�resolved�in�an�open,�fair�and�timely�manner.�

Information�about�giving�feedback�should�be�provided�to�consumers�/�patients�prior�to�or�at�admission,�and�staff�should�offer�periodic�reminders.�Further�reminders�can�be�displayed�in�appropriate�areas�such�as�waiting-rooms�and�at�reception,�and�should�be�prominent�upon�the�organisation’s�website.�

Correct�complaints�management�also�requires�the�provision�and/or�facilitation�of�consumer�/�patient�support.�Information�about�giving�feedback�or�lodging�a�complaint�should�be�made�available�in�a�range�of�languages�drawn�from�the�organisation’s�knowledge�of�the�community�it�serves,�and�in�Braille�and/or�audio�format,�if�appropriate.�

Another�vital�form�of�consumer�/�patient�support�is�that�of�advocacy.�Professional�advocates�may�represent�the�consumer�/�patient�throughout�the�complaints�process.�Some�large�organisations�employ�Patient�Representatives�or�Consumer�Advocates�to�listen�to�consumer�/�patient�concerns,�offer�advice�and,�if�requested,�take�direct�action�in�the�complaints�process�on�the�consumer�/�patient’s�behalf.�While�it�is�not�mandatory�to�provide�this�form�of�support,�the�organisation�should�make�consumers�/�patients�aware�that�external�advocacy�services�exist,�what�they�do,�and�that�they�have�a�right�to�access�these�services�if�they�wish.�They�should�also�supply�all�necessary�information�for�doing�so,�such�as�contact�details.�This�information�should�be�provided�in�an�appropriate�range�of�languages.

Information�on�advocacy�can�be�found�at:�http://www.healthinsite.gov.au/topics/Consumer_Advocacy

Prompt points

¼ How are consumers / patients informed of their right to provide feedback? When and where does this happen?

¼ By what different means may a complaint be lodged within the organisation by consumers / patients or their representatives?

¼ Does the organisation provide Patient Representatives or Consumer Advocates to support consumers / patients and/or their carers through the complaints process? If not, what advocacy groups does the organisation provide contact details for?

FeedbackThe�provision�of�feedback�by�the�organisation�throughout�the�investigation�process,�with�a�formal�acknowledgement�at�the�end,�lets�the�consumer�know�that�his�or�her�concerns�are�being�taken�seriously�and�true�resolution�sought.�The�processes�by�which�feedback�is�provided�to�the�complainant�should�be�detailed�within�the�organisation’s�complaints�management�policy,�and�any�failure�or�breakdown�in�the�system�rigorously�investigated.

Another�necessary�aspect�of�complaints�management�is�feedback�to�staff,�including�managers.�Where�the�investigation�of�a�complaint�concludes�with�the�recommendation�of�changes�to�systems�and�processes,�this�must�be�acknowledged�and�acted�upon�at�the�managerial�level,�and�the�changes�communicated�to�staff.�

It�is�vital�that�changes�made�either�to�the�complaints�management�system�or�to�organisation�processes�are�communicated,�as�well�as�the�reasons�for�them,�so�that�all�relevant�staff�are�aware�of�any�new�procedures,�and�that�all�staff�are�reminded�of�the�importance�of�consumer�complaints.�The�effectiveness�of�the�communication�process�should�be�regularly�evaluated.

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Prompt points

¼ How often is feedback provided to the complainant during the complaints investigation process? How is the complainant informed that a complaint has been resolved?

¼ How does the organisation communicate to staff any changes made as a result of a complaint investigation?

¼ How are compliments from consumers / patients disseminated within the organisation?

¼ How does the organisation obtain feedback about its complaints management system?

¼ How does the organisation ensure that its provision of support services to consumers / patients and staff are appropriate and effective?

Evidence commonly presented

Consider whether the following will help to address criterion 2.1.4

¼ Complaints management system ¼ Policies and procedures, including:

– complaints – open disclosure – how complaints management is addressed

during orientation ¼ Integration of incident and complaints

management systems ¼ Information available to consumers / patients on

how to provide feedback or lodge a complaint ¼ Evidence of staff training in complaints handling,

conflict resolution and open disclosure ¼ Evidence that the organisation facilitates the

access of consumers / patients to support personnel including translators and advocates

Performance measurementThis�criterion�states�that:�“Healthcare�complaints�and�feedback�are�managed�to�ensure�improvements�to�the�systems�of�care”.�Effective�processes�for�responding�to�feedback,�for�resolving�and/or�investigating�complaints,�and�for�making�improvements�to�the�organisation’s�systems�and�processes�as�a�result�are�vital�to�the�provision�of�safe,�high�quality�healthcare.�The�organisation�should�be�able�to�demonstrate�that�it�has�systems�to�receive�and�act�upon�consumer�feedback�and�complaints,�and�that,�where�necessary,�improvements�are�made�to�its�services�and�processes�as�a�consequence.

Some�common�suggested�performance�measures�are�as�follows:

Number�of�complaints�lodged�by�consumers�/�patients

Total number of consumers / patients seen / admitted

Number�of�complaints�resolved�without�formal�investigation

Total number of complaints received

Number�of�complaints�lodged�about�the�complaints�management�system

Total number of complaints lodged

Number�of�complaints�by�specialty�/�category

Total number of complaints

Comment:organisationtodefine‘specialty/category’

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seCtion 5Standards, criteria, elements and guidelinesstandard 2.1:�The�governing�body�leads�the�organisation�in�its�commitment�to�improving�performance�and�ensures�the�effective�management�of�corporate�and�clinical�risks

280  The ACHS EQuIP5 Guide  Book 2  Accreditation, Standards and Guidelines  Support and Corporate Functions

1.� AS�ISO�10002—2006�Customersatisfaction–Guidelinesforcomplaintshandlinginorganizations.

2.� Tasmanian�Department�of�Health�and�Human�Services.�ComplimentsandcomplaintspolicyforTasmania’sagencyfundedcommunitysectororganisations.Hobart�TAS;�Government�of�Tasmania;�2009.

3.� Department�of�Veterans’�Affairs.�Complaints,complimentsandfeedback.�Canberra�ACT;�Australian�Government.�Accessed�from�http://www.dva.gov.au/contact_us/Pages/index.aspx�on�13�August�2010.

4.� Australian�Council�for�Safety�and�Quality�in�Health�Care.�Betterpracticeguidelinesoncomplaintsmanagementforhealthcareservices.Canberra�ACT;�Australian�Council�for�Safety�and�Quality�in�Health�Care;�2004.

5.� Australian�Council�for�Safety�and�Quality�in�Health�Care.�Complaintsmanagementhandbookforhealthcareservices.Canberra�ACT;�Australian�Council�for�Safety�and�Quality�in�Health�Care;�2005.

6.� NSW�Health.�Policydirective:Complaintmanagementpolicy.�Sydney;�NSW�Health;�2006.

7.� Standards�Australia.�HB�229:2006Handbook:Thewhyandhowofcomplaintshandling.

8.� Australian�Commission�on�Safety�and�Quality�in�Health�Care�(ACSQHC).�Australiancharterofhealthcarerights(forconsumers).�Sydney�NSW;�ACSQHC;�2008.

Guidelines1.� AS�4608:2004�Disputemanagementsystems.�Second�edn.

2.� WA�Office�of�Safety�and�Quality�in�Healthcare.�WesternAustralianhealthcomplaintmanagementtoolkit2009.Perth;�WA�Department�of�Health;�2009.

Further readingRomios�P,�Newby�L,�Wohlers�M�etal.Turningwrongsintorights:learningfromconsumerreportedincidents–anannotatedliteraturereview.�Melbourne�VIC;�Health�Issues�Centre,�La�Trobe�University;�2003.

Criterion 2.1.4

Healthcare�complaints�and�feedback�are�managed�to�ensure�improvements��to�the�systems�of�care.�(continued)

Number�of�consumers�/�patients�informed�about�the�complaints�process

Total number of consumers / patients seen / admitted

Number�of�consumers�/�patients�satisfied�with�access�to�support�personnel

Total number of consumers / patients surveyed

Number�of�staff�members�satisfied�with�the�support�services�provided

Total number of staff members surveyed

Number�of�complaint�investigations�resolved�within�the�designated�timeframe

Total number of complaints investigated

References

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October 2010  281

2.2�Human�Resources�Management�Standard

The�standard�is:�Human resources management supports quality health care, a competent workforce and a satisfying working environment for staff.

The�intent�of�this�standard�is�to�ensure�the�organisation’s�workforce�is�recruited�and�managed�in�a�manner�that�supports�the�provision�of�quality�and�safe�care�and�services.�Human�resources�management�practices�should�also�support�the�organisation’s�goals�and�objectives.�

The�standard�for�the�workforce�management�contains�five�criteria.�These�are:�

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

2.2.2� �The�recruitment, selection and appointment system�ensures�that�the�skill�mix�and�competence�of�staff,�and�mix�of�volunteers,�meet�the�needs�of�the�organisation.

2.2.3�� �The�continuing employment and performance development system ensures�the�competence�of�staff�and�volunteers.

2.2.4� �The�learning and development system ensures�the�skill�and�competence�of�staff�and�volunteers.�

2.2.5� Employee support systems�and�workplace�relations�assist�the�organisation�to�achieve�its�goals

Human resources management�is�the�policies,�practices�and�systems�that�influence�employees’�behaviours,�attitudes�and�performance1.

seCtion 5Standards, criteria, elements and guidelines

1.� de�Cieri�H�and�Kramer�R.�(Adapted�from�Noe,�Hollenbeck,�Gerhart�&�Wright.)�HumanResourceManagementinAustralia:strategy,people,performance.Sydney�NSW;�McGraw-Hill�Australia;�2003.

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seCtion 5Standards, criteria, elements and guidelinesstandard 2.2:�Human�resources�management�supports�quality�health�care,�a�competent�workforce�and�a�satisfying�working�environment�for�staff

282  The ACHS EQuIP5 Guide  Book 2  Accreditation, Standards and Guidelines  Support and Corporate Functions

IntentThe�health�workforce�ranges�from�workers�with�no�formal�qualifications�providing�support�services�through�to�highly�qualified�specialists�working�in�technology-intensive�positions,�and�also�includes��non-clinical�staff.�It�is�acknowledged�that�the�workforce�is�supported�by�volunteers�and�carers.

The�intent�of�this�criterion�is�to�ensure�that�the�organisation�has�plans�to�meet�its�current�and�future�needs�within�each�segment�of�its�workforce.

Relationships of 2.2.1 with other criteriaWorkforce�planning�provides�a�vision�for,�and�responds�to,�all�aspects�of�workforce�management�(Standard�2.2).�Workforce�planning�should�reflect�the�organisation’s�strategic�and�planning�goals�(Criterion�3.1.1).

The�availability,�quality�and�fallibility�of�staff�presents�a�risk�factor�for�all�organisations,�but�even�more�so�for�service�organisations�with�a�responsibility�to�ensure�the�safety�of�the�public,�such�as�healthcare�organisations.�The�control�of�safety�factors�associated�with�workforce�planning�is�an�aspect�of�the�organisation’s�integrated�risk�management�framework�(Criterion�2.1.2),�and�failure�in�this�area�may�lead�to�incidents�(Criterion�2.1.3)�and�complaints�(Criterion�2.1.4).

Workforce planning Forward�planning�is�needed�to�ensure�that�the�organisation�can�respond�to�the�changing�needs�of�communities,�governments,�health�services�and�employees�now�and�into�the�future.�Comprehensive�workforce�planning�takes�time,�meaningful�stakeholder�engagement,�and�collaboration.�Good�planning�ensures�that�the�longer-term�and�broader�goals�of�the�organisation�can�be�met�despite�the�urgency�of�immediate�demands.

The�approach�to�workforce�planning�will�differ�depending�on�whether�it�aims�to�address�immediate�needs�(the�next�shift),�short-term�needs�(less�than�one�year)�or�longer-term�goals�(three�to�five�years).�

Criterion LA – Awareness sA – implementationLA plus the following

MA – evaluationSA plus the following

eA – excellenceMA plus the following

oA – LeadershipEA plus the following

Criterion 2.2.1

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

a)� Systems�exist�to�ensure�that�the�skill�mix�of�clinical�and�support�staff�meets�consumer�/�patient�needs.

b)� Documented�policy�and�procedures�for�workforce�planning�and�management�are�available�to�staff.

c)� Policy�/�guidelines�for�safe�working�hours�exist.�

d)� Strategies�are�in�place�to�ensure�safe,�quality�treatment�and�care�if�prescribed�levels�of�skill�mix�of�clinical�and�support�staff�are�not�available.

a)� The�workforce�strategic�plan�is�clearly�linked�to�the�organisation’s�strategic�direction�and�goals.

b)� The�organisation’s�workforce�planning�reflects�current�and�future�needs�of�consumers�/�patients�and�staff.

c)� Workforce�management�functions�and�responsibilities�are�clearly�identified.

d)� Fatigue�prevention�and�management�strategies�are�implemented.

e)� Staff�members�are�advised�of,�and�have�access�to,�workforce�policies�and�procedures.

f)� There�are�contingency�plans�to�manage�workforce�shortages.

a)� The�workforce�policy,�plan,�goals�and�strategic�direction�are�regularly�reviewed,�evaluated�and�improvements�are�made�as�required.

b)� Performance�measures�are�used�on�a�regular�basis�to�evaluate�employee�fatigue,�and�improvements�are�made�as�required.

a)� Performance�measures�and�processes�for�workforce�planning�are�compared�internally�and�with�external�systems,�and�improvements�are�made�to�ensure�better�practice.

and/or

b)� The�organisation�conducts�research�and�develops�innovative�ways�to�improve�workforce�management.

a)� The�organisation�demonstrates�it�is�a�leader�in�planning�for�current�and�future�workforce�requirements.

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October 2010  283

A�number�of�external�changes�that�will�affect�workforce�planning�in�healthcare�organisations�in�upcoming�years�have�been�identified.�The�potential�impact�of�these�and�other�environmental�factors�should�be�considered�by�the�organisation.�They�include:

• the�need�to�provide�more�flexible�working�arrangements

• changes�from�State�/�Territory-based�to�national�professional�registration�and�continuing�education

• new�clinical�schools�with�larger�numbers�of�trainees�requiring�clinical�experience�

• expanding�roles�for�nurses�and�midwives

• changing�gender�balance�in�some�health�professions

• the�ageing�of�the�nursing�workforce

• demand�exceeding�supply�in�many�health�professions,�and�the�associated�reliance�on�overseas-trained�professionals.

Organisations�may�benefit�from�considering�these�principal�steps�in�a�workforce�planning�process1:

• review�the�environment�in�which�the�organisation�operates

• forecast�workforce�demand

• forecast�workforce�supply

• analyse�gaps�and�generate�strategies

• monitor�and�evaluate.

A�process�was�developed�by�Victoria’s�Department�of�Human�Services�to�assist�rural�planners�to�evaluate�workforce�needs�without�requiring�sophisticated�computer�tools.�A�description�of�this�process,�which�may�also�be�useful�in�other�settings,�is�available�online1�at:�http://www.health.vic.gov.au/ruralhealth/downloads/rural_health_workforce_planning_guidelines.pdf�

Good�planning�should�involve�organisational�managers,�not�because�this�will�meet�EQuIP�requirements,�but�because�those�working�within�the�organisation�understand�its�current�needs�and�can�consider�future�challenges.�To�assist�the�process1:

• make�available�the�best�possible�information�for�planning,�including�the�work�already�undertaken�in�environmental�review

• encourage�a�consultative�process�in�which�the�manager�involves�others�with�relevant�knowledge

• use�a�structured�approach�to�prompt�consideration�of�different�factors�that�may�impact�on�staffing�needs.

Criterion LA – Awareness sA – implementationLA plus the following

MA – evaluationSA plus the following

eA – excellenceMA plus the following

oA – LeadershipEA plus the following

Criterion 2.2.1

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

a)� Systems�exist�to�ensure�that�the�skill�mix�of�clinical�and�support�staff�meets�consumer�/�patient�needs.

b)� Documented�policy�and�procedures�for�workforce�planning�and�management�are�available�to�staff.

c)� Policy�/�guidelines�for�safe�working�hours�exist.�

d)� Strategies�are�in�place�to�ensure�safe,�quality�treatment�and�care�if�prescribed�levels�of�skill�mix�of�clinical�and�support�staff�are�not�available.

a)� The�workforce�strategic�plan�is�clearly�linked�to�the�organisation’s�strategic�direction�and�goals.

b)� The�organisation’s�workforce�planning�reflects�current�and�future�needs�of�consumers�/�patients�and�staff.

c)� Workforce�management�functions�and�responsibilities�are�clearly�identified.

d)� Fatigue�prevention�and�management�strategies�are�implemented.

e)� Staff�members�are�advised�of,�and�have�access�to,�workforce�policies�and�procedures.

f)� There�are�contingency�plans�to�manage�workforce�shortages.

a)� The�workforce�policy,�plan,�goals�and�strategic�direction�are�regularly�reviewed,�evaluated�and�improvements�are�made�as�required.

b)� Performance�measures�are�used�on�a�regular�basis�to�evaluate�employee�fatigue,�and�improvements�are�made�as�required.

a)� Performance�measures�and�processes�for�workforce�planning�are�compared�internally�and�with�external�systems,�and�improvements�are�made�to�ensure�better�practice.

and/or

b)� The�organisation�conducts�research�and�develops�innovative�ways�to�improve�workforce�management.

a)� The�organisation�demonstrates�it�is�a�leader�in�planning�for�current�and�future�workforce�requirements.

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seCtion 5Standards, criteria, elements and guidelinesstandard 2.2:�Human�resources�management�supports�quality�health�care,�a�competent�workforce�and�a�satisfying�working�environment�for�staff

284  The ACHS EQuIP5 Guide  Book 2  Accreditation, Standards and Guidelines  Support and Corporate Functions

Criterion 2.2.1

Workforce�planning�supports�the�organisation’s�current�and�future�ability�to�address�needs.�(continued)

Prompt points

¼ How does the workforce plan address the goals and objectives outlined in the organisation’s strategic plan?

¼ What are the key factors affecting workforce supply?

¼ What characteristics of the workforce and labour supply have been considered when developing the workforce plan?

¼ Who is responsible for preparing and implementing the workforce plan?

Contingency planning for workforce shortages Workforce�shortages�can�occur�on�a�short-term,�shift-by-shift�basis.�Available�staff�crises�can�be�managed�using�a�contingency�plan,�which�may�include�strategies�such�as�reprioritising�tasks,�allocating�tasks�to�different�staff�members,�and�relying�on�a�pool�of�filler�staff,�which�may�consist�mostly�of�previous�employees,�and�sourcing�casual�staff�from�agencies.2

Ongoing�skill�shortages�should�be�addressed�through�longer-term�planning.�Considerable�research�has�demonstrated�that�targeted�programs�can�lead�to�cultural�change�with�subsequent�positive�outcomes�for�business�performance.3

Attracting�good�people�and�retaining�them�is�clearly�an�important�goal.�Magnet�hospitals�are�those�able�to�recruit�the�best�qualified�nurses�and�then�retain�these�staff.�US�research�undertaken�in�the�1990s�suggested�that�participatory�management,�effective�leadership,�professional�practice�environments�(illustrated�by�the�existence�of�quality�care,�positive�staffing�relationships�and�autonomy�of�practice�amongst�nursing�staff)�and�clearly�defined�career�development�pathways�are�key�issues�in�the�recruitment�and�retention�of�nursing�staff.4�Among�the�most�important�workplace�features�for�nurses�who�participated�in�a�review�of�‘magnet�characteristics’�in�an�Australian�context5�were:

• working�in�clinical�environments�characterised�by�good�levels�of�consumer�/�patient�care

• being�supervised�by�credible,�effective�managers

• positive�professional�relationships�with�medical�colleagues.

Prompt points

¼ How does the organisation ensure that the right people with the required skills and behaviours are available when and where they are needed on a day-to-day basis?

¼ How are short-term labour shortages managed to maintain quality, safe care? What patterns of skill shortages exist? What improvements have been made?

¼ How are day-to-day shortages being minimised by strategic planning?

Responsibilities for workforce managementLine�managers�and�supervisors�have�a�responsibility�for�staff�employed�below�them.�Because�workforce�management�can�be�challenging�and�time�consuming�for�individuals,�and�is�extremely�important�for�the�organisation,�all�managers�should�be�aware�of�their�specific�responsibilities�as�a�supervisor�of�their�staff.�

Depending�on�organisational�size�and�structure,�line�managers�will�carry�different�degrees�of�responsibility�for�the�following�aspects�of�workforce�management6:

• appointments�–�placing�the�right�person�in�the�right�job

• induction�–�starting�new�employees�in�their�roles

• training�–�teaching�employees�tasks�that�are�new�to�them

• staff�development�–�improving�the�job�performance�of�each�person�and�developing�skills�so�that�staff�are�prepared�for�internal�advancement

• team�building�–�gaining�creative�cooperation�and�developing�smooth�working�relationships

• interpreting�the�company’s�employment�policies�and�procedures

• fiscal�control�–�managing�labour�costs

• culture�–�creating�and�maintaining�departmental�morale

• OH&S�–�protecting�employees’�health�and�physical�safety.

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The�manager’s�human�resources�(HR)�responsibilities�and�organisational�key�performance�indicators�(KPIs)�in�workforce�management�should�be�clearly�documented�within�his�or�her�position�description,�and�signed�off.

It�is�particularly�important�that�those�responsibilities�borne�by�line�managers�are�differentiated�from�those�of�the�HR�department.�When�HR�responsibilities�are�outsourced,�the�differentiating�of�responsibilities�should�be�specifically�outlined�in�contracts�/�other�agreements�and�communicated�to�line�managers,�so�that�no�steps�in�the�recruiting�and�staff�support�processes�are�neglected.

Human�resource�department�responsibilities�generally�fall�into�three�specific�areas:

• line�management�within�their�own�department�–�supervising�activities�of�their�own�staff

• coordinating�HR�policy�and�actions�–�to�ensure�that�workforce�decisions�are�adopted�and�executed,�particularly�in�OH&S,�health�(including�records�of�immunity�testing,�vaccinations,�allergies),�credentialling�(e.g.�ensuring�professional�staff�have�current�registrations�and�are�abiding�by�scopes�of�practice),�liaison�with�unions,�scheduling�shift�personnel

• staff�(service�and�transactional�functions)�–�hiring,�training,�evaluating,�rewarding,�counselling,�promoting�and�terminating�employment.

Relative�responsibilities�of�internal�or�outsourced�HR�providers�for�the�different�tasks�listed�above�must�be�clearly�defined�to�enable�cooperative�management�of�staff�issues�between�line�managers�and�the�HR�department.�Without�due�care,�there�is�potential�for�duplication�and/or�for�omission�of�important�tasks.

Prompt points

¼ Within the organisation, who or which department takes responsibility for appointments, induction, training, staff development, HR policies and procedures, HR budgeting and fiscal control, organisational culture and OH&S? Where are these responsibilities recorded?

Skill mix of clinical and support staffThe�term�‘skill�mix’�is�used�to�describe�the�mix�of�positions,�grades�or�occupations�within�a�unit�/�organisation.7�Skill�mix�can�also�refer�to�the�combinations�of�activities�or�skills�needed�for�each�position�within�the�organisation.�

Planning�for�future�requirements,�particularly�in�an�under-resourced�labour�market,�requires�visionary�management�by�line�managers�in�order�to�meet�current�needs�while�allowing�skills�development.�Where�there�are�shortages�of�staff�and�an�inadequate�mix�of�skills,�a�problem�that�particularly�confronts�regional�and�remote�organisations,�flexible�and�creative�management�may�be�required�to�provide�services�to�meet�consumer�/�patient�demand.�

Creative�workforce�management�may�be�needed�to�overcome�a�skills�shortage�or�improve�the�cost-effectiveness�of�the�health�workforce;�this�may�involve�staff�travelling�between�facilities,�job�sharing,�dual�role�timetabling�or�provision�of�supervised�activities�for�staff�being�upskilled.�

Education�and�recruitment�can�change�the�skill�mix�within�a�team.�A�more�flexible�workforce�achieved�by�upskilling�and�reskilling�health�professionals�can�assist�in�meeting�evolving�needs.8�Clinical�staff�can�acquire�new�skills�and�be�authorised�to�undertake�additional�tasks.�Upskilling�has�the�potential�to�improve�continuity�of�care�and�quality,�especially�in�chronic�disease�management.8

Increasingly,�nurses�and�allied�health�professionals�are�being�upskilled�to�relieve�highly-qualified�physicians�so�that�they�can�focus�their�attentions�elsewhere.�For�example,�diabetes�educators�and�dietitians�assist�endocrinologists�in�managing�the�care�of�people�with�diabetes,�freeing�physicians�to�focus�on�clinical�aspects�of�care.�Pathologists�are�freed�to�support�physicians�in�interpreting�test�results�when�they�work�in�collaboration�with�colleagues�trained�in�medical�laboratory�science.

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seCtion 5Standards, criteria, elements and guidelinesstandard 2.2:�Human�resources�management�supports�quality�health�care,�a�competent�workforce�and�a�satisfying�working�environment�for�staff

286  The ACHS EQuIP5 Guide  Book 2  Accreditation, Standards and Guidelines  Support and Corporate Functions

Criterion 2.2.1

Workforce�planning�supports�the�organisation’s�current�and�future�ability�to�address�needs.�(continued)

Prompt points

¼ How well is recruitment coordinated in this organisation? Who is responsible for recruiting decisions? How are recruiting responsibilities documented to avoid duplication or omission of tasks?

¼ How well does the skill mix for the organisation / department meet the service requirements?

¼ How does the organisation make sure the skill mix is still suitable when there are changes such as service requirements, casemix, cost containment, new processes and procedures? How does workforce planning reflect the organisation’s longer-term strategic plan? How are learnings from workforce planning incorporated into the strategic planning process?

¼ How have changes to the skill mix been identified, solved and implemented?

¼ What is the role of recruitment, selection and appointment, and of learning and development, in enhancing the skill mix?

Policies and proceduresWorkplace�policies�and�procedures�should�communicate�at�least�the�minimum�performance�level�required�and�reflect�legal�aspects�of�workforce�management,�so�that�the�workforce�can�contribute�to�meeting�the�goals�and�objectives�of�the�organisation.�Policies�and�procedures�should�cover�aspects�relevant�to�the�organisation.�For�example:

• legal�and�ethical�aspects�such�as�agreements,�awards�and�contracts

• job�design

• recruitment

• selection�and�appointment

• orientation�and�integration

• code�of�conduct

• performance�management

• pay,�leave�and�conditions

• learning�and�development

• managing�diversity

• workplace�relations.

Prompt points

¼ How are staff made aware of workforce policies and procedures?

¼ How well do these policies and procedures assist staff with understanding the system and supporting them to perform well?

¼ How does the organisation know that the workforce policies and procedures are current and relevant?

Safe working hours and fatigue managementFatigue�caused�by�long�working�hours�can�impair�judgement�and�competence.9�There�is�a�risk�of�diminished�quality�of�care,�and�a�risk�to�the�health�and�safety�of�the�individual.10�

Policy�and/or�guidelines�on�safe�working�hours�and�fatigue�management�should�be�developed�with�staff�input�and�made�readily�available�to�the�entire�workforce,�including�non-employee�workers�such�as�visiting�medical�officers�(VMOs)�and�students.�University�departments�that�send�trainees�to�the�organisation�should�also�be�informed.�

Safe�working�hours�can�be�used�to�manage�fatigue�risks�which�can�be�planned�through�better�rostering.11�If�a�potential�risk�is�identified,�the�use�of�risk�identification�tools�such�as�the�FatigueAssessmentTool,�accessible�from�the�Australian�Medical�Association’s�website,�and�management�according�to�the�Australian�Medical�Association’s10�or�other�professional�bodies’�codes�of�practice12,�can�assist.�Nursing�unions�hold�seminars�to�assist�their�members�to�manage�shift�work�and�fatigue.

Fatigue�risk�management�includes�eliminating�or�minimising�risks�arising�from�the�hazards�associated�with�shift�work�and�extended�working�hours.10�It�is�important�that�staff�have�time�to�eat�and�drink�even�when�their�workloads�are�heavy�or�access�to�dining�facilities�limited:�hypovolaemia�and�hypoglycaemia�may�extend�reaction�times�or�impair�psychomotor�performance.13

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October 2010  287

Fatigue�represents�a�serious�risk�to�consumers�/�patients�and�staff�alike,�and�must�be�proactively�managed�to�avoid�incidents.�Depending�on�the�records�available,�a�measure�of�continuous�hours�worked�by�individuals�is�a�reliable�guide�to�the�potential�for�fatigue.�Organisations�should�consider�what�data�are�already�being�collected�that�might�give�an�indication�of�continuous�hours�being�worked;�for�instance,�in�a�surgical�setting,�the�theatre�scheduling�database�(often�known�as�an�Operating�Room�Management�Information�System�or�ORMIS)�may�provide�insights�into�hours�being�worked.�Vehicle�logs�may�give�insights�into�hours�worked�by�staff�who�see�consumers�/�patients�in�their�homes.�

Fatigue�may�play�a�role�in�adverse�events,�so�time�of�day�and�overtime�hours�should�be�considered�in�any�evaluation,�such�as�a�Root�Cause�Analysis�of�an�incident.�Where�fatigue�may�be�an�issue,�a�team�approach�that�considers�the�unique�demands�and�resources�of�the�workplace�will�be�key�to�finding�ways�to�minimise�these�risks.�Ideas�for�managing�these�challenges�that�have�been�trialled�successfully�should�be�shared�between�teams�or�organisations.

Prompt points

¼ What strategies / practices are used to minimise errors and incidents when someone is fatigued? How effective are these strategies?

¼ How is fatigue risk systematically identified? Which staff groups are at most risk? What controls are in place to manage risk?

¼ What aspects of organisational culture may lead people to work long hours even when fatigued?

¼ What longer-term planning is being conducted to minimise risks associated with fatigue?

¼ How is fatigue, or the potential for fatigue, managed in employees / casual staff who may be engaged in other employment?

Evidence commonly presented

Consider whether the following will help to address criterion 2.2.1

¼ Evaluation of the achievement of workforce plans

¼ Evaluation of the workforce planning process

¼ Review of policies and procedures documentation

¼ Fatigue risk policy

¼ Fatigue risk assessment and management plans

¼ Evaluation of skill mix against service requirements

¼ Minutes of meetings relating to workforce planning, skills shortages, fatigue management and whether actions have been addressed

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seCtion 5Standards, criteria, elements and guidelinesstandard 2.2:�Human�resources�management�supports�quality�health�care,�a�competent�workforce�and�a�satisfying�working�environment�for�staff

288  The ACHS EQuIP5 Guide  Book 2  Accreditation, Standards and Guidelines  Support and Corporate Functions

Criterion 2.2.1

Workforce�planning�supports�the�organisation’s�current�and�future��ability�to�address�needs.�(continued)

Performance measurementThis�criterion�states�that:�“Workforce�planning�supports�the�organisation’s�current�and�future�ability�to�address�needs.”�The�organisation�should�have�clearly�defined�processes�and�responsibilities�for�the�recruitment�and�retention�of�staff,�both�clinical�and�non-clinical,�so�that�both�current�and�future�workplace�needs�are�met.

Some�common�suggested�performance�measures�are�as�follows:

Number�of�FTE�staff�resigning�from�the�organisation�/�area�/�department�within�the�previous�year

Total number of FTE positions defined within the organisation / area / department

Comment:FTE=full-timeequivalent

Number�of�overtime�hours�worked

Total number of FTE staff

Number�of�sick�days�taken

Total number of FTE staff

Number�of�nursing�hours�worked

Total number of consumer / patient bed days by specialty / unit

Comment:thismeasuremightbemonitoredforotherprofessionalgroupsasappropriateforthespecificneedsoftheorganisation/department

Agency�nurse�hours�worked�in�the�specified�time�frame

Total nurse hours worked in the specified time frame

Number�of�workforce�plan�key�performance�indicators�(KPIs)�met�within�specified�timeframe

Total number of workforce plan KPIs

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References 1.� Victorian�Rural�and�Regional�Health�and�Aged�Care�

Services.�Ruralhealthworkforceplanningguidelines.Melbourne�VIC;�Dept�of�Human�Services;�2006.

2.� Blythe�J,�Baumann�A,�Zeytinoglu�I�etal.Full-time�or�part-time�work�in�nursing:�Preferences,�tradeoffs�and�choices.�Healthcare�Quarterly�2005;�8(3):�69-77.

3.� Sanders�EJ�and�Cooke�RA.�Translating“soft”changesinto“hard”dollars:Financialreturnsfromorganisationalcultureimprovement.�Arlington�Heights�USA;�Human�Synergistics;�2005.�Accessed�from�http://www.humansynergistics.com.au/content/articles/papers/financial-roi-culture-rob-cooke-jun-05/default.asp�on�14�April�2010.

4.� Upenieks�V.�Recruitment�and�retention�strategies�literature�review.�MedscapeToday(30�March�2010).�Accessed�from�http://www.medscape.com/viewarticle/449690_3�on�1�September�2010.

5.� Joyce�J�and�Crookes�P.�Developing�a�tool�to�measure�‘magnetism’�in�Australian�nursing�environments.��AustJAdvNurs�2007;�25(1):�17-23.

6.� Dessler�G,�Griffiths�J�and�Lloyd-Walker�B.�Humanresourcemanagement.�2nd�edn.�Sydney�NSW;�Pearson�Education�Australia;�2004.

7.� Buchan�J�and�Dal�Poz�MR.�Skill�mix�in�the�health�care�workforce:�reviewing�the�evidence.�BullWorldHealthOrgan�2002;�80(7):�575-580.

8.� Duckett�SJ.�Interventions�to�facilitate�health�workforce�restructure.�AustNZHealthPolicy�2005;�2(1):�14.

9.� Nocera�A�and�Khursandi�DS.�Doctors’�working�hours:�can�the�medical�profession�afford�to�let�the�courts�decide�what�is�reasonable?�MedJAust�1998;�168(12):�616-618.

10.� Australian�Medical�Association�(AMA).�Nationalcodeofpractice–hoursofwork,shiftworkandrosteringforhospitaldoctors.Canberra�ACT;�AMA;�2005.

11.� Australian�Medical�Association.�Safehourscampaignfatigueriskassessmenttool.Accessed�from�http://safehours.ama.com.au/�on�31�August�2010.

12.� Royal�Australasian�College�of�Surgeons�(RACS).�Standardsforsafeworkinghoursandconditionsforfellows,surgicaltraineesandinternationalmedicalgraduates.�Melbourne�VIC;�RACS;�2007.

13.� Association�of�Anaesthetists�of�Great�Britain�and�Ireland�(AAGBI).�Fatigueandanaesthetists.London�UK;�AAGBI;�2005�

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seCtion 5Standards, criteria, elements and guidelinesstandard 2.2:�Human�resources�management�supports�quality�health�care,�a�competent�workforce�and�a�satisfying�working�environment�for�staff

290  The ACHS EQuIP5 Guide  Book 2  Accreditation, Standards and Guidelines  Support and Corporate Functions

IntentRecruitment�involves�targeting�suitable�applicants�and�receiving�applications,�and�is�followed�by�a�selection�process�to�rank�candidates�and�determine�the�most�suitable�person�to�fill�a�position.�

Following�reference�checking,�credentialling,�criminal�record�/�working�with�children�checks�and�any�other�relevant�checks,�the�chosen�applicant�is�offered�a�position�and�appointed.�These�processes�and�their�associated�documentation�will�provide�much�of�the�evidence�for�this�criterion.

The�intent�of�this�criterion�is�to�ensure�that�all�aspects�of�recruitment,�selection�and�appointment�meet�the�needs�of�the�organisation.

Relationships of 2.2.2 with other criteriaComprehensive�workforce�planning�(Criterion�2.2.1)�identifies�the�staff�needed�to�allow�the�organisation�to�achieve�the�goals�outlined�in�its�strategic�and�operational�plans�(Criterion�3.1.1).�If�recruitment�is�subcontracted�to�external�service�providers,�this�arrangement�must�be�managed�so�as�to�ensure�the�quality�of�the�service�delivery,�assessed�against�the�terms�of�agreement�(Criterion�3.1.4).�Failures�in�the�processes�for�recruiting�appropriately�qualified�staff�may�lead�to�incidents�(Criterion�2.1.3)�and�complaints�(Criterion�2.1.4).

Organisational�need�will�determine�the�recruitment�of�clinicians,�whose�suitability�for�available�positions�will�be�managed�via�the�processes�of�credentialling�and�defining�the�scope�of�clinical�practice�(Criterion�3.1.3).�

Recruitment, selection and appointmentRecruitment,�selection�and�appointment�processes�must�meet�legislated�obligations.�Equal�opportunity�and�anti-discrimination�legislation�requires�that�the�recruitment�process,�including�the�selection�criteria,�is�consistent�with�the�position�specifications.�Employers�should�operate�in�accordance�with�the�Commonwealth�Acts�covering�fair�work�and�work�relations,�OH&S�and�privacy.�In�addition,�there�are�different�Acts�operating�within�each�State�/�Territory�jurisdiction,�with�detailed�regulations�pertaining�particularly�to�OH&S�and�industrial�relations�issues.�A�range�of�Commonwealth�and�State�/�Territory�legislation�protects�against�discrimination�based�on�stated�criteria,�such�as�race,�age�and�gender.

Criterion LA – Awareness sA – implementationLA plus the following

MA – evaluationSA plus the following

eA – excellenceMA plus the following

oA – LeadershipEA plus the following

Criterion 2.2.2

The�recruitment,�selection�and�appointment�system�ensures�that�the�skill�mix�and�competence�of�staff,�and�mix�of�volunteers,�meets�the�needs�of�the�organisation.

a)� Recruitment,�selection�and�appointment�are�undertaken�in�accordance�with�legislative�requirements,�jurisdictional�policy�/�regulations�and�organisational�policy�/�guidelines.

b)� Recruitment�processes�ensure�staff�and�volunteers�have�the�necessary�licences,�registration,�qualifications,�skills�and�experience�to�perform�their�work.

a)� The�recruitment�system�ensures�an�adequate�number�and�skill�mix�of�staff�to�provide�the�organisation’s�services.

b)� All�departments�/�units�comply�with�the�organisation’s�recruitment,�selection�and�appointment�requirements.

c)� The�volunteer�recruitment�system�supports�an�adequate�number�and�mix�of�volunteers�to�provide�applicable�services.

d)� There�is�a�system�and�program�for�the�orientation�and�integration�of�all�staff�and�volunteers.

a)� Performance�measures�are�used�to�evaluate�and�improve�recruitment,�selection�and�appointment�systems,�and�adapt�them�to�changing�service�requirements,�where�required.

b)� The�orientation�and�integration�system�is�evaluated�and�improved�on�a�regular�basis.

a)� Performance�measures�and�processes�for�recruitment,�selection,�appointment,�orientation�and�integration�are�compared�internally�and�with�external�systems,�and�improvements�are�made�to�ensure�better�practice.

and/or

b)� Developments�in�research�inform�the�recruitment,�selection,�appointment,�orientation�and�integration�systems.

a)� The�organisation�demonstrates�it�is�a�leader�in�recruitment,�selection,�appointment,�orientation�and�integration�systems.

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October 2010  291

From�2010,�the�‘Modern�Awards’�program�will�move�a�number�of�professions,�including�nursing�and�aged�care,�onto�nationally�negotiated�awards,�through�a�phased�transition�over�five�years.1�Administration�of�legislation�covering�the�professional�practice�of�medical�doctors,�nurses�and�other�health�professionals�in�all�Australian�States�and�Territories�falls�under�the�remit�of�the�National�Registration�and�Accreditation�Scheme2,�and�is�administered�by�the�Australian�Health�Practitioner�Regulation�Agency�(AHPRA).�Information�is�available�at:�http://www.ahpra.gov.au�

Types�of�workforce�agreements�undertaken�between�organisations�and�their�health�professionals�may�vary,�with�marked�differences�in�the�contracted�agreements�used�within�the�private�and�public�sector.�Private�hospital�policy�in�relation�to�staff�/�contractors�may�be�covered�in�organisational�by-laws�which�themselves�must�reflect�legislation�governing�the�operation�of�private�healthcare�facilities�in�the�relevant�State�/�Territory.

Volunteers�are�not�covered�by�the�legislation�referenced�above.�State�/�Territory-based�laws�generally�include�clauses�to�protect�volunteers�from�personal�liability.�However,�specific�conditions�may�preclude�cover�for�volunteers�/�the�organisation.�Both�the�organisation�and�volunteers�should�be�fully�aware�of�the�terms�and�conditions�of�any�Volunteer�Protection�clauses�operating�in�their�State�/�Territory�and�understand�their�rights�and�responsibilities�in�relation�to�this�legislation.�Volunteer�appointments�may�also�be�conditional�on�police�and/or�working�with�children�checks.

Organisations�need�to�be�aware�of�the�legislated�obligations�that�apply�to�them�and�monitor�any�changes�to�legislation.�These�requirements�should�be�reflected�in�their�policies.�

Details�covered�by�employment�contracts�include:

• hours�of�employment�and�full-time,�part-time�or�casual�employment�status�–�permanent�or�stated�temporary�duration

• salary�and�benefits

• start�date�and�probation�period

• any�other�conditions�of�employment;�this�may�include�signed�agreements�relating�to�position�description,�confidentiality,�workplace�safety.�

Criterion LA – Awareness sA – implementationLA plus the following

MA – evaluationSA plus the following

eA – excellenceMA plus the following

oA – LeadershipEA plus the following

Criterion 2.2.2

The�recruitment,�selection�and�appointment�system�ensures�that�the�skill�mix�and�competence�of�staff,�and�mix�of�volunteers,�meets�the�needs�of�the�organisation.

a)� Recruitment,�selection�and�appointment�are�undertaken�in�accordance�with�legislative�requirements,�jurisdictional�policy�/�regulations�and�organisational�policy�/�guidelines.

b)� Recruitment�processes�ensure�staff�and�volunteers�have�the�necessary�licences,�registration,�qualifications,�skills�and�experience�to�perform�their�work.

a)� The�recruitment�system�ensures�an�adequate�number�and�skill�mix�of�staff�to�provide�the�organisation’s�services.

b)� All�departments�/�units�comply�with�the�organisation’s�recruitment,�selection�and�appointment�requirements.

c)� The�volunteer�recruitment�system�supports�an�adequate�number�and�mix�of�volunteers�to�provide�applicable�services.

d)� There�is�a�system�and�program�for�the�orientation�and�integration�of�all�staff�and�volunteers.

a)� Performance�measures�are�used�to�evaluate�and�improve�recruitment,�selection�and�appointment�systems,�and�adapt�them�to�changing�service�requirements,�where�required.

b)� The�orientation�and�integration�system�is�evaluated�and�improved�on�a�regular�basis.

a)� Performance�measures�and�processes�for�recruitment,�selection,�appointment,�orientation�and�integration�are�compared�internally�and�with�external�systems,�and�improvements�are�made�to�ensure�better�practice.

and/or

b)� Developments�in�research�inform�the�recruitment,�selection,�appointment,�orientation�and�integration�systems.

a)� The�organisation�demonstrates�it�is�a�leader�in�recruitment,�selection,�appointment,�orientation�and�integration�systems.

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292  The ACHS EQuIP5 Guide  Book 2  Accreditation, Standards and Guidelines  Support and Corporate Functions

Criterion 2.2.2

The�recruitment,�selection�and�appointment�system�ensures�that�the�skill�mix�and�competence�of�staff,�and�mix�of�volunteers,�meets�the�needs�of�the�organisation.�(continued)

All�employment�contracts�should�be�signed�by�both�parties�to�demonstrate�mutual�agreement.

Various�performance�measures�may�be�used�to�evaluate�and�improve�recruitment,�selection,�and�appointment�systems�within�the�organisation.�For�example,�outcomes�of�three�monthly�probationary�performance�reviews�may�provide�guidance�as�to�the�effectiveness�of�the�existing�programs.�Monitoring�departures�of�new�staff�within�the�probationary�period,�and�analysing�trends�detected�through�conducting�exit�interviews�for�all�departing�staff,�may�also�identify�system�issues.

Prompt points

¼ How does the recruitment process support the organisation to ensure the best person is recruited to a position? How is the process evaluated?

¼ Which sections of legislation and regulations inform the policies that govern recruitment, selection and appointment? How does the organisation ensure that relevant sections of legislation and regulations are met?

¼ What are the legal and other risks that may impact upon the organisation if recruitment, selection and appointment policies and procedures are not followed? How is non-compliance with policy managed?

¼ If the recruitment process is outsourced, what documentation from the external provider indicates that it meets legislative and regulatory requirements?

Service provisionRecruitment�goals�should�align�with�broader�strategic�and�operational�goals�as�identified�through�workforce�planning,�which�is�addressed�within�criterion�2.2.1.�The�recruitment�system�requires�access�to�records�of�departmental�staff,�position�titles�/�roles�and�their�position�descriptions.�

It�may�be�a�challenge�to�fill�all�positions�full�time�and�permanently.�In�situations�of�workforce�shortage,�managers�should�have�processes�that�allow�them�to�consider�alternative�approaches�to�recruitment�and�appointment,�to�adapt�to�the�challenges�of�service�provision.�Examples�of�processes�to�cover�staff�shortages�might�include�job-sharing�arrangements,�restructuring�of�team�responsibilities,�conditional�appointments,�or�short-term,�casual�appointments�linked�to�specific�projects.

Prompt points

¼ How are strategic planning, operational planning and workforce planning linked to recruiting?

¼ What recruitment responses can support departmental needs for particular skills or staff availability?

¼ How is the skill mix within the relevant team reviewed before a new position or replacement is recruited? How are future service needs considered as part of this process?

Checking credentials Pre-employment�screening�is�an�essential�risk�management�process�for�organisations,�particularly�for�recruited�senior�staff.�Screening�is�mandatory�in�some�States�/�Territories�for�certain�positions,�such�as�those�involving�working�with�children,�or�Responsible�Officer�roles�within�the�financial�services�sector.�Where�casual�staff�are�sourced�from�agencies,�it�is�important�to�confirm�that�all�agency�staff�have�themselves�been�screened�and�have�met�the�standards�of�the�contracting�healthcare�facility.�These�standards�may�be�more�specific,�or�higher,�than�the�standards�of�the�agency.

It�is�important�that�claimed�qualifications�and�experience�are�verified.�Academic�and�professional�qualifications�should�be�checked�with�the�appropriate�universities�and�colleges3,�dates�of�employment�with�payroll�departments,�and�reference�checks�sought�from�past�line�managers.�Other�checks�include�criminal�history�checks,�checks�with�professional�Boards�and�Colleges,�and�directorships�and�company�affiliations.�Large�organisations�may�subcontract�this�work.�

The�Australian�Medical�Council�(AMC)�assesses�international�medical�graduates�(IMGs)�who�wish�to�practise�specialty�medicine�in�Australia,�and�makes�recommendations�to�the�Medical�Board�of�Australia.4�Since�mid-2007,�a�national�process�has�ensured�that�all�IMGs�are�assessed�through�one�of�

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four�different�pathways�before�they�are�registered�to�practise�medicine�in�Australia.5�Organisations�must�ensure�that�their�overseas-trained�doctors�have�met�the�requirements�of�the�AMC�and�have�a�legitimate�Australian�registration�to�practise.

If�formal�qualifications�are�required�to�fulfil�a�position,�whether�clinical�or�non-clinical,�a�system�for�verifying�and�recording�a�copy�of�the�qualification�is�suggested.�Methods�for�verifying�skills�include�conducting�referee�checks,�skills�testing�by�peers�and�viewing�samples�of�written�work.�

Prompt points

¼ Describe the pre-employment screening process undertaken for a managerial staff member. How does the process change when the staff member will occupy a clinical role?

¼ What processes are in place to check staff who will be working with children?

Volunteer recruitmentConsiderable�planning,�management,�feedback�and�review�are�required�to�achieve�an�effective�management�program�for�volunteers.�It�is�important�that�the�volunteer�program�complements�the�work�undertaken�by�paid�staff,�and�that�there�is�no�perceived�threat�to�existing�positions.

The�organisation�needs�to�provide�a�clear�explanation�of�the�reasons�for�using�volunteers�instead�of�employing�staff�to�undertake�those�roles.�

Prompt points

¼ What organisational structures and/or processes support volunteers to perform a volunteer role to the best of their ability?

¼ What volunteer recruitment and retention strategies are in place?

¼ What new ways of using volunteers has the organisation considered?

¼ How do you monitor satisfaction of volunteers in their role?

Orientation and integrationOrientation�provides�new�staff�or�volunteers�with�a�background�to�the�organisation,�for�example�the�mission,�vision�and�values�and�introduction�to�the�organisational�culture.5�Orientation�programs�vary�greatly�between�organisations,�and�should�be�developed�to�meet�the�specific�needs�of�the�organisation�and�in�response�to�characteristics�or�the�identity�of�the�participants.�Formal�orientation�programs�involving�presentations�may�be�used�when�large�numbers�of�staff�require�an�introduction�to�an�organisation.�This�approach�is�commonly�used�for�junior�clinicians�in�large�teaching�hospitals,�although�alternative�options�are�emerging�that�utilise�improved�telecommunications.�

New�staff�should�receive�orientation�covering�the�organisation�and�key�staff�members,�and�more�specific�information�about�the�department�/�unit�in�which�the�staff�member�will�be�based.�Formal�orientation�programs�that�allocate�delivery�of�specific�content�to�a�single�person�will�reduce�the�risk�that�key�information�is�omitted.�

Volunteers�should�also�receive�orientation�to�facilitate�integration�with�the�organisation.�Effective�integration�of�volunteers�can�maximise�volunteer�contribution,�reduce�risks�to�the�organisation�and�minimise�issues�or�tension�developing�between�paid�and�volunteer�staff.6�

Staff�surveys�and�performance�reviews�provide�opportunities�to�assess�the�effectiveness�of�orientation�and�integration�processes.�Information�gained�by�individual�managers�highlighting�system�flaws�should�be�acted�on�if�local,�or�if�reflecting�broader�system�issues,�used�to�improve�the�existing�orientation�and�integration�program.

Prompt points

¼ What skills / knowledge / values are imparted to new employees during orientation and integration?

¼ How does the organisation know the orientation and integration system has helped new employees with starting to become productive on the job?

¼ How is the orientation and integration adapted for different groups of personnel, including casual and contract staff, and volunteers?

¼ How has the organisation used feedback about the orientation and integration program to continuously improve the program?

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seCtion 5Standards, criteria, elements and guidelinesstandard 2.2:�Human�resources�management�supports�quality�health�care,�a�competent�workforce�and�a�satisfying�working�environment�for�staff

294  The ACHS EQuIP5 Guide  Book 2  Accreditation, Standards and Guidelines  Support and Corporate Functions

Criterion 2.2.2

The�recruitment,�selection�and�appointment�system�ensures�that�the�skill�mix�and�competence�of�staff,�and�mix�of�volunteers,�meets�the�needs�of�the�organisation.�(continued)

Evidence commonly presented

Consider whether the following will help to address criterion 2.2.2

¼ Evaluation of recruitment and selection policies, procedures and processes

¼ Review of orientation and integration with policies and procedures

¼ Manager training / knowledge of recruitment and selection in line with organisational policies and procedures

¼ Audits of recruitment and selection records for compliance with the policy or procedure to be followed for the positions filled

¼ Audits of orientation and integration records for completion by new staff / volunteers

¼ Review of agreements with external recruitment agencies such as recruitment firms and government suppliers including any performance indicators and performance evaluation and feedback

¼ Feedback from orientation and integration sessions

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Performance measurementThis�criterion�states�that:�“The�recruitment,�selection�and�appointment�system�ensures�that�the�skill�mix�and�competence�of�staff,�and�mix�of�volunteers,�meets�the�needs�of�the�organisation”.�The�organisation’s�processes�for�the�recruitment,�appointment�and�orientation�of�staff�and�volunteers�should�meet�all�legislative�requirements�and�organisational�needs.

Some�common�suggested�performance�measures�are�as�follows:

Number�of�interview�selection�panels�constituted�according�to�organisational�policy

Total number of interview selection panels

Number�of�staff�on�interview�selection�panels�educated�in�recruitment�procedure�and�policy

Total number of staff on interview selection panels

Number�of�vacancies�filled�within�X�weeks�of�incumbent�vacating�position

Total number of vacancies

Comment:organisationtodefine‘X’

Number�of�new�staff�who�complete�a�departmental�orientation�session�within�1�week�of�commencement�of�employment

Total number of new staff employed

Number�of�staff�who�participated�in�an�orientation�and�integration�program�within�1�month�of�commencing�work

Total number of new staff employed

Number�of�casual�/�agency�staff�provided�with�orientation

Total number of casual / agency staff contracted

Number�of�days�where�services�are�closed�due�to�staff�shortages

Total number of days where services are closed (due to any reason)

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seCtion 5Standards, criteria, elements and guidelinesstandard 2.2:�Human�resources�management�supports�quality�health�care,�a�competent�workforce�and�a�satisfying�working�environment�for�staff

296  The ACHS EQuIP5 Guide  Book 2  Accreditation, Standards and Guidelines  Support and Corporate Functions

Criterion 2.2.2

The�recruitment,�selection�and�appointment�system�ensures�that�the�skill�mix�and�competence�of�staff,�and�mix�of�volunteers,�meets�the�needs�of�the�organisation.�(continued)

Number�of�inappropriate�staffing�levels�through�inappropriate�planning

Total number of inappropriate staffing levels

Comment:‘inappropriatestaffinglevels’and‘inappropriateplanning’tobedefinedinadvancebytheorganisation

Number�of�staff�satisfied�with�their�workload

Total number of staff surveyed

Number�of�new�employees�that�stay�for�at�least�X�months

Total number of new employees

Comment:organisationtodefine‘X’;Xshouldbegreaterthantheprobationaryperiod

Number�of�interviews�conducted

Total number of job applications received

Number�of�applicants�interviewed

Total number of vacancies

Number�of�terminations�after�short�service

Total number of terminations

Comment:organisationtodefine‘shortservice’

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October 2010  297

References1.� Fair�Work�Australia�and�Fair�Work�Ombudsman.�Fairwork

online.�Canberra�ACT.�Accessed�from�http://www.fairwork.gov.au/Pages/default.aspx�on�17�March�2010.

2.� National�Health�Workforce�Taskforce�(NHWT).�Intergovernmentalagreementforanationalregistrationandaccreditationschemeforthehealthprofessions.�Canberra�ACT;�NHWT;�2008.

3.� Medical�Board�of�Queensland.�Policystatementfortheverificationofqualification.Brisbane�QLD;�Medical�Board�of�Queensland;�undated.

4.� Australian�Health�Practitioner�Regulation�Agency�(AHPRA).�Specialistregistration.�Canberra�ACT;�AHPRA.�Accessed�from�http://www.ahpra.gov.au/Registration/Registration-Process/Specialist-Registration.aspx�on�16�July�2010.

5.� Dessler�G,�Griffiths�J�and�Lloyd-Walker�B.�Humanresourcemanagement.2nd�edn.�Sydney�NSW;�Pearson�Education�Australia;�2004.

6.� National�Health�and�Medical�Research�Council�(NHMRC).�Workingwithvolunteersandmanagingvolunteerprogramsinhealthcaresettings.�Melbourne�VIC;�NHMRC;�2003.

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seCtion 5Standards, criteria, elements and guidelinesstandard 2.2:�Human�resources�management�supports�quality�health�care,�a�competent�workforce�and�a�satisfying�working�environment�for�staff

298  The ACHS EQuIP5 Guide  Book 2  Accreditation, Standards and Guidelines  Support and Corporate Functions

Criterion LA – Awareness sA – implementationLA plus the following

MA – evaluationSA plus the following

eA – excellenceMA plus the following

oA – LeadershipEA plus the following

Criterion 2.2.3

The�continuing�employment�and�performance�development�system�ensures�the�competence�of�staff�and�volunteers.

a)� Staff�and�volunteers�are�provided�with�a�written�position�description�outlining�their�role,�responsibilities�and�accountabilities.

b)� Staff�and�volunteers�are�provided�with�appropriate�supervision�by�experienced,�trained�and�qualified�staff.

c)� Performance�of�staff,�including�contracted�staff�and�volunteers,�is�reviewed�in�accordance�with�organisation-wide�requirements.

d)� Accurate�and�complete�personnel�records,�including�training�records,�are�maintained�and�kept�confidential.

e)� The�organisation�has�policy�/�guidelines�for�the�process�of�managing�a�complaint�or�concern�about�a�clinician.

f)� The�organisation�has�policy�/�guidelines�for�the�process�of�managing�a�complaint�or�concern�about�a�member�of�staff,�including�contracted�staff�and�volunteers.

a)� There�is�a�performance�development�system�that�ensures:

� (i)� �clinical,�non-clinical�staff�and�volunteers�are�competent�and�accountable�for�their�work

� (ii)� �there�is�active�participation�of�both�the�manager�and�employee�in�performance�review

� (iii)� �areas�for�improvement�and�additional�educational�and�development�needs�are�identified.

b)� There�is�a�system�that�ensures�professional�and�other�licensed�staff�provide�verified�documentary�evidence�to�demonstrate�their�continuing�registration�with�the�relevant�regulatory�body.

c)� Staff�comply�with�published�codes�of�professional�practice,�relevant�to�their�professional�role.

d)� Position�descriptions,�including�accountabilities�and�responsibilities,�are�regularly�reviewed.

e)� There�is�a�process�for�managing�a�complaint�or�a�concern�about�a�clinician.�

f)� There�is�a�process�for�managing�a�complaint�or�concern�about�a�member�of�staff,�including�contracted�staff�and�volunteers.

a)� The�performance�development�system�is�integrated�with�any�relevant�service�plans�or�changing�service�requirements.

b)� Evaluation�is�undertaken�to�ensure�staff,�including�contracted�staff,�and�when�appropriate�volunteers,�have�participated�in�performance�review�and�development.

c)� Performance�measures�are�used�to�evaluate�and�improve�the�performance�development�system.�

d)� Staff�participate�in�evaluating�the�performance�development�system.

e)� The�process�for�managing�a�complaint�or�concern�about�a�clinician�is�evaluated,�and�improved�as�required.

f)� The�process�for�managing�a�complaint�or�concern�about�a�staff�member,�including�contracted�staff�member�or�volunteer,�is�evaluated,�and�improved�as�required.

a)� Performance�development�measures�and�processes�are�compared�internally�and�with�external�systems,�and�improvements�are�made�to�ensure�better�practice.�

and/or

b)� The�evaluation�of�the�continuing�employment�and�performance�development�system�demonstrates�that�the�system�is�effective�in�staff�development.

a)� The�organisation�demonstrates�it�is�a�leader�in�continuing�employment�and�performance�development�systems.

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October 2010  299

Criterion LA – Awareness sA – implementationLA plus the following

MA – evaluationSA plus the following

eA – excellenceMA plus the following

oA – LeadershipEA plus the following

Criterion 2.2.3

The�continuing�employment�and�performance�development�system�ensures�the�competence�of�staff�and�volunteers.

a)� Staff�and�volunteers�are�provided�with�a�written�position�description�outlining�their�role,�responsibilities�and�accountabilities.

b)� Staff�and�volunteers�are�provided�with�appropriate�supervision�by�experienced,�trained�and�qualified�staff.

c)� Performance�of�staff,�including�contracted�staff�and�volunteers,�is�reviewed�in�accordance�with�organisation-wide�requirements.

d)� Accurate�and�complete�personnel�records,�including�training�records,�are�maintained�and�kept�confidential.

e)� The�organisation�has�policy�/�guidelines�for�the�process�of�managing�a�complaint�or�concern�about�a�clinician.

f)� The�organisation�has�policy�/�guidelines�for�the�process�of�managing�a�complaint�or�concern�about�a�member�of�staff,�including�contracted�staff�and�volunteers.

a)� There�is�a�performance�development�system�that�ensures:

� (i)� �clinical,�non-clinical�staff�and�volunteers�are�competent�and�accountable�for�their�work

� (ii)� �there�is�active�participation�of�both�the�manager�and�employee�in�performance�review

� (iii)� �areas�for�improvement�and�additional�educational�and�development�needs�are�identified.

b)� There�is�a�system�that�ensures�professional�and�other�licensed�staff�provide�verified�documentary�evidence�to�demonstrate�their�continuing�registration�with�the�relevant�regulatory�body.

c)� Staff�comply�with�published�codes�of�professional�practice,�relevant�to�their�professional�role.

d)� Position�descriptions,�including�accountabilities�and�responsibilities,�are�regularly�reviewed.

e)� There�is�a�process�for�managing�a�complaint�or�a�concern�about�a�clinician.�

f)� There�is�a�process�for�managing�a�complaint�or�concern�about�a�member�of�staff,�including�contracted�staff�and�volunteers.

a)� The�performance�development�system�is�integrated�with�any�relevant�service�plans�or�changing�service�requirements.

b)� Evaluation�is�undertaken�to�ensure�staff,�including�contracted�staff,�and�when�appropriate�volunteers,�have�participated�in�performance�review�and�development.

c)� Performance�measures�are�used�to�evaluate�and�improve�the�performance�development�system.�

d)� Staff�participate�in�evaluating�the�performance�development�system.

e)� The�process�for�managing�a�complaint�or�concern�about�a�clinician�is�evaluated,�and�improved�as�required.

f)� The�process�for�managing�a�complaint�or�concern�about�a�staff�member,�including�contracted�staff�member�or�volunteer,�is�evaluated,�and�improved�as�required.

a)� Performance�development�measures�and�processes�are�compared�internally�and�with�external�systems,�and�improvements�are�made�to�ensure�better�practice.�

and/or

b)� The�evaluation�of�the�continuing�employment�and�performance�development�system�demonstrates�that�the�system�is�effective�in�staff�development.

a)� The�organisation�demonstrates�it�is�a�leader�in�continuing�employment�and�performance�development�systems.

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seCtion 5Standards, criteria, elements and guidelinesstandard 2.2:�Human�resources�management�supports�quality�health�care,�a�competent�workforce�and�a�satisfying�working�environment�for�staff

300  The ACHS EQuIP5 Guide  Book 2  Accreditation, Standards and Guidelines  Support and Corporate Functions

Criterion 2.2.3

The�continuing�employment�and�performance�development�system�ensures�the�competence�of�staff�and�volunteers.�(continued)

IntentThe�intent�of�this�criterion�is�to�ensure�that�the�healthcare�organisation�and�the�individual�staff�member�take�equal�responsibility�for�maintaining�the�skills,�performance�and�competence�required�to�provide�quality�health�care.�

Throughout�this�criterion,�wherever�the�terms�‘staff’�and�‘staff�members’�are�not�further�clarified,�it�should�be�assumed�that�‘staff’�includes�employed�staff�and�contracted�staff,�seconded�staff�and�visiting�clinicians�while�working�within�the�organisation,�and�volunteers,�regardless�of�their�working�hours.

Relationships of 2.2.3 with other criteriaManagement�of�a�staff�member’s�performance�and�facilitating�their�ongoing�development�follows�on�from�their�appointment,�orientation�and�integration�(Criterion�2.2.1).�With�respect�to�clinicians,�this�will�further�involve�credentialling�and�delineation�of�the�scope�of�clinical�practice�(Criterion�3.1.3).

The�organisation’s�learning�and�development�system�provides�opportunities�for�employees�and�volunteers�to�develop�their�skills�and�improve�their�performance�(Criterion�2.2.4).�Effective�implementation�and�management�of�support�systems�and�workplace�relations�should�facilitate�long-term�employment�and�positive�employee�relations�(Criterion�2.2.5).

Position descriptions All�staff�should�have�a�documented,�dated�position�description,�which�is�kept�current�and�includes�specification�of�responsibilities,�accountabilities,�functions�and�activities�(including�scope�of�clinical�practice)�and�the�frequency�and�process�of�performance�appraisal.�

Position�descriptions�should�be�kept�up-to-date�to�support�high�productivity�and�to�focus�communications�between�employees�and�supervisors.�The�descriptions�should�be�dynamic�and�reflect�any�changes�in�duties�and�responsibilities�over�time.�A�joint�review�of�the�position�description�should�be�made�regularly�by�the�employee�and�the�supervisor,�and�changes�in�duties�and�responsibilities�discussed.�Updates�are�required�following�significant�changes�to�employment�structures�or�duties.�Review�of�the�position�description�could�be�undertaken�in�conjunction�with�the�performance�review,�which�is�usually�an�annual�event.

The�date�of�the�review�should�be�recorded�on�the�document.�If�there�are�changes�to�the�position�description,�the�body�responsible�for�employment�records�should�be�notified.�

Accountability�and�responsibility�are�not�the�same�thing,�although�a�single�person�may�be�both�responsible�for�something�and�as�a�result�may�be�held�accountable�for�a�failure�in�respect�of�it.�However,�multiple�people�may�be�responsible�for�the�same�thing,�so�the�person�held�‘accountable’�should�be�clearly�identified.

Preparing�position�descriptions�for�volunteers�aims�to�formalise�the�relationship�between�the�organisation�and�its�helpers.�It�will�emphasise�the�rights�and�responsibilities�of�both�parties.�Conducting�a�support�task�audit�will�highlight�the�type�and�amount�of�work�that�needs�to�be�done�to�enable�paid�staff�to�concentrate�on�core�activities.�It�is�preferable�that�paid�staff�members�play�an�active�role�in�the�volunteer�employment�process.�This�will�ensure�that�all�volunteer�work�complements�rather�than�duplicates�the�work�of�paid�staff.1�Clear�position�descriptions�may�also�focus�volunteer�recruitment�activities.

Prompt points

¼ Where does the organisation hold its centralised file of all position descriptions? Who is responsible for ensuring that all current positions have relevant position descriptions? How frequently is this process undertaken?

¼ How are roles and responsibilities of volunteers defined and managed by the organisation?

¼ How is senior management kept updated on the status of position descriptions for all personnel? What reporting mechanisms monitor the currency and coverage of position descriptions?

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Personnel records and training recordsPersonnel�records�should�be�accurate,�complete,�confidential�and�only�available�to�authorised�personnel�as�outlined�in�the�organisation’s�policy�and�procedures.�The�personnel�records�system�will�contain�personal�information�and�should�be�managed�in�accordance�with�the�National�Privacy�Principles�and�jurisdictional�legislation.�Access�of�employees�to�their�own�personnel�records�should�be�according�to�legal�regulations�and�organisational�policy.�Policy�and�procedures�should�protect�personnel�information�through�internal�systems�such�as:

• specifying�staff�with�limited�and�unlimited�access�to�specific�files

• restricting�physical�movement�of�staff�files�or�specifying�the�computer�terminals�through�which�information�is�accessed

• defining�the�circumstances�in�which�specified�information�may�be�disclosed.

Information�commonly�included�on�personnel�files�or�stored�in�a�Human�Resources�Information�System�includes:�

• personal�details,�employment�details,�position�description,�terms�and�conditions�of�employment,�relevant�educational�and�professional�qualifications�

• the�employment�contract�and�records�of�referee�and�other�validation�checks

• AHPRA�registration�number�(where�applicable),�and�dates�of�any�professional�registration�checks

• scope�of�practice�(where�applicable)

• designated�financial�authority

• record�of�staff�orientation

• record�of�attendance�at�fire�/�emergency�management�training

• record�of�education�and�training,�including�mandatory�training�such�as�child�protection�systems

• record�of�annual�performance�reviews

• records�of�leave

• record�of�any�compensable�injuries

• records�of�vaccinations

• disclosed�health�information,�such�as�allergies�or�carer�responsibilities

• record�of�any�formal�disciplinary�action.

The�management�system�for�personnel�records�should�abide�by�relevant�jurisdictional�legislation�and�organisational�policy�/�by-laws.�Most�jurisdictions�have�legislation�relating�to�privacy�of�the�records�and�their�retention�and�disposal.�

Prompt points

¼ What systems ensure that confidential information recorded on personnel records is restricted so that it is reviewed only under relevant circumstances by authorised staff?

¼ What processes help to ensure that personnel records are complete and regularly updated?

Professional registration and codes of professional practiceOrganisations�should�be�aware�of�the�requirements�for�registration�for�the�different�classes�of�healthcare�professionals�that�it�employs�or�who�deliver�care�from�their�premises�or�under�their�masthead.�Where�licences�/�registration�require�renewal,�there�should�be�an�alert�system�primed�to�the�expiry�date�for�all�staff�licences�to�ensure�that�where�the�organisation�does�not�administer�the�renewal�process,�renewal�details�are�confirmed.�National�registration�of�many�healthcare�professions�will�make�it�easier�to�confirm�the�registration�of�clinicians�through�an�online�database.�Information�is�available�at:�http://www.ahpra.gov.au/Registration/Registers%20of%20Practitioners.aspx�

In�addition�to�ensuring�that�clinical�staff�meet�their�obligations�for�registration,�the�organisation�should�also�monitor�whether�staff�are�meeting�their�professional�obligations�for�ongoing�professional�development�(CPD).�In�particular,�regular�updating�of�achievement�for�nurses�will�be�necessary,�as�their�scope�of�practice�may�be�expanded�following�completion�of�training�modules�and/or�advanced�skills�competency�checks.�The�review�/�updating�process,�and�particularly�any�associated�renumeration�implications,�should�be�understood�by�all�relevant�staff.

From�1�July�2010,�the�HealthPractitionerRegulationNationalLawAct2009�(Cth)�defines�registration�and�other�professional�obligations�for�the�majority�of�clinical�professions.�Under�this�Act,�specified�health�professions�and�their�titles�are�limited�to�use�by�those�registered�in�the�profession.�Professional�boards�coordinate�national�registration�under�the�umbrella�of�the�Australian�Health�Practitioner�Regulation�Agency�(AHPRA).

Under�AHPRA,�each�national�professional�board�ensures�that�registered�professionals�meet�requirements�for�professional�indemnity�insurance,�continuing�professional�development�standards,�English�language�skills,�and�requirements�in�relation�to�previous�practice�and�criminal�history.�

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seCtion 5Standards, criteria, elements and guidelinesstandard 2.2:�Human�resources�management�supports�quality�health�care,�a�competent�workforce�and�a�satisfying�working�environment�for�staff

302  The ACHS EQuIP5 Guide  Book 2  Accreditation, Standards and Guidelines  Support and Corporate Functions

Criterion 2.2.3

The�continuing�employment�and�performance�development�system�ensures�the�competence�of�staff�and�volunteers.�(continued)

The�AHPRA�national�healthcare�professional�boards�each�have�a�code�of�professional�conduct�by�which�their�members�are�expected�to�abide.�The�boards�receive�complaints�about,�and�notifications�of�health�issues�that�are�affecting,�professional�performance.�Following�a�complaint�or�notification,�the�relevant�board�reviews�the�case�and�decides�on�appropriate�action.�Clinicians�are�required�to�commit�to�fulfil�the�board’s�decision.�Any�notifications�are�recorded�beside�the�clinician’s�name�on�the�website�of�the�appropriate�boards�for�a�predetermined�period�of�time.�If�conditions�are�met�and�no�further�complaints�/�notifications�received�within�the�prescribed�time�period,�the�notification�is�subsequently�removed�from�the�public�record.

Prompt points

¼ What system is used for ensuring that all associated clinicians have maintained their registration? Would this process alert the organisation to a clinician who has received a notification from their professional board? In these cases, what, if any, action would be taken to follow up?

¼ How does the organisation use AHPRA’s registers of practitioners? Is the organisation recording AHPRA registration numbers for their practitioners to facilitate group checks?

¼ How does the organisation use the published professional codes of practice in their management of clinical staff?

Performance development and reviewThe�performance�development�system�aligns�employees’�goals,�skills,�talents,�and�performance�outcomes�with�the�organisation’s�vision,�mission,�and�goals�by�supporting�continuous�learning�and�competence�development,�by�clarifying�expectations�and�performance�standards�and�providing�feedback,�evaluation,�and�recognition�of�performance.�It�is�designed�to�promote�and�support�the�professional�development�of�the�organisation’s�employees.2

All�staff�should�be�informed�about�how�their�performance�will�be�managed�and�the�results�of�their�performance�review.�A�proper�assessment�of�the�employee’s�performance�takes�into�account�both�the�work-related�requirements�of�the�organisation�and�identified�employee�interests.�Wherever�possible,�aligning�individual�goals�with�the�goals�of�the�unit,�department�and�organisation�should�build�the�staff-employer�relationship�and�promote�staff�retention.�

Performance�review�of�all�staff�should3:�

• be�assessed�and�documented�three�months�after�initial�employment,�or�as�agreed�in�the�contract,�and�then�annually�or�according�to�the�employment�contract

• be�impartial,�transparent�and�capable�of�review�

• be�based�on�the�staff�member’s�position�description,�and�consider�any�changes�to�that�position�description

• be�in�accordance�with�organisation-wide�requirements

• identify�strengths�in�performance�

• include�the�active�participation�of�managers�and�staff

• involve�setting�performance�goals�

• follow�up�issues�from�previous�reviews.

Contracted�staff�fulfil�roles�within�an�organisation,�while�employed�by�an�intermediary�organisation.�The�roles�are�usually�casual�and/or�project-based.�Agency�nurses�are�contracted�staff.�Feedback�regarding�the�performance�of�contracted�staff�will�usually�be�made�through�their�employing�agency.�In�cases�where�performance�is�considered�inadequate,�the�organisation�/�ward�/�department�may�request�that�this�person�not�be�sent�again.�By�maintaining�a�centralised�record�system,�the�organisation�can�avoid�having�the�same�person�contracted�to�different�departments�within�the�organisation�subsequent�to�their�performance�being�considered�inadequate.�

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The�performance�review�for�volunteers�should�not�be�a�threatening�process.�Instead,�the�discussion�should�allow�the�goals�of�both�the�organisation�and�the�individual�to�be�clearly�understood,�facilitating�reassignment�of�tasks�or�improvements�to�internal�processes.�

Organisations�are�not�expected�to�complete�performance�reviews�on�all�volunteer�staff.�Within�a�large�volunteer�program,�records�of�participant�training�should�be�maintained.�It�would�be�considered�acceptable�for�performance�reviews�to�be�conducted�on�a�grouped�/�team�basis�or�to�follow�up�identified�performance�issues.�Methods�and�approaches�would�be�proportionate�to�the�roles�and�responsibilities�of�the�volunteers.�

Organisations�that�appoint�consumer�representatives�to�committees�should�consider�these�roles�and�their�HR�designations,�as�this�may�have�implications�for�insurance�cover,�payments�for�meals,�travel�or�parking,�training,�and�performance�review�needs.�Procedures�should�be�updated�accordingly.�

Regardless�of�whether�the�format�is�formal�or�casual,�and�the�circumstances�positive�or�strained,�exit�interviews�with�departing�staff�and�volunteers�should�be�undertaken�and�the�information�recorded�to�facilitate�further�planning�and�refinement�of�the�program.�

Prompt points

¼ How is the performance evaluation system designed so that performance reviews are conducted in an objective, constructive manner? How are the process and outcomes of performance management monitored against the organisation’s requirements?

¼ How is the performance of volunteers reviewed and reported?

¼ How does the system monitor the performance of clinicians? How does it ensure that clinicians are working within their defined scope of practice? How are clinicians supported in expanding their competencies within the organisation’s goals?

¼ What processes are used for identifying areas for performance improvement and ensuring that appropriate experience / training / education occurs?

SupervisionStaff�and�volunteers�should�be�provided�with�supervision,�management�and�professional�support.�

Clarity�regarding�supervisory�roles�and�responsibilities�will�be�required.�The�long-held�clinical�teaching�philosophy,�“see�one,�do�one,�teach�one”,�is�inadequate�to�ensure�competency�as�it�fails�to�take�into�consideration�differences�between�individual�practitioners�and�puts�consumers�/�patients�at�risk.�

Important�points�to�note�are:

• consultants�identified�as�responsible�for�clinical�care�should�understand�and�actively�participate�in�their�teaching�/�coordination�/�supervision�role.�To�achieve�accountability,�this�responsibility�must�be�clearly�documented�in�the�agreement�with�the�consultant

• orientation�of�junior�clinicians�should�extend�beyond�administrative�responsibilities�to�cover�clinical�care�responsibility�and�routes�for�accessing�assistance�when�required.

Mentoring�is�one�form�of�supervision.�In�clinical,�support�and�administrative�areas,�mentoring�programs�may�facilitate�professional�growth;�provide�information,�guidance�and�constructive�feedback;�assist�with�reviewing�decisions;�support�and�encourage;�highlight�shortfalls�in�agreed�performance;�and�should�maintain�confidentiality.

This�may�occur�through:

• informal�or�formal�support�by�a�more�experienced�person

• a�mutual�relationship�where�employees�share�experiences

• a�developmental�process�where�the�mentee�grows�in�skills,�knowledge�and�confidence

• a�strategy�to�share�intellectual�and�other�resources

• guided�learning�by�a�mentor.�

Traditionally�this�has�been�a�one-to-one�relationship,�but�group�mentoring�may�be�a�beneficial�option.4

Not�all�supervision�and�support�should�be�provided�by�a�person’s�direct�manager�/�supervisor.�Organisations�could�consider�the�use�of�peer�supervision�and�support.�Peer�supervision�can�take�a�number�of�forms�and�is�relatively�common�in�both�the�nursing�and�allied�health�professions.5

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seCtion 5Standards, criteria, elements and guidelinesstandard 2.2:�Human�resources�management�supports�quality�health�care,�a�competent�workforce�and�a�satisfying�working�environment�for�staff

304  The ACHS EQuIP5 Guide  Book 2  Accreditation, Standards and Guidelines  Support and Corporate Functions

Criterion 2.2.3

The�continuing�employment�and�performance�development�system�ensures�the�competence�of�staff�and�volunteers.�(continued)

Prompt points

¼ What processes / systems ensure that there is adequate supervision for junior clinical staff on all shifts?

¼ What processes / systems are used to ensure that senior clinical staff meet the obligations within their position descriptions for the supervision and development of junior staff?

Complaints about staffA�complaint�or�concern�about�a�clinician,�contracted�staff�member�or�volunteer�may�come�from�another�staff�member,�a�professional�group�/�team,�or�from�an�external�source.

In�reality,�there�are�many�ways�that�the�organisation�could�be�alerted�to�concerns�about�a�clinician:

• receipt�of�a�complaint�from�a�consumer�/�patient,�family�member,�or�person�external�to�the�organisation

• receipt�of�a�complaint�or�concern�raised�by�other�clinicians�or�staff�within�the�organisation

• an�external�investigation,�such�as�coronial�inquiries,�or�by�a�centralised�complaint�body,�such�as�the�health�services�ombudsman�or�similar�independent�body

• during�normal�performance�review�processes�

• during�the�investigation�of�an�incident�or�routine�case�review�processes

• during�review�of�consumer�/�patient�records�for�another�purpose

• during�routine�peer�reviews.

A�policy�and�system�should�be�in�place�to�manage�complaints�or�concerns�about�a�clinician.�This�is�an�important�component�of�improving�consumer�/�patient�safety�and�clinical�quality�within�an�organisation.�Some�organisations�may�choose�to�address�the�process�for�management�of�a�complaint�or�concern�about�a�clinician�in�their�by-laws.

Organisations�should�be�cognisant�that�HealthPractitionerRegulationNationalLawAct2009�(Cth)�obliges�those�healthcare�professionals�that�fall�under�the�auspice�of�this�law�to�notify�the�relevant�professional�board�of�impaired�behaviour�that�might�lead�to�the�public�being�placed�at�risk�of�harm�by�healthcare�professionals�(see�S.140�of�the�Act�above).6�Decisions�in�response�to�such�notifications�will�be�made�by�the�boards�of�the�relevant�professional�bodies.

Steps�for�managing�a�complaint�or�concern�about�a�clinician�include7:

• identification�of�the�complaint

• notification�to�relevant�managers�/�stakeholders

• investigation�of�the�complaint

• actions�in�response�to�the�identified�performance�issues

• reporting�the�outcomes�to�any�relevant�internal�or�external�organisations.�

Where�complaints�about�senior�staff�members�are�raised�by�staff,�management�should�also�be�conscious�of�the�potential�threat�to�a�‘whistleblower’;�action�may�be�needed�to�protect�whistleblowers�from�intimidation�or�to�counter-suggestions�of�incompetence.8,�9

Bullying�and�harassment�are�an�ongoing�issue�in�many�areas�of�health�care.�Some�national�professional�bodies,�including�the�Royal�Australasian�College�of�Surgeons10�and�the�Australian�Medical�Association11,�have�prepared�public�papers�on�respectful�behaviour�and�management�of�bullying�and�harassment.�Where�the�allegation�is�of�criminal�misconduct,�the�organisation�has�an�obligation�to�notify�police�and/or�other�relevant�bodies�such�as�Commissions�against�Corruption.�Complaints�regarding�registered�health�practitioners�should�be�referred�to�the�relevant�professional�board.

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October 2010  305

Prompt points

¼ How does the organisation’s system / process for managing a complaint about a clinician meet legislated requirements? How does this compare to the processes used to manage complaints about a non-clinical staff member? A volunteer? Subcontracted staff?

¼ Is protection for staff who submit a complaint (a ‘whistleblower’) State / Territory legislated, or covered by organisational policy? How does the complaint investigation process protect a complainant during the period of the investigation?

Evidence commonly presented

Consider whether the following will help to address criterion 2.2.3

¼ Education records

¼ Index / file of position descriptions

¼ Records of regular performance reviews

¼ Records of training provided

¼ Checks of clinicians’ registration – against the professional register or through filed copies of the registration papers

¼ Performance management policies, guidelines, templates

Performance measurementThis�criterion�states�that:�“The�continuing�employment�and�performance�development�system�ensures�the�competence�of�staff�and�volunteers”.�The�organisation�should�be�able�to�demonstrate�its�commitment�to�the�support�and�development�of�its�staff�via�policies�and�processes�governing�training,�education,�supervision,�performance�reviews�and�complaints�handling.

Some�common�suggested�performance�measures�are�as�follows:

Number�of�appointments�made�to�internal�candidates

Total number of appointments made

Comment:numbermaybeatotalcountorcalculatedbasedonfull-timeequivalents(FTEs)

Number�of�permanent�staff�with�current�position�descriptions�

Total number of permanent staff

Comment:numbermaybeatotalcountorcalculatedbasedonfull-timeequivalents(FTEs)

Number�of�identified�staff�who�successfully�complete�relevant�work�competencies�

Total number of identified staff required to complete work competencies

Comment:e.g.bloodmanagement,firetraining,manualhandling/task

Number�of�staff�who�participate�in�performance�reviews

Total number of staff

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seCtion 5Standards, criteria, elements and guidelinesstandard 2.2:�Human�resources�management�supports�quality�health�care,�a�competent�workforce�and�a�satisfying�working�environment�for�staff

306  The ACHS EQuIP5 Guide  Book 2  Accreditation, Standards and Guidelines  Support and Corporate Functions

Criterion 2.2.3

The�continuing�employment�and�performance�development�system�ensures�the�competence�of�staff�and�volunteers.�(continued)

Number�of�staff�with�development�needs�identified�at�appraisals,�whose�needs�have�been�met�

Total number of staff with development needs identified at appraisals

Comment:followupatnextperformancereview

Number�of�complaints�received�about�staff�members

Total number of staff

Number�of�harassment�complaints�received

Total number of staff

Number�of�discrimination�complaints�received

Total number of staff

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October 2010  307

References1.� Australian�Institute�for�Community�Practice�and�Governance�

(AICPG).�Designingpositiondescriptionsforvolunteers.�Melbourne�VIC;�AICPG.�Accessed�from�http://www.ourcommunity.com.au/management/view_help_sheet.do?articleid=83�on�13�April�2010.

2.� De�Cieri�H,�Kramer�R,�Noe�R�etal.HumanresourcemanagementinAustralia:strategy–people–performance.Sydney�NSW;�McGraw�Hill;�2003.

3.� University�of�Denver.�Performancereviewanddevelopmentsystem.�Denver�USA;�Denver�University.�Accessed�from�http://www.du.edu/hr/employment/performance_management.html�on�31�August�2010.

4.� McIntyre�E�and�Mills�J.�Mentoring�matters.�Adelaide�SA;�Primary�Health�Care�Research�&�Information�Service�(PHC�RIS);�2009.

5.� NSW�Health.�Guideline:Clinician’stoolkitforimprovingpatientcare.�Sydney;�NSW�Health;�2005.

6.� AHPRA�Medical�Board�of�Australia.�Consultationpaperoncodesandguidelinescomprisingguidelinesonadvertisingandguidelinesonmandatorynotification.Melbourne�VIC;�Medical�Board�of�Australia;�2010.

7.� Hunter�New�England�Area�Health�Service�(HNEAHS).�Managingaconcernorcomplaintaboutaclinician.Newcastle;�NSW�Health.�Accessed�from�http://www.hnehealth.nsw.gov.au/cg2/professional_practice/concern_or_complaint_about_a_clinician�on�13�April�2010.

8.� Faunce�TA�and�Bolsin�SN.�Three�Australian�whistleblowing�sagas:�lessons�for�internal�and�external�regulation.�MedJAust�2004;�181(1):�44-47.

9.� Johnstone�M-J.�Patient�safety,�ethics�and�whistleblowing:�a�nursing�response�to�the�events�at�the�Campbelltown�and�Camden�hospitals.�AustHealthRev2004;�28(1):�13-19.

10.� Royal�Australasian�College�of�Surgeons�(RACS).�Bullyingandharassment–recognition,avoidanceandmanagement.�Melbourne�VIC;�RACS;�not�dated.

11.� Australian�Medical�Association�(AMA).�Workplacebullyingandharassment–AMApositionstatement.Canberra�ACT;�AMA;�2009.

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seCtion 5Standards, criteria, elements and guidelinesstandard 2.2:�Human�resources�management�supports�quality�health�care,�a�competent�workforce�and�a�satisfying�working�environment�for�staff

308  The ACHS EQuIP5 Guide  Book 2  Accreditation, Standards and Guidelines  Support and Corporate Functions

IntentThe�intent�of�this�criterion�is�to�ensure�that�the�organisation’s�learning�and�development�system�for�its�staff�and�volunteers�is�structured,�planned�and�comprehensive.�

Relationships of 2.2.4 with other criteriaLearning�and�development�is�an�important�aspect�of�the�creation�of�a�competent�workforce�that�performs�within�a�satisfying�working�environment�(Standard�2.2).�Some�aspects�of�learning�and�development�will�be�voluntary,�while�others�will�be�mandated�by�legislation�or�policy,�for�example,�fire�and�disaster�safety�training�(Criterion�3.2.4)�and�health�records�management�(Criterion�2.3.1).�For�clinical�staff,�learning�and�development�can�facilitate�credentialling�and�expanding�the�scope�of�clinical�practice�(Criterion�3.1.3).�It�is�also�vital�for�those�clinicians�who�recruit�consumers�/�patients�for�research�projects,�and�associated�staff�involved�in�such�projects�(Criterion�2.5.1).�

Criterion LA – Awareness sA – implementationLA plus the following

MA – evaluationSA plus the following

eA – excellenceMA plus the following

oA – LeadershipEA plus the following

Criterion 2.2.4

The�learning�and�development�system�ensures�the�skill�and�competence�of�staff�and�volunteers.

a)� The�organisation�provides�training�in�accordance�with�legislative�and�policy�requirements.�

b)� Staff�and�volunteers�are�consulted�about�their�learning�and�development�needs.

a)� There�is�a�planned�and�documented�staff�development�program.

b)� There�is�an�evidence-based�learning�and�development�system�available�to�staff�and�volunteers�that:

� (i)� �identifies�both�the�needs�of�the�organisation�and�the�staff

� (ii)� �is�linked�to�the�performance�development�system

� (iii)� �ensures�staff�remain�competent�to�perform�their�work.

c)� There�is�a�process�to�identify�mandatory�training�for�staff�and�volunteers.

d)� The�organisation�provides�adequate�resources�for�learning�and�development.�

e)� Staff�contribute�to�the�teaching�and�supervision�of�students�when�relevant.

a)� Performance�measures�are�used�to�evaluate�learning�and�development�systems,�and�the�systems�are�improved�as�required.�

b)� The�student�teaching�and�supervision�program�is�evaluated,�and�improved�as�required.

a)� Performance�measures�for�learning�and�development�are�used,�compared�internally�and�with�external�systems,�and�improvements�are�made�to�ensure�better�practice.

and/or

b)� The�student�teaching�and�supervision�program�is�compared�with�external�programs,�and�improvements�are�made�to�ensure�better�practice.

and/or

c)� There�are�innovative�practices�for�learning�and�development.

a)� The�organisation�demonstrates�it�is�a�leader�in�learning�and�development�systems.

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Staff learning and development system The�learning�and�development�system�identifies�the�development�and�education�needs�of�the�organisation�and�individual�staff.1�

Depending�upon�on�the�organisation’s�specific�circumstances�and�needs,�the�learning�and�development�system�may�oversee:

• mandatory�training�that�responds�to�legislated�requirements�–�for�example,�fire�and�emergency�management,�OH&S,�health�records�management

• training�in�organisational�systems,�programs,�equipment�and�administrative�/�governance�structures�at�an�organisation-wide�or�departmental�level�

• training�in�response�to�identified�performance�gaps�–�for�instance,�based�on�review�and�benchmarking�of�performance�indicators,�a�series�of�complaints,�findings�of�an�investigation�of�a�consumer�/�patient�or�staff�safety�incident,�or�in�response�to�ACHS�survey�recommendations

• continuing�professional�development�–�to�advance�clinical�knowledge�and�to�meet�individuals’�mandated�requirements�for�ongoing�professional�registration

• personal�mentoring�coordinated�within�the�organisation’s�planning�(mentors�may�be�sourced�from�within�or�outside�the�organisation;�some�professional�organisations,�such�as�the�Australasian�Council�of�Health�Service�Management�(ACHSM)2,�facilitate�mentoring)

• advanced�skills�accreditation�for�relevant�professionals

• broadly�relevant�training�in�people�skills,�counselling,�teamwork,�communication,�management�and/or�continuous�quality�improvement.

Criterion LA – Awareness sA – implementationLA plus the following

MA – evaluationSA plus the following

eA – excellenceMA plus the following

oA – LeadershipEA plus the following

Criterion 2.2.4

The�learning�and�development�system�ensures�the�skill�and�competence�of�staff�and�volunteers.

a)� The�organisation�provides�training�in�accordance�with�legislative�and�policy�requirements.�

b)� Staff�and�volunteers�are�consulted�about�their�learning�and�development�needs.

a)� There�is�a�planned�and�documented�staff�development�program.

b)� There�is�an�evidence-based�learning�and�development�system�available�to�staff�and�volunteers�that:

� (i)� �identifies�both�the�needs�of�the�organisation�and�the�staff

� (ii)� �is�linked�to�the�performance�development�system

� (iii)� �ensures�staff�remain�competent�to�perform�their�work.

c)� There�is�a�process�to�identify�mandatory�training�for�staff�and�volunteers.

d)� The�organisation�provides�adequate�resources�for�learning�and�development.�

e)� Staff�contribute�to�the�teaching�and�supervision�of�students�when�relevant.

a)� Performance�measures�are�used�to�evaluate�learning�and�development�systems,�and�the�systems�are�improved�as�required.�

b)� The�student�teaching�and�supervision�program�is�evaluated,�and�improved�as�required.

a)� Performance�measures�for�learning�and�development�are�used,�compared�internally�and�with�external�systems,�and�improvements�are�made�to�ensure�better�practice.

and/or

b)� The�student�teaching�and�supervision�program�is�compared�with�external�programs,�and�improvements�are�made�to�ensure�better�practice.

and/or

c)� There�are�innovative�practices�for�learning�and�development.

a)� The�organisation�demonstrates�it�is�a�leader�in�learning�and�development�systems.

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seCtion 5Standards, criteria, elements and guidelinesstandard 2.2:�Human�resources�management�supports�quality�health�care,�a�competent�workforce�and�a�satisfying�working�environment�for�staff

310  The ACHS EQuIP5 Guide  Book 2  Accreditation, Standards and Guidelines  Support and Corporate Functions

Criterion 2.2.4

The�learning�and�development�system�ensures�the�skill�and�competence�of�staff�and�volunteers.�(continued)

Planning�should�define�the�objectives�of�learning�before�determining�the�mode�for�delivery�of�education,�and�should�evaluate�the�effectiveness�and�cost-benefit�of�any�program�against�these�pre-identified�goals.

Documents�that�demonstrate�organisational�planning�for�the�learning�and�development�program�may�include:

• training�/�learning�needs�analysis�reports�or�submissions

• an�annual�learning�and�development�plan�that�refers�to�the�organisation’s�strategic�and�operational�plans,�and/or�reflects�feedback�received�through�questionnaires,�focus�groups�or�staff�performance�reviews

• tenders�or�requests�for�quote�that�specify�learning�objectives

• training�program�proposals�that�reflect�identified�and�communicated�learning�objectives.

Evidence�that�the�learning�program�reflects�the�needs�of�the�organisation�may�include:

• matching�of�staff�development�/�learning�program�goals�to�organisation�goals�or�expanded�service�plans

• identification�of�the�organisation’s�mandatory�training�components�and�evidence�that�staff�attend�applicable�mandatory�training�sessions,�for�example,�fire�training,�infection�control,�risk�management,�CPR,�OH&S

• continuing�education�programs�(internal�and�external)�relevant�to�expanding,�changing�or�specialty�areas�of�service�provision,�or�to�the�specific�populations�that�it�services�(e.g.�age�groups,�categories�of�disability�or�cultures)

Evidence�that�the�learning�program�reflects�the�needs�of�staff�may�be�demonstrated�through:

• links�to�the�performance�development�system

• links�to�a�staff�survey

• attainment�of�competency�ratings,�advanced�skills�accreditation�or�expanded�scopes�of�practice�that�meet�goals�expressed�during�performance�review

• surveys�/�feedback�from�staff�attending�organisation-funded�training.

In�the�case�of�volunteers,�depending�upon�the�size�and�scope�of�the�program,�formal�training�may�not�be�cost-effective.�However,�a�process�of�orientation,�in-house�training�and�regular�revision�of�competencies�could�be�followed.�

A�policy�on�training�and�development�for�volunteers�may�include3:

• the�objectives�for�volunteer�training�and�development

• an�outline�of�training�programs�available�or�learning�goals

• the�appraisal�of�volunteer�performance�

• provision�of�feedback�/�acknowledgement�to�volunteers.

Topics�that�may�be�valuable�to�volunteers�include�an�organisational�overview�describing�areas�of�current�volunteer�involvement,�volunteer�responsibilities�and�expectations.�Information�on�infection�control,�confidentiality�guidelines,�and�information�to�assist�interactions�with�vulnerable�people�or�multicultural�groups�may�also�be�useful.�Attendance�at�training�sessions�should�be�documented�in�the�volunteer’s�record.

Prompt points

¼ How is the education and training component of the organisation’s staff development plan linked back to other organisational plans?

¼ What records are kept of staff development? How are these used for reporting to management on an organisation-wide or departmental basis, and for documenting individual compliance with mandatory training?

¼ Who is responsible for learning and development at the organisation? How does the organisation monitor whether its clinical training is evidence-based?

Mandatory training Mandatory�training�requirements�differ�between�jurisdictions,�however�across�many�jurisdictions�mandatory�training�relates�to�emergency�and�disaster�management,�occupational�health�and�safety,�health�records�management�and�privacy.�Additional�training�/�certification�may�be�required�for�staff�working�with�dangerous�goods,�radiation,�children,�food�and�in�other�specific�areas.

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Organisations�should�be�aware�of�the�specific�legislative�requirements�for�their�jurisdiction,�and�may�demonstrate�compliance�through�evidence�that:�

• approved�training�programs�were�provided�by�appropriately�qualified�trainers�

• training�was�attended�by�sufficient�numbers�of�relevant�staff�to�manage�risks�to�the�organisation�and�to�its�consumers�/�patients�(for�instance,�that�night�duty�staff�and�visiting�medical�staff�could�access�and�attend�emergency�training)

• records�of�attendance�have�been�included�in�/�linked�to�the�performance�records�of�individual�staff.

Training�may�also�be�mandated�for�specific�staff�by�the�employing�organisation,�a�department�of�health,�local�council,�ownership�body�or�public�service�authority.�Such�training�will�usually�be�documented�in�policy.�Similar�attention�to�record�keeping�will�be�expected�so�that�organisations�can�monitor�and�ensure�attendance�by�relevant�staff.

Prompt points

¼ What proportion of staff has attended mandatory training in handling an emergency such as a fire? What records are used to track attendance?

¼ What other training is mandatory in the organisation’s jurisdiction?

Determining learning and development needs Annual�performance�review�provides�an�opportunity�for�managers�to�determine�the�career�goals�of�their�staff�and�to�suggest�specific�training�/�education�to�address�identified�areas�for�development�and�improvement.�Review�meeting�notes�should�record�the�agreed�goals�for�personal�learning�and�development.�Team�meetings�or�feedback�forms�may�also�be�used�to�gain�information�on�staff�and�volunteer�learning�and�development�needs.

It�is�rarely�possible�to�align�organisational�/�departmental�goals�with�the�training�goals�and�ambitions�of�all�staff.�However,�managers�should�objectively�consider�personal�goals�alongside�team�dynamics,�personal�strengths�and�aptitudes,�budgets,�staffing�schedules,�and�proposed�changes�to�departmental�services,�when�assigning�staff�to�training�programs.�

Prompt points

¼ How satisfied are staff members with the accessibility and quality of learning and development?

¼ How are peers, managers and/or supervisors involved in applying learning to the workplace?

Evaluating and improving learning and development systemsTo�effectively�evaluate�a�program,�it�is�important�that�there�are�clear�organisational�goals�for�commissioning�a�training�course�or�for�sending�staff�members�to�attend�one.�Even�though�time�may�have�passed�since�the�original�decision�regarding�training�was�made,�the�evaluation�should�be�against�the�original�goals�that�guided�the�decision�or�the�brief�given�to�trainers.�

Evaluation�forms�will�usually�be�completed�following�a�training�session.�Feedback�provides�a�useful�guide�for�refining�future�training�programs.�In�addition�to�collating�feedback�from�onsite�programs�commissioned�by�the�organisation,�feedback�from�staff�attending�programs�off-site�may�be�used�to�evaluate�their�relevance�and�cost-effectiveness.�Post-training�testing�or�follow-up�reviews�provide�useful�feedback�on�the�effectiveness�of�learning�and�development�programs.�

Staff�surveys�offer�a�valuable�opportunity�to�determine�whether�the�learning�and�development�program�responds�to�those�needs�previously�identified�by�staff�and�whether�staff�believe�their�training�has�relevance�to�changing�workplace�needs.

In�addition,�indicators�may�be�collected�to�monitor�overall�compliance�with�legislated�training�requirements�(i.e.�proportion�of�staff�attending�specific�mandatory�training�within�designated�time�periods).�From�a�risk�management�perspective,�the�importance�of�mandatory�training�is�reflected�in�organisational�culture.�

Prompt points

¼ What does the organisation do with feedback from training programs?

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seCtion 5Standards, criteria, elements and guidelinesstandard 2.2:�Human�resources�management�supports�quality�health�care,�a�competent�workforce�and�a�satisfying�working�environment�for�staff

312  The ACHS EQuIP5 Guide  Book 2  Accreditation, Standards and Guidelines  Support and Corporate Functions

Criterion 2.2.4

The�learning�and�development�system�ensures�the�skill�and�competence�of�staff�and�volunteers.�(continued)

Teaching and supervision of students Consumer�/�patient�safety�is�dependent�on�adequate�supervision�of�students�and�newly�graduated�clinicians.�In�the�context�of�this�criterion,�any�reference�to�‘students’�includes�interns�and�registrars,�as�well�as�experienced�staff�who�are�still�learning.�

There�are�large�variations�in�competencies�among�new�graduates,�due�to�their�natural�abilities�and�variations�between�different�universities.4�Since�2010,�national�competency�frameworks�have�been�developed�for�each�nationally�registered�profession5,�aiming�to�provide�more�solid�measures�against�which�healthcare�organisations�can�consider�their�programs�for�student�training.�

Some�State�/�Territory�health�departments�have�procedures6,�7,�8�and�offer�or�support�education�programs9,�10�or�guidelines11�to�develop�the�teaching�and�supervision�skills�of�their�staff.�

The�Australian�Medical�Association�undertakes�an�annual�survey�of�junior�doctor�training,�education�and�supervision,�which�is�available�from�their�website,�at�http://ama.com.au.�The�national�feedback�on�teaching�and�supervision�in�the�nation’s�public�teaching�hospitals�provides�a�useful�foundation�for�review�of�training�issues�in�a�teaching�organisation.�

Organisations�must�plan�their�approach�to�the�management�of�junior�clinical�staff�and�students�working�on�their�premises�so�that:

• impositions�on�consumers�/�patients�are�controlled�

• students�have�opportunities�to�gain�essential�skills�

• risks�of�error�are�minimised

• wherever�possible,�supervisory�staff�can�also�gain�from�the�experience.�

These�objectives�create�conflicting�demands�which�will�only�be�resolved�by�monitoring�indicators�of�performance,�and�responding�to�feedback�from�both�supervisors�and�those�who�are�supervised.

Prompt points

¼ How is supervision of students / junior staff encouraged and improved?

¼ What actions have been taken to manage any risks associated with care provided by junior clinicians / students?

¼ How does the organisation evaluate its teaching programs for students?

Resources for learning and developmentLearning�and�development�options�will�depend�on�resources;�these�are�likely�to�be�financial,�but�may�also�be�related�to�staffing,�equipment�and�physical�access.�

For�most�onsite,�face-to-face�training,�cost-effectiveness�will�be�greatest�when�all�available�positions�in�a�training�session�can�be�filled.�

Developing�a�learning�and�development�budget�will�assist�in�determining�whether�proposed�training�plans�can�be�supported.�It�is�important�to�consider�both�direct�and�indirect�costs�in�a�training�budget.�Direct�education�costs�are�the�easily�identified,�concrete�costs�for�the�program�–�fees�for�attendance,�the�providers’�fees�and�salaries�of�training�coordinators.�Indirect�costs�of�learning�and�development�include�participants’�wages,�the�cost�of�covering�the�workload�of�absent�staff�and�administration�associated�with�training.

Where�budgets�are�limited,�research�may�identify�alternatives�to�traditional�learning�structures.�Consider�the�scope�for�on-the-job�coaching�and�mentoring,�extra-curricular�positions,�360�degree�feedback,�self-directed�study,�video�presentations,�teleconferencing,�job�shadowing,�group�training,�higher�duties�assignments�or�secondments,�special�projects,�training�one�person�to�teach�other�staff,�internal�and�external�networking,�buddy�systems,�professional�reading�and�e-learning.

Mandatory�training�is�an�unavoidable�investment.�Where�there�is�potential�for�disagreements�regarding�the�allocation�of�learning�and�development�resources,�there�should�be�a�guiding�document�against�which�planning�decisions�are�made.�This�is�likely�to�be�the�operational�plan�or�the�workforce�development�plan.

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October 2010  313

Where�it�impacts�performance�in�key�areas,�training�can�have�immediate�benefits.�In�other�areas,�the�investment�may�be�less�tangible�and�more�difficult�to�measure.�As�a�result,�learning�and�development�may�be�seen�as�an�‘easy�target’�for�cost-cutting.�When�justifying�the�allocation�of�‘adequate’�resources�to�learning�and�development,�it�may�be�helpful�to�present�the�benefits�of�training�/�education12�in�a�financially�driven�context,�such�as:

• safer�practices�that�can�reduce�insurance�premiums

• increased�productivity,�which�can�improve�consumer�/�patient�throughput

• reduced�maintenance�and�repair�costs

• greater�commitment�from�staff

• improved�staff�retention

• less�lost�time�or�other�wastage.

Prompt points

¼ How is learning and development resourced to meet both the short- and long-term goals of the organisation?

¼ What recognition and resourcing for learning and development is there by management?

Evidence commonly presented

Consider whether the following will help to address criterion 2.2.4

¼ Learning and development plan / staff development plan

¼ Ongoing education programs / training linked to assessment

¼ Identified mandatory training schedule, attendance register and follow-up of non-attendees

¼ Links to the education program from identification of training needs in performance appraisal system

¼ Assessment / evaluation of learning and development needs – satisfaction of staff

¼ Conference attendance support

¼ Access to journals and reference material

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seCtion 5Standards, criteria, elements and guidelinesstandard 2.2:�Human�resources�management�supports�quality�health�care,�a�competent�workforce�and�a�satisfying�working�environment�for�staff

314  The ACHS EQuIP5 Guide  Book 2  Accreditation, Standards and Guidelines  Support and Corporate Functions

Criterion 2.2.4

The�learning�and�development�system�ensures�the�skill�and�competence�of�staff�and�volunteers.�(continued)

Performance measurementThis�criterion�states�that:�“The�learning�and�development�system�ensures�the�skill�and�competence�of�staff�and�volunteers”.�The�organisation�should�be�able�to�demonstrate�that�it�meets�its�requirements�with�respect�to�mandatory�training�/�education,�and�also�facilitates�the�voluntary�learning�and�development�of�its�staff.�

Some�common�suggested�performance�measures�are�as�follows:

Number�of�staff�who�have�completed�all�appropriate�mandatory�training�sessions�

Total number of staff required to complete mandatory training

Number�of�mandatory�training�programs�reviewed�within�the�past�two�years�to�meet�changing�needs

Total number of mandatory training programs

Comment:thismeasurecouldbeseparatelyextendedtonon-mandatorytrainingprograms,butinthatcontext,itwouldmeasurelevelofinterestandaccessratherthancompliance

Number�of�staff�who�request�to�attend�an�external�training�session�and�who�attend

Total number of staff who request to attend an external training session

Number�of�staff�participating�in�internal�training�sessions

Total number of staff invited to attend internal training sessions

Number�of�internal�training�sessions�that�satisfy�staff�needs

Total number of internal training sessions held

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References1.� Gephart�MA,�Marsick�VJ,�Van�Buren�ME�and�Spiro�

MS.�Learning�organizations�come�alive.�TrainingandDevelopment1996;�50:�34-45.

2.� Australasian�College�of�Health�Service�Management.�Mentoring.�Sydney�NSW;�ACHSE.�Accessed�from�http://www.achsm.org.au/members-services/mentoring/�on�10�August�2010.

3.� National�Health�and�Medical�Research�Council�(NHMRC).�Workingwithvolunteersandmanagingvolunteerprogramsinhealthcaresettings.Melbourne�VIC;�NHMRC;�2003.

4.� Productivity�Commission.Australia’shealthworkforce.Canberra�ACT;�Productivity�Commission;�2006.

5.� Australian�Health�Practitioner�Regulation�Agency�(AHPRA).�Approvedprogramsofstudy.Canberra�ACT;�AHPRA.�Accessed�from�http://www.ahpra.gov.au/en/Education/Approved-Programs-of-Study.aspx�on�10�August�2010.

6.� Victoria’s�Mental�Health�Services.�Clinicalsupervisionguidelines.Melbourne;�Victorian�Dept�of�Health;�2005.

7.� NSW�Health.�Drugandalcoholclinicalsupervisionguidelines.�Sydney;�NSW�Health;�2006.

8.� WA�Mental�Health�Commission.ClinicalsupervisionframeworkforWAmentalhealthservicesandclinicians.�Perth;�WA�Department�of�Health;�2005.

9.� WA�Department�of�Health.�Culturallysecureapproachtoclinicalsupervision.�Perth;�WA�Health.�Accessed�from�http://www.healthinfonet.ecu.edu.au/health-resources/conferences?cid=575�on�9�August�2010.

10.� University�of�Western�Australia,�Faculty�of�Medicine,�Dentistry�and�Health�Sciences.�Teachingontherun.Perth�WA;�University�of�Western�Australia.�Accessed�from�http://www.meddent.uwa.edu.au/teaching/on-the-run�on�9�August�2010.

11.� Postgraduate�Medical�Council�of�Western�Australia�(PMCWA).�WesternAustralianjuniordoctorcurriculum–guidelinesforteachingandlearning:postgraduateyears1and2.Perth�WA;�PMCWA;�2006.

12.� Qld�Dept�of�Education�and�Training.Benefitsoftraining.Brisbane;�Queensland�Government.�Accessed�from�http://www.training.qld.gov.au/employers/training-staff/benefits.html�on�18�May�2010.

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seCtion 5Standards, criteria, elements and guidelinesstandard 2.2:�Human�resources�management�supports�quality�health�care,�a�competent�workforce�and�a�satisfying�working�environment�for�staff

316  The ACHS EQuIP5 Guide  Book 2  Accreditation, Standards and Guidelines  Support and Corporate Functions

IntentEmployee�support�systems�and�workplace�relations�are�a�vital�aspect�of�the�organisation’s�human�resources�management.�The�intent�of�this�criterion�is�to�promote�a�structured,�planned�and�comprehensive�system�for�managing�workplace�relations,�and�to�ensure�that�there�is�an�effective�employee�assistance�system�that�is�tailored�to�specific�staff�requirements�and�permits�the�development�of�a�network�of�support�for�staff�within�the�organisation.

Relationships of 2.2.5 with other criteriaThe�provision�of�employee�support�systems�and�the�facilitation�of�workplace�relations�is�a�vital�component�of�the�organisation’s�management�of�human�resources�(Standard�2.2)�and�will�support�the�organisation’s�staff�recruitment�and�appointment�(Criterion�2.2.2),�performance�development�(Criterion�2.2.3),�and�learning�and�professional�development�(Criterion�(2.2.4).�A�secure,�motivated�workforce�is�essential�for�the�provision�of�quality,�safe�care�and�services�(Criterion�3.1.1).�The�organisation’s�management�of�its�workforce�is�an�aspect�of�its�integrated�risk�management�framework�(Criterion�2.1.2),�and�failure�to�implement�proper�support�systems�and�workplace�relations�may�lead�to�incidents�(Criterion�2.1.3)�and�complaints�(Criterion�2.1.4).

Criterion LA – Awareness sA – implementationLA plus the following

MA – evaluationSA plus the following

eA – excellenceMA plus the following

oA – LeadershipEA plus the following

Criterion 2.2.5

Employee�support�systems�and�workplace�relations�assist�the�organisation�to�achieve�its�goals.

a)� The�workplace�rights�and�responsibilities�of�management�and�staff�are�clearly�defined,�communicated�and�respected.

b)� Staff�are�consulted�about�industrial�relations�and�support�services�in�their�workplace.

c)� Managers�have�the�skills�to�identify�‘at�risk’�staff�behaviour.�

d)� Staff�know�how�to�access�employee�support�services.

e)� Management�and�staff�have�access�to�information�about�grievance�processes.�

a)� Management�and�staff�work�cooperatively�to�achieve�effective�workplace�relations.

b)� The�organisation�supports�flexible�work�practices�to�sustain�work-life�balance.

c)� There�is�a�system�that�motivates�staff�and�identifies�the�value�of�staff�through�appropriate�acknowledgement.

d)� Managers�facilitate�staff�access�to�industrial�relations�and�employee�support�services.

e)� An�employee�assistance�program�is�implemented.

f)� There�is�a�consultative�and�transparent�system�to�identify,�manage�and�resolve�workplace�relations�issues.

g)� Workplace�relations�are�coordinated�with�relevant�external�groups.

a)� Performance�measures�are�used�on�a�regular�basis�to�evaluate�workplace�relations,�and�improvements�are�made�as�required.

b)� Performance�measures�are�used�on�a�regular�basis�to�evaluate�staff�support�services,�and�improvements�are�made�as�required.

a)� Performance�measures�for�workplace�relations�are�measured,�compared�internally�and�with�external�systems,�and�improvements�are�made�to�ensure�better�practice.

and/or

b)� Performance�measures�for�staff�support�services�are�compared�internally�and�with�external�systems,�and�improvements�are�made�to�ensure�better�practice.

a)� The�organisation�demonstrates�it�is�a�leader�in�employee�support�systems�and�workplace�relations.

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Staff support and assistance servicesOrganisational�employee�support�services�should�enhance�a�productive,�flexible�workplace.�The�services�provided�may�be�available�onsite�or�sourced�through�a�collaborative�agreement�with�another�provider,�who�may�have�an�office�onsite�or�at�another�location.�The�key�point�is�that�the�organisation�works�to�ensure�that�staff�are�aware�of�the�services�available�and�know�how�to�access�them.�

An�employee�assistance�program�(EAP)�is�a�proven�strategy�for�assisting�employees�and�their�families�with�personal�and�work-related�problems,�difficulties�and�concerns�that�they�may�experience�from�time�to�time,�and�which�affect�the�work�performance�of�an�employee.�

An�employee�assistance�program�may�include:

• mechanisms�for�early�intervention�to�enable�staff�to�seek�assistance�and�support

• encouragement�of�staff�to�recognise�and�seek�assistance�with�personal�problems�before�they�escalate

• an�effective�human�resources�and�OH&S�framework�that�promotes�workplace�health,�preventative�services�and�the�wellbeing�of�staff

• childcare�information�and�referral�services�

• elder�care�information�and�referral�services�

• support�groups�for�employees�with�family�issues

• counselling�services�

• recognition�and�reward�programs

• caring�for�those�with�work-�and�non-work�related�injuries.

Work-related�issues�where�the�EAP�may�provide�useful�support�include�internal�conflict�situations�and�stress�management�following�a�trauma�crisis�or�another�significant�incident.�The�EAP�provider�may�suggest�that�an�employee�seek�other�specific�professional�assistance,�such�as�from�a�medical�or�legal�practitioner.�Some�EAPs�extend�service�provision�to�immediate�family�members.

Criterion LA – Awareness sA – implementationLA plus the following

MA – evaluationSA plus the following

eA – excellenceMA plus the following

oA – LeadershipEA plus the following

Criterion 2.2.5

Employee�support�systems�and�workplace�relations�assist�the�organisation�to�achieve�its�goals.

a)� The�workplace�rights�and�responsibilities�of�management�and�staff�are�clearly�defined,�communicated�and�respected.

b)� Staff�are�consulted�about�industrial�relations�and�support�services�in�their�workplace.

c)� Managers�have�the�skills�to�identify�‘at�risk’�staff�behaviour.�

d)� Staff�know�how�to�access�employee�support�services.

e)� Management�and�staff�have�access�to�information�about�grievance�processes.�

a)� Management�and�staff�work�cooperatively�to�achieve�effective�workplace�relations.

b)� The�organisation�supports�flexible�work�practices�to�sustain�work-life�balance.

c)� There�is�a�system�that�motivates�staff�and�identifies�the�value�of�staff�through�appropriate�acknowledgement.

d)� Managers�facilitate�staff�access�to�industrial�relations�and�employee�support�services.

e)� An�employee�assistance�program�is�implemented.

f)� There�is�a�consultative�and�transparent�system�to�identify,�manage�and�resolve�workplace�relations�issues.

g)� Workplace�relations�are�coordinated�with�relevant�external�groups.

a)� Performance�measures�are�used�on�a�regular�basis�to�evaluate�workplace�relations,�and�improvements�are�made�as�required.

b)� Performance�measures�are�used�on�a�regular�basis�to�evaluate�staff�support�services,�and�improvements�are�made�as�required.

a)� Performance�measures�for�workplace�relations�are�measured,�compared�internally�and�with�external�systems,�and�improvements�are�made�to�ensure�better�practice.

and/or

b)� Performance�measures�for�staff�support�services�are�compared�internally�and�with�external�systems,�and�improvements�are�made�to�ensure�better�practice.

a)� The�organisation�demonstrates�it�is�a�leader�in�employee�support�systems�and�workplace�relations.

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seCtion 5Standards, criteria, elements and guidelinesstandard 2.2:�Human�resources�management�supports�quality�health�care,�a�competent�workforce�and�a�satisfying�working�environment�for�staff

318  The ACHS EQuIP5 Guide  Book 2  Accreditation, Standards and Guidelines  Support and Corporate Functions

Criterion 2.2.5

Employee�support�systems�and�workplace�relations�assist�the�organisation�to�achieve�its�goals.�(continued)

Employee�assistance�program�services�are�often�outsourced,�which�may�provide�advantages�of�confidentiality,�particularly�where�services�cover�personal�or�work-related�issues�that�may�threaten�job�security�such�as�alcohol�and�drug�issues,�family�issues�and�relationship�difficulties,�grief�and�bereavement,�health�and�lifestyle�issues,�gambling�and�addictions,�financial�/�legal�referrals,�mental�health�issues,�and�work-family�issues.�Organisations�should�work�with�their�employees�to�provide�services�that�meet�identified�needs,�are�accessible�and�as�far�as�possible,��cost-effective.

The�role�and�proactivity�of�labour�unions�within�the�health�service�varies�between�professions�and�between�jurisdictions.�The�introduction�of�‘modern�awards’�has�changed�the�roles�and�relationships�of�industrial�relations�in�recent�years.�The�key�point�is�that�whenever�industrial�relations�issues�are�dealt�with,�there�should�be�representation�for�staff�by�elected�representatives�who�require�support�from�persons�qualified�in,�or�with�access�to�advice�on,�the�relevant�legal�issues.�

The�AustralianFairWorkAct2009�(Cth)�sets�a�minimum�standard�for�industrial�relations�support�for�Australian�workers.�It�recognises�a�legitimate�role�for�unions�and�employer�organisations.�Freedom�of�association�laws�ensure�that�an�employer�cannot�dismiss�an�employee�because�he�or�she�is,�or�is�not,�a�member�of�a�union;�all�employees�have�access�to�remedies�for�breaches�of�freedom�of�association�provisions.�Organisations�should�support�these�rights�and�negotiate�with�workers�towards�mutually�acceptable�conditions.

Prompt points

¼ How is the availability of EAP services communicated to staff? Does the organisation know (preferably anonymously) whether the service is used?

¼ How active are unions / professional bodies within the organisational workforce? How does the organisation facilitate staff access to industrial relations information and support?

Workplace rights and responsibilitiesIn�Australia,�many�rights�and�responsibilities�of�workers�and�of�employers�are�recorded�in�jurisdictional�legislation.�Information�for�workers�who�are�employed�under�Commonwealth�legislation�is�available�from�the�Fair�Work�website�at�http://www.fairwork.gov.au/Pages/default.aspx,�which�has�separate�sections�providing�information�for�employees,�employers�and�contractors.�In�2009,�ten�minimum�standards�of�employment�were�included�within�the�FairWorkAct2009�(Cth).�These�apply�for�all�employees�covered�by�the�national�workplace�relations�system�and�relate�to�hours�and�timing�of�work,�leave�entitlements,�termination�and�redundancy,�and�the�provision�of�a�Fair�Work�information�statement.�Many�healthcare�positions�involve�shift�work,�uniforms,�equipment,�travel�and/or�supervisory�responsibilities;�the�specific�details�of�responsibilities�associated�with�these�should�be�clearly�outlined�in�position�descriptions�to�avoid�misunderstandings.�

Further�rights�and�responsibilities�may�also�be�included�within�specific�workplace�agreements�and�awards.�An�example�would�be�any�references�to�grievance�management.�

Some�health�departments�(all�but�Victoria,�NT,�ACT)�continue�to�operate�under�their�State�/�Territory�workplace�legislation;�rights�and�responsibilities�should�be�guided�by�the�jurisdictional�legislation�that�applies.�There�may�also�be�variations�between�jurisdictions�(and�even�between�organisations)�regarding�the�awards�on�which�salaries�are�set.�

Additional�rights�and�responsibilities�are�associated�with�professional�legislation,�codes�and�guidelines.�For�the�ten�nationally�registered�professions,�associated�regulations�can�be�accessed�through�links�to�the�appropriate�boards�from�the�Australian�Health�Practitioner�Regulation�Agency�website1,�as�can�details�of�any�relevant�codes�and�guidelines�http://www.ahpra.gov.au/Education/Continuing-Professional-Development.aspx�

Physicians�and�other�clinicians�who�operate�from�an�independent�practice�will�also�have�obligations�arising�from�their�business�arrangements�with�the�organisation,�and�in�this�context�it�is�extremely�important�that�the�respective�rights�and�responsibilities�of�both�business�entities�are�stated�clearly�in�their�agreement.�Registered�clinicians�would�be�expected�to�also�abide�by�these�conditions,�and�would�be�reported�to�their�professional�board�for�failure�to�comply.

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October 2010  319

Prompt points

¼ What rights and responsibilities are outlined in employment agreements for different categories of staff employed by or contracted to the organisation?

‘At-risk’ staff behaviour‘At-risk’�behaviour�involves�actions�and�reactions�from�health�professionals�and�other�staff�that�put�consumer�/�patient�care�and�safety�at�risk.�

The�HealthPractitionerRegulationNationalLawAct2009�(Cth)�obliges�those�healthcare�professionals�that�fall�under�the�auspices�of�this�law�to�notify�the�relevant�professional�board�of�impaired�behaviour�that�might�lead�to�the�public�being�placed�at�risk�of�harm�by�healthcare�professionals.2�Organisations�should�consider�this�Act�when�developing�systems�around�identifying�and�responding�to�‘at-risk’�behaviour.

Responding�to�disruptive�behaviours�can�present�challenges�for�managers�who�must�find�a�balance�between�supportive�and�disciplinary�responses.�Training�in�counselling�and�team�building�may�assist�managers�to�respond�empathetically�to�these�issues�if�and�when�they�arise.

Prompt points

¼ How does the organisation manage disruptive behaviours?

¼ What training is available to managers to assist them to recognise and manage ‘at-risk’ behaviours by team members?

Resolving workplace relations issuesStrategies�that�may�be�used�to�implement�effective�workplace�relations�could�include:

• incident�monitoring�that�identifies�workplace�issues

• distributing�documents�on�rights�and�responsibilities,�for�example,�codes�of�conduct,�prevention�of�harassment,�discrimination,�natural�justice,�standards�of�workplace�behaviour,�OH&S�standards,�access�to�industrial�relations�information

• monitoring�compliance�with�policies�and�procedures�and�statutory�requirements�

• identification�of�relevant�external�groups

• active�involvement�of�managers,�employees�and,�where�applicable,�their�representative�associations

• formal�training�and�development�for�managers�and�staff�

• a�formal�mechanism�for�staff�representation�and�evidence�of�regular�consultation�and�communication�between�staff�and�management

• a�staff�grievance�process�or�other�systems�to�manage�misunderstandings�/�disputes

• appropriate�monitoring�of�the�workplace�relations�management�system.

Data�on�workplace�issues�should�be�monitored�and�analysed�and�systems�put�in�place�to�facilitate�this.�Workplace�relations�management�should�be�included�in�the�overall�risk�management�plan�of�the�organisation.

Workplace�grievances�should�be�managed�in�an�effective�and�fair�way�for�all�parties�concerned.�Organisations�need�to�ensure�that:

• grievance�procedures�are�understood�by�both�management�and�staff

• all�staff�have�access�to�effective�and�fair�processes

• relevant�jurisdictional�legislative�requirements�are�met.

To�resolve�issues�in�the�workplace,�there�should�be�formal�processes�to�facilitate�discussions�between�the�different�parties,�with�the�goal�of�solving�disagreements�without�the�involvement�of�lawyers.�

Collective�workplace�agreements�may�include�processes�for�handling�grievances;�these�formalise�the�responsibilities�of�the�respective�parties�in�resolving�disagreements.�It�is�important�that�any�workplace�agreement�processes�align�with�existing�organisational�procedures�for�handling�internal�complaints�about�working�conditions.�Both�staff�and�management�should�understand�the�process�to�be�followed,�and�be�able�to�access�this�information�if�and�when�it�is�needed.�The�information�should�be�appropriate�so�that�both�parties�can�seek�information�and�advice�about�resolving�any�issue(s).�

Ideally,�industrial�relations�processes�provide�a�mechanism�that�will�prevent�relations�deteriorating�to�disputes.�Performance�measures�can�track�the�numbers�of�hours�lost�per�employee�in�industrial�relations�meetings�and�more�specifically,�disputes.�Similarly,�a�rise�in�the�number�of�disputes�that�result�in�court�appearances�may�indicate�a�failure�to�resolve�issues�through�alternative�mechanisms.�Surveys�of�staff�can�also�monitor�the�whether�workplace�relations�processes�are�meeting�staff�needs.�

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seCtion 5Standards, criteria, elements and guidelinesstandard 2.2:�Human�resources�management�supports�quality�health�care,�a�competent�workforce�and�a�satisfying�working�environment�for�staff

320  The ACHS EQuIP5 Guide  Book 2  Accreditation, Standards and Guidelines  Support and Corporate Functions

Criterion 2.2.5

Employee�support�systems�and�workplace�relations�assist�the�organisation�to�achieve�its�goals.�(continued)

Prompt points

¼ What systems are used to manage workplace relations issues within the organisation?

¼ What mechanisms ensure that processes are consultative and transparent?

¼ What outside groups provide support to employees and assist them to manage workplace relations discussions?

Maintaining work-life balanceThe�National�Employment�Standards3�which�were�initiated�in�2010�include�specific�recognition�of�a�need�for�flexible�work�practices�to�assist�workers�to�maintain�their�family�life�and�to�support�voluntary�community�service�in�specific�areas.

Work-life�balance�initiatives�can�help�employers�and�employees�to�be�productive�and�healthy�in�their�work�and�community�lives.�Flexible�work�arrangements�will�assist�staff�at�different�times�in�their�lives�to�allow�for�young�people�to�study,�parents�to�have�time�with�children,�employees�to�maintain�their�health�and�be�active�in�the�community�and�for�the�older�workers�approaching�retirement�to�contribute�on�reduced�hours.

The�nature�of�the�work�within�a�healthcare�setting�may�preclude�some�forms�of�flexible�work�practices,�however�organisations�should�consider�individual�circumstances�in�their�decision�making�in�relation�to:�

• working�hours�including�reduction�in�hours�worked,�changes�to�start�/�finish�times,�working�additional�hours�to�make�up�for�lost�time

• flexible�work�patterns�such�as�working�‘split-shifts’�or�job-sharing�arrangements,�or�taking�time�off�in�lieu�of�overtime�payments

• flexible�work�locations,�which�may�be�applicable�for�some�positions

• flexible�leave�arrangements,�for�instance�accessing�annual�leave�in�single�day�periods�or�as�part�of�single�days�or�taking�accrued�rostered�days�off�as�part�days.

Some�workers�may�choose�to�support�emergency�organisations�such�as�reserve�defence�forces�

and�community�emergency�teams.�Workplace�entitlements�are�now�in�place�under�the�National�Employment�Standards�to�support�community�service�commitments;�organisations�may�choose�to�extend�their�support�beyond�the�minimum�time�periods�stated�or�to�additional�community�service�organisations.�

Prompt points

¼ What actions have been taken by the organisation to support the work-life balance of its employees?

¼ What has been the impact of any efforts to improve the flexibility of work practices within the organisation?

Staff motivation and acknowledgement of performanceIn�all�professions,�most�workers�seek�three�overarching�goals�from�their�work4:�

• equity:�to�be�respected�and�to�be�treated�fairly�in�areas�such�as�pay,�benefits,�and�job�security

• achievement:�to�be�proud�of�one’s�job,�accomplishments,�and�employer

• camaraderie:�to�have�good,�productive�relationships�with�fellow�employees.�

To�maintain�an�enthusiastic�workforce,�management�must�meet�all�three�goals.�Indeed,�employees�who�work�for�companies�where�just�one�of�these�factors�is�missing�are�three�times�less�enthusiastic�than�workers�at�companies�where�all�elements�are�present.�Goals�cannot�be�substituted:�improved�recognition�cannot�replace�better�pay,�money�cannot�substitute�for�taking�pride�in�a�job�well�done,�and�pride�alone�will�not�pay�the�mortgage.

Examples�of�methods�that�organisations�and/or�managers�may�use�to�acknowledge�performance�include:

• formal�awards,�such�as�employee-of-the-year,�or�similar

• thank�you�notes

• celebratory�meals�for�the�team

• time-in-lieu�following�periods�of�hard�work

• bonus�payments

• opportunities�to�attend�conferences�or�other�events

• ensuring�that�external�compliments�are�passed�on.

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October 2010  321

Motivation�should�be�monitored�through�performance�reviews,�other�meetings�and�interviews�and�staff�surveys.�

Prompt points

¼ What measures does the organisation use to monitor motivation?

¼ How does the organisation acknowledge and reward high performance?

Evidence commonly presented

Consider whether the following will help to address criterion 2.2.5

¼ Employee assistance program (EAP) utilisation records

¼ Records of negotiations of flexible work practices with staff

¼ Documentation of flexible work arrangements

¼ Employee acknowledgement awards

¼ Workplace relations disputes / grievances reports and documented resolution

¼ Records of communication between the organisation and relevant unions

¼ Staff satisfaction surveys of workplace relations issues such as pay and conditions, participation in workplace decisions, teamwork, workplace culture and knowledge of employee support programs

¼ Training records regarding workplace relations issues such as conflict resolution, discrimination, bullying and harassment prevention

¼ Records of how occurrences of ‘at-risk’ staff behaviours are addressed

¼ Communication materials about employee support services

¼ Internal communications regarding workplace relations issues

¼ Demonstrated use of employee support programs

¼ Evaluation of quality of staff information about employee support services

Performance measurementThis�criterion�states�that:�“Employee�support�systems�and�workplace�relations�assist�the�organisation�to�achieve�its�goals”.�The�organisation�should�be�able�to�demonstrate�that�it�meets�its�legislative�requirements�in�terms�of�workplace�relations,�and�that�it�provides�systems�of�support�for�its�staff,�including�a�formal�employee�assistance�program,�that�facilitate�the�meeting�of�organisational�goals.

Some�common�suggested�performance�measures�are�as�follows:

Number�of�staff�who�are�aware�of�the�employee�assistance�program�

Total number of staff surveyed

Comment:i.e.thatthisisafreeandconfidentialserviceavailableforstafftoaccess

Number�of�staff�who�are�satisfied�with�the�employee�assistance�program

Total number of staff who have used the employee assistance program

Comment:asprovidedinde-identifiedformbyEAPprovider

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seCtion 5Standards, criteria, elements and guidelinesstandard 2.2:�Human�resources�management�supports�quality�health�care,�a�competent�workforce�and�a�satisfying�working�environment�for�staff

322  The ACHS EQuIP5 Guide  Book 2  Accreditation, Standards and Guidelines  Support and Corporate Functions

Criterion 2.2.5

Employee�support�systems�and�workplace�relations�assist�the�organisation�to�achieve�its�goals.�(continued)

Number�of�episodes�of�harassment�/�bullying�/�discrimination

Total number of staff

Number�of�hours�lost�due�to�disputes

Total number of work hours

Number�of�hours�leave�taken�due�to�stress

Total number of hours of leave taken

Number�of�staff�undertaking�industrial�relations�training

Total number of FTE staff

Comment:FTE=full-timeequivalent

Number�of�staff�satisfied�with�the�management�of�workplace�issues

Total number of staff surveyed

References1.� Australian�Health�Practitioner�Regulation�Agency�(AHPRA).�

AboutAHPRA.Canberra�ACT;�AHPRA.�Accessed�from�http://www.ahpra.gov.au/About-AHPRA.aspx�on�31�August�2010.

2.� AHPRA�Medical�Board�of�Australia.�Consultationpaperoncodesandguidelinescomprisingguidelinesonadvertisingandguidelinesonmandatorynotification.Melbourne�VIC;�Medical�Board�of�Australia;�2010.

3.� Fair�Work�Australia.�TheNationalEmploymentStandards(Part2-2).�Canberra�ACT;�Fair�Work�Australia.�Accessed�from�http://www.fwa.gov.au/documents/awardmod/nes.pdf�on�21�June�2010.

4.� Sirota�D,�Mischkind�LA�and�Meltzer�MI.�Stop�demotivating�your�employees!�HarvardManagementUpdate�2006;�11(1).�Accessed�from�http://www.sirota.com/pdfs/Stop_Demotivating_Your_Employees_Harvard_Management_Update_Jan_2006.pdf�on�6�September�2010.

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October 2010  323

2.3�Information�Management�Standard

The�standard�is:�Information management systems enable the organisation’s goals to be met.

The�intent�of�this�standard�is�to�ensure�that�data�and�information�meets�the�organisation’s�needs�and�supports�the�delivery�of�quality�care�and�service.�

The�principles�of�good�information�management�are�the�same�regardless�of�the�size�and�type�of�organisation�and�the�complexity�of�the�information�technology.�There�are�increasing�requirements�for�information�management�to�support�organisational�performance�and�healthcare�delivery.�

There�are�four�criteria�in�this�standard.�They�are:

2.3.1� �Health records management�systems�support�the�collection�of�information�and�meet�the�consumer�/�patient�and�organisation’s�needs.

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

2.3.3� Data and information are collected, stored and used�for�strategic,�operational�and�service�improvement�purposes.

2.3.4� �The�organisation�has�an�integrated�approach�to�the�planning,�use�and�management�of�information and communication technology�(I&CT).

seCtion 5Standards, criteria, elements and guidelines

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seCtion 5Standards, criteria, elements and guidelinesstandard 2.3:�Information�management�systems�enable�the�organisation’s�goals�to�be�met

324  The ACHS EQuIP5 Guide  Book 2  Accreditation, Standards and Guidelines  Support and Corporate Functions

Criterion LA – Awareness sA – implementationLA plus the following

MA – evaluationSA plus the following

eA – excellenceMA plus the following

oA – LeadershipEA plus the following

Criterion 2.3.1

Health�records�management�systems�support�the�collection�of�information�and�meet�the�consumer�/�patient�and�organisation’s�needs.

a)� There�is�a�health�records�management�policy�and�system�that�ensures:

� (i)� �the�secure,�safe�and�systematic�storage�of�data�and�records

� (ii)� �timely�and�accurate�retrieval�of�records�stored�on�or�off-site

� (iii)� �consumer�/�patient�privacy�when�information�is�communicated

� (iv)� �retention�and�destruction�according�to�all�relevant�standards�/�legislation�/�policy�/�guidelines.

b)� Each�consumer�/�patient�is�allocated�an�organisation-wide�unique�identifier.

c)� Where�multiple�records�for�the�consumer�/�patient�exist�they�are�cross-referenced.

d)� Clinical�classification�is�undertaken�for�all�inpatient�admissions�in�accordance�with�jurisdictional�standards,�where�available,�or�guidelines.�

e)� Documented�guidelines�are�available�for�consumers�/�patients�on�how�to�access�their�health�records.

a)� The�health�records�management�system�is�managed�with�reference�to�any�relevant�standards,�codes�of�practice�and�industry�guidelines.

b)� There�is�a�system�to�support�the�allocation�and�maintenance�of�the�unique�identifier.

c)� A�central�index�of�identifiers�is�maintained.

d)� The�health�record�is�linked�to�other�health�information�systems�using�the�unique�identifier.

e)� All�components�of�the�health�record�are�accounted�for�at�a�central�point,�and�are�monitored.�

f)� Training�on�health�record�keeping�and�records�management�is�available�for�relevant�staff.

g)� Coding�and�reporting�time�frames�meet�internal�and�external�requirements.

h)� Healthcare�workers�participate�in�the�analysis�of�data�including�clinical�classification�information.�

i)� Requests�by�consumers�/�patients�for�access�to�health�records�are�met�within�a�set�period�in�accordance�with�jurisdictional�policy�/�legislation.

a)� Health�records�management�systems�are�evaluated,�and�improvements�are�made�as�required.

b)� Checks�for�consumers�/�patients�that�have�multiple�identifiers�are�regularly�made�on�the�central�index,�and�improvements�/�links�are�made�when�required.

c)� The�tracking�and�monitoring�of�health�records�is�evaluated,�and�improvements�are�made�when�required.

d)� Coding�and�reporting�processes�are�evaluated,�and�improvements�are�made�when�required.

a)� Health�records�management�systems�are�compared�internally�and�with�external�systems,�and�improvements�are�made�to�ensure�better�practice.

and/or

b)� Systems�for�managing�unique�identifiers�are�compared�internally�and�with�external�systems,�and�improvements�are�made�to�ensure�better�practice.

and/or

c)� Coding�performance�indicators�are�compared�externally,�and�improvements�are�made�to�ensure�better�practice.

a)� The�organisation�demonstrates�it�is�a�leader�in�health�records�management.

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October 2010  325

Criterion LA – Awareness sA – implementationLA plus the following

MA – evaluationSA plus the following

eA – excellenceMA plus the following

oA – LeadershipEA plus the following

Criterion 2.3.1

Health�records�management�systems�support�the�collection�of�information�and�meet�the�consumer�/�patient�and�organisation’s�needs.

a)� There�is�a�health�records�management�policy�and�system�that�ensures:

� (i)� �the�secure,�safe�and�systematic�storage�of�data�and�records

� (ii)� �timely�and�accurate�retrieval�of�records�stored�on�or�off-site

� (iii)� �consumer�/�patient�privacy�when�information�is�communicated

� (iv)� �retention�and�destruction�according�to�all�relevant�standards�/�legislation�/�policy�/�guidelines.

b)� Each�consumer�/�patient�is�allocated�an�organisation-wide�unique�identifier.

c)� Where�multiple�records�for�the�consumer�/�patient�exist�they�are�cross-referenced.

d)� Clinical�classification�is�undertaken�for�all�inpatient�admissions�in�accordance�with�jurisdictional�standards,�where�available,�or�guidelines.�

e)� Documented�guidelines�are�available�for�consumers�/�patients�on�how�to�access�their�health�records.

a)� The�health�records�management�system�is�managed�with�reference�to�any�relevant�standards,�codes�of�practice�and�industry�guidelines.

b)� There�is�a�system�to�support�the�allocation�and�maintenance�of�the�unique�identifier.

c)� A�central�index�of�identifiers�is�maintained.

d)� The�health�record�is�linked�to�other�health�information�systems�using�the�unique�identifier.

e)� All�components�of�the�health�record�are�accounted�for�at�a�central�point,�and�are�monitored.�

f)� Training�on�health�record�keeping�and�records�management�is�available�for�relevant�staff.

g)� Coding�and�reporting�time�frames�meet�internal�and�external�requirements.

h)� Healthcare�workers�participate�in�the�analysis�of�data�including�clinical�classification�information.�

i)� Requests�by�consumers�/�patients�for�access�to�health�records�are�met�within�a�set�period�in�accordance�with�jurisdictional�policy�/�legislation.

a)� Health�records�management�systems�are�evaluated,�and�improvements�are�made�as�required.

b)� Checks�for�consumers�/�patients�that�have�multiple�identifiers�are�regularly�made�on�the�central�index,�and�improvements�/�links�are�made�when�required.

c)� The�tracking�and�monitoring�of�health�records�is�evaluated,�and�improvements�are�made�when�required.

d)� Coding�and�reporting�processes�are�evaluated,�and�improvements�are�made�when�required.

a)� Health�records�management�systems�are�compared�internally�and�with�external�systems,�and�improvements�are�made�to�ensure�better�practice.

and/or

b)� Systems�for�managing�unique�identifiers�are�compared�internally�and�with�external�systems,�and�improvements�are�made�to�ensure�better�practice.

and/or

c)� Coding�performance�indicators�are�compared�externally,�and�improvements�are�made�to�ensure�better�practice.

a)� The�organisation�demonstrates�it�is�a�leader�in�health�records�management.

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326  The ACHS EQuIP5 Guide  Book 2  Accreditation, Standards and Guidelines  Support and Corporate Functions

Criterion 2.3.1

Health�records�management�systems�support�the�collection�of�information�and�meet�the�consumer�/�patient�and�organisation’s�needs.�(continued)

IntentThe�intent�of�this�criterion�is�to�ensure�that�the�organisation’s�health�records�management�system�facilitates�the�provision�of�care.�A�key�purpose�of�health�records�is�to�support�continuity�of�care.�Health�records�must�therefore�be�managed�so�as�to�be�kept�complete,�up-to-date�and�available�to�relevant�clinicians�in�a�timely�manner.

Each�organisation�should�ensure�the�integrity,�safety,�controlled�access�to�and�security�of�all�health�records.

Although�issues�related�to�paper-based�records�systems�versus�electronic�systems�may�differ,�the�goals�of�record�keeping�are�fundamental�regardless�of�the�method(s)�used�to�maintain�those�records.�The�health�records�management�criterion�does�not�direct�the�form�of�record�keeping,�but�is�provided�to�ensure�that�health�records�are�maintained�to�manage�risk�to�the�organisation.

Relationships of 2.3.1 with other criteriaSafe,�high�quality�care�depends�upon�the�timely�and�accurate�gathering�of�data�into�the�health�record�(Criterion�1.1.8),�which�must�then�be�kept�secure�yet�accessible�to�relevant�clinicians�by�an�effective�health�records�management�system,�and�which�may�be�wholly�or�partly�operated�through�the�organisation’s�information�and�communication�technology�framework�(Criterion�2.3.4).

Efficient�health�records�management�supports�effective�ongoing�care�(Criterion�1.1.6)�and�the�processes�of�clinical�handover�(Criterion�1.1.5).�It�is�an�aspect�of�the�organisation’s�integrated�risk�management�framework�(Criterion�2.1.2),�and�failure�to�implement�a�fully�effective�system�may�lead�to�incidents�(Criterion�2.1.3)�and�complaints�(Criterion�2.1.4).�Access�to�his�or�her�health�record�is�a�fundamental�right�of�the�consumer�/�patient�(Criterion�1.6.2).

Health records management systemPolicies�and�procedures�for�the�health�records�management�system�should�include�the�following�areas:

• information�privacy

• updating�of�information,�such�as�consumer�/�patient�information

• storage�

• damage

• retrieval

• retention

• destruction

• unique�identification

• personal�identification

• clinical�classification.

Three�Australian�standards�(AS)�provide�guidance�in�relation�to�health�records:

• AS�2828:1999�Paper-basedhealthcarerecords

• AS�ISO�15489.1:2002Recordsmanagement–General

• AS�ISO�15489.2:2002�Recordsmanagement–Guidelines

• AS�ISO�23081.1:2006�Informationanddocumentation–Recordsmanagementprocesses–Metadataforrecords.Part1:Principles.

Records�management�involves�the�planning,�control�and�protection�of�records�and�documents�of�the�organisation.�For�the�purpose�of�this�criterion,�records�refer�to�all�clinical�records,�both�electronic�and�paper-based,�and�should�refer�to�AS�ISO�15489:2002�Recordsmanagement,�health�records�acts�and�jurisdictional�privacy�laws.�Information�is�available�for�individual�States�and�Territories�from�the�Office�of�the�Federal�Privacy�Commissioner.1

Damage�to�paper�records�can�be�minimised�by�ensuring�that�light,�humidity,�heat,�vermin�and�moisture�are�monitored�and�controlled,�and�that�fire�prevention�practices�and�detection�systems�are�used.�

Storage�areas�or�systems�should�enable�storage�of�records�for�at�least�as�long�as�required�by�legislation.�

Each�State�/�Territory�health�department�has�set�schedules�for�retention�and�disposal�of�various�record�types.�Policy�and�procedure�should�direct�staff�as�to�how�long�records�should�be�kept�and�responsibility�for�destruction�of�records�should�be�assigned�to�the�relevant�authority.�

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Destruction�procedures�should�consider:

• destruction�according�to�the�retention�schedule

• systems�for�easy�identification�of�records�that�should�be�culled�and�destroyed,�such�as�having�a�year�of�last�use�on�the�front�of�the�record

• confidentiality

• that�contractors,�if�used,�are�destroying�records�according�to�the�contract�and�that�evidence�of�destruction�is�provided

• the�best�method�of�destruction,�for�example�burning�or�shredding�for�hard�copy�records,�wiping�disks�clean�or�the�disks�physically�destroyed�for�electronic�records.�

Organisations�should�ensure�that�records�stored�by�contractors�are�retained�under�appropriate�standards�and�according�to�organisational�policy.

Regardless�of�whether�the�record�is�in�primary�or�secondary�storage,�accurate�and�timely�data�/�information�retrieval�relies�upon�satisfactory:

• record�filing�systems�

• record�tracking�systems

• a�retrieval�system�that�meets�needs

• policies�and�procedures�that�are�useful,�especially�for�casual�employees�and�after-hours�staff

• compliance�with�policies�and�procedures.

This�can�be�monitored�by�tracking�the:

• timeliness�of�record�retrieval�

• accuracy�of�responses�to�requests�for�records

• satisfaction�of�staff�/�consumers�who�request�records.�

Prompt points

¼ How does the organisation manage hard copy and electronic records in a way that makes it easy for approved people to find the information they need?

¼ What are the systems for health records storage, retrieval and destruction? How are staff advised of these procedures?

¼ How are paper records stored? How are records destroyed?

¼ How are electronic records archived?

¼ What future planning is in place for electronic records storage, retention and destruction?

Consumer / patient access The�organisation�should�have�processes�in�place�by�which�the�consumer�/�patient�can�gain�access�to�his�or�her�own�health�record,�and�this�information�should�be�proactively�provided�to�the�individual�prior�to�or�upon�admission.�This�aspect�of�consumer�/�patient�rights�is�discussed�in�more�detail�within�criterion�1.6.2.�Organisations�should�have�policy�and�procedures�to�manage�requests�for�access�to�personal�health�records�and�any�requests�should�be�noted�in�the�consumer�/�patient’s�health�record.�The�period�of�time�within�which�the�organisation�must�respond�to�a�request�for�access�to�a�health�record�will�be�jurisdictionally�determined.

The�content�of�the�health�record�must�be�protected�because�it�contains�information�about�individuals�that�may�be�personally�or�financially�damaging�if�accessed�inappropriately.�

The�National�Privacy�Principles�(2001)2–4�and�the�PrivacyAct1988�(Cth)�can�assist�organisations�to�implement�systems�to�protect�the�privacy�of�consumer�/�patient�information.�Most�States�and�Territories�have�developed�guidelines�and�legislation�in�relation�to�information�privacy.�Healthcare�organisations�should�refer�to�both�Commonwealth�and�State�/�Territory�legislation�for�direction�in�meeting�the�principles�of�privacy.

Prompt points

¼ Where is the organisation’s information on consumer / patient access to their health records available?

¼ How are consumers / patients advised about access to their health record?

¼ How are staff made aware of the procedures? How is compliance with procedures and timeliness of response to consumer requests for health record access monitored?

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328  The ACHS EQuIP5 Guide  Book 2  Accreditation, Standards and Guidelines  Support and Corporate Functions

Criterion 2.3.1

Health�records�management�systems�support�the�collection�of�information�and�meet�the�consumer�/�patient�and�organisation’s�needs.�(continued)

Unique identifier A�unique�identifier�is�an�organisation-produced�number,�code,�or�letters,�of�whatever�sort,�given�to�a�single�consumer�/�patient,�for�the�first�and�every�subsequent�attendance�at�the�organisation.�The�unique�identifier�helps�to�identify�each�consumer�/�patient�and�ensures�continuity�of�care.�Safety�and�quality�can�be�compromised�if�the�consumer�/�patient�is�not�correctly�identified,�and�when�wrong�or�insufficient�health�information�is�used�for�care.�Development�of�policy�and�procedure�would�include�consideration�of:

• personal�details�that�should�be�collected�to�adequately�allocate�the�consumer�/�patient�unique�identifier.�State�/�Territory�health�departments�have�guidelines�for�identification�information�that�should�be�referenced

• systems�to�support�the�allocation�and�maintenance�of�the�unique�identifier�

• cross-referencing�of�unavoidable�multiple�records

• the�need�for�phonetic�searches�of�names�that�sound�alike�but�are�spelt�differently

• the�need�for�alias�searches�to�identify�people�who�use�more�than�one�name

• processes�to�differentiate�between�people�with�the�same�name

• processes�for�tracking�provision�of�care�where�consumers�/�patients�access�services�anonymously.

Prompt points

¼ What system-based precautions prevent different sites / departments issuing a second identifier to the same person?

¼ How are multiple identifiers revealed? What process is followed when multiple identifiers are discovered?

¼ What changes have / will be made for the roll out of the individual health identifier (HPI-I) and health provider identifiers (HPI-O)?

Monitoring and tracking health recordsConsumer�/�patient�health�records�have�multiple�uses�and�many�people�have�legitimate�access�to�them.�As�more�organisations�begin�to�move�to�electronic�health�records,�security�will�become�more�of�an�issue.�The�risks�in�health�record�security�have�become�more�than�a�matter�of�controlling�access�to�the�storage�area�of�paper�files.

Potential�risks�associated�with�inappropriate�access�to�health�information�include:

• incorrect�or�misinformed�perceptions�by�persons�whose�knowledge�has�not�been�authorised�by�the�consumer�/�patient

• fraudulent�claims�tied�to�Medicare�numbers�or�private�health�insurance�details

• the�publicising�of�historical�health�events�or�disabilities�in�contexts�that�may�disadvantage�or�embarrass�an�individual

• reluctance�of�insurers�to�accept�applications�from�higher-risk�individuals

• falsification�of�records�by�researchers�seeking�career�benefits�linked�to�research�funding,�recruitment�for�clinical�trials�or�positive�outcomes�of�treatment�protocols

• unsought�involvement�of�consumers�/�patients�in�legal�proceedings�related�to�quality�of�care

• inappropriate�direct�marketing�from�suppliers�of�drugs,�devices�or�even�nutritional�products�and�services�for�specific�classes�of�consumer�/�patient.

Health�information�is�valuable�only�if�it�is�accurate,�complete�and�available�for�use�when�needed.�In�order�for�this�to�occur,�organisations�must�implement�systems�to�ensure�all�of�the�health�information�about�a�consumer�/�patient�is�in�one�central�place,�or�that�it�can�be�easily�located�when�different�parts�of�a�health�record�are�not�stored�together.�This�means�that,�centrally,�there�is�a�record�of�where�all�elements�or�components�of�the�health�record�are�at�any�given�time.5

Where�there�are�different�components�of�an�individual�health�record,�these�should�be�cross-referenced.�Instances�where�health�records�may�need�to�be��cross-referenced�include,�but�are�not�limited�to:

• health�records�that�are�part�paper-based�and�part�electronic�

• paper-based�health�records�that�have�been�separated�because�of�their�bulk�and�older�entries�archived

• health�records�stored�in�different�wards�/�departments�within�one�organisation

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October 2010  329

• records�that�include�items�that�require�incompatible�storage�systems,�such�as�video�footage,�large�radiographs,�sound�recordings

• health�records�that�are�used�for�staff�working��off-site�that�are�a�component�of�an�organisation-wide�health�record.

Organisations�should�ensure�that�all�components�of�the�health�record�are�tracked�and�monitored.�

Tracking�the�location�of�components�of�the�health�record�requires�a�system�that�monitors�removal�of�a�health�record�and�records�the�department�/�person�responsible�for�that�record�until�the�health�record�is�returned�to�the�central�location�and�the�system�updated.�Health�record�policy�should�also�address�circumstances�where�a�health�record�is�temporarily�removed�from�the�premises.�

Some�organisations�store�information�within�different�systems�and�in�these�instances�the�health�information�should�be�linked�to�the�individual’s�health�record�by�using�the�consumer�/�patient�unique�identifier.�Instances�where�health�information�may�be�stored�elsewhere�and�should�be�linked�include:

• results�of�investigations�stored�in�a�central�file

• registration�on�tissue�/�organ�donation�banks

• rural�hospitals�attended�by�a�local�general�practitioner�where�the�GP�clinic�records�contain�further�information.

Prompt points

¼ How does the organisation identify instances where health records should be cross-referenced? How are records that should be linked identified?

¼ How is the movement of health records tracked and monitored? How are complaints from staff about clinicians who inappropriately remove records managed by the organisation? What policies are available to address these issues?

¼ How are complaints from clinical staff who are unable to locate health records / files within a record managed by the organisation?

Clinical coding and reportingSystems�should�be�in�place�that�consider�and�include�the�ICD-10-AM�codes,�the�Australian�Coding�Standards,�the�clinical�coder�workforce,�and�clinician�input,�to�ensure�that�coding�is�clinically�appropriate,�efficient,�accurate�and�timely.�

Coding�policies�and�procedures�help�to�ensure�that�data�are�accurate.�They�recognise�the�need�to�check�accuracy�and�monitor�input�for�whatever�classification�system�is�used.�National�organisations,�such�as�the�National�Casemix�and�Classification�Centre�(NCCC)6,�have�expertise�in�clinical�coding�and�can�provide�advice�on�clinical�coding�and�reporting.�Coding�performance�indicator�results�can�be�trended�and�compared�to�those�from�other�organisations�to�determine�whether�the�organisation�meets�best�practice,�and�to�identify�opportunities�for�improvement.�

Mechanisms�to�assist�staff�to�meet�internal�and�external�timelines�include:

• ongoing�coding�education�for�relevant�staff

• access�to�support�mechanisms,�such�as�standards�and�guidelines

• monitoring�coding�workload�and�the�allocation�of�resources

• monitoring�turnaround�time�and�mentoring�/�educating�staff�on�areas�of�weakness

• networking�with�other�organisations�that�use�the�same�classification�system�to�identify�alternative�mechanisms

• assisting�staff�under�time�pressures�to�prioritise�their�workloads�and�manage�their�obligations�more�effectively,�by�removing�interruptions�or�other�pressures.

Prompt points

¼ What training / qualifications are held by staff involved in clinical classification?

¼ Are relevant standards available for staff who need to code or interpret clinical data? How are they made available?

¼ How are clinicians involved in clinical classification?

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330  The ACHS EQuIP5 Guide  Book 2  Accreditation, Standards and Guidelines  Support and Corporate Functions

Criterion 2.3.1

Health�records�management�systems�support�the�collection�of�information�and�meet�the�consumer�/�patient�and�organisation’s�needs.�(continued)

Staff education and trainingTraining�in�any�aspect�of�health�records�will�differ�for�administrative�staff�and�clinical�staff.�Training�needs�may�be�pre-empted�by�reviewing�position�descriptions,�the�changing�case�load�across�departments,�plans�for�new�record�systems�and�strategic�/�operational�plans.

In�each�circumstance,�the�organisation�should�consider:

• the�time�commitment�required�to�learn�a�new�system�/�task

• the�risks�associated�with�incorrect�compliance�with�records�systems�and�processes

• the�availability�of�skilled�staff�to�teach�/�mentor�staff�who�are�learning�and�monitor�their�output

• whether�there�is�the�budget�and�equipment��for�in-house�training�of�groups

• whether�there�are�suitable�outsourced�courses�available.

Relevant�staff�should�have�basic�induction�training�on�how�consumers�/�patients�can�access�their�records,�management�of�consumer�/�patient�administration�systems,�electronic�health�records,�the�management�of�paper�records,�legibility�and�completeness�of�record�keeping,�and�retention�and�disposal�of�records.�Explaining�the�reasons�for�policies�on�the�management�of�health�records�and�the�risks�associated�with�poor�record�keeping�will�assist�in�compliance.�The�goal�should�be�to�promote�responsible�health�record�keeping�as�a�cooperative�team�activity�essential�for�safe,�multidisciplinary�care,�which�may�help�to�overcome�perceptions�that�it�is�merely�a�bureaucratic�obligation.�As�with�any�other�training,�attendance�should�be�documented�in�the�relevant�personnel�files.

Prompt points

¼ What health records training needs have been identified by the organisation? What options have been investigated to meet those needs? What has been the feedback on the training undertaken so far?

¼ How is training provided at orientation? How is attendance documented?

¼ What current staff members or groups have recently received health records training?

Evidence commonly presented for this criterion

Consider whether the following will help to address criterion 2.3.1

¼ Policy / guidelines / by-laws and procedures for health records management

¼ Systems for management of health records, including:

– storage / location / security – retrieval processes – unique identifiers – use of clinical classification

¼ Health record audits

¼ Evidence of qualifications of health records management staff, including clinical coders

¼ Performance indicators

¼ Consumer / patient master index or central index

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October 2010  331

Performance measurementThis�criterion�states�that:�“Health�records�management�systems�support�the�collection�of�information�and�meet�the�consumer�/�patient�and�organisation’s�needs”.�Effective,�coordinated�management�systems�are�vital�to�ensure�both�appropriate�access�to,�and�secure�storage�of,�confidential�health�information.�The�organisation�should�be�able�to�demonstrate�that�it�has�efficient,�secure�systems�of�health�records�management�in�place,�that�it�provides�all�necessary�information,�training�and�support�for�staff,�and�that�it�monitors�and�improves�the�performance�of�its�systems.

Some�common�suggested�performance�measures�as�follows:

Number�of�clinicians�/�managers�who�have�a�login�to�access�a�computer

Total number of clinicians / managers

Number�of�staff�who�receive�education�on�information�systems

Total number of staff

Number�of�clinical�staff�who�have�access�to�clinical�information�systems�

Total number of clinical staff

Comment:examplesofclinicalinformationsystemsincludeClinicalInformationAccessProgram(CIAP),Medline,etc.

Number�of�health�records�/�summaries�of�health�records�provided�to�consumers�/�patients�upon�request�within�the�allotted�time�period

Total number of health records / summaries of health records requested by consumers / patients

Number�of�health�record�duplications�identified

Total number of health records audited

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332  The ACHS EQuIP5 Guide  Book 2  Accreditation, Standards and Guidelines  Support and Corporate Functions

Criterion 2.3.1

Health�records�management�systems�support�the�collection�of�information�and�meet�the�consumer�/�patient�and�organisation’s�needs.�(continued)

Records�or�parts�of�records�not�available�(within�reasonable�time�from�request)�because�they�could�not�be�located

Total number of consumers / patients admitted / seen

Comment:organisationtodefine‘reasonabletime’

Records�or�parts�of�records�not�available�(within�reasonable�time�from�request)�for�any�reason

Total number of consumers / patients admitted / seen

Comment:organisationtodefine‘reasonabletime’

References1.� Office�of�the�Federal�Privacy�Commissioner.�Stateand

territoryprivacylaws.Sydney�NSW;�Australian�Government.�Accessed�from�http://www.privacy.gov.au/aboutus/contact�on�1�September�2010.

2.� Office�of�the�Federal�Privacy�Commissioner.�Nationalprivacyprinciples(extractedfromthePrivacyAmendment(PrivateSector)Act2000).�Sydney�NSW;�Australian�Government;�2001.

3.� Office�of�the�Federal�Privacy�Commissioner.�Nationalprivacyprinciples.Private�sector�information�sheet.�Vol.�1.�Canberra�ACT;�Office�of�the�Privacy�Commissioner;�2006.

4.� Office�of�the�Federal�Privacy�Commissioner.�Nationalprivacyprinciples.�Information�sheet.�Canberra�ACT;�Office�of�the�Privacy�Commissioner;�2008.

5.� Abdelhak�M,�Grostick�S,�Hanken�MA�and�Jacobs�E.�Healthinformation:Managementofastrategicresource.Second�edn.�Philadelphia�USA;�Saunders;�2001.

6.� National�Casemix�and�Classification�Centre�(NCCC).�Homepage.�Wollongong�NSW;�University�of�Wollongong.�Accessed�from�http://nccc.uow.edu.au/index.html�on�1�September�2010.

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334  The ACHS EQuIP5 Guide  Book 2  Accreditation, Standards and Guidelines  Support and Corporate Functions

IntentThe�intent�of�this�criterion�is�to�focus�on�issues�beyond�clinical�records�and�to�ensure�that�the�organisation’s�records�management�systems�facilitate�effective�management�of�the�organisation�and�associated�research�and�education�activities.�

Each�organisation�should�ensure�the�integrity,�safety,�appropriate�access�and�security�of�all�records,�including�but�not�limited�to�staff�records,�clinical�registers,�film,�prints,�financial�information�and�minutes�of�meetings.�Policy�/�guidelines�and�procedures�for�records�management�systems�should�include�the�following�areas:

• information�privacy

• management�of�updating�information,�such�as�personnel�information

• storage

• risk�minimisation

• retrieval

• retention

• destruction

• version�control�for�draft�documents.

Relationships of 2.3.2 with other criteriaEstablishing�and�maintaining�an�effective�records�management�framework�represents�a�significant�business�challenge�for�many�organisations.�This�task�is�made�more�difficult�by�changing�legislative�and�other�requirements�and�ongoing�developments�in�information�technology.

Criterion LA – Awareness sA – implementationLA plus the following

MA – evaluationSA plus the following

eA – excellenceMA plus the following

oA – LeadershipEA plus the following

Criterion 2.3.2

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

a)� There�is�a�corporate�records�management�policy�and�system�that�ensures:

� (i)� �the�secure,�safe�and�systematic�storage�of�data�and�records

� (ii)� �timely�and�accurate�retrieval�of�records�stored�on�or�off-site

� (iii)� �appropriate�retention�and�destruction�of�records�

� according�to�all�relevant�standards�/�legislation�/�policy�/�guidelines.

b)� Policy�/�guidelines�exist�that�define�the�governance�and�accountability�for�corporate�records�management.

c)� The�corporate�records�management�system�specifies�the�requirements�for�standardised�record�creation�and�tracking.

d)� Staff�are�made�aware�of�their�responsibilities�in�relation�to�corporate�records�management.

a)� The�corporate�records�management�system�is�managed�with�reference�to�any�relevant�standards,�legislation,�policy,�codes�of�practice�and�industry�guidelines.

b)� Corporate�records�created�by�the�organisation�are�supported�by�relevant�records�systems.

c)� Training�on�corporate�record�keeping�and�records�management�is�available�for�staff.�

a)� Corporate�records�management�systems�are�evaluated�and�improvements�are�made�as�required.

b)� Training�on�corporate�record�keeping�and�records�management�is�evaluated,�and�improved�as�required.�

c)� Corporate�records�creation�and�tracking�is�evaluated�and�improved�as�required.

a)� Corporate�records�management�systems�are�compared�internally�and�with�external�systems,�and�improvements�are�made�to�ensure�better�practice.

a)� The�organisation�demonstrates�it�is�a�leader�in�corporate�records�management.

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The�management�of�corporate�records�has�some�commonalities�with�the�management�of�health�records�(Criterion�2.3.1);�both�will�be�impacted�by�systems�for�the�collection,�use�and�storage�of�data�(Criterion�2.3.3)�and�by�the�management�of�information�and�communications�technology�(Criterion�2.3.4).�Corporate�records�systems�will�in�turn�play�a�significant�role�in�many�aspects�of�the�organisation’s�governance�and�management�(Criteria�3.1.1�and�3.1.2),�human�resources�management�(Standard�2.2),�in�particular�workforce�planning�(Criterion�2.2.1),�and�orientation�and�training�(Criterion�2.2.2).�Corporate�records�management�is�a�vital�component�of�the�organisation’s�integrated�risk�management�framework�(Criterion�2.1.2).

Corporate records policy and systemsThe�records�management�policy�/�guideline�for�corporate�records�should�refer�to�AS�ISO�15489:2002�Recordsmanagement1�and�to�all�relevant�Federal,�State�and�Territory�Acts2�including�privacy�laws.�Information�on�privacy�laws�are�available�for�individual�States�/�Territories�from�the�Office�of�the�Federal�Privacy�Commissioner.2�

Criterion LA – Awareness sA – implementationLA plus the following

MA – evaluationSA plus the following

eA – excellenceMA plus the following

oA – LeadershipEA plus the following

Criterion 2.3.2

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

a)� There�is�a�corporate�records�management�policy�and�system�that�ensures:

� (i)� �the�secure,�safe�and�systematic�storage�of�data�and�records

� (ii)� �timely�and�accurate�retrieval�of�records�stored�on�or�off-site

� (iii)� �appropriate�retention�and�destruction�of�records�

� according�to�all�relevant�standards�/�legislation�/�policy�/�guidelines.

b)� Policy�/�guidelines�exist�that�define�the�governance�and�accountability�for�corporate�records�management.

c)� The�corporate�records�management�system�specifies�the�requirements�for�standardised�record�creation�and�tracking.

d)� Staff�are�made�aware�of�their�responsibilities�in�relation�to�corporate�records�management.

a)� The�corporate�records�management�system�is�managed�with�reference�to�any�relevant�standards,�legislation,�policy,�codes�of�practice�and�industry�guidelines.

b)� Corporate�records�created�by�the�organisation�are�supported�by�relevant�records�systems.

c)� Training�on�corporate�record�keeping�and�records�management�is�available�for�staff.�

a)� Corporate�records�management�systems�are�evaluated�and�improvements�are�made�as�required.

b)� Training�on�corporate�record�keeping�and�records�management�is�evaluated,�and�improved�as�required.�

c)� Corporate�records�creation�and�tracking�is�evaluated�and�improved�as�required.

a)� Corporate�records�management�systems�are�compared�internally�and�with�external�systems,�and�improvements�are�made�to�ensure�better�practice.

a)� The�organisation�demonstrates�it�is�a�leader�in�corporate�records�management.

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336  The ACHS EQuIP5 Guide  Book 2  Accreditation, Standards and Guidelines  Support and Corporate Functions

Criterion 2.3.2

Corporate�records�management�systems�support�the�collection�of�information�and�meet�the�organisation’s�needs.�(continued)

Records�are�an�organisation’s�corporate�memory.�They�provide�evidence�of�actions�and�decisions�and�represent�a�vital�asset�to�support�daily�functions�and�operations.�Records�support�policy�formation�and�managerial�decision�making,�protecting�the�interests�of�the�organisation�as�well�as�the�rights�of�staff�and�consumers�/�patients,�and�help�in�the�delivery�of�services�in�a�consistent�and�equitable�way.�They�also�support�consistency,�continuity,�efficiency�and�productivity�in�program�delivery,�management�and�administration.

Organisations�should�ensure�policies�/�guidelines�address�the�requirements�for�retention,�storage,�archiving�and�destruction�of�all�corporate�records,�including,�but�not�limited�to,�minutes�of�any�meetings,�personnel�records,�governance�decisions,�plans,�financial�records�and�any�other�documents�developed�and/or�received�by�the�organisation.3�Policies�should�also�give�guidance�about�the�use,�storage�and�retention�of�less�formal�means�of�internal�and�external�communication�including�hard�copy�memos�and�mail,�email�and�sms�messages.

How�corporate�records�are�managed�will�depend�on�the�type�of�record,�the�requirements�of�the�organisation�and�the�relevant�standards,�guidelines�and�Acts.�Organisational�policies�/�guidelines�and�procedures�should�address�these�issues.�For�example,�meeting�minutes�will�be�managed�in�different�ways,�and�the�type�of�meeting�will�dictate�where�and�how�the�records�need�to�be�stored,�and�how�long�they�need�to�be�retained.�Final�versions�of�key�corporate�files�such�as�Board�meeting�minutes,�annual�reports�and�policy�documents�should�be�filed�in�an�unalterable�format�and�archived�in�a�manner�that�preserves�the�content�for�long�term�storage�and�accessibility,�even�as�key�personnel�and�technology�change.�

Organisations�should�incorporate�record�retention�into�their�records�management�system.�Record�retention�requirements�should�be�documented�when�each�new�record�is�generated�and�relevant�staff�should�be�aware�of�these�requirements.4

Prompt points

¼ How are corporate records distinguished from health records in organisational policies and procedures?

¼ What are the organisation’s retention policies / procedures for tax records? Asset records such as contracts and title deeds? Financial records?

¼ Is there delineated responsibility for the management of corporate records?

Systems to ensure consistent records The�format�of�paper-based�records�and�how�they�are�created�is�often�apparent�by�their�appearance.�However,�systems�for�creation�of�legal�records,�for�example,�minutes�of�meetings�of�Boards,�may�be�subject�to�specific�processes�such�as�storage�in�a�tamper-proof�journal,�and�policy�should�address�how�these�records�are�created�and�by�whom.�In�the�case�of�electronic�records,�security�levels,�file�paths�and�access�should�be�considered�and�the�requirements�for�creation�documented.�Standardised�record�creation�and�filing,�whether�paper-based�or�electronic,�assists�in�locating�records�and�ensuring�that�retention�and�destruction�schedules�are�met.5

Records�that�leave�the�central�control�should�be�tracked�and�monitored,�so�that�the�organisation�is�aware�of�who�holds�the�record,�especially�if�it�is�a�single�copy�of�a�paper-based�record�or�if�circulation�of�the�information�could�have�legal�ramifications.

Tracking�of�the�movement�and�use�of�records�within�a�records�system�is�required�to:

• identify�outstanding�action�required

• enable�retrieval�of�a�record

• prevent�loss�of�records

• monitor�usage�for�systems�maintenance�and�security,�and�maintain�an�auditable�trail�of�records�transactions,�for�example,�capture�or�registration,�classification,�indexing,�storage,�access�and�use,�migration�and�disposition

• maintain�the�capacity�to�identify�the�operational�origins�of�individual�records�where�systems�have�been�amalgamated�or�migrated.

Tracking�mechanisms�may�record�the�item�identifier,�the�title,�the�person�or�unit�having�possession�of�the�item�and�the�time�/�date�of�movement.

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Adherence�to�records�management�processes�and�file�management�systems�is�required�to�control�important�documents�as�they�evolve�through�a�series�of�drafts.�Documents�emailed�outside�the�organisation�for�comment�or�editing�can�be�challenging�to�track;�a�system�for�version�control�is�necessary.�It�is�important�that�staff�approach�record�keeping�with�discipline�to�ensure�that�all�files�including�emails�and�SMS�messages�are�effectively�backed�up.

Prompt points

¼ How does the organisation ensure compliance with records management policy?

¼ What system does the organisation use to monitor and track corporate records? How is the system evaluated? What changes have been made following evaluation of the system?

Staff training and educationThere�should�be�central�control�over�what�organisationally-relevant�documents�are�stored�and�where�they�are�stored.�Policy�should�direct�staff�on�corporate�records�management.�Staff�responsibilities�should�be�highlighted�during�orientation,�and�training�should�be�provided�to�ensure�compliance�with�the�policy.

Staff�training�needs�will�differ�according�to�position�descriptions�and�individual�responsibilities�with�respect�to�access�and�management�of�corporate�records.�The�specific�documents�that�need�to�be�handled�by�an�administration�staff�member�vary�greatly�from�those�that�are�important�for�clinical�staff.

Staff�training�programs�on�record�keeping�remain�important�and�should�cover�topics�such�as:�

• what�is�a�record?

• why�records�need�to�be�kept

• record�keeping�obligations�of�all�staff

• how�to�file�records�in�corporate�record�keeping�systems

• when�and�how�to�dispose�of�records.�

Records�management�training�often�only�talks�of�records�in�general�terms,�outlining�statements�such�as�‘records�are�any�documents�that�provide�evidence�of�a�decision�or�activity’.�In�practice,�not�every�document�or�email�should�be�kept,�and�general�statements�do�little�to�help�staff�make�judgements�about�what�to�file�and�where�to�file�it.�Training�programs�need�to�be�tailored�to�ensure�all�staff�are�aware�of�the�organisation’s�expectations�and�their�own�responsibilities.

A�training�program�for�record�keeping�and�records�management�should�be�established�and�provided�for�staff�with�records�management�responsibilities,�other�staff�with�records�use�responsibilities�and�new�recruits.

Prompt points

¼ How does the organisation provide records management training to new staff? How is the training tailored to different positions?

¼ What checks are done to ensure staff are aware of their responsibilities when creating, handling, and storing records?

¼ Which, if any, corporate records are audited regularly to ensure adherence to policy and processes?

Evidence commonly presented

Consider whether the following will help to address criterion 2.3.2

¼ Policies / guidelines and procedures for corporate records management

¼ Facilities or equipment for management of corporate records, including:

– storage / location / security – file management systems – search / retrieval processes – privacy / confidentiality compliance – templates that speed recording or

structure content of records ¼ Corporate records audit results or other

performance indicators

¼ Systems for managing organisational needs, including:

– monitoring changes in legislation and tracking compliance

– asset registers – filing of contracts – financial and accounting records – corporate records – correspondence – human resources records – industrial relations records – minutes of meetings

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References1.� AS�ISO�15489.2:2002�Recordsmanagement:Guidelines.

2.� Office�of�the�Federal�Privacy�Commissioner.�Stateandterritoryprivacylaws.�Sydney�NSW;�Australian�Government.�Accessed�from�http://www.privacy.gov.au/aboutus/contact�on�1�September�2010.

3.� NSW�Health.�Records–Principlesforcreation,management,storageanddisposalofhealthcarerecords.�Sydney;�NSW�Health;�2005.

4.� Information�Enterprises�Australia.�Australianrecordretentionmanual.�Fremantle�WA;�Information�Enterprises�Australia;�2009.

5.� AS�ISO�15489.1:2002�Recordsmanagement:General.

Criterion 2.3.2

Corporate�records�management�systems�support�the�collection�of�information�and�meet�the�organisation’s�needs.�(continued)

Performance measurementThis�criterion�states�that:�“Corporate�records�management�systems�support�the�collection�of�information�and�meet�the�organisation’s�needs”.�The�organisation�should�be�able�to�demonstrate�both�that�it�fulfils�its�legislative�responsibilities�for�the�collection,�storage,�destruction�and�confidential�management�of�corporate�records,�and�that�it�has�systems�in�place�that�facilitate�its�need�for�efficient�operation�and�quality�service�provision.

Some�common�suggested�performance�measures�are�as�follows:

Number�of�corporate�records�that�comply�with�standards�for�such�areas�as�storage,�policies,�procedures

Total number of corporate records reviewed

Number�of�reports�to�State�/�Territory�health�departments�that�are�accurate�(i.e.�error�free)�

Total number of reports submitted to State / Territory health departments

Number�of�reporting�submissions�to�external�bodies�that�meet�timeframes

Total number of reporting submissions to external bodies

Number�of�staff�who�have�completed�education�/�training�in�corporate�records�management

Total number of staff requiring education / training in corporate records management

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Criterion LA – Awareness sA – implementationLA plus the following

MA – evaluationSA plus the following

eA – excellenceMA plus the following

oA – LeadershipEA plus the following

Criterion 2.3.3

Data�and�information�are�collected,�stored�and�used�for�strategic,�operational�and�service�improvement�purposes.

a)� The�collection,�storage�and�use�of�data�comply�with�professional�and�statutory�requirements.

b)� Policy�/�guidelines�exist�for�the�validation�and�protection�of�data�and�information.

c)� Data�are�available�for:

� (i)� research

� (ii)� development

� (iii)� improvement�activities

� (iv)� education

� (v)� �corporate�and�clinical�decision�making.�

d)� Resources�exist�for�the�assessment,�analysis�and�use�of�data.

e)� Reference�and�resource�materials�are�available�for�use�by�staff.

a)� An�information�management�plan�is�implemented�and�identifies�the�needs�of�the�organisation�at�all�levels.

b)� A�system�is�implemented�for�validation�and�protection�of�data�and�information.

c)� Data�storage�and�retrieval�are�facilitated�through�effective�classification�and�indexing.

d)� Responsibility�and�accountability�for�action�on�data�and�information�are�clearly�delineated.

e)� Databases�are�linked�to�provide�access�within�and�across�units�and�departments.

f)� Staff�have�access�to�training�on�information�and�data�management.

g)� Liaison�with�external�bodies�improves�the�quality�of�information�supplied�and�received.

h)� The�organisation�contributes�to�external�databases�and�registers.

i)� There�are�systems�to�provide�information�for�authorised�stakeholders�that�are�consistent�with�jurisdictional�privacy�legislation.

j)� The�needs�of�staff�for�reference�and�resource�materials�are�identified,�analysed�and�prioritised.

a)� Systems�used�for�validation�and�protection�of�data�and�information�are�evaluated�and�improved�as�required.

b)� Monitoring�and�analysis�of�clinical�and�non-clinical�data�and�information�occurs�to�ensure:

� (i)� �accuracy,�integrity�and�completeness

� (ii)� �timeliness�of�information�and�reports

� (iii)� �the�needs�of�the�organisation�are�met,�

� and�improvements�are�made�as�required.

c)� Training�is�evaluated�to�ensure�it�improves�skills�in�information�and�data�management.�

d)� Data�use�and�reporting�processes�are�evaluated�and�improved�as�required.

e)� The�organisation�reviews�results�from�external�databases�and�registers�and�improves�care�and�services�as�indicated.

f)� Reference�management�and�resource�material�systems�are�evaluated�and�improved�as�required.

a)� Information�and�data�management�systems�are�compared�internally�and�with�external�systems,�and�improvements�are�made�to�ensure�better�practice.

and/or

b)� Systems�for�the�management�of�reference�and�resource�material�are�compared�internally�and�with�external�systems,�and�improvements�are�made�to�ensure�better�practice.�

and/or

c)� The�organisation�undertakes�research�into�information�systems�and�data�management�and�collection�systems,�and�acts�on�results.

a)� The�organisation�demonstrates�it�is�a�leader�in�the�collection,�use�and�storage�of�data�and�information.

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Criterion LA – Awareness sA – implementationLA plus the following

MA – evaluationSA plus the following

eA – excellenceMA plus the following

oA – LeadershipEA plus the following

Criterion 2.3.3

Data�and�information�are�collected,�stored�and�used�for�strategic,�operational�and�service�improvement�purposes.

a)� The�collection,�storage�and�use�of�data�comply�with�professional�and�statutory�requirements.

b)� Policy�/�guidelines�exist�for�the�validation�and�protection�of�data�and�information.

c)� Data�are�available�for:

� (i)� research

� (ii)� development

� (iii)� improvement�activities

� (iv)� education

� (v)� �corporate�and�clinical�decision�making.�

d)� Resources�exist�for�the�assessment,�analysis�and�use�of�data.

e)� Reference�and�resource�materials�are�available�for�use�by�staff.

a)� An�information�management�plan�is�implemented�and�identifies�the�needs�of�the�organisation�at�all�levels.

b)� A�system�is�implemented�for�validation�and�protection�of�data�and�information.

c)� Data�storage�and�retrieval�are�facilitated�through�effective�classification�and�indexing.

d)� Responsibility�and�accountability�for�action�on�data�and�information�are�clearly�delineated.

e)� Databases�are�linked�to�provide�access�within�and�across�units�and�departments.

f)� Staff�have�access�to�training�on�information�and�data�management.

g)� Liaison�with�external�bodies�improves�the�quality�of�information�supplied�and�received.

h)� The�organisation�contributes�to�external�databases�and�registers.

i)� There�are�systems�to�provide�information�for�authorised�stakeholders�that�are�consistent�with�jurisdictional�privacy�legislation.

j)� The�needs�of�staff�for�reference�and�resource�materials�are�identified,�analysed�and�prioritised.

a)� Systems�used�for�validation�and�protection�of�data�and�information�are�evaluated�and�improved�as�required.

b)� Monitoring�and�analysis�of�clinical�and�non-clinical�data�and�information�occurs�to�ensure:

� (i)� �accuracy,�integrity�and�completeness

� (ii)� �timeliness�of�information�and�reports

� (iii)� �the�needs�of�the�organisation�are�met,�

� and�improvements�are�made�as�required.

c)� Training�is�evaluated�to�ensure�it�improves�skills�in�information�and�data�management.�

d)� Data�use�and�reporting�processes�are�evaluated�and�improved�as�required.

e)� The�organisation�reviews�results�from�external�databases�and�registers�and�improves�care�and�services�as�indicated.

f)� Reference�management�and�resource�material�systems�are�evaluated�and�improved�as�required.

a)� Information�and�data�management�systems�are�compared�internally�and�with�external�systems,�and�improvements�are�made�to�ensure�better�practice.

and/or

b)� Systems�for�the�management�of�reference�and�resource�material�are�compared�internally�and�with�external�systems,�and�improvements�are�made�to�ensure�better�practice.�

and/or

c)� The�organisation�undertakes�research�into�information�systems�and�data�management�and�collection�systems,�and�acts�on�results.

a)� The�organisation�demonstrates�it�is�a�leader�in�the�collection,�use�and�storage�of�data�and�information.

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342  The ACHS EQuIP5 Guide  Book 2  Accreditation, Standards and Guidelines  Support and Corporate Functions

Criterion 2.3.3

Data�and�information�are�collected,�stored�and�used�for�strategic,�operational�and�service�improvement�purposes.�(continued)

IntentHealth�care�is�information-dependant�and�cannot�be�provided�efficiently�without�facts;�therefore,�the�collection,�use�and�storage�of�data�are�integral�to�the�management�of�all�healthcare�organisations.�

The�intent�of�this�criterion�is�to�ensure�that�there�are�systems�in�place�for�the�collection�of�data�and�information,�that�data�and�information�are�made�available�for�use�in�a�timely�manner,�and�that�data�and�information�are�stored�safely�and�used�effectively�so�as�to�meet�the�organisation’s�needs.

Relationships of 2.3.3 with other criteriaWithin�healthcare�organisations,�the�collection,�storage�and�usage�of�data�are�most�conspicuous�in�the�creation�and�maintenance�of�consumer�/�patient�health�records�(Criterion�1.1.8)�and�the�implementation�of�systems�for�health�record�management�(Criterion�3.2.1).�However,�data�systems�also�impact�significantly�upon�the�management�of�other�important�records,�including�personnel�information�(Standard�2.2),�corporate�records�(Criterion�2.3.2)�and�all�research�documentation�(Criterion�2.5.1).�In�addition,�data�from�incidents�(Criterion�2.1.3)�and�complaints�(Criterion�2.1.4)�should�be�recorded�and�analysed�to�minimise�recurrence.

Effective�management�systems�for�information�and�communication�technology�(Criterion�2.3.4)�will�assist�organisations�to�collect,�access,�store�and�use�data�and�information.�The�organisation�must�ensure�the�security�of�all�records,�both�paper-based�and�electronic�(Criterion�3.2.5).

Data and information managementOrganisations�produce�an�overwhelming�volume�of�information�and�certain�types�of�information�need�to�be�managed�in�different�ways.�The�data�and�information�management�system�should�ensure�that�data�and�information�are�available,�accessible�and�relevant�to�the�strategic�and�operational�needs�of�the�organisation.�In�addition,�organisations�will�need�to�ensure�there�are�sufficient�resources�to�manage�this�information.

Three�major�categories�of�information�within�many�organisations�are:

• key�corporate�information�

• information�shared�within�an�organisation�

• information�communicated�externally.

Organisations�should�consider�these�categories�when�developing�information�management�plans.�File�formats,�the�storage�media�chosen,�how�the�system�is�backed�up,�access�restrictions�and�other�factors�will�be�influenced�by�legislation�governing�retention,�confidentiality�issues�and�whether�the�information�will�be�shared�with�other�departments,�organisations�and�data�systems.�

Policies�and�procedures�for�information�and�data�management�and�collection�systems�may�include:�

• identifying�and�planning�for�the�organisation’s�information�needs�

• defining�and�capturing�data�and�information�from�various�sources�and�in�compliance�with�all�statutory�requirements

• linking�and�combining�different�types�of�data�and�information�within�and�outside�the�organisation

• analysing�data�and�transforming�them�into�information�that�is�easily�interpreted�by�the�user

• transmitting�and�reporting�data�and�information�

• managing�all�types�of�records

• storing�data�and�information�so�they�are�easy�to�retrieve

• educating�and�training�users�on�the�appropriate�and�ethical�ways�of�collecting�and�using�data�and�information

• obtaining�input�from�users�to�ensure�the�data�collected�and�reported�are�useful�and�relevant�

• ensuring�data�and�information�are�available�at�points�of�care�for�care�planning�and�decision�making

• processes�to�monitor�the�quality�of�data�and�information,�including�data�reliability,�accuracy�and�validity�from�both�internal�and�external�sources

• comparing�organisational�performance�and�outcomes�internally�and�externally�with�other�healthcare�organisations�and�best-practice�standards�

• systems�and�procedures�for�managing�financial�data.�

Databases�are�used�to�store�information�in�a�predictable�structure.�Well-designed�databases�and�information�systems�can�respond�to�questioning.�Repetition�of�information�within�a�database�may�use�

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October 2010  343

a�lot�of�memory,�but�when�designed�with�appropriate�links�between�key�fields,�the�capability�of�databases�can�be�expanded�in�this�way.�Similarly,�links�between�databases�can�tie�together�clinical�information�from�multiple�sources�and�sometimes�overcome�fundamental�design�differences�between�storage�systems.�Tools�such�as�HL7�may�play�a�major�role�in�achieving�these�goals�of�integrating�data�from�independent�database�sources.

Prompt points

¼ How has the organisation identified and described its needs for information management?

¼ How does the organisation provide access to data within and across all units?

¼ What training is provided to staff? How are staff requiring training identified? Are there programs to improve the generic computer skills of ‘frontline’ staff?

¼ Is training provided as part of orientation? Is training provided on the specific applications used within the organisation?

¼ What improvements have been made in response to insights gained from the collection of data and information, and their analysis?

Data collection, use, storage and retrievalData�management�should�comply�with�relevant�privacy�protocols,�such�as�the�Privacy(PrivateSector)Regulations2001�(Cth)�on�personal�privacy�protection.�Information�is�available�at�http://www.privacy.gov.au

When�data�are�collected�from�different�sources,�organisations�should�have�systems�in�place�to�reduce�the�error�rate;�the�most�effective�way�of�maintaining�data�quality�in�a�database�is�to�manage�the�data�at�the�point�of�collection�and�data�entry,�and�then�to�segregate�data.�

Having�standardised�processes�and�procedures�and�experienced�people�collecting�the�data�are�key�prerequisites.

Information�use�should�be�appropriate�and�managed�effectively.�Data�should�be�sorted�into�categories�so�that�a�problem�or�issue�can�be�understood.�Analysing�data�and�identifying�the�essential�elements�creates�information�and�helps�organisations�to�consider�what�needs�to�be�done�next.�

Healthcare�professionals�who�use�and�report�data�should�be�involved�in�its�analysis.�Responsibility�and�accountability�for�action�on�data�and�information�and�accuracy�of�data�should�be�clearly�defined�within�the�organisation�and�communicated�to�all�staff.�

Information�can�be�used�to�improve�performance,�for�research�and�development,�education�(staff�and�consumer�/�patient)�and�decision�making�(clinical�and�non-clinical).�Examples�of�uses�include:

• demographic�information�may�guide�updates�to�local�health�promotion�strategies�

• clinical�indicator�data�may�provide�insights�into�variations�in�the�effectiveness�of�care�delivery�systems�or�treatment�protocols�within�or�between�organisations

• complication�rates�or�variance�data�may�influence�the�ongoing�development�of�clinical�pathways

• incident�data�may�guide�priority�setting�when�improving�organisational�care�delivery�processes

• complaints�data�can�be�used�to�improve�care�and�services

• infection�surveillance�data�may�indicate�effectiveness�of,�or�breakdowns�in,�preventative�systems

• relative�utilisation�rates�can�be�used�to�assess�appropriateness�of�services

• Diagnosis�Related�Group�(DRG)�information�may�highlight�local�demand�and�assist�the�planning�of�new�services.

The�ways�in�which�data�and�information�are�stored�will�depend�on�the�type�of�data�or�information,�as�well�as�the�media�in�which�they�are�held.�Organisations�should�ensure�that�there�is�policy�addressing�the�methods�of�data�collection,�use�and�storage,�depending�on�the�form�the�information�takes.�Policy�should�consider1:

• the�clinical�and�business�data�that�is�most�sensitive�from�the�perspectives�of�the�organisation’s�consumers�/�patients,�clinicians,�and�the�administrators�

• where�the�most�sensitive�clinical�data�resides

• the�origin�and�nature�of�any�risks.

The�organisation�should�determine�what�controls�will�best�manage�the�risks�and�protect�sensitive�and�critical�data.�Security�of�data�should�be�managed�centrally�and�security�systems�should�be�regularly�tested.�

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344  The ACHS EQuIP5 Guide  Book 2  Accreditation, Standards and Guidelines  Support and Corporate Functions

Criterion 2.3.3

Data�and�information�are�collected,�stored�and�used�for�strategic,�operational�and�service�improvement�purposes.�(continued)

Prompt points

¼ How does the organisation ensure compliance with regulatory and professional standards?

¼ How are staff notified of lines of responsibility for data and information management?

¼ How does the organisation ensure staff understand the meaning of data and what its purpose is?

Validation and protectionThere�should�be�processes�for�confirming�the�accuracy�of�all�data�used�to�support�decisions,�reports�and�funding.�Validating�the�data�at�time�of�entry�into�the�organisation’s�systems�is�undoubtedly�the�best�and�most�efficient�means�of�maintaining�quality.�In�doing�so,�organisations�will�reduce�the�need�for�validation�tools,�and�the�time�and�resources�allocated�for�costly�manual�inspection�of�data,�rectification�at�source�and�rework�in�a�second�collation.

Data�validation�is�often�a�multi-step�process�where�a�small�sample�of�data�is�closely�examined,�and�depending�on�whether�the�quality�is�within�acceptable�levels�of�tolerance�(i.e.�the�examination�of�a�pre-agreed�sample�size�yields�more�or�less�errors�than�a�benchmark),�a�decision�may�be�made�to�extend�the�sample,�or�instead�test�all�the�data�for�one�or�more�characteristics.�This�recognises�how�commonly�data�may�be�problematic.�Irregular�data�have�a�high�probability�of�also�being�inaccurate,�particularly�if�collected�by�different�personnel�or�through�different�processes,�and�must�be�rechecked�before�the�irregularity�is�confirmed�as�a�characteristic.

Prompt points

¼ How is the policy for validation and protection of data and information implemented? How is this system evaluated?

¼ How does the organisation address rating reliability?

External databases Data�and�information�that�are�available�from�other�clinical�information�systems,�either�internally�or�externally,�can�be�utilised�in�conjunction�with�health�record�data�as�long�as�any�ethical�and�privacy�concerns�are�addressed.�Having�timely�information�from�these�sources�can�enhance�care.�Examples�of�these�types�of�clinical�information�systems�include:

• pathology�and�radiology�results�by�secure�or�encrypted�phone�/�fax�/�computer�/�email

• external�pharmacy�data

• films,�images,�graphs�and�prints

• clinical�pathway�variance�data

• Clinical�Information�Access�Program�(CIAP)

• Doctors�reference�site

• Cochrane�Library�database

• Medline.

Each�organisation�should�be�aware�of�mandatory�external�data�collection�and�reporting�requirements.�

To�meet�these�requirements,�data�should�be�accessible�and�reporting�timelines�and�mechanisms�identified.�Some�of�these�data�collections�include:�

• inpatient�statistics�collection

• infectious�disease�notification�

• jurisdictional�data�collections

• cancer�notifications

• midwives�data�collection�

• suspected�child�abuse�/�domestic�violence

• deaths�/�coroner’s�cases�

• victims�of�crime

• other�clinical�registries�including�those�monitoring�stroke�patients�(AuSCR),�clinical�trials,�rehabilitation�outcomes�(AROC),�cardiac�procedures�(ACPR),�burns,�femoral�neck�fractures�(NOffRA)2,�and�cancer�registries�(AIHW)

• employer�responsibilities�to�the�relevant�Taxation�Act,�such�as�social�service�garnishees,�payment�of�group�tax,�tax�status�

• payroll�information,�such�as�income�tax,�leave�entitlements,�superannuation�payments,�etc.

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October 2010  345

External�entities�often�use�an�organisation’s�information.�Organisations�should�ensure�that�there�is�a�system�in�place�to�produce�such�information�for�external�entities�and�that�they�have�the�authority�to�access�and�use�the�information�in�compliance�with�Commonwealth�and�State�/�Territory�legislation�and�other�requirements.�These�external�entities�include:

• Departments�of�Health

• funders�of�health�care

• insurers

• accreditation�and�certification�agencies�

• legislators

• coroners

• courts�of�law

• media

• stakeholders

• local�government�

• benchmarking�groups

• local�community.

Prompt points

¼ What external databases does the organisation contribute to? How does the organisation coordinate data submission to external databases?

¼ Is secure messaging used to transfer data to external sources?

¼ How has the quality of information collected by the organisation improved through liaison with external bodies?

References and resources for staffStaff�access�to,�and�utilisation�of,�reference,�research�and�other�resource�materials3�are�of�crucial�importance�in�supporting�evidence-based�practice�and�improving�quality�programs�and�services�in�health�care.�

An�organisation’s�processes�for�managing�reference,�research�and�other�resource�materials�should�be�based�on�current�and�future�needs�and�utilise�links�with�relevant�external�databases,�information�networks,�bodies�of�expert�help�and�administrative�or�research�knowledge.�

New�staff�are�likely�to�require�training�in�order�to�understand�the�information�available�to�them�and�to�become�efficient�and�effective�in�accessing�information�when�it�is�most�needed.

Evaluation�of�information�materials�should�consider�the�cost�effectiveness�of�different�options�for�information�provision.�Any�evaluation�should�also�identify�which�information�is�absolutely�key�for�safe�practice�and�ensure�that�alternative�access�in�cases�of�electronic�systems�failure�is�considered.

Prompt points

¼ How are the needs of staff for reference and resource tools identified?

¼ How are reference and resource materials made available to staff? What is the use rate by staff?

¼ How is usage and cost effectiveness of information provision analysed?

Evidence commonly presented

Consider whether the following will help to address criterion 2.3.3

¼ Information management strategic plan

¼ Types of data collected and the utilisation of data

¼ Evidence of data linkages

¼ Evidence of training for staff in data management

¼ Reported errors in coding

¼ Reported errors in records

¼ Satisfaction with financial reports and budget development

¼ Evaluation of data collected

¼ Systems to manage information on:

– document control – relevant monitoring – validation and protection of data

¼ Evaluation of systems

¼ Policies and procedures such as mandatory reporting, accountability, etc.

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seCtion 5Standards, criteria, elements and guidelinesstandard 2.3:�Information�management�systems�enable�the�organisation’s�goals�to�be�met

346  The ACHS EQuIP5 Guide  Book 2  Accreditation, Standards and Guidelines  Support and Corporate Functions

Criterion 2.3.3

Data�and�information�are�collected,�stored�and�used�for�strategic,�operational�and�service�improvement�purposes.�(continued)

Performance measurementThis�criterion�states�that:�“Data�and�information�are�collected,�stored�and�used�for�strategic,�operational�and�service�improvement�purposes”.�Safe,�high�quality�health�care�is�information-dependent,�and�organisations�should�be�able�to�demonstrate�that�they�have�systems�for�managing�the�collection�and�use�of�data�to�support�all�facets�of�their�operation.

Some�common�suggested�performance�measures�are�as�follows:

Number�of�staff�satisfied�with�computer�access

Total number of staff

Number�of�staff�who�have�completed�education�/�training�in�data�/�information�collection�and�storage

Total number of staff requiring education / training in data / information collection and storage

Number�of�staff�who�have�undertaken�training�courses�to�improve�their�computer�skills

Total number of staff invited to undertake training to improve their computer skills

Number�of�pathology,�imaging,�etc.�reports�received�within�X�hours,�that�enable�clinical�decision�and�appropriate�care

Total number of requests for pathology, imaging, etc. reports

Comment:theorganisationtodefine‘X’

Number�of�incidents�that�relate�to�problems�with�delivery�of�service�due�to�lack�of�information

Total number of incidents that relate to problems with delivery of service

Number�of�users�satisfied�with�information�provided�in�reports

Total number of users surveyed

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October 2010  347

References1.� RSA�Security�and�Frost�&�Sullivan.�Informationrisk

managementforhealthcareorganizations:Sixbestpracticesforprotectingyourhealthinformation.Palo�Alto�USA;�Frost�&�Sullivan;�2008.

2.� Australian�Commission�on�Safety�and�Quality�in�Health�Care�(ACSQHC).�Australianclinicalqualityregistries.Sydney�NSW;�ACSQHC.�Accessed�from�http://www.health.gov.au/internet/safety/publishing.nsf/Content/PriorityProgram-08_CQRegistries�on�28�June�2010.

3.� Health�Libraries�Australia.�GuidelinesforAustralianhealthlibraries.4th�edn.�Canberra�ACT;�Australian�Library�&�Information�Association�(ALIA);�2008.

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348  The ACHS EQuIP5 Guide  Book 2  Accreditation, Standards and Guidelines  Support and Corporate Functions

IntentInformation�management�is�a�term�used�to�encompass�all�of�the�systems�and�processes�for�the�creation�and�use�of�information�within�an�organisation.�In�a�technological�context,�information�management�is�a�collective�term�that�includes�electronic�systems�designed�to�facilitate�communication�and�the�flow�of�information.�These�technologies�include�personal�computers,�the�internet,�email,�videoconferencing,�telehealth�and�mobile�technologies�such�as�handheld�or�tablet�computers.�

The�intent�of�this�criterion�is�to�ensure�that�the�organisation’s�information�and�communication�technology�needs�are�met�through�appropriate�use�and�management�of�technology.�

Relationships of 2.3.4 with other criteriaInformation�and�communication�technology�(I&CT)�within�healthcare�organisations�supports�many�areas�of�service�delivery,�including�health�record�content�(Criterion�1.1.8),�and�the�management�of�health�records�(Criterion�2.3.1),�corporate�records�(Criterion�2.3.2)�and�human�resources�records�(Standard�2.2).�All�data�collected,�stored�and�used�within�the�organisation�(Criterion�2.3.3)�must�be�managed.�Many�medical�devices�and�other�clinical�equipment�also�rely�upon�software�and�technology�(Criterion�3.2.2).�

Correct�and�responsible�use�of�I&CT�should�be�addressed�during�staff�orientation�(Criterion�2.2.2).�Where�organisations�rely�upon�external�service�providers�and�operators�of�sections�of�their�I&CT�strategic�development�and�service�delivery,�appropriate�and�detailed�service�agreements�will�be�required�(Criterion�3.1.4).�The�organisation’s�approach�to�planning,�use�and�management�of�I&CT�is�an�aspect�of�its�integrated�risk�management�framework�(Criterion�2.1.2)�and�of�organisational�security�(Criterion�3.2.5).

Criterion LA – Awareness sA – implementationLA plus the following

MA – evaluationSA plus the following

eA – excellenceMA plus the following

oA – LeadershipEA plus the following

Criterion 2.3.4

The�organisation�has�an�integrated�approach�to�the�planning,�use�and�management�of�information�and�communication�technology�(I&CT).

a)� There�is�effective�governance�of�I&CT�that�is�supported�by�policy�and�procedure.

b)� Licences�are�purchased�as�required.

c)� A�system�of�I&CT�operational�support�exists.�

d)� There�is�a�documented�plan�for�managing�I&CT�risks�and�crises.

a)� A�strategy�for�current�and�future�I&CT�needs�is�implemented.

b)� Strategies�for:

� (i)� backup

� (ii)� security�

� (iii)� protection�of�privacy

� (iv)� virus�detection

� are�implemented�and�used.

c)� There�is�a�planned�system�for�preventative�maintenance�for�I&CT.

d)� A�strategy�and�plan�for�disaster�recovery�/�business�continuity�is�implemented.

e)� The�integrated�I&CT�system�supports�the�collection,�aggregation�and�analysis�of�data.�

a)� The�I&CT�system,�including�compliance�with�I&CT�policy�and�procedures,�is�evaluated�and�improved�as�required.

b)� The�preventative�maintenance�and�repair�system�for�I&CT�is�evaluated�regularly�and�improved�as�required.

c)� The�risk�and�crisis�management�system�for�I&CT�is�evaluated�regularly�and�improved�as�required.

a)� The�I&CT�system�is�compared�with�external�systems�and�improvements�are�made�to�ensure�better�practice.

and/or

b)� The�preventative�maintenance�system�is�compared�with�external�systems�and�improvements�are�made�to�ensure�better�practice.

and/or

c)� Risk�and�crisis�management�systems�are�compared�with�external�systems�and�improvements�are�made�to�ensure�better�practice.

and/or

d)� The�organisation�undertakes�research�into�I&CT�systems�and�implements�improved�systems.

a)� The�organisation�demonstrates�it�is�a�leader�in�the�planning,�use�and�management�of�I&CT.

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October 2010  349

Policies and proceduresAn�I&CT�plan�supported�by�policy�and�procedures�for�all�aspects�of�I&CT�management�is�required.�This�will�develop�the�organisation’s�capacity�to�effectively�manage�I&CT�applications�and�infrastructures�to�support�the�organisation’s�operations�and�business.�The�plan�should�be�proportionate�to�the�size,�role�and�complexity�of�the�organisation�and�similarly,�to�the�range�and�programs�of�I&CT�in�the�organisation.

The�I&CT�plan�should�include�(but�not�be�limited�to):

• communications�technologies�(voice,�video,�data)

• applications�and�services

• integration�with�the�current�infrastructure

• management�of�data,�information�and�knowledge

• change�management�and�workflow�redesign

…�and�should�consider:

• ongoing�maintenance,�updating�and�development�of�I&CT�for�the�organisation

• organisational�strategic�and�investment�plans

• the�national�e-health�strategy�

• planned�outcomes�from�future�investment�in�I&CT.

To�achieve�the�outcomes�proposed�within�the�I&CT�plan,�there�will�need�to�be�clear�governance�and�accountability�over�a�number�of�key�areas�including:

• oversight�of�the�vision�and�its�alignment�with�jurisdictional�and�national�health�objectives

• maintenance,�implementation�and�ongoing�review�

• information�management�and�technology�policies,�principles�and�standards

• funding,�to�ensure�long-term�sustainability�

• common�expectations,�including�implementation�of�and�compliance�with�policies,�protocols�and�standards�within�the�organisation

• personal�use�of�IC&T

• inappropriate�use�of�IC&T.

Criterion LA – Awareness sA – implementationLA plus the following

MA – evaluationSA plus the following

eA – excellenceMA plus the following

oA – LeadershipEA plus the following

Criterion 2.3.4

The�organisation�has�an�integrated�approach�to�the�planning,�use�and�management�of�information�and�communication�technology�(I&CT).

a)� There�is�effective�governance�of�I&CT�that�is�supported�by�policy�and�procedure.

b)� Licences�are�purchased�as�required.

c)� A�system�of�I&CT�operational�support�exists.�

d)� There�is�a�documented�plan�for�managing�I&CT�risks�and�crises.

a)� A�strategy�for�current�and�future�I&CT�needs�is�implemented.

b)� Strategies�for:

� (i)� backup

� (ii)� security�

� (iii)� protection�of�privacy

� (iv)� virus�detection

� are�implemented�and�used.

c)� There�is�a�planned�system�for�preventative�maintenance�for�I&CT.

d)� A�strategy�and�plan�for�disaster�recovery�/�business�continuity�is�implemented.

e)� The�integrated�I&CT�system�supports�the�collection,�aggregation�and�analysis�of�data.�

a)� The�I&CT�system,�including�compliance�with�I&CT�policy�and�procedures,�is�evaluated�and�improved�as�required.

b)� The�preventative�maintenance�and�repair�system�for�I&CT�is�evaluated�regularly�and�improved�as�required.

c)� The�risk�and�crisis�management�system�for�I&CT�is�evaluated�regularly�and�improved�as�required.

a)� The�I&CT�system�is�compared�with�external�systems�and�improvements�are�made�to�ensure�better�practice.

and/or

b)� The�preventative�maintenance�system�is�compared�with�external�systems�and�improvements�are�made�to�ensure�better�practice.

and/or

c)� Risk�and�crisis�management�systems�are�compared�with�external�systems�and�improvements�are�made�to�ensure�better�practice.

and/or

d)� The�organisation�undertakes�research�into�I&CT�systems�and�implements�improved�systems.

a)� The�organisation�demonstrates�it�is�a�leader�in�the�planning,�use�and�management�of�I&CT.

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seCtion 5Standards, criteria, elements and guidelinesstandard 2.3:�Information�management�systems�enable�the�organisation’s�goals�to�be�met

350  The ACHS EQuIP5 Guide  Book 2  Accreditation, Standards and Guidelines  Support and Corporate Functions

Criterion 2.3.4

The�organisation�has�an�integrated�approach�to�the�planning,�use�and�management�of�information�and�communication�technology�(I&CT).�(continued)

Prompt points

¼ How is I&CT governed? Who has ultimate responsibility for I&CT?

¼ How is compliance with the I&CT policy ensured?

¼ What checks are made to determine whether the organisation’s system meets requirements for both appropriate access and privacy of different classes of records?

Strategic planningEffective�use�of�I&CT�requires�an�integrated�approach�to�the�planning�and�use�of�technology.�Planning�helps�to�ensure�that�I&CT�improves�the�effectiveness�and�efficiency�of�the�organisation’s�management�of�information�via�collection,�aggregation�and�analysis�of�data.�

Larger�organisations�often�develop�a�separate�information�technology�plan�as�an�integral�part�of�their�information�management�plan.�Smaller�organisations�may�include�information�management�and�I&CT�within�the�overall�strategic�and�business�plans.�

It�may�also�be�useful�to�consider�the�following�issues:�

• responsibility�for�management�of�the�organisation’s�information�technology�

• users’�needs�and�expectations

• the�form�in�which�information�will�be�kept,�for�example,�electronic�or�microfilm�

• the�relationship(s)�between�information�held�in�various�forms�

• how�systems�will�be�linked�and�work�together,�including�support�for�management�of�the�systems

• data�uniformity�through�the�definition�of�key�data�elements�

• standard�operating�environment�across�the�whole�organisation

• version�control�of�documents

• State�/�Territory,�national�and�international�guidelines�and�standards

• legal�issues,�such�as�legally�authorised�use�of�software�

• confidentiality�issues

• I&CT�purchases�requiring�consultation�with�key�personnel,�purchasing�against�set�criteria�related�to�business�requirements

• applications�and�infrastructure

• coordination�of�service-specific�databases

• education�for�relevant�staff�in�I&CT�use,�organisational�policy�and�staff�responsibilities

• management�if�systems�are�upgraded�/�changed�to�ensure�access�to�existing�data

• the�need�for�specific�types�of�management�planning�systems�to�enhance�the�organisation’s�I&CT�systems,�such�as�behaviour�management,�cost�management,�I&CT�change�management,�I&CT�project�management,�availability�management�and�capacity�management.

Prompt points

¼ How are the organisation’s I&CT needs decided? Who is involved in this?

¼ How are anticipated future needs decided and documented?

Systems maintenance and operational supportSoftware�licensing�and�copyright�regulations�are�obligatory�to�ensure�that�intellectual�property�rights�and�title�to�products�are�retained�by�product�owners.�Organisations�should�ensure�that�there�are�appropriate�licences�for�all�software�being�used�on�their�computers.�Staff�should�be�made�aware�of�the�need�to�operate�systems�within�the�legal�requirements�of�the�respective�licence�arrangements.�Policy�should�list�approved�software�and�include�procedures�for�the�review�and�introduction�of�other�software.�

Logical�security�comprises�security�features�that�are�built�into�communications,�information�technology�(IT)�and�other�information�management�(IM)�systems.�Secure�data�storage�is�of�the�utmost�importance�in�a�healthcare�setting.�Compliance�with�the�National�Privacy�Principles�(NPP)1-3�and�the�relevant�State�/�Territory�legislation�should�be�considered�at�all�times.�The�paper-based�sections�of�records,�both�consumer�/�patient�health�records�and�corporate�records,�must�be�stored�securely.

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October 2010  351

Organisations�should�have�reliable�back-up�systems�for�electronic�data�and�a�disaster�recovery�plan.�All�computer�terminals�should�have�secure�access�with�screensavers�and�default�to�standby�if�the�terminal�is�left�unattended�for�a�certain�period�of�time.�Firewalls�and�other�relevant�security�systems�should�be�installed�on�all�computers�and�servers�as�planned.�Consideration�should�be�included�in�these�aspects�of�the�plan�for�extended�and�all-hours�actions�in�the�case�of�problems�with�data�management.

There�should�be�a�Help�Desk�or�other�service�to�ensure�that�users�of�I&CT�have�reliable�and�timely�support,�especially�when�problems�arise�that�could�undermine�the�effective�management�and�use�of�data�and�information.�

Prompt points

¼ How does the organisation decide licence requirements for software? How are allocated licences registered / documented? What procedures are followed if additional licences are needed?

¼ How often are backup strategies and disaster plans tested? When was the last time they were tested? How well did the system work and what changes were needed?

Staff education and trainingHealth�is�a�technology-reliant�industry�prone�to�incidents.4�One�of�the�greatest�contributors�to�incidents�is�human�error�and�in�the�case�of�technology,�specifically�operator�error.

Training�in�I&CT�is�an�important�activity�undertaken�to�ensure�staff�at�all�levels�have�the�necessary�skills�to�carry�out�their�roles�effectively.�Training�is�particularly�important�as�part�of�orientation�to�the�organisation�and�should�be�reinforced�with�follow-up�training�and/or�retraining�where�necessary.�

Organisations�should�decide�what�training�is�needed�for�staff,�how�the�training�will�be�carried�out,�how�the�organisation�will�evaluate�the�effectiveness�of�its�education�and�training�activities�and�what�processes�will�be�put�in�place�to�improve�the�delivery�and�effectiveness�of�I&CT�education�and�training�programs.�This�should�then�be�documented�and�incorporated�into�the�orientation�program.�

Prompt points

¼ What types of data are collected by the organisation? Who is allowed to enter the data?

¼ What training is provided to data entry staff? Who interprets the data?

Risk management and crisis planningAs�with�all�systems�in�health�care,�organisations�should�consider�a�risk�management�framework�that�includes�a�prioritisation�schedule�when�addressing�risks�to�I&CT.�This�should�include:

• emergency�operating�procedures

• a�recovery�plan(s)�with�systems�priority

• disaster�and�contingency�planning

• software,�hardware,�telecommunication�networks�

• technical�expertise�to�control�and�maintain�operational�processes

• planned�preventative�maintenance�processes�

• security�and�processes�to�manage�breaches�of�security;�protecting�security�of�data�by�controlling�file�access.�Data�should�be�securely�available�to�authorised�users�while�denied�to�others.�Security�passwords�can�be�used�on�stand-alone�computers.�Passwords�and�security�access�levels�can�be�used�on�networked�systems.�Security�should�be�considered�when�data�are�transferred�from�one�system�to�another

• use�of�firewalls�and�other�electronic�devices�which�control�the�flow�of�data�in�and�out�of�the�organisation

• remote�access�procedures

• regular�backup�processes�and�storage�of�backup,�for�example,�away�from�electromagnetic�sources�or�off-site�

• accidental�and�deliberate�corruption�or�sabotage

• security�of�faxes,�email�and�telephones,�including�mobile�phones,�and�the�preservation�of�confidentiality.�Policy�and�procedures�for�sending�faxes�and�emails�that�contain�sensitive�information�help�minimise�risk.�

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seCtion 5Standards, criteria, elements and guidelinesstandard 2.3:�Information�management�systems�enable�the�organisation’s�goals�to�be�met

352  The ACHS EQuIP5 Guide  Book 2  Accreditation, Standards and Guidelines  Support and Corporate Functions

Criterion 2.3.4

The�organisation�has�an�integrated�approach�to�the�planning,�use�and�management�of�information�and�communication�technology�(I&CT).�(continued)

Reviewing�records�of�equipment�purchase�and�maintenance,�and�the�monitoring�of�system�and�technology�failures�and�costs,�assist�in�the�development�of�strategies�to�ensure�systems�are�protected�and�operate�effectively.�Data�on�failures�and�resource�utilisation�can�be�used�to�monitor�performance.�Preventative�maintenance�reduces�downtime�and�the�need�for�crisis�maintenance.��It�also�can�increase�users’�satisfaction.

Prompt points

¼ Where is the risk and crisis management plan stored? How often is it reviewed? Who contributed to the plan?

¼ What protective actions help to protect I&CT security for the organisation?

I&CT support for data processingOne�way�that�organisations�can�support�the�collection,�aggregation�and�analysis�of�data�is�through�providing�sufficient�numbers�of,�and�ease�of�access�to,�computers�that�have�up-to-date�and�appropriate�programs�for�analysis�of�data.�Staff�should�be�provided�with�training�and�support�to�perform�their�tasks.�

Within�the�organisation’s�I&CT�policy,�instructions�and�contact�details�should�be�provided�on�how�to�access�and�receive�operational�support�both�within�the�organisation�and�from�external�locations.�The�data�management�policy�should�also�outline�the�system�for�the�validation�and�protection�of�data.�Poorly�collected�data�that�are�subsequently�used�by�managers�to�guide�decision�making�can�have�devastating�consequences.�Unexpected�clinical�data�should�not�be�acted�upon�without�further�review,�as�many�non-clinical�factors�can�impact�measurements,�for�example,�from�medical�devices.�

For�these�reasons,�data�entry�should�be�performed�by�trained�staff.�Although�all�staff�may�access�data,�only�appropriate�staff�should�update�or�make�changes�to�the�data.�

The�system�used�for�the�validation�and�protection�of�data�and�information�will�be�reviewed�through�its�inclusion�in�the�data�management�policy,�which�should�be�evaluated�and�improved�as�part�of�the�Continuous�Quality�Improvement�policy�review�plan.�

Prompt points

¼ What training is provided to staff? Following I&CT training, how is the competency of staff using the systems reviewed?

¼ How does the organisation decide what training to provide in-house? How does it decide what training is provided externally?

¼ How often is I&CT training reviewed? What were the results of the last review? What changes were made in response to these findings?

Evidence commonly presented

Consider whether the following will help to address criterion 2.3.4

¼ Policies, including all aspects of information handling

¼ Maintenance schedules of information technology hardware

¼ Contingency plans for emergencies or disasters

¼ Evidence of licences for software

¼ Evidence of consultation with staff / relevant stakeholders to determine current and future needs for hardware / software

¼ Risk management strategies

¼ Evidence of monitoring of downtime and disasters

¼ Schedule for maintenance of systems

¼ Evaluation of systems

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October 2010  353

Performance measurementThis�criterion�states�that:�“The�organisation�has�an�integrated�approach�to�the�planning,�use�and�management�of�information�and�communication�technology�(I&CT)”.�The�organisation�should�be�able�to�demonstrate�effective�and�integrated�management�of�information�technology,�as�well�as�the�provision�of�appropriate�training,�to�ensure�that�it�achieves�its�goals�for�the�safe�use�of�medical�devices,�data�storage,�and�health�and�corporate�records�management�and�security.

Some�common�suggested�performance�measures�are�as�follows:

Number�of�staff�for�whom�the�level�of�I&CT�access�is�appropriate

Total number of staff

Number�of�staff�whose�IT�training�needs�were�identified�and�met

Total number of staff

Number�of�requests�for�IT�assistance�that�were�resolved�within�X�minutes

Total number of requests for IT assistance

Comment:theorganisationtodefine‘X’

Number�of�hours�of�system�downtime�per�week�/�month

Total number of user hours per week / month

Number�of�programs�for�which�there�is�a�valid�licence

Total number of programs

Number�of�complaints�received�related�to�IT�privacy�breaches

Total number of complaints received

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seCtion 5Standards, criteria, elements and guidelinesstandard 2.3:�Information�management�systems�enable�the�organisation’s�goals�to�be�met

354  The ACHS EQuIP5 Guide  Book 2  Accreditation, Standards and Guidelines  Support and Corporate Functions

References1.� Office�of�the�Federal�Privacy�Commissioner.�National

privacyprinciples(extractedfromthePrivacyAmendment(PrivateSector)Act2000).Sydney�NSW;�Australian�Government;�2001.

2.� Office�of�the�Federal�Privacy�Commissioner.�Nationalprivacyprinciples.Private�sector�information�sheet.�Vol.�1.�Canberra�ACT;�Office�of�the�Privacy�Commissioner;�2006.

3.� Office�of�the�Federal�Privacy�Commissioner.�Nationalprivacyprinciples.Information�sheet.�Canberra�ACT;�Office�of�the�Privacy�Commissioner;�2008.

4.� Institutes�of�Medicine�Committee�on�Quality�of�Health�Care�in�America.�Toerrishuman:buildingasaferhealthsystem.�Washington�DC�USA;�National�Academy�Press;�2000.

Relevant standardsAS�2828:1999Paper-basedhealthcarerecords.Second�edn.

AS�13335.3:2003�Informationtechnology–GuidelinesforthemanagementofITsecurity.

AS�ISO�18308:2005�Healthinformatics–Requirementsforanelectronichealthrecordarchitecture.

AS�ISO�15489.2:2002RecordsManagement:Guidelines.

AS/NZS�13594:1998�Informationtechnology–Lowerlayerssecurity.

AS/NZS�4444.2:2000�Informationsecuritymanagement–specificationforinformationsecuritymanagementsystems.

AS�ISO�20514:2005�Healthinformatics–Electronichealthrecord–definition,scopeandcontext.

Criterion 2.3.4

The�organisation�has�an�integrated�approach�to�the�planning,�use�and�management�of�information�and�communication�technology�(I&CT).�(continued)

Number�of�FTE�staff�involved�in�IT�planning

Total number of FTE staff

Comment:FTE=full-timeequivalent

Number�of�staff�satisfied�with�IT�services�/�equipment

Total number of staff surveyed

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October 2010  355

2.4�Population�Health�Standard

The�standard�is:�The organisation promotes the health of the population.

The�intent�of�this�standard�is�to�ensure�that�all�healthcare�organisations�take�responsibility�for�promoting�the�health�and�wellness�of�the�Australian�population,�in�some�way.�The�extent�of�this�responsibility�is�dependent�on�the�size�and�type�of�organisation�and�on�the�location�of�the�service.

There�is�one�criterion�in�this�standard.�This�is:

2.4.1� �Better�health and wellbeing is promoted�by�the�organisation�for�consumers�/�patients,�staff,�carers�and�the�wider�community.�

This�standard�and�criterion�focus�on�three�main�aspects�of�population�health:�

• health�promotion

• health�protection

• surveillance.

A�great�deal�of�progress�has�been�made�in�improving�the�health�of�the�population�over�the�past�20�years�through�a�combination�of�improving�social�and�environmental�conditions,�providing�a�wider�range�of�prevention�services�and�public�education.�Healthcare�organisations,�the�community,�government�and�public�and�private�institutions�cannot�however�become�complacent.�

During�this�time,�the�burden�has�shifted�from�communicable�diseases�to�non-communicable�diseases�such�as�heart�disease,�chronic�respiratory�disease,�diabetes�type�2�and�mental�health�problems.�New�diseases,�new�threats�to�health�and�new�health�challenges�constantly�emerge�and�need�to�be�managed�in�effective�and�innovative�ways.�Increasing�health�inequalities�will�have�a�significant�effect�on�population�health�status�in�a�range�of�ways.�At�the�same�time,�the�demography�of�the�Australian�population�is�changing,�bringing�new�resources,�opportunities�and�issues.�All�healthcare�organisations�have�roles�to�play�in�the�process�of�improving�population�health.

seCtion 5Standards, criteria, elements and guidelines

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seCtion 5Standards, criteria, elements and guidelinesstandard 2.4:�The�organisation�promotes�the�health�of�the�population

356  The ACHS EQuIP5 Guide  Book 2  Accreditation, Standards and Guidelines  Support and Corporate Functions

IntentThe�intent�of�this�criterion�is�to�ensure�that�all�healthcare�organisations�take�some�measure�of�responsibility�for�promoting�the�health�and�wellbeing�of�the�Australian�population.�The�organisation�should�demonstrate�that�it�has�delineated�its�responsibility�in�this�respect�via�consideration�of�its�consumer�/�patient�population,�and�its�size,�services�and�location.

Relationships of 2.4.1 with other criteriaThe�organisation�has�an�obligation�to�provide�safe,�high�quality�care�(Standard�1.5).�Many�of�the�programs�by�which�the�organisation�regulates�and�improves�aspects�of�its�care,�including�those�addressing�medication�safety�(Criterion�1.5.1),�infection�control�(Criterion�1.5.2),�falls�prevention�(Criterion�1.5.4)�and�nutritional�needs�(Criterion�1.5.7),�can�be�adapted�for�inclusion�in�preventive�health�programs�for�the�broader�community.�Population�health�initiatives�are�more�likely�to�be�effective�if�the�community�is�involved�in�their�planning,�delivery�and�evaluation�(Criterion�1.6.1).�They�should�also�consider�the�diverse�needs�and�diverse�backgrounds�of�those�within�the�community�(Criterion�1.6.3).

Criterion LA – Awareness sA – implementationLA plus the following

MA – evaluationSA plus the following

eA – excellenceMA plus the following

oA – LeadershipEA plus the following

Criterion 2.4.1

Better�health�and�wellbeing�is�promoted�by�the�organisation�for�consumers�/�patients,�staff,�carers�and�the�wider�community.

a)� Staff�and�other�key�stakeholders�are�informed�of�population�health�principles�and�participate�in�evidence-based�health�promotion�strategies.

b)� The�organisation�is�aware�of�the�current�and�emerging�health�priority�areas.

c)� The�organisation�is�aware�of�its�statutory�requirements�for�reporting�public�health�matters.

a)� Policy�/�guidelines�are�implemented�that�are�consistent�with�health�promotion�programs�and�interventions�and�reflect�jurisdictional�priorities.

b)� The�organisation�works�collaboratively�and�has�partnerships�in�place�to�utilise�resources�effectively,�to�support�health�promotion�activities.

c)� The�organisation�optimises�the�delivery�of�health�promotion�programs�and�interventions�to�consumers�/�patients�and�carers.

d)� Training�and�resources�are�available�for�staff�to�support�the�development�of�evidence-based�health�promotion�and�interventions�to�consumers�/�patients,�carers�and�the�wider�community.

e)� Opportunistic�health�promotion�/�education�strategies�are�undertaken�in�partnership�with�consumers�/�patients,�carers,�staff�and�the�wider�community.�

f)� Health�surveillance�data�is�appropriate�to�the�organisation.

a)� The�outcomes�of�health�promotion�programs�and�interventions�are�evaluated�for�their�effectiveness�in�improving�the�health�and�wellbeing�of�consumers�/�patients,�staff,�carers�and�the�wider�community,�and�improved�as�required.

b)� Performance�measures�are�developed,�and�quantitative�or�qualitative�data�collected,�to�evaluate�the�effectiveness�/�outcomes�of�health�promotion�programs�and�interventions�implemented�by�the�organisation.

a)� Health�promotion�programs�and�interventions�together�with�results�are�compared�with�similar�programs�internally�and�externally,�and�improvements�are�made�to�ensure�better�practice.

and/or

b)� Strategic�plans�are�informed�by�relevant�population�health�data�and�reflect�current�jurisdictional�priorities.

and/or

c)� Research�is�undertaken�into�population�health�programs�and�interventions�and�results�are�published�in�peer�review�journals.

a)� The�organisation�demonstrates�it�is�a�leader�in�health�promotion.

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October 2010  357

The�organisation�also�has�a�responsibility�for�the�health�and�wellbeing�of�its�staff,�and�health�promotion�within�the�organisation�should�be�integrated�with�other�staff�support�services�(Criterion�2.2.5).

As�with�all�programs�implemented,�the�organisation’s�health�promotion�strategies�should�be�evaluated�for�their�appropriateness�(Criterion�1.3.1)�and�effectiveness�(1.4.1).

Public health prioritiesHealth�promotion�is�the�process�of�enabling�consumers�/�patients�to�increase�control�over,�and�to�improve,�their�health.1�It�is�described�as�the�use�of�activities�that�are�designed�to�advance�health�status.�Health�promotion�is�concerned�not�only�with�strengthening�the�skills�and�capabilities�of�individuals�but�also�with�actions�directed�towards�changing�social,�environmental�and�economic�conditions�in�order�to�improve�population�and�individual�health.2

Criterion LA – Awareness sA – implementationLA plus the following

MA – evaluationSA plus the following

eA – excellenceMA plus the following

oA – LeadershipEA plus the following

Criterion 2.4.1

Better�health�and�wellbeing�is�promoted�by�the�organisation�for�consumers�/�patients,�staff,�carers�and�the�wider�community.

a)� Staff�and�other�key�stakeholders�are�informed�of�population�health�principles�and�participate�in�evidence-based�health�promotion�strategies.

b)� The�organisation�is�aware�of�the�current�and�emerging�health�priority�areas.

c)� The�organisation�is�aware�of�its�statutory�requirements�for�reporting�public�health�matters.

a)� Policy�/�guidelines�are�implemented�that�are�consistent�with�health�promotion�programs�and�interventions�and�reflect�jurisdictional�priorities.

b)� The�organisation�works�collaboratively�and�has�partnerships�in�place�to�utilise�resources�effectively,�to�support�health�promotion�activities.

c)� The�organisation�optimises�the�delivery�of�health�promotion�programs�and�interventions�to�consumers�/�patients�and�carers.

d)� Training�and�resources�are�available�for�staff�to�support�the�development�of�evidence-based�health�promotion�and�interventions�to�consumers�/�patients,�carers�and�the�wider�community.

e)� Opportunistic�health�promotion�/�education�strategies�are�undertaken�in�partnership�with�consumers�/�patients,�carers,�staff�and�the�wider�community.�

f)� Health�surveillance�data�is�appropriate�to�the�organisation.

a)� The�outcomes�of�health�promotion�programs�and�interventions�are�evaluated�for�their�effectiveness�in�improving�the�health�and�wellbeing�of�consumers�/�patients,�staff,�carers�and�the�wider�community,�and�improved�as�required.

b)� Performance�measures�are�developed,�and�quantitative�or�qualitative�data�collected,�to�evaluate�the�effectiveness�/�outcomes�of�health�promotion�programs�and�interventions�implemented�by�the�organisation.

a)� Health�promotion�programs�and�interventions�together�with�results�are�compared�with�similar�programs�internally�and�externally,�and�improvements�are�made�to�ensure�better�practice.

and/or

b)� Strategic�plans�are�informed�by�relevant�population�health�data�and�reflect�current�jurisdictional�priorities.

and/or

c)� Research�is�undertaken�into�population�health�programs�and�interventions�and�results�are�published�in�peer�review�journals.

a)� The�organisation�demonstrates�it�is�a�leader�in�health�promotion.

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seCtion 5Standards, criteria, elements and guidelinesstandard 2.4:�The�organisation�promotes�the�health�of�the�population

358  The ACHS EQuIP5 Guide  Book 2  Accreditation, Standards and Guidelines  Support and Corporate Functions

Criterion 2.4.1

Better�health�and�wellbeing�is�promoted�by�the�organisation�for�consumers�/�patients,�staff,�carers�and�the�wider�community.�(continued)

Health�promotion�programs�often�focus�action�on�the�reduction�of�levels�of�major�non-communicable�diseases,�such�as�cardiovascular�diseases,�cancer,�chronic�respiratory�diseases�and�diabetes,�and�communicable�diseases,�through�coordinated,�comprehensive�health�promotion�and�disease�prevention�measures.�The�aim�is�to�promote�healthier�lifestyles�in�communities�and�to�prevent�and�control�common�risk�factors,�such�as�hypertension,�lipaemia,�obesity,�smoking,�alcohol�abuse,�unhealthy�diet�and�sedentary�lifestyle.�

This�criterion�includes�elements�that�focus�on�the�three�main�aspects�of�population�health:

• health�promotion

• health�protection

• surveillance.

Government�priorities�may�influence�resource�allocation�in�health�prevention�and�treatment.�Because�planning�is�undertaken�by�people�with�specialist�expertise,�and�greater�funding�is�likely�to�be�available,�these�should�be�considered�as�priorities�by�the�majority�of�organisations.�Government�priority�setting�should�not�be�based�solely�on�incidence�or�severity�of�a�health�problem,�but�should�reflect�available�evidence�on�the�cost-effectiveness�of�interventions,�particularly�preventative�measures.3�Additionally,�organisations�will�understand�the�demographics�of�their�local�area�and�its�populations,�which�will�shape�their�response�to�national�and�jurisdictional�priorities.�

To�assess�the�determinants�of�health�in�its�local�area,�the�organisation�should�ask�the�following�questions�and�monitor�the�answers�over�time:

• Are�the�factors�determining�good�health�changing�for�the�better?

• Where�and�for�whom�are�these�factors�changing?

• Is�it�the�same�for�everyone?

As�Australia�entered�the�21st�century,�seven�National�Health�Priority�Areas�were�chosen�for�focused�attention�at�a�national�level�because�of�their�significant�contribution�to�the�burden�of�illness�and�injury�in�the�Australian�community.�The�National�Health�Priority�Areas�identified�by�government�are4:

• arthritis�and�musculoskeletal�conditions�

• asthma�

• cancer�control�

• cardiovascular�health�

• diabetes�mellitus�

• injury�prevention�and�control�(national)�

• mental�health.�

The�National�Chronic�Disease�strategy�provides�guidance�on�government�planning�and�an�overarching�framework�to�manage�these�conditions4,�while�the�Australian�Institute�of�Health�and�Welfare�coordinates�activity�in�this�area�across�the�States�and�Territories�of�Australia.5

A�number�of�Australian�population�groups�are�also�seen�to�be�of�special�interest�from�a�health�perspective�because�of�their�high�incidence�of�health�problems�compared�to�the�remainder�of�the�population6,�7:

• people�with�a�disability

• socioeconomically�disadvantaged�Australians

• indigenous�people

• people�living�in�rural�and�remote�areas

• prisoners

• veterans.

Health�outcomes�for�indigenous�people�are�so�different�from�the�remainder�of�the�Australian�population�that�they�are�now�separately�monitored.�Membership�of�the�‘indigenous�population’�is�determined�by�participating�individuals�–�inclusion�relies�on�self�identification�by�Aboriginal�and�Torres�Strait�Islanders�who�should�be�asked�for�this�information�according�to�guidelines.8

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October 2010  359

Planning�in�larger�public�organisations�should�draw�on�the�multifaceted�approach�of�the�World�Health�Organization’s�Ottawa�Charter�for�Health�Promotion9,�developed�in�1986.�This�remains�the�basis�upon�which�population�health�strategies�are�developed.�It�has�six�key�components:

• building�healthy�public�policy

• creating�supporting�environments

• supporting�and�strengthening�community�action

• developing�personal�self�care�skills

• reorienting�health�services

• promoting�health�promotion�in�other�health�and�disability�services.

Prompt points

¼ What jurisdictional and national priorities for health promotion are reflected in the organisation’s planning?

¼ What local demographics influence the selection of appropriate health promotion messages and messaging?

Staff education and training Because�of�the�time�pressures�on�many�clinical�staff,�organisations�may�need�to�ensure�their�staff�are�validated�in�preventative�health�action�and�have�access�to�tools�for�efficiently�educating�their�consumers�/�patients,�providing�relevant�information�and�taking�opportunities�for�referral�to�other�providers.�

Opportunities�for�staff�training�in�preventative�health�actions�and�resources�might�be�built�into:

• orientation�programs

• training�focused�on�access�to�information�resources�(particularly�where�these�are�located�on�organisation�intranets)

• performance�and�education�discussions�with�managers

• formal�or�informal�mentoring�contexts.�

Encouraging�staff�members�to�become�involved�in�broader�health�promotion�committees�and�programs�can�help�to�build�internal�capacity�and�organisational�awareness�of�projects�and�new�initiatives.�There�are�sometimes�opportunities�for�organisations�to�participate�in�research�and�pilot�studies�that�will�build�staff�knowledge�and�may�provide�unique�opportunities�for�consumers�/�patients.�

Organisations�might�choose�to�pursue�new�ties�with�relevant�Federal�and�jurisdictional�governments,�professional�bodies�or�universities,�ideally�facilitated�through�the�professional�networks�of�key�staff.�

Ongoing�education�and�networking�through�attendance�at�conferences�and�scanning�relevant�journals�may�alert�the�organisation�to�effective�projects�undertaken�by�similar�organisations.�Relevant�groups�involved�in�health�promotion�include:�

• Public�Health�Association�of�Australia��http://www.phaa.net.au

• Australian�Health�Promotion�Association��http://www.healthpromotion.org.au/

• Australasian�Faculty�of�Public�Health�Medicine�http://www.racp.edu.au/page/racp-faculties/australasian-faculty-of-public-health-medicine/

• Nutrition�Society�of�Australia��http://www.nsa.asn.au/

• Australian�Diabetes�Educators�Association��http://www.adea.com.au/.�

Recognising�the�limited�opportunities�for�advanced�training�in�nutrition�at�many�institutions,�the�Australian�Public�Health�Nutrition�Academic�Collaboration�(APHNAC)�offers�special�public�health�nutrition�units�by�distance�education.10�These�can�be�included�in�specified�undergraduate�and�postgraduate�programs�at�a�number�of�Australian�universities.

Staff�training�to�improve�preventative�health�awareness�and�opportunistic�health�promotion�skills�among�clinical�staff�could�be�achieved�through�onsite�programs�or�by�sending�staff�to�professional�development�programs,�such�as�those�offered�by�many�State�/�Territory�Departments�of�Health.�

Prompt points

¼ Is the organisation aware of staff members with further training in public health / preventative medicine training? Are any staff currently involved in further study in this area?

¼ What training or mentoring is available to improve clinicians’ skills in opportunistic health promotion?

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seCtion 5Standards, criteria, elements and guidelinesstandard 2.4:�The�organisation�promotes�the�health�of�the�population

360  The ACHS EQuIP5 Guide  Book 2  Accreditation, Standards and Guidelines  Support and Corporate Functions

Criterion 2.4.1

Better�health�and�wellbeing�is�promoted�by�the�organisation�for�consumers�/�patients,�staff,�carers�and�the�wider�community.�(continued)

Surveillance and reportingSurveillance�is�defined�as�the�ongoing,�systematic�collection,�analysis�and�interpretation�of�health-related�data�essential�to�the�planning,�implementation�and�evaluation�of�public�health�practice11,�and�is�closely�integrated�with�the�timely�dissemination�of�these�data�to�those�responsible�for�prevention�and�control.�

All�healthcare�organisations�should�be�aware�of�their�legislated�obligations�in�relation�to�surveillance�and�for�the�reporting�of�infectious�diseases.�This�is�addressed�within�criterion�1.5.2.�

In�addition,�public�facilities�will�have�State�/�Territory�government�obligations�for�the�reporting�of�information�about�service�provision,�such�as�emergency�department�waiting�times,�elective�surgery�lists�and�other�indicators.�In�some�States�/�Territories,�a�more�regulated�framework�for�reporting�has�been�introduced12;�the�Clinical�Excellence�Commission�in�NSW�has�developed�a�‘Quality�Systems�Assessment’�program,�and�the�Queensland�Health�and�Quality�Complaints�Commission�has�released�statutory�standards�under�section�20�of�the�HealthQualityandComplaintsCommissionAct2006(Qld),�with�which�it�is�the�legal�duty�of�providers�to�comply.

Performance�measures�for�health�promotion�need�to�be�carefully�reviewed�to�determine�their�relevance�to�the�organisation;�the�selection�process�should�include�consideration�of�the�purpose�of�monitoring�performance�and�whether�action�could�be�taken�if�performance�deteriorated�or�was�considered�to�be�inadequate.�Using�measures�that�are�submitted�externally�(such�as�jurisdictional�health�department�data�or�ACHS�clinical�indicators)�will�provide�opportunities�to�benchmark�performance�against�similar�organisations.�

Prompt points

¼ How is the organisation’s health surveillance data captured, collated and reported? In addition to meeting statutory obligations, how is the data used by the organisation in promoting public health?

¼ What measures are being / have been used to review recent health promotion activities undertaken by the organisation? How were the outcomes of projects reviewed? What occurred following the review of this data?

Health promotion activitiesAny�healthcare�admission�may�provide�an�opportunity�for�promoting�good�health�practices�for�consumers�/�patients.�In�both�formal�and�informal�contexts,�consumers�/�patients�and�their�families�can�be�made�aware�of�health�and�wellness�strategies�they�may�adopt�to�improve�their�health�and�wellbeing.�Advice�and�recommendations�from�a�healthcare�professional�can�make�a�significant�contribution�to�behaviour�change.�There�is�significant�evidence�that�confirms�the�effectiveness�of�professional�advice�in�driving�smoking�cessation.13

Areas�where�planned�and�structured�health�promotion�strategies�targeting�consumers�/�patients�have�proven�effective�include�changing�nutrition�(folate�for�pregnant�women),�promoting�exercise,�encouraging�longer�periods�of�breastfeeding,�promoting�weight�loss,�and�in�cessation�of�smoking.�It�is�not�suggested�that�all�healthcare�organisations�should�be�providing�programs�in�these�areas,�but�if�they�are�available�locally,�that�the�organisation�knows�how�and�where�to�access�them.�

Health�promotion�and�protection�strategies�are�also�important�for�staff;�examples�include�immunisation,�stress�management,�occupational�health�risk�management,�smoking�cessation�and�exercise�programs.�

Opportunistic�health�promotion�may�be�initiated�by�any�healthcare�provider�as�part�of�general�discussions�with�consumers�/�patients�and�their�carers.�It�may�be�fundamental�to�and�directly�linked�with�the�reason�for�admission,�or�an�incidental�discussion�point.�

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October 2010  361

Specialist�organisations,�such�as�day�procedure�centres,�might�demonstrate�their�health�promotion�commitments�through�education�and�information�on�ongoing�care�for�the�conditions�that�they�treat.�For�example,�an�organisation�that�works�in�macular�degeneration�might�educate�consumers�/�patients�and�provide�visual�test�cards�so�that�consumers�/�patients�could�distribute�them�to�family�members�for�screening.�They�could�promote�information�evenings�offered�by�branches�of�the�Royal�Blind�Society,�which�might�assist�consumers�/�patients�to�better�manage�their�deteriorating�vision�and�avoid�other�injuries.

Prompt points

¼ How does the organisation work with the community to develop health promotion programs?

¼ Describe a health promotion program undertaken by this organisation that has been evaluated? Based on the evaluation, if the organisation were to repeat the program, what would be done differently?

¼ How has the organisation optimised a program to get the best achievable outcomes for its consumer / patient population?

Collaborative work and partnershipsWithin�Australia,�there�are�many�member�organisations�and�charities�doing�valuable�work�in�health�promotion.�Groups�that�focus�on�the�government’s�priority�disease�areas�include:

• Heart�Foundation�of�Australia��http://www.heartfoundation.org.au

• Cancer�Council�of�Australia��http://www.cancer.org.au/

• Diabetes�Australia��http://www.diabetesaustralia.com.au/

• Arthritis�Australia��http://www.arthritisaustralia.com.au/

• Asthma�Australia��http://www.asthmaaustralia.org.au/

• Mental�health�groups�including�SANE�Australia,�the�Black�Dog�Institute,�PANDA�and�Beyond�Blue.

The�initiatives�of�these�and�many�other�groups�in�fundraising,�education,�research�and�community�outreach�provide�many�opportunities�for�collaborative�activities.�As�a�starting�point�for�discussions,�these�groups�provide�excellent�information�resources�for�clinicians�and�consumers�/�patients,�which�can�be�considered�for�use�within�healthcare�organisations.�

Prompt points

¼ What collaborative links and partnerships does the organisation use to support its health promotion activities?

¼ What challenges does the collaboration present for the organisation? Has the collaboration facilitated more effective, timely and cost-effective delivery of programs?

Evidence commonly presented

Consider whether the following will help to address criterion 2.4.1

¼ Health protection programs, including staff vaccination records

¼ Declared commitment / philosophy / policy

¼ Survey data regarding disease prevalence

¼ Evidence of staff education programs

¼ Health promotion programs and information available on relevant programs for consumers / patients

¼ Review of care plans / pathways

¼ Evaluation of discharge plans

¼ Policies and procedures on:

– reporting infectious diseases – management of consumers / patients with

infectious diseases

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seCtion 5Standards, criteria, elements and guidelinesstandard 2.4:�The�organisation�promotes�the�health�of�the�population

362  The ACHS EQuIP5 Guide  Book 2  Accreditation, Standards and Guidelines  Support and Corporate Functions

Criterion 2.4.1

Better�health�and�wellbeing�is�promoted�by�the�organisation�for�consumers�/�patients,�staff,�carers�and�the�wider�community.�(continued)

Performance measurementThis�criterion�states�that:�“Better�health�and�wellbeing�is�promoted�by�the�organisation�for�consumers�/�patients,�staff,�carers�and�the�wider�community”.�The�organisation�should�be�able�to�demonstrate�its�health�promotion�activities�with�respect�to�each�of�these�target�population�groups,�and�that�it�supports�and�facilitates�staff�involvement�in�health�promotion�activities.

Some�common�suggested�performance�measures�are�as�follows:

Number�of�health�promotion-related�policies�/�by-laws�/�guidelines�/�procedures�that�reflect�national,��State�/�Territory�and�local�priorities�for�health�promotion

Total number of health promotion-related policies / by-laws / guidelines / procedures

Number�of�clinical�staff�with�tertiary�qualifications�in�health�promotion

Total number of clinical staff

Number�of�clinical�staff�who�have�received�training�in�population�health�principles�and�development�of�evidence-based�health�promotion�and�interventions

Total number of clinical staff

Number�of�clinical�staff�who�have�received�training�or�mentoring�in�opportunistic�health�promotion

Total number of clinical staff

Number�of�health�promotion�strategies�that�address�at�least�one�of�the�six�key�Ottowa�Charter�components

Total number of health promotion strategies

Number�of�health�promotion�initiatives�that�are�developed�and�implemented�in�partnership�with�other�organisations

Total number of health promotion initiatives developed and implemented

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October 2010  363

Number�of�health�promotion�initiatives�that�target�high-risk�population�groups

Total number of health promotion initiatives

Comment:organisationtonominatehigh-riskpopulationgroup

Number�of�prevention�and�early�intervention�initiatives�that�focus�on�children�and�young�people

Total number of prevention and early intervention initiatives

Number�of�consumers�/�patients�whose�self�identified�program�goals�were�met

Total number of consumers / patients who set goals at the commencement of a specific health promotion program

Number�of�the�eligible�population�screened�for�a�specific�medical�condition�(e.g.�breast�cancer,�bowel�cancer)

Total number of eligible population

Number�of�consumers�/�patients�who�are�smokers,�and�to�whom�a�smoking�cessation�program�has�been�actively�promoted

Total number of consumers / patients who are smokers

Number�of�children�whose�vaccination�status�was�checked�when�seen�/�admitted

Total number of children seen / admitted

Number�of�consumers�/�patients�who�receive�follow�up�/�recall�requests�following�screening�/�assessment,�and�who�return�to�the�service

Total number of consumers / patients who receive follow up / recall requests following screening / assessment

Number�of�staff�enrolled�in�health�promotion�programs�promoted�through�the�organisation

Total number of staff eligible for enrolment in health promotion programs promoted through the organisation

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seCtion 5Standards, criteria, elements and guidelinesstandard 2.4:�The�organisation�promotes�the�health�of�the�population

364  The ACHS EQuIP5 Guide  Book 2  Accreditation, Standards and Guidelines  Support and Corporate Functions

Criterion 2.4.1

Better�health�and�wellbeing�is�promoted�by�the�organisation�for�consumers�/�patients,�staff,�carers�and�the�wider�community.�(continued)

References1.� World�Health�Organization�(WHO).�Healthpromotion

glossary.Geneva�CH:�WHO;�1998.�Accessed�from�http://www.who.int/hpr/NPH/docs/hp_glossary_en.pdf�on�1�September�2010.�

2.� World�Health�Organization�–�Europe.�Standardsforhealthpromotioninhospitals.Copenhagen�DK;�WHO;�2004.

3.� Segal�L�and�Chen�Y.Prioritysettingmodelsforhealth–Theroleforprioritysettingandacritiqueofalternativemodels.Melbourne�VIC;�Centre�for�Health�Program�Evaluation;�2001.

4.� National�Health�Priority�Action�Council�(NHPAC).�Nationalchronicdiseasestrategy.Canberra�ACT;�Australian�Health�Ministers’�Advisory�Council�(AHMAC);�2005.

5.� Australian�Institute�of�Health�&�Welfare�(AIHW).�Chronicdisease:Nationalchronicdiseasestrategy.�Canberra�ACT;�AIHW.�Accessed�from�http://www.health.gov.au/internet/main/publishing.nsf/Content/pq-ncds-strat�on�17�August�2010.

6.� Australian�Institute�for�Health�and�Welfare�(AIHW).�Australia’shealth.Australia’s�health�series�no�12.�Canberra�ACT;�AIHW;�2010.

7.� Allen�Consulting�Group.�Fairhealthfacts.�Melbourne�VIC;�Department�of�Human�Services;�2009.

���

8.� Victorian�Department�of�Health�and�Victorian�Aboriginal�Community�Controlled�Health�Organisation.�Aboriginalhealthpromotionandchroniccarepartnershipprogramguidelines.�Melbourne�VIC;�Dept�of�Health;�2005.

9.� World�Health�Organization.�Ottawa�Charter�for�health�promotion.�Firstinternationalconferenceonhealthpromotion.�Ottawa�Canada,�21�November�1986.�Accessed�from�http://www.who.int/hpr/NPH/docs/ottawa_charter_hp.pdf�on�1�September�2010.

10.� Australian�Public�Health�Nutrition�Academic�Collaboration�(APHNAC).�WelcometoAPHNAC.Accessed�from�http://www.new.webtemplate.com.au/bridgehead/Aphnac/default.php�on�1�July�2010.

11.� World�Health�Organization�(WHO).Publichealthsurveillance.Geneva�CH;�WHO.�Accessed�from�http://www.who.int/immunization_monitoring/burden/routine_surveillance/en/index.html�on�2�September�2010.

12.� Australian�Commission�on�Safety�and�Quality�in�Health�Care�(ACSQHC).�DevelopingasafetyandqualityframeworkforAustralia.�Sydney�NSW;�ACSQHC;�2008.

13.� Zwar�NA,�Richmond�R,�Borland�R�etal.�SmokingcessationguidelinesforAustraliangeneralpractice:Practicehandbook.�Sydney�NSW;�RACGP�Guideline�Development�Group;�2004.

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October 2010  365

2.5�Research�Standard

The�standard�is:�The organisation encourages and adequately governs the conduct of health and medical research to improve the safety and quality of health care.

The�intent�of�the�Research�standard�is�two-fold:

• to�encourage�organisations�to�participate�in�research�to�further�the�evidence�available�to�health�care�organisations�for�providing�high�quality�care

• to�ensure�that�if�health�care�organisations�engage�in�clinical�or�health�services�research,�the�research�is�governed�effectively,�in�accordance�with�acceptable�guidelines�and�standards.

There�is�one�criterion�in�this�standard.�This�is:

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

Most�organisations�have�developed�and�implemented�policies�and�systems�for�clinical�and�corporate�risk�management,�human�resources�and�information�management�and�for�managing�the�environment�in�which�health�care�is�provided.�Organisations�should�understand�their�responsibilities�for�the�management�or�governance�of�research,�and�this�responsibility�should�not�rest�with�a�human�research�ethics�committee�(HREC).

seCtion 5Standards, criteria, elements and guidelines

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seCtion 5Standards, criteria, elements and guidelinesstandard 2.5:�The�organisation�encourages�and�adequately�governs�the�conduct�of�health�and�medical�research�to�improve�the�safety�and�quality�of�health�care

366  The ACHS EQuIP5 Guide  Book 2  Accreditation, Standards and Guidelines  Support and Corporate Functions

IntentThe�intent�of�this�criterion�is�to�encourage�participation�in�research,�in�order�to�further�the�knowledge�and�evidence�available�to�healthcare�organisations;�and�to�ensure�that�when�organisations�do�engage�in�clinical�or�health�services�research,�there�is�appropriate�oversight�and�that�the�participating�consumers�/�patients�and�staff�are�protected.

Relationships of 2.5.1 with other criteriaResearch,�whether�medical,�scientific�or�informational,�is�undertaken�in�order�to�increase�knowledge�and,�ultimately,�to�improve�the�care�given�to�the�consumer�/�patient�and�to�have�a�positive�impact�on�the�community�as�a�whole.�The�proper�conduct�of�research�requires�that�participating�consumers�/�patients�are�informed�of�their�rights�and�responsibilities�(Criterion�1.6.2),�and�that�they�are�able�to�give�informed�consent�(Criterion�1.1.3).�The�organisation�must�manage�any�risks�involved�in�the�research�(Criterion�2.1.2),�and�failure�to�do�so�may�lead�to�incidents�and�complaints�(Criteria�2.1.3�and�2.1.4).�The�research�program�requires�organisational�oversight�and�governance�(Criterion�3.1.2).�External�organisations�that�manage�research,�and�Human�Research�Ethics�Committees�and�Animal�Ethics�Committees�from�other�bodies,�are�external�service�providers�(Criterion�3.1.4).

Criterion LA – Awareness sA – implementationLA plus the following

MA – evaluationSA plus the following

eA – excellenceMA plus the following

oA – LeadershipEA plus the following

Criterion 2.5.1

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

a)� The�organisation�fosters�and�encourages�clinical�and�health�services�research.

b)� Research�policy�/�guidelines�is�consistent�with:

� (i)� key�NHMRC�statements

� (ii)� jurisdictional�legislation

� (iii)� codes�of�conduct.

c)� The�governing�body�demonstrates�its�responsibility�for�the�governance�of�research.

d)� The�research�policy�/�guidelines�define�which�research�requires�ethics�approval�and�under�what�conditions�ethics�approval�will�apply.

e)� Staff�are�aware�of�the�research�policy�/�guidelines.

f)� Formal�agreements�exist�with�collaborating�agencies.

a)� The�research�policy�/�guideline�is�implemented.

b)� Scientific�review�standards�of�research�are�applied�and�demonstrated�within�the�body�of�work.

c)� The�respective�responsibilities�of�all�parties�involved�in�research�are�identified�and�documented.

d)� The�role�and�reporting�lines�of�the�organisation’s�human�research�ethics�committee�(HREC)�are�clearly�defined.

e)� The�HREC�is�adequately�resourced.

f)� Ethics�approval�processes�are�timely,�transparent�and�effective.

g)� Consumers�and�researchers�work�in�partnership�to�make�decisions�about�research�priorities,�policy�and�practices.

a)� Performance�measures�are�used�to�evaluate�the�effectiveness�of�the�governance�of�research.

b)� The�system�for�ensuring�effective�research�governance�is�evaluated,�and�is�improved�as�required.

a)� Research�outcomes�are�implemented�in�the�organisation�and�are�used�to�demonstrate�improvements�in�health�care.

and/or

b)� The�organisation�participates�voluntarily�in�a�regular�external�evaluation�of�research�governance.

a)� The�organisation�demonstrates�that�it�is�a�leader�in�research�risk�management.

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October 2010  367

Addressing this criterionResearch�involves�a�systematic�and�rigorous�inquiry�or�investigation,�to�discover�or�confirm�facts�or�principles.�The�ultimate�purpose�of�healthcare�research�is�to�improve�consumer�/�patient�care.�Advances�in�surgical�technique,�the�development�of�new�drugs,�new�or�improved�treatment�options�and�refinements�to�treatment�regimes�rely�on�research.

However,�it�is�imperative�that�where�research�requires�the�participation�of�consumers�/�patients�/�subjects,�they�are�not�placed�at�risk�by�a�research�experiment,�or�at�no�greater�risk�than�that�posed�by�their�disease�condition,�no�matter�how�laudable�the�anticipated�research�outcome.�

Research�projects�undertaken�in�healthcare�settings�take�a�range�of�formats:

• organisations�may�have�dedicated�research�facilities�where�much�of�the�primary�work�may�not�involve�human�subjects

• organisations�may�trial�new�procedures�as�part�of�a�project�coordinated�by�their�owners,�the�WHO�or�a�government�body�

• clinicians�at�a�facility�may�recruit�and�monitor�consumers�/�patients�as�part�of�a�clinical�trial�managed�for�a�pharmaceutical�company�or�university

• organisations�may�have�researching�clinicians�who�undertake�and�publish�primary�research�within�their�own�specialty�area

• organisations�may�undertake�investigations�to�compare�different�approaches�to�providing�clinical�care,�usually�within�the�facility�(many�Quality�Improvement�projects�are�of�this�type).

Criterion LA – Awareness sA – implementationLA plus the following

MA – evaluationSA plus the following

eA – excellenceMA plus the following

oA – LeadershipEA plus the following

Criterion 2.5.1

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

a)� The�organisation�fosters�and�encourages�clinical�and�health�services�research.

b)� Research�policy�/�guidelines�is�consistent�with:

� (i)� key�NHMRC�statements

� (ii)� jurisdictional�legislation

� (iii)� codes�of�conduct.

c)� The�governing�body�demonstrates�its�responsibility�for�the�governance�of�research.

d)� The�research�policy�/�guidelines�define�which�research�requires�ethics�approval�and�under�what�conditions�ethics�approval�will�apply.

e)� Staff�are�aware�of�the�research�policy�/�guidelines.

f)� Formal�agreements�exist�with�collaborating�agencies.

a)� The�research�policy�/�guideline�is�implemented.

b)� Scientific�review�standards�of�research�are�applied�and�demonstrated�within�the�body�of�work.

c)� The�respective�responsibilities�of�all�parties�involved�in�research�are�identified�and�documented.

d)� The�role�and�reporting�lines�of�the�organisation’s�human�research�ethics�committee�(HREC)�are�clearly�defined.

e)� The�HREC�is�adequately�resourced.

f)� Ethics�approval�processes�are�timely,�transparent�and�effective.

g)� Consumers�and�researchers�work�in�partnership�to�make�decisions�about�research�priorities,�policy�and�practices.

a)� Performance�measures�are�used�to�evaluate�the�effectiveness�of�the�governance�of�research.

b)� The�system�for�ensuring�effective�research�governance�is�evaluated,�and�is�improved�as�required.

a)� Research�outcomes�are�implemented�in�the�organisation�and�are�used�to�demonstrate�improvements�in�health�care.

and/or

b)� The�organisation�participates�voluntarily�in�a�regular�external�evaluation�of�research�governance.

a)� The�organisation�demonstrates�that�it�is�a�leader�in�research�risk�management.

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seCtion 5Standards, criteria, elements and guidelinesstandard 2.5:�The�organisation�encourages�and�adequately�governs�the�conduct�of�health�and�medical�research�to�improve�the�safety�and�quality�of�health�care

368  The ACHS EQuIP5 Guide  Book 2  Accreditation, Standards and Guidelines  Support and Corporate Functions

Criterion 2.5.1

The�organisation’s�research�program�develops�the�body�of�knowledge,�protects�staff�and�consumers�/�patients�and�has�processes�to�appropriately�manage�the�organisational�risk�associated�with�research.�(continued)

The�types�and�scale�of�the�research�projects�being�undertaken�by�an�organisation�will�determine�which�elements�of�this�criterion�are�applicable�to�its�circumstances.�From�an�organisational�perspective,�research�activity�offers�both�benefits�and�risks,�and�presents�logistical�and�managerial�challenges.�

When�responding�to�this�criterion,�an�organisation�should�consider�the�types�of�research�it�undertakes�and�the�implications�of�that�research�in�terms�of:

• organisational�governance�(financial�and�legal�implications,�clinical�and�ethical�risks,�benefits�to�society)

• ethics

• risks�to,�and�obligations�to,�participating�consumers�/�patients�/�subjects

• day-to-day�administration�and�management�(research�may�cause�surges�of�activity,�competing�for�resources�with�other�consumers�/�patients�or�staff)

• researchers�and�research�staff�(who�require�training�and�may�be�diverted�from�other�tasks)

• other�staff,�particularly�liaison�people�such�as�those�at�reception�(who�should�be�aware�of�the�project,�if�not�all�its�details)

• the�local�and�broader�community.

Where�a�project�has�implications�in�a�limited�number�of�these�areas,�it�may�be�possible�to�claim�‘Not�Applicable’�status�for�some�elements.�Organisations�should�discuss�these�issues�with�their�Customer�Service�Manager.�

All�EQuIP�member�organisations�are�expected�to�be�monitoring�the�quality�of�their�care�delivery�and�continually�improving�their�processes.�Small�research�projects�will�be�used�to�test�and�monitor�improvements�as�they�are�introduced,�through�the�process�of�continuous�quality�improvement�(CQI).�If�CQI�is�the�only�form�of�research�undertaken�by�the�organisation,�the�organisation�may�be�able�to�claim�an�exemption�from�this�criterion.

Which�QI�projects�are�defined�as�research�to�fulfil�the�requirements�of�this�criterion?�The�answer�should�be�determined�by�the�scale�and�risk�associated�with�the�project.�Quality�Improvement�projects�with�at�least�two�of�these�features:

1.� Funding�by�a�body�outside�the�organisation

2.� Approval�of�the�project�by�a�Human�Research�Ethics�Committee�(HREC)

3.� An�objective�to�develop�a�marketable�product�that�might�be�adopted�by�other�organisations�(e.g.�a�wound�care�solution,�alternative�bandaging�technique,�software�tool)

4.� Coordination�by�a�central�agency,�such�as�a�State�/�Territory�health�department�or�the�Australian�Commission�on�Safety�and�Quality�in�Health�Care

5.� Planning�for�publication�in�a�peer-reviewed�journal

6.� Impact�on�non-participating�staff�and/or�consumers�/�patients

...�would�be�considered�to�have�the�scale�and�reach�both�within�and�beyond�the�organisation�to�be�counted�as�research�for�the�purposes�of�this�criterion.

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October 2010  369

Types of research undertaken within healthcare settings

Potential for direct risk to participating consumer / patient / subject

experiment description

impact of experiment on consumer / patient’s treatment

Components of research: considering research projects in terms of their various aspects may assist in responding to the element(s)

Governance awareness

organisational management awareness

ethics Committee (eC) review

Consumer / patient education and consent

Research team training

other staff informed of the project

Higher Clinical�trial�or�other�controlled�experiment�where�treatment�of�individual�consumers�/�patients�is�varied�for�the�purpose�of�the�research

Selection�of�treatment�pathway�determined�by�experimental�profile�which�may�be�randomised

Yes Sometimes HREC Yes Yes General�awareness,�with�more�information�as�appropriate

Only�variations�to�normal�treatment�are�through�additional�sample�collection�(tissues,�blood,�urine,�etc.),�measurements�or�imaging�

Inconvenience�to�consumer�/�patient

Small�risks�associated�with�some�sample�collection�(e.g.�biopsy,�radiography)

Yes Sometimes HREC Yes Yes As�appropriate

Variations�to�process�that�have�no�direct�clinical�ramifications�(e.g.�administration�of�admission�processes,�number�or�type�of�staff�assigned�to�a�task)

Minimal�physical�risk;�Potential�for�inconvenience

Where�scale�is�very�large�or�project�prestigious‡

Where�scale�is�large

HREC Yes** Yes As�appropriate

Low Only�variations�to�normal�treatment�and�process�are�through�observation�or�survey�/�interview

Minimal�physical�risk;�Potential�for�inconvenience

Where�scale�is�very�large�or�project�prestigious‡

Where�scale�is�large

HREC Yes** Yes As�appropriate,�but�usually�no

Retrospective�study�of�records�with�or�without�consumer�/�patient�contact

No�physical�risk

Almost�never Where�there�are�staffing�or�operational�risks

HREC*� No†† Yes Usually�no

Nil Animal�studies Not�applicable Yes No Animal�EC Not�applicable

Yes No

Basic�research:�Non-living�substrates,�single�celled�organisms�or�cell�cultures

Not�applicable Yes No Only�in�exceptional�circum-stances†

Not�applicable

Yes No

*� Where�record�is�used�outside�its�original�clinical�context†� Genetically�engineered�organisms,�use�of�embryonic�tissue,�etc.‡� Project�would�need�to�have�the�potential�to�impact�the�organisation�through�cost,�risk,�consumer�/�patient�or�staff�

dissatisfaction�or�damaged�reputation�with�collaborators�(funding�bodies�or�participating�organisations)

**� Except�where�experimental�success�depends�on�a�naive�participant.�However,�permission�to�use�any�recordings��and�observations�is�highly�likely.

††� Study�would�be�explained�at�time�of�follow-up�contact

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seCtion 5Standards, criteria, elements and guidelinesstandard 2.5:�The�organisation�encourages�and�adequately�governs�the�conduct�of�health�and�medical�research�to�improve�the�safety�and�quality�of�health�care

370  The ACHS EQuIP5 Guide  Book 2  Accreditation, Standards and Guidelines  Support and Corporate Functions

Criterion 2.5.1

The�organisation’s�research�program�develops�the�body�of�knowledge,�protects�staff�and�consumers�/�patients�and�has�processes�to�appropriately�manage�the�organisational�risk�associated�with�research.�(continued)

Governance of researchWhere�research�is�a�significant�activity�for�an�organisation,�it�would�be�anticipated�that�there�is�a�framework�within�which�it�is�undertaken.�The�framework�is�a�construct�of�governance;�it�considers�current�and�existing�research�results,�and�organisational�expertise�and�experience,�and�uses�these�to�guide�new�and�relevant�research�activities.�The�framework�will�assist�the�organisation�to�facilitate�good�research�concepts,�and�to�direct�project�planning�and�applications�for�funding.�Performance�measures�may�relate�to�funding�achievements,�publication�in�peer-reviewed�journals,�or�commercialisation�of�developments�realised�through�research.

As�part�of�its�commitment�to�fostering�and�encouraging�research,�the�management�of�the�organisation�should�appropriately�support�the�use�of�the�organisation’s�resources�by�those�carrying�out�the�research,�and�ensure�the�implementation�of�the�policies�and�guidelines�under�which�the�research�is�to�be�conducted.�The�purpose�of�research�governance�is�to�ensure�research�integrity�through�accountability,�transparency�and�responsibility.1,�2�The�three�key�components�of�research�governance�are:

• the�protection�of�consumers�/�patients,�carers�and�staff�involved�in�research:�this�includes�such�matters�as�consent,�the�provision�of�appropriate�and�safe�facilities�in�which�clinical�research�may�be�undertaken,�and�the�monitoring�of�consumers�/�patients’�wellbeing

• the�protection�of�researchers:�this�includes�training,�facilities,�processes�for�the�proper�conduct�of�research,�and�appropriate�employment�arrangements

• the�protection�of�the�organisation:�this�includes�matters�that�might�pose�a�risk�to�the�organisation�or�bring�the�organisation�into�disrepute,�for�example,�the�risk�to�the�reputation�of�that�organisation�posed�by�dishonest�research,�financial�risk,�intellectual�property�risk,�commercial�arrangements,�and�liability�with�regard�to�consumer�/�patient�harm.

It�is�important�that�the�need�for�review�by�a�Human�Research�Ethics�Committee�(HREC)�is�not�confused�with�the�need�for�research�governance.�The�organisation’s�management�should�be�aware�of�research�that�presents�specific�risks�or�opportunities�for�the�organisation.�In�addition�to�the�researcher’s�responsibility,�organisations�should�aim�to�ensure�that�projects�receive�appropriate�HREC�oversight.�This�requires�their�understanding�that�if�the�organisation�is�engaged�in�clinical�or�health�services�research,�the�governing�body�is�responsible�for�the�governance�of�that�research.�In�relation�to�clinical�research,�the�responsibility�does�not�rest,�by�default�or�any�other�means,�with�the�HREC.�Such�committees�have�a�different�role�that�is�related�to�the�research,�but�it�is�not�for�the�governance�of�the�research.�In�this�respect,�the�role�of�the�HREC�should�be�clearly�defined�within�the�organisation’s�policies�and�guidelines.�Similarly,�governance�bodies�that�do�not�have�an�organisational�HREC�should�consider�access�in�advance�of�the�need�arising�–�even�low-risk�quality�projects�undertaken�in�healthcare�organisations�will�frequently�draw�upon�health�records�or�require�cooperation�from�consumers�/�patients�to�complete�surveys�or�interviews.

In�the�absence�of�an�HREC,�organisations�should�have�a�designated�executive�member�/�group�that�is�familiar�with�the�NationalStatementonEthicalConductinHumanResearch3,�and�can�review�any�research�project�proposal,�and�assist�in�determining�the�need�for�HREC�involvement.

Organisations�should�review�and�revise�their�policies�and�performance�measures�at�regular�intervals,�and�make�improvements�according�to�available�evidence�and�their�performance�outcomes.�There�is�no�formal�body�that�does�external�evaluations�of�research�governance�for�health�facility�research.�Organisations�should�look�to�peers�to�assist�with�this.

Smaller�organisations�that�undertake�only�low-risk�projects�and�do�not�have�or�need�an�HREC�might�consider�evaluating�their�research�governance�through:

• recording�and�monitoring�consultations�about�research�projects�with�the�designated�executive�member�/�group�

• monitoring�the�executive�member�/�group’s�knowledge�of�relevant�parts�of�the�National�Statement.

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October 2010  371

Prompt points

¼ How does the organisation demonstrate its commitment to fostering and encouraging research?

¼ What is an example of a research project undertaken within this organisation?

¼ How often are the governance policies and performance measures reviewed? What changes have been made in response to a review of policies or performance measures?

Policies, guidelines and standardsClinical�research�involving�human�subjects,�and�the�organisational�policies�that�govern�it,�should�be�consistent�with�the�key�National�Health�and�Medical�Research�Council�(NHMRC)�statements.�These�are:

• NationalStatementonEthicalConductinHumanResearch.The�Australian�Government�National�Health�and�Medical�Research�Council,�2007�(incorporating�all�updates�as�of�September�2009)3�

• TheAustralianCodefortheResponsibleConductofResearch.�Developed�and�issued�jointly�by�the�National�Health�and�Medical�Research�Council,�the�Australian�Research�Council�and�Universities�Australia,�20071

• ValuesandEthics:GuidelinesforEthicalConductinAboriginalandTorresStraitIslanderHealthResearch.�The�Australian�Government�National�Health�and�Medical�Research�Council,�2003.2

In�addition�to�these�three�key�statements,�research�is�governed�by�laws�(Federal�and/or�State�/�Territory),�and�by�other�guidelines�and�codes�of�conduct,�which�deal�with�matters�such�as�privacy,�confidentiality,�consent,�biosafety�and�professional�standards.

The�research�policy�/�guidelines�adopted�by�an�organisation�would�be�expected�to�be�appropriate�for,�and�congruent�with,�the�level�of�risk�associated�with�research�activities�undertaken�by�the�organisation.�The�application�of�a�standard�across�research�practices�will�provide�many�benefits�to�all�involved.4�

These�include:

• enhanced�contribution�to�organisational�goals,�culture�and�knowledge

• best-practice�performance

• increased�efficiency�in�bringing�safe�and�effective�new�therapies�and�organisational�improvements�to�and�for�the�consumer

• external�recognition�as�an�organisation�that�adheres�to�best-practice�standards�through�self�regulation

• enhanced�standards�within�clinical�research

• confidence�in�the�competence�and�level�of�expertise�of�employees

• a�benchmark�for�the�content�of�education�and�training�programs�for�researchers

• increased�marketability�for�an�individual�clinical�research�professional.

Prompt points

¼ How does the organisation ensure widespread awareness of, and alignment with, legislated requirements and the standards developed by the NHMRC?

¼ Is the organisation involved in collaborative research?

¼ What formal research agreements has the organisation entered into?

Ethical review and approval of researchMany�organisations�conduct�basic�health�research�that�does�not�involve�human�or�even�animal�subjects;�this�may�have,�for�example,�a�biological,�engineering,�statistical�or�literature�review�focus.�Fundamental�research�such�as�this�usually�does�not�require�ethical�review.�However,�the�organisation’s�managers�should�be�aware�of�the�broad�areas�of�research�undertaken�and�any�risks�associated�with�them.�Those�organisations�housing�research�involving�genetically�modified�organisms�(GMOs)�will�require�a�licence�and�pre-certified�facilities,�and�the�research�will�be�administered�through�the�Office�of�the�Gene�Technology�Regulator5�and�monitored�by�a�local,�often�institutional,�Biosafety�Committee.�Organisations�with�facilities�that�operate�in�this�sector�should�be�aware�of�the�GeneTechnologyAct2000�(Cth)�and�its�associated�regulations.

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seCtion 5Standards, criteria, elements and guidelinesstandard 2.5:�The�organisation�encourages�and�adequately�governs�the�conduct�of�health�and�medical�research�to�improve�the�safety�and�quality�of�health�care

372  The ACHS EQuIP5 Guide  Book 2  Accreditation, Standards and Guidelines  Support and Corporate Functions

Criterion 2.5.1

The�organisation’s�research�program�develops�the�body�of�knowledge,�protects�staff�and�consumers�/�patients�and�has�processes�to�appropriately�manage�the�organisational�risk�associated�with�research.�(continued)

Research�that�involves�humans�and�that�has�any�risk�of�causing�harm�physically,�psychologically�or�spiritually,�or�that�potentially�could�breach�confidentiality�or�privacy,�must�always�be�submitted�to�a�properly�constituted�HREC.�This�includes�research�where�members�of�the�organisation’s�staff�are�the�participants.

Some�organisations�in�which�human�research�is�conducted�will�have�their�own�HREC,�and�it�is�the�responsibility�of�the�establishing�organisation�to�ensure�that�its�committee�is�adequately�resourced.�Other�organisations,�which�choose�not�to�establish�their�own�committee�or�in�which�the�establishment�of�such�a�committee�would�be�impractical,�may�make�use�of�the�services�of�another�organisation’s�committee,�usually�upon�payment�of�an�appropriate�fee.�The�website�of�the�NHMRC�provides�an�overview�of�HRECs,�including�a�comprehensive�state-by-state�list�of�all�registered�HRECs�and�information�on�such�issues�as�fees.6

Prompt points

¼ Does the organisation have its own HREC? How is the body constituted within organisational policy?

¼ If the organisation does not have its own HREC, where are human research proposals submitted for review?

¼ Does the organisation have an internal review committee? How does the organisation ensure that committee members are familiar with the requirements of the NHMRC’s National Standard on Ethical Conduct in Human Research?

¼ Does the organisation conduct animal-based medical research? To what Animal Ethics Committee does it submit its research proposals? Where does it display its project approval numbers?

Participation in researchAll�participants�in�research,�including�participating�consumers�/�patients,�bear�a�degree�of�responsibility�for�the�correct�conduct�of�the�research.�An�organisation�that�intends�to�undertake�research�must�first�put�in�place�a�research�policy�that�will�frame�and�support�the�correct�management�of�any�research�program�it�undertakes�or�collaborates�in.�In�addition�to�covering�organisational�risk�management�and�project�management,�the�research�policy�should�outline�minimum�standards�for�the�protection�of�research�subjects�/�participants,�staff�assisting�with�the�research�project�and�other�organisational�staff,�including:

• the�responsibilities�of�all�parties

• participant�indemnity

• participant�consent�processes

• the�protection�and�support�of�researchers�and�assisting�staff

• management�of�inquiries�and�complaints.

In�the�interest�of�transparency,�the�organisation’s�research�policy�should�be�made�available�to�consumers�/�patients,�staff,�and�any�other�interested�party.

In�December�2004,�the�NHMRC�published�a�model�framework�for�consumer�and�community�participation�in�health�and�medical�research7�and�a�resource�pack�to�assist�in�the�implementation�of�the�framework.8�These�documents�are�important�references�for�organisations�undertaking�research�and�should�be�incorporated�into�organisational�research�policy.�They�provide�advice�for�organisations�on�why�consumer�and�community�participation�in�research�is�important,�what�is�meant�by�‘involvement’�and�‘participation’,�and�how�to�achieve�it�at�various�levels�of�research.�It�is�relevant�to�many�different�types�of�research�and�the�governance�thereof.�

As�with�many�specialised�work�areas,�the�purposes�and�processes�of�research�may�not�be�evident�to�the�community,�or�even�to�uninvolved�staff�within�the�organisation.�By�including�staff�and�members�of�the�public�in�open�discussion�and�planning,�the�goals,�techniques�and�successes�of�research�may�be�better�communicated,�and�any�misunderstandings�overcome�by�building�networks,�expanding�knowledge�and�raising�levels�of�awareness.�The�organisation�may�arrange�‘Open�Days’�to�publicise�its�research�program(s)�and�its�achievements,�or�deliver�education�sessions�through�community�groups�or�other�public�forums.�The�NHMRC�documents7,�8�are�also�effective�education�tools�for�consumers�and�researchers.�

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October 2010  373

Prompt points

¼ How is the organisation’s research policy accessible to staff? How is the community made aware of research undertaken by the organisation? How can community members access the organisation’s research policy?

¼ How are consumers / patients and/or members of the community involved with research undertaken by the organisation?

Evidence commonly presented

Consider whether the following will help to address criterion 2.5.1

¼ Policies on research

¼ Involvement in research programs

¼ Evidence of ethics approval processes

¼ Evidence of awareness of research in relevant areas

¼ Evidence of qualifications for roles undertaken

¼ Evidence of consumer / patient participation in research

¼ Evidence of formal agreements or contracts

¼ Minutes from meetings

Performance measurementThis�criterion�states�that:�“The�organisation’s�research�program�develops�the�body�of�knowledge,�protects�staff�and�consumers�/�patients�and�has�processes�to�appropriately�manage�the�organisational�risk�associated�with�research”.�It�is�important�that�the�organisation�be�able�to�demonstrate�that�it�encourages�and�governs�health�and�medical�research�to�improve�the�safety�and�quality�of�health�care,�while�effectively�managing�the�associated�risk.

Some�common�suggested�performance�measures�are�as�follows:

Number�of�research�projects�approved�(HREC,�AEC,�internal�committee)

Total number of research projects submitted for approval

Number�of�staff�participating�in�research�projects�or�activities�during�the�previous�twelve�months

Total number of staff

Number�of�research-related�incidents

Total number of research projects or activities

Number�of�research�projects�amended�or�stopped�due�to�animal�welfare�issues

Total number of animal-based research projects

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seCtion 5Standards, criteria, elements and guidelinesstandard 2.5:�The�organisation�encourages�and�adequately�governs�the�conduct�of�health�and�medical�research�to�improve�the�safety�and�quality�of�health�care

374  The ACHS EQuIP5 Guide  Book 2  Accreditation, Standards and Guidelines  Support and Corporate Functions

References1.� National�Health�and�Medical�Research�Council�(NHMRC),�

Australian�Research�Council�(ARC)�and�Universities�Australia.�Australiancodefortheresponsibleconductofresearch.�Melbourne�VIC;�NHMRC;�2007.

2.� National�Health�and�Medical�Research�Council�(NHMRC).�Valuesandethics:GuidelinesforethicalconductinAboriginalandTorresStraitIslanderhealthresearch.�Melbourne�VIC;�NHMRC;�2003.

3.� National�Health�and�Medical�Research�Council�(NHMRC),�Australian�Research�Council�(ARC)�and�Australian�Vice-Chancellors’�Committee.�Nationalstatementonethicalconductinhumanresearch.Canberra�ACT;�Australian�Government;�2007.

4.� Institute�for�Clinical�Research�(ICR).�Clinicalresearchprofessionalstandardsforprofessionalpractice:Raisingthestandardsforclinicalresearch.�Bourne�End�UK;�ICR;�2005.

5.� Office�of�the�Gene�Technology�Regulator�(OGTR).�WelcometotheOfficeoftheGeneTechnologyRegulatorwebsite.�Canberra�ACT;�Australian�Department�of�Health�and�Ageing.�Accessed�from�http://www.ogtr.gov.au/internet/ogtr/publishing.nsf/Content/home-1�on�13�August�2010.

6.� National�Health�and�Medical�Research�Council�(NHMRC).�Overviewofhumanresearchethicscommittees.�Melbourne�VIC;�NHMRC.�Accessed�from�http://www.nhmrc.gov.au/health_ethics/hrecs/overview.htm�on�29�June�2010.

7.� National�Health�and�Medical�Research�Council�(NHMRC)�Amodelframeworkforconsumerandcommunityparticipationinhealthandmedicalresearch.�Canberra�ACT;�Australian�Government;�2004.

8.� National�Health�and�Medical�Research�Council�(NHMRC).�Resourcepackforconsumerandcommunityparticipationinhealthandmedicalresearch.Canberra�ACT;�Australian�Government;�2004.

Standards and guidelinesUnited�States�Department�of�Health�and�Human�Services.�Protectionofhumansubjects.�Code�of�Federal�Regulations:�Public�Welfare�Part�46.�Washington�DC�USA;�Dept�of�Health�and�Human�Services;�2009.

Further readingMonash�University.�Aguidetogoodresearchpractice.Melbourne�VIC;�Faculty�of�Medicine,�Nursing�and�Health�Services�at�Monash�University;�2003.

Jackson�CL,�Nicholson�C,�Doust�J�etal.�Seriously�working�together:�integrated�governance�models�to�achieve�sustainable�partnerships�between�health�care�organisations.�MedJAust2008;�188(8Suppl):�S57-S60.

Katz�SJ�and�Martin�BR.�Whatisresearchcollaboration?Research�Policy.�Brighton�UK;�University�of�Sussex;�1995.

National�Health�and�Medical�Research�Council�(NHMRC).�Removingthebarriers–Outcomespaper.�National�Clinical�Research�Forum.�Sydney;�NSW�Ministry�for�Science�and�Medical�Research;�2005.

Australian�Commission�on�Safety�and�Quality�in�Health�Care�(ACSQHC).�Researchframeworkprinciples.�Sydney�NSW;�ACSQHC;�2008.

Criterion 2.5.1

The�organisation’s�research�program�develops�the�body�of�knowledge,�protects�staff�and�consumers�/�patients�and�has�processes�to�appropriately�manage�the�organisational�risk�associated�with�research.�(continued)

Number�of�consumers�/�patients�experiencing�an�adverse�event�during�or�as�a�result�of�participation�in�a�research�project

Total number of consumers / patients enrolled in research projects

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October 2010  375

3.1�Leadership�and�Management�Standard

The�standard�is:�The governing body leads the organisation’s strategic direction to ensure the provision of quality, safe services.

The�intent�of�this�standard�is�to�ensure�that�an�organisation�is�aware�of�and�manages�all�the�key�components�of�governance�of�a�healthcare�organisation.�The�standards�and�criteria�contained�in�this�functional�area�provide�guidance�on�how�healthcare�organisations�can�achieve�effective�corporate�and�clinical�governance.�

There�are�five�criteria�in�this�standard.�They�are:

3.1.1� �The�organisation�provides�quality,�safe�health�care�and�services�through�strategic and operational planning and development.

3.1.2� Governance�is�assisted�by�formal�structures�and�delegation�practices�within�the�organisation.

3.1.3 Processesfor credentialling and defining the scope of clinical practicesupportsafe,qualityhealthcare.

3.1.4� External�service�providers�are�managed�to�maximise�quality,�safe�health�care�and�service�delivery.

3.1.5� Documented corporate and clinical policies and proceduresassisttheorganisationtoprovidequality,safehealthcare.

These�standards�and�criteria�emphasise�the�need�for�strong�leadership,�governance�and�direction.�

seCtion 5Standards, criteria, elements and guidelines

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seCtion 5Standards, criteria, elements and guidelinesstandard 3.1:�The�governing�body�leads�the�organisation’s�strategic�direction�to�ensure�the�provision�of�quality,�safe�services

376  The ACHS EQuIP5 Guide  Book 2  Accreditation, Standards and Guidelines  Support and Corporate Functions

IntentThe�intent�of�this�criterion�is�to�ensure�that�healthcare�organisations�have�an�integrated�planning�process�that�begins�at�the�strategic�level�and�guides�everyday�work�through�operational�planning.�A�well-articulated�strategic�plan�that�is�supported�by�a�detailed�operational�plan(s)�allows�everyone�to�work�towards�the�same�vision,�mission�and�values,�while�providing�clear�direction�regarding�each�unit,�team�or�individual’s�role�in�the�achievement�of�the�organisation’s�strategic�objectives�and�service�development.

Relationships of 3.1.1 with other criteriaThe�organisation’s�strategic�and�operational�planning�should�articulate�its�commitment�to�the�delivery�of�safe,�high�quality�care�(Standard�1.1),�continuous�quality�improvement�(Criterion�2.1.1),�the�management�of�risk�(Criterion�2.1.2)�and�consumer�participation�(Criterion�1.6.1).�The�planning�will�consider�all�operational�aspects�of�the�organisation,�including�human�resources�(Standard�2.2),�information�technology�(Criterion�2.3.4),�governance�(Criterion�3.1.2)�and�the�safety�of�consumers�/�patients,�visitors�and�staff�(Standard�3.2).

Criterion LA – Awareness sA – implementationLA plus the following

MA – evaluationSA plus the following

eA – excellenceMA plus the following

oA – LeadershipEA plus the following

Criterion 3.1.1

The�organisation�provides�quality,�safe�health�care�and�services�through�strategic�and�operational�planning�and�development.

a)� An�organisational�strategic�plan�has�been�developed�and�includes�values,�vision�and�mission.

b)� Service�delivery�needs�of�the�communities�are�analysed�and�considered�when�developing�strategic�and�operational�plans.

c)� There�is�recognition�of�the�need�to�develop�relationships�with�relevant�organisations�and�communities�to�achieve�organisational�and�strategic�objectives.

d)� There�is�a�planned�approach�to�the�development�of�facilities�and�services.

e)� Operational�plans�are�developed�to�achieve�the�organisation’s�goals�and�objectives�and�guide��day-to-day�activities.

f)� The�activities�of�the�organisation�are�covered�by�appropriate�by-laws,�articles�of�association�and/or�policies�and�procedures.

a)� Organisational�and�service�planning�aligns�with�strategic�objectives.

b)� Clinical�and�non-clinical�service�planning�reflects�projected�service�demands.

c)� Planning�identifies�priority�areas�for�care�/�service�development�and�the�most�efficient�use�of�resources

d)� Stakeholders�and�where�appropriate,�consumers�/�patients�and�carers�are�involved�in�the�development�and�implementation�of�plans.

e)� Relationships�with�relevant�external�organisations�are�formally�recognised�in�the�planning�process.

f)� Change�and�risk�management�strategies�are�documented�to�achieve�the�objectives�of�the�strategic�and�operational�plans.

g)� Planned�changes�are�clearly�communicated�to�relevant�stakeholders.

a)� The�governing�body�evaluates�progress�towards�achieving�the�vision,�goals�and�strategic�objectives�of�the�strategic�plan,�and�takes�remedial�action�as�required.

b)� Changes�driven�by�the�strategic�plan�are�evaluated�in�consultation�with�relevant�stakeholders.

a)� The�process�of�service�planning�and�development�is�compared�with�external�systems,�and�improvements�are�made�to�ensure�better�practice.

and/or

b)� Achievement�against�strategic�objectives�is�compared�with�external�systems,�and�improvements�are�made�to�ensure�better�practice.

a)� The�organisation�demonstrates�it�is�a�leader�in�providing�quality,�safe�care�and�services�through�strategic�and�operational�planning�and�development.

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October 2010  377

Organisational planningStrategic�planning�is�a�process�that�articulates�the�organisation’s�vision�and�mission,�its�values,�and�planned�objectives;�what�it�intends�to�achieve�for�its�community.�The�process�of�strategic�planning�is�a�function�of�the�governing�body�but�ideally�involves�staff,�stakeholders�and�consumers�as�well.

Organisational�strategy�defines�what�an�organisation�seeks�to�do�and�how�it�plans�to�do�it.�While�a�formal�plan�may�guide�overall�direction,�strategy�development�is�a�continuous�process,�enabling�the�organisation�to�respond�to�changes�in�its�environment�as�appropriate.1�Strategic�planning�is�a�management�tool�that�helps�an�organisation�to�assess�and�adjust�the�organisation’s�direction�in�response�to�a�changing�environment�–�to�focus�its�energy,�and�to�ensure�that�members�of�the�organisation�are�working�toward�the�same�goals.2

The�outcome�of�effective�health�service�strategic�planning�is�clarity�of�direction�for�service�development�and�resource�investment.�This�direction�should�be�evidence-based�and�reflect�strategic�objectives,�service�policies�and�population�needs�and�priorities.�Planning�is�developed�through�consumer,�clinician�and�stakeholder�consultation,�and�needs�to�acknowledge�affordability�and�the�workforce�necessary�to�deliver�the�plan.�Therefore,�planning�must�consistently�be�tested�against�the�strategic�direction�of�the�system�and�the�health�needs�of�the�population�served.3

Criterion LA – Awareness sA – implementationLA plus the following

MA – evaluationSA plus the following

eA – excellenceMA plus the following

oA – LeadershipEA plus the following

Criterion 3.1.1

The�organisation�provides�quality,�safe�health�care�and�services�through�strategic�and�operational�planning�and�development.

a)� An�organisational�strategic�plan�has�been�developed�and�includes�values,�vision�and�mission.

b)� Service�delivery�needs�of�the�communities�are�analysed�and�considered�when�developing�strategic�and�operational�plans.

c)� There�is�recognition�of�the�need�to�develop�relationships�with�relevant�organisations�and�communities�to�achieve�organisational�and�strategic�objectives.

d)� There�is�a�planned�approach�to�the�development�of�facilities�and�services.

e)� Operational�plans�are�developed�to�achieve�the�organisation’s�goals�and�objectives�and�guide��day-to-day�activities.

f)� The�activities�of�the�organisation�are�covered�by�appropriate�by-laws,�articles�of�association�and/or�policies�and�procedures.

a)� Organisational�and�service�planning�aligns�with�strategic�objectives.

b)� Clinical�and�non-clinical�service�planning�reflects�projected�service�demands.

c)� Planning�identifies�priority�areas�for�care�/�service�development�and�the�most�efficient�use�of�resources

d)� Stakeholders�and�where�appropriate,�consumers�/�patients�and�carers�are�involved�in�the�development�and�implementation�of�plans.

e)� Relationships�with�relevant�external�organisations�are�formally�recognised�in�the�planning�process.

f)� Change�and�risk�management�strategies�are�documented�to�achieve�the�objectives�of�the�strategic�and�operational�plans.

g)� Planned�changes�are�clearly�communicated�to�relevant�stakeholders.

a)� The�governing�body�evaluates�progress�towards�achieving�the�vision,�goals�and�strategic�objectives�of�the�strategic�plan,�and�takes�remedial�action�as�required.

b)� Changes�driven�by�the�strategic�plan�are�evaluated�in�consultation�with�relevant�stakeholders.

a)� The�process�of�service�planning�and�development�is�compared�with�external�systems,�and�improvements�are�made�to�ensure�better�practice.

and/or

b)� Achievement�against�strategic�objectives�is�compared�with�external�systems,�and�improvements�are�made�to�ensure�better�practice.

a)� The�organisation�demonstrates�it�is�a�leader�in�providing�quality,�safe�care�and�services�through�strategic�and�operational�planning�and�development.

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seCtion 5Standards, criteria, elements and guidelinesstandard 3.1:�The�governing�body�leads�the�organisation’s�strategic�direction�to�ensure�the�provision�of�quality,�safe�services

378  The ACHS EQuIP5 Guide  Book 2  Accreditation, Standards and Guidelines  Support and Corporate Functions

Criterion 3.1.1

The�organisation�provides�quality,�safe�health�care�and�services�through�strategic�and�operational�planning�and�development.�(continued)

Major�strategic�planning�activities�include:�

• strategic�analysis�(see�Strategic�/�needs�analysis�section�below)

• seizing�the�future�and�being�responsive�to�the�environment�in�which�the�organisation�operates

• setting�strategic�directions

• being�clear�about�the�organisation’s�objectives�

• being�aware�of�the�organisation’s�resources

• action�planning.1

Long-�and�short-term�objectives�are�essential�for�effective�management�of�the�organisation.�Action�planning�is�carefully�laying�out�how�the�strategic�objectives�will�be�accomplished�using�the�identified�methods�or�strategies.�This�often�includes�declaring�specific�results�for�each�objective.�Reaching�a�strategic�objective�typically�involves�accomplishing�a�set�of�results,�or�milestones,�along�the�way.1

Therefore,�the�strategic�plan�establishes�an�organisation’s�overall�strategic�objectives,�is�organisation-wide�and�is�responsive�to�the�organisation’s�risks.�It�identifies�the�organisation’s�long-term�direction,�where�resources�are�to�be�allocated,�what�services�are�available�and�what�is�needed.�The�governing�body�approves�the�plan,�which�is�then�implemented�and�revised�as�necessary.

The�operational�plan�is�a�short-term�plan�that�details�the�methods�or�strategies�by�which�the�strategic�plan�will�be�accomplished,�and�can�be�developed�for�specific�sites�/�areas�/�programs�/�services.�It�identifies�responsibilities�and�timeframes�in�a�format�that�can�be�easily�understood.�The�strategic�plan�and�operational�plans�can�be�aligned�using�performance�indicators.�Performance�improvement,�change�management�and�risk�management�processes�should�also�be�included�to�ensure�the�achievement�of�outcomes�identified�in�the�strategic�plan.�

In�summary,�the�organisation’s�strategic�and�operational�plans�should�be�integrated,�responsive�to�the�needs�of�the�community�and�developed�cooperatively�by�management,�staff�and�the�community,�along�with�other�relevant�health�service�providers�and�stakeholders.�Operational�plans�should�be�aligned�with�the�strategic�plan�and�performance�indicators�used�to�facilitate�monitoring�and�progress�towards�achievement�of�strategic�objectives.�

Prompt points

¼ What are the organisation’s vision, mission, strategic objectives and values and how do these guide planning?

¼ How are these made known to all stakeholders?

¼ What framework and processes does the organisation use to develop strategic and operational plans?

¼ What role do stakeholders play in strategic and operational planning?

¼ What evidence of identified needs, priorities, appropriateness and effectiveness is used to guide planning?

¼ How are areas for care / service development prioritised?

¼ How is action planning undertaken?

¼ What strategies are in place to achieve the organisation’s objectives?

¼ What change or risk management strategies are documented?

¼ How do operational plans achieve the organisation’s objectives and guide day-to-day activity?

¼ How does the organisation ensure that operational plans guide performance improvement and the management of change and risk?

¼ How is progress monitored against objectives outlined in the strategic and operational plans, and corrective action taken if necessary?

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Strategic / needs analysisStrategic�or�needs�analysis�includes�conducting�a�scan,�or�review,�of�the�organisation’s�environment,�for�example,�of�the�political,�social,�economic�and�technical�environment.�Various�driving�forces�in�the�environment�should�be�carefully�considered,�such�as�increasing�competition,�change�in�policy�direction,�changing�demographics,�etc.1�As�healthcare�organisations�operate�within�a�complex�local�and�national�political�context,�it�is�important�to�bring�an�understanding�of�the�climate�and�culture�both�within�the�organisation�and�in�the�wider�health�and�community�environment�into�the�planning�process.�Being�attuned�to�health�strategy�and�policy�at�a�national�and�local�level�and�being�able�to�plan�ahead�in�a�way�that�takes�account�of�these�factors�is�necessary�for�the�delivery�of�appropriate,�quality�care.�This�includes�recognition�that�the�boundaries�between�organisations�are�not�important,�that�services�should�work�across�boundaries,�and�that�no�one�organisation�in�the�health�service�can�‘stand�alone’.4

The�focus�on�continuous�improvement�in�provision�of�health�care�requires�leaders�who�stay�aware�of�best�clinical�and�management�practice.�Being�aware�of�practice�elsewhere�enables�them�to�replicate�or�improve�upon�it�in�their�own�organisations�and�across�the�health�community.�Leaders�are�held�accountable�for�service�delivery�in�their�own�organisation.�Thus,�they�need�to�understand�how�services�are�being�delivered�to�consumers�/�patients,�to�pick�up�early�warning�signs�of�difficulty,�and�to�seize�opportunities�to�improve�the�consumer�/�patient�experience.4�

Identifying�and�planning�for�possible�internal�and�external�challenges�assists�the�organisation�to�be�prepared.�An�external�challenge�could�be�described�as�a�challenge�imposed�on�an�organisation�by�external�forces,�or�the�‘rules�of�success’.�These�could�include:

• changes�in�legislation�or�regulation�

• technological�advances

• government�department�restructures�

• governing�organisation�restructures�or�takeover�

• national�workforce�shortages

• external�disasters�such�as�earthquakes,�transport�accidents�or�bushfires

• outside�competition

• change�in�government�policy�that�may�impact�on�the�organisation.�

An�internal�challenge�may�be�described�as�a�challenge�within�the�organisation,�and�could�include:�

• recruitment�issues

• technological�crises

• the�Emergency�Department�being�full�to�capacity

• an�unavailability�of�beds�in�the�organisation�

• a�continuing�adverse�financial�trend.�

Prompt points

¼ What processes are used to determine and analyse key factors in the external environment?

¼ How does the organisation anticipate and ensure adaptability to changing circumstances?

¼ How are internal and external challenges addressed?

¼ How is projected demand for clinical and non-clinical services incorporated into planning processes?

¼ What evidence is used to support provision (or non-provision) of particular services?

Building relationships and collaboration in planningTo�ensure�a�comprehensive�approach�to�planning,�it�is�crucial�for�strategic�and�operational�planning�processes�to�incorporate�formal�consideration�and�recognition�of�the�relationships�that�exist,�or�need�to�be�developed,�between�the�healthcare�organisation�and�other�bodies,�such�as�other�health�services,�community�organisations,�health�funds�and�government�bodies.�Broad�consultation�will�help�to�identify�and�address�the�needs�and�expectations�of�the�organisation’s�internal�and�external�customers.�The�involvement�of�managers,�staff�and�the�community�in�strategic�and�operational�planning,�as�well�as�the�implementation�of�those�plans,�will�ensure�that�needs,�expectations�and�opportunities�are�determined�and�considered.�

Healthcare�organisations�should�define�their�communities,�or�the�populations�they�serve.�These�are�the�people�and�groups�who�have�an�interest�in�the�organisation,�and�its�outcomes,�or�who�are�affected�in�some�way�by�its�activities.5�Organisations�will�identify�their�communities,�as�discussed�within�criterion�1.2.1,�in�order�to�meet�their�needs.�They�may�also�find�it�useful�to�analyse�the�influence�of�various�stakeholders�associated�with�the�organisation,�and�the�impact�such�influence�may�have�on�planning.5�

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seCtion 5Standards, criteria, elements and guidelinesstandard 3.1:�The�governing�body�leads�the�organisation’s�strategic�direction�to�ensure�the�provision�of�quality,�safe�services

380  The ACHS EQuIP5 Guide  Book 2  Accreditation, Standards and Guidelines  Support and Corporate Functions

Criterion 3.1.1

The�organisation�provides�quality,�safe�health�care�and�services�through�strategic�and�operational�planning�and�development.�(continued)

Consumer�participation�should�occur�at�multiple�levels�of�the�organisation�through�activities�such�as�consumer�partnership�in�governance�and�management�committees�and�within�improvement�initiatives�or�clinical�risk�management�activities,�as�well�as�broader�community�consultation.�Consumer�participation�should�be�actively�sought�in�planning,�and�the�utilisation�of�consumer�/�patient�complaints,�compliments,�surveys�and�Freedom�of�Information�(FOI)�requests�should�inform�improvements.�Strategies�should�be�in�place�to�ensure6,�7:

• consumers�participate�in�planning,�improvement�and�monitoring�organisational�processes�

• there�is�clear,�open�and�respectful�communication�between�consumers�and�the�organisation�at�all�levels,�including�strategically�

• services�respond�with�humanity�to�the�diverse�needs�of�consumers�/�patients�and�the�community�

• services�learn�from�consumer�/�patient�feedback�on�clinical�care�and�service�delivery.�

Once�the�composition�of�a�healthcare�organisation’s�community�is�determined,�how�representatives�are�actively�sought�for�participation�in�planning�will�vary.�For�example,�one�organisation�may�hold�focus�groups�comprised�of�referring�practitioners�to�obtain�their�input,�while�another�may�invite�consumers�through�a�local�advertising�campaign�to�apply�for�positions�on�its�governing�body.

Prompt points

¼ How are the views of diverse stakeholders incorporated into planning processes?

¼ How is consumer participation encouraged and supported in planning activities?

¼ How is stakeholder influence acknowledged, balanced and managed?

¼ How does the organisation actively create conditions for successful partnership work?

¼ How are partnerships utilised to support planning for ‘joined up’ or integrated care?

¼ What communication and distribution channels are utilised for informing management, staff and the community of plans and any changes?

¼ How is the quality and effectiveness of collaborative partnerships evaluated?

Change managementChange�management�is�the�process�of�managing�the�effective�implementation�of�organisational�strategies,�ensuring�that�permanent�changes�in�objectives,�behaviours,�relationships,�processes�and�systems�are�achieved�to�the�organisation’s�advantage.�Change�management�has�been�recognised�as�a�complex,�dynamic�process,�during�which�unanticipated�events�and�behaviours�may�emerge.�Change�is�seen�as�a�learning�process�that�is�not�linear�and�sequential,�but�a�continuous�process�of�transition�involving�continual�adjustment�of�objectives,�unanticipated�events�and�disruption.8�An�organisation’s�willingness�and�ability�to�adapt�to�changing�circumstances,�along�with�the�development�of�flexible�strategies,�assist�the�organisation�to�continue�to�achieve�its�overall�strategic�objectives�and�mission.�

Communicating�the�vision�and�rationale�for�change�and�service�improvement,�and�engaging�and�facilitating�others�to�work�collaboratively�to�achieve�real�improvement,�are�essential�components�when�instituting�change.�Leadership�is�critical�in�establishing�the�organisational�climate�that�people�experience,�whether�the�context�is�a�hospital,�a�community�setting�or�a�network.�How�prepared�people�are�to�expend�the�extra�effort�required�to�implement�change�is�impacted�by�this�climate.�Strong�and�clear�leadership�is�critical�in�inspiring�people�to�make�changes�and�in�getting�diverse�stakeholders�to�work�effectively�together.�As�health�services�become�more�integrated�with�other�agencies,�it�is�also�critical�that�leaders�provide�clarity�about�individual�and�team�roles.4

A�change�leader�needs�to4:

• manage�the�team

• secure�the�right�resources�and�support

• create�the�right�team�conditions

• articulate�a�compelling�vision�of�change

• mobilise�people’s�energy�and�commitment

• make�change�inclusive�and�effective.

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October 2010  381

While�changing�organisational�structure�is�a�popular�thing�to�do,�much�research�suggests�that�this�often�results�in�poor�outcomes,�with�the�benefits�sought�by�those�who�initiate�restructuring�only�rarely�being�achieved.�Instead,�there�are�strong�arguments�for�making�improvements�to�systems�and�cultures.�This�means�striving�to�influence�and�shape�how�people�tackle�change,�their�behaviours�and�practices,�attitudes�and�values,�which�are�the�fundamental�building�blocks�of�successful�and�sustainable�change.�

Utilising�an�interactive,�problem-solving�approach�along�with�a�range�of�tools�helps�to�promote�change�and�measure�progress.9

In�summary:

• establish�a�change�agenda�and�improvement�program

• anticipate�change�and�be�responsive�in�a�planned�manner

• communicate�vision�and�rationale�for�change

• engage�and�facilitate�others�to�work�collaboratively

• prioritise�effort�to�get�the�best�outcomes

• focus�on�making�improvements�to�systems�and�cultures,�rather�than�structure�alone

• involve�relevant�staff�and�consumers�throughout�the�design,�implementation�and�evaluation�phases

• utilise�an�interactive,�problem-solving�approach,�along�with�a�range�of�tools

• secure�resources�and�support

• support�staff�through�change�processes

• be�open�and�transparent�in�communication�with�stakeholders:

– internal�stakeholders�such�as�staff,�visiting�medical�officers

– the�wider�community

– external�service�providers,�such�as�local�government�community�services�and�general�practitioners

– external�stakeholders,�such�as�State�/�Territory�government,�corporate�office,�etc.�

• identify�and�measure�the�outcomes�of�any�significant�change�process;�review�and�evaluation�of�achievement�against�planned�outcomes�feeds�back�into�the�planning�process.

Prompt points

¼ How does the organisation strategically anticipate and plan for change?

¼ How are opportunities likely to achieve the greatest outcomes determined?

¼ Are there examples where challenges were overcome and change management strategies were effectively used? Were these documented?

¼ Was the organisation able to direct efforts to improving systems or cultures?

¼ What approach was taken?

¼ How was the vision and rationale for change communicated?

¼ How did the organisation ensure collaborative stakeholder engagement throughout?

¼ How were risks identified, documented and managed?

¼ What evaluation strategies were built in and how are changes evaluated?

¼ What examples demonstrate that evaluation findings have resulted in changes to clinical and non-clinical areas?

¼ How have findings been utilised to further refine the strategy, or inform other activities?

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seCtion 5Standards, criteria, elements and guidelinesstandard 3.1:�The�governing�body�leads�the�organisation’s�strategic�direction�to�ensure�the�provision�of�quality,�safe�services

382  The ACHS EQuIP5 Guide  Book 2  Accreditation, Standards and Guidelines  Support and Corporate Functions

Criterion 3.1.1

The�organisation�provides�quality,�safe�health�care�and�services�through�strategic�and�operational�planning�and�development.�(continued)

Evidence commonly presented

Consider whether the following will help to address criterion 3.1.1

¼ Framework and process for developing strategic and operational plans including categories for participants

¼ Vision, mission, strategic objectives and value statements

¼ Strategic and operational plans with objectives and targets and links to other plans

¼ Legislative compliance activities – team reviews, audits, mortality and morbidity review meetings, etc.

¼ Examples of internal and external challenges that have been addressed

¼ Examples of issues where change management strategies are used

¼ Communication and distribution channels for informing management, staff and the community of plans and any changes

¼ Reports of progress to objectives and targets in the strategic and operational plans

¼ Reports of evaluation of changes to the organisation’s systems, culture, services, structures or practices

Performance measurementThis�criterion�states�that:�“The�organisation�provides�quality,�safe�health�care�and�services�through�strategic�and�operational�planning�and�development”.�All�aspects�of�the�organisation’s�operation�must�be�addressed�within�its�processes�for�planning�and�development.�The�organisation�should�be�able�to�demonstrate�how�these�processes�facilitate�effective�care�outcomes�and�continuous�quality�improvement.

Some�common�suggested�performance�measures�are�as�follows:

Number�of�documented�strategic�/�operational�/�departmental�objectives�achieved�annually

Total number of documented strategic / operational / departmental objectives

Number�of�staff�educated�about�legislation�related�to�their�area�of�responsibility

Total number of staff in a particular area

Number�of�department�/�unit�plans�that�are�deployed�from�organisational�operational�/�strategic�plans

Total number of department / unit plans

Number�of�operational�/�strategic�plans�developed�with�stakeholder�involvement

Total number of operational / strategic plans

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October 2010  383

References1.� McNamara�C.�Basicdescriptionofstrategicplanning

(includingkeytermstoknow).�Minneapolis�USA;�Authenticity�Consulting.�Accessed�from�http://www.managementhelp.org/plan_dec/str_plan/basics.htm�on�3�March�2010.

2.� Bryson�JM.�Strategicplanningforpublicandnonprofitorganizations:Aguidetostrengtheningandsustainingorganizationalachievement.3rd�edn.�San�Francisco�USA;�Jossey�Bass;�2004.

3.� NSW�Health.�PolicyDirective:Areahealthcareservicesplans–NSWHealthguidefordevelopment.Sydney;�NSW�Health;�2005.

4.� National�Health�Service�(NHS).�Institute�for�Innovation�and�Improvement.�NHSleadershipqualitiesframework.London�UK;�NHS;�2006.

5.� Maddern�J,�Courtney�M,�Montgomery�J�and�Nash�R.�Strategy�and�organisational�design�in�health�care.�In:�Harris�MG�(ed.)�Managinghealthservices:conceptsandpractice.�2nd�edn.�Sydney�NSW;�Elsevier�Australia;�2006.

6.� Victorian�Rural�and�Regional�Health�and�Aged�Care�Services�Division.�Doingitwithus,notforus:Strategicdirection2010–13.�Melbourne;�Victorian�Department�of�Health;�2009.

7.� KPMG�Australia.�ReviewofthecurrentstateofclinicalgovernanceinVictoria.�Melbourne�VIC;�KPMG;�2008.

8.� Telford�K,�Maddock�A,�Isam�C�and�Kralik�D.�Managing�change�in�the�context�of�a�community�health�organisation.�AustJPrimHealth�2006;�12(2):�156-166.

9.� Braithwaite�J.�An�empirical�assessment�of�social�structural�and�cultural�change�in�clinical�directorates.�HealthCareAnal2006;�14(4):�185-193.

Number�of�operational�/�strategic�plans�that�formally�recognise�relationships�with�external�organisations

Total number of operational / strategic plans

Number�of�consumers�/�consumer�representatives�who�contributed�to�operational�/�strategic�planning

Total number of individuals / groups who contributed to operational / strategic planning

Number�of�strategic�objectives�achieved�per�planning�cycle

Total number of objectives in strategic plan per planning cycle

Number�of�documented�change�management�and�risk�management�strategies�for�strategic�objectives

Total number of objectives in operational / strategic plan

Number�of�communications�from�governing�body�/�leadership�team�that�convey�vision�and�rationale�for�change

Total number of changes implemented

Number�of�outcome�measures�met�with�respect�to�specific�changes

Total number of outcome measures set for specific changes

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seCtion 5Standards, criteria, elements and guidelinesstandard 3.1:�The�governing�body�leads�the�organisation’s�strategic�direction�to�ensure�the�provision�of�quality,�safe�services

384  The ACHS EQuIP5 Guide  Book 2  Accreditation, Standards and Guidelines  Support and Corporate Functions

Criterion LA – Awareness sA – implementationLA plus the following

MA – evaluationSA plus the following

eA – excellenceMA plus the following

oA – LeadershipEA plus the following

Criterion 3.1.2

Governance�is�assisted�by�formal�structures�and�delegation�practices�within�the�organisation.

a)� The�governing�body�is�aware�of�its�role�for�strategy�and�monitoring.

b)� The�governing�body’s�duties�and�responsibilities�are�defined,�documented�and�comply�with�relevant�legislation.�

c)� Leaders�and�managers�understand�their�role�as�promoters�of�organisational�culture.

d)� Terms�of�reference,�membership�and�procedures�are�in�place�for�meetings�of�the�governing�body.�

e)� A�formal�delegation�system�exists.

f)� A�formal�system�to�appoint�senior�managers�exists�that�identifies�the�accountability�of�managers�for�the�safe�provision�of�services.�

g)� A�system�exists�to�govern�decision�making�with�ethical�implications.

h)� There�are�records�of�ethical�decisions�that�have�been�referred�by�a�clinician�to�the�nominated�consultative�body�for�ethical�decision�making.

i)� Financial�processes�are�consistent�with�legislative�and�government�requirements.

j)� The�organisation�has�a�budget�development�and�review�process.

k)� Allocation�of�resources�is�based�on�the�service�requirements�identified�in�the�strategic�and�operational�planning�processes.

a)� Members�of�the�governing�body�receive�formal�orientation�and�ongoing�education�regarding�their�role.

b)� The�vision,�mission�and�values�are�demonstrated�through�the�culture�of�the�organisation.

c)� Leaders�and�managers�are�educated�in�their�role�as�promoters�of�organisational�culture.

d)� The�governing�body�ensures�that�committees�have�access�to�terms�of�reference,�membership�and�procedures.

e)� Minutes,�decisions�and�actions�of�committee�and�governing�body�meetings�are�recorded�and�confirmed.

f)� Decisions�of�the�governing�body�are�implemented.

g)� The�governing�body�receives,�monitors�and�assesses�issues�referred�for�ethical�consideration.�

h)� The�organisation�has�sound�financial�management�practices�that�ensure�its�ongoing�financial�viability.

i)� Useful,�timely�and�accurate�financial�reports�are�provided�to�the�governing�body�and�managers�with�delegated�financial�authority.

j)� The�governing�body�regularly�shares�information�about�its�activities�and�decisions�with�relevant�stakeholders.

a)� The�vision,�mission�and�values�of�the�organisation�are�evaluated�and�changes�are�made�as�required.

b)� The�governing�body�assesses�its�performance,�and�the�performance�of�its�members,�and�improvements�are�made�as�required.

c)� The�governing�body�receives,�evaluates�and�takes�action�to�respond�to�reports�on�the�quality�of�care�and�services.

d)� The�outcomes�of�clinical�ethical�issues�are�reviewed�and�improvements�are�made�as�required.

e)� Organisational�structures�and�processes�are�reviewed�to�ensure�quality�services�are�delivered.

f)� Compliance�with�delegations�is�monitored�and�evaluated�and�improved�as�required.

g)� The�effectiveness�of�formally�constituted�committees�is�monitored,�regularly�evaluated�and�improved�as�required.

h)� By-laws,�operating�requirements�and�management�requirements�are�regularly�reviewed�to�reflect�current�requirements.

i)� Financial�performance�is�evaluated�and�improved�as�required.

a)� All�members�of�the�governing�body�have�qualifications�in�governance.

and/or

b)� The�organisation�demonstrates�that�its�governance�enables�a�culture�that�results�in�good�clinical�outcomes,�as�demonstrated�through�clinical�indicator�and�business�performance�data.�

and/or

c)� Governance�structures�are�compared�with�external�systems�and�models,�and�improvements�are�made�to�ensure�better�practice.�

and/or

d)� Delegations�are�compared�with�external�systems,�and�improvements�are�made�to�ensure�better�practice.

and/or�

e)� Financial�management�performance�indicators�are�compared�with�external�organisations,�and�improvements�are�made�to�ensure�better�practice.

a)� The�organisation�demonstrates�it�is�a�leader�in�governance�assisted�by�formal�structures�and�delegation�practices.

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October 2010  385

Criterion LA – Awareness sA – implementationLA plus the following

MA – evaluationSA plus the following

eA – excellenceMA plus the following

oA – LeadershipEA plus the following

Criterion 3.1.2

Governance�is�assisted�by�formal�structures�and�delegation�practices�within�the�organisation.

a)� The�governing�body�is�aware�of�its�role�for�strategy�and�monitoring.

b)� The�governing�body’s�duties�and�responsibilities�are�defined,�documented�and�comply�with�relevant�legislation.�

c)� Leaders�and�managers�understand�their�role�as�promoters�of�organisational�culture.

d)� Terms�of�reference,�membership�and�procedures�are�in�place�for�meetings�of�the�governing�body.�

e)� A�formal�delegation�system�exists.

f)� A�formal�system�to�appoint�senior�managers�exists�that�identifies�the�accountability�of�managers�for�the�safe�provision�of�services.�

g)� A�system�exists�to�govern�decision�making�with�ethical�implications.

h)� There�are�records�of�ethical�decisions�that�have�been�referred�by�a�clinician�to�the�nominated�consultative�body�for�ethical�decision�making.

i)� Financial�processes�are�consistent�with�legislative�and�government�requirements.

j)� The�organisation�has�a�budget�development�and�review�process.

k)� Allocation�of�resources�is�based�on�the�service�requirements�identified�in�the�strategic�and�operational�planning�processes.

a)� Members�of�the�governing�body�receive�formal�orientation�and�ongoing�education�regarding�their�role.

b)� The�vision,�mission�and�values�are�demonstrated�through�the�culture�of�the�organisation.

c)� Leaders�and�managers�are�educated�in�their�role�as�promoters�of�organisational�culture.

d)� The�governing�body�ensures�that�committees�have�access�to�terms�of�reference,�membership�and�procedures.

e)� Minutes,�decisions�and�actions�of�committee�and�governing�body�meetings�are�recorded�and�confirmed.

f)� Decisions�of�the�governing�body�are�implemented.

g)� The�governing�body�receives,�monitors�and�assesses�issues�referred�for�ethical�consideration.�

h)� The�organisation�has�sound�financial�management�practices�that�ensure�its�ongoing�financial�viability.

i)� Useful,�timely�and�accurate�financial�reports�are�provided�to�the�governing�body�and�managers�with�delegated�financial�authority.

j)� The�governing�body�regularly�shares�information�about�its�activities�and�decisions�with�relevant�stakeholders.

a)� The�vision,�mission�and�values�of�the�organisation�are�evaluated�and�changes�are�made�as�required.

b)� The�governing�body�assesses�its�performance,�and�the�performance�of�its�members,�and�improvements�are�made�as�required.

c)� The�governing�body�receives,�evaluates�and�takes�action�to�respond�to�reports�on�the�quality�of�care�and�services.

d)� The�outcomes�of�clinical�ethical�issues�are�reviewed�and�improvements�are�made�as�required.

e)� Organisational�structures�and�processes�are�reviewed�to�ensure�quality�services�are�delivered.

f)� Compliance�with�delegations�is�monitored�and�evaluated�and�improved�as�required.

g)� The�effectiveness�of�formally�constituted�committees�is�monitored,�regularly�evaluated�and�improved�as�required.

h)� By-laws,�operating�requirements�and�management�requirements�are�regularly�reviewed�to�reflect�current�requirements.

i)� Financial�performance�is�evaluated�and�improved�as�required.

a)� All�members�of�the�governing�body�have�qualifications�in�governance.

and/or

b)� The�organisation�demonstrates�that�its�governance�enables�a�culture�that�results�in�good�clinical�outcomes,�as�demonstrated�through�clinical�indicator�and�business�performance�data.�

and/or

c)� Governance�structures�are�compared�with�external�systems�and�models,�and�improvements�are�made�to�ensure�better�practice.�

and/or

d)� Delegations�are�compared�with�external�systems,�and�improvements�are�made�to�ensure�better�practice.

and/or�

e)� Financial�management�performance�indicators�are�compared�with�external�organisations,�and�improvements�are�made�to�ensure�better�practice.

a)� The�organisation�demonstrates�it�is�a�leader�in�governance�assisted�by�formal�structures�and�delegation�practices.

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seCtion 5Standards, criteria, elements and guidelinesstandard 3.1:�The�governing�body�leads�the�organisation’s�strategic�direction�to�ensure�the�provision�of�quality,�safe�services

386  The ACHS EQuIP5 Guide  Book 2  Accreditation, Standards and Guidelines  Support and Corporate Functions

Criterion 3.1.2

Governance�is�assisted�by�formal�structures�and�delegation�practices�within�the�organisation.�(continued)

IntentThe�intent�of�this�criterion�is�to�ensure�that�the�required�structures�and�processes�are�in�place�for�effective�management�of�the�organisation,�that�individual�roles�and�responsibilities�are�understood,�and�that�there�are�clear�channels�of�communication�and�accountability.�

Relationships of 3.1.2 with other criteriaThe�delivery�of�care�that�is�high�quality�(Standard�1.1)�and�safe�(Standard�1.5)�relies�on�robust�governance�structures�and�delegations.

Formal�governance�structures,�leadership�and�delegation�practices�are�necessary�to�action�strategic�and�operational�plans�(Criterion�3.1.1),�to�support�and�drive�organisational�commitment�to�improving�performance�and�the�management�of�corporate�and�clinical�risk�(Standard�2.1),�and�to�successfully�manage�and�support�a�skilled�and�competent�workforce�(Standard�2.2).�Structures�must�also�be�in�place�to�govern�research�and�research�ethics�(Criterion�2.5.1),�which�is�distinct�from�general�decision�making�with�ethical�implications.

GovernanceGovernance�is�the�system�by�which�organisations�are�directed�and�controlled.1�In�healthcare,�it�is�a�leadership�responsibility�to�set�organisational�agendas�for,�and�monitor,�both�corporate�and�clinical�governance.�The�governing�body�and�senior�managers�need�to�ensure�that�the�organisation�is�performing�effectively,�that�services�are�being�delivered�according�to�predefined�standards�and�that�mechanisms�are�in�place�to�take�remedial�action�when�problems�are�encountered.2�Having�adequate�reporting�mechanisms�and�reviewing�clinical�and�organisational�performance�through�accurate�interpretation�of�data�on�a�regular�basis�are�preconditions�to�effective�governing�body�and�executive�leadership.

In�addressing�this�criterion,�organisations�should�define�which�body�carries�legal�accountability�and/or�scope�of�organisational�responsibility�for�the�functions�covered.�Governance�structures�vary�from�context�to�context,�jurisdiction�to�jurisdiction�and�organisation�to�organisation.�In�the�case�of�the�small�private�organisation,�the�governing�body�may�be�an�individual�owner�or�a�group�of�senior�managers.�Public�organisations�may�have�a�governing�body�of�

directors,�a�Board,�a�group�of�senior�managers�and/or�a�chief�executive�appointed�by�a�government�agency.�Some�operate�under�an�arrangement�whereby�aspects�of�governance�responsibilities,�such�as�those�relating�to�human�resources,�finance�or�information�communication�technology,�are�split�between�the�organisation�and�a�central�corporate�body;�this�is�common�for�organisations�that�are�members�of�a�large�private�company�or�an�Area�Health�Service.�Where�organisations�are�distanced�from�a�Board�or�central�decision-making�authority,�the�executive�management�group�may�make�governance�decisions�within�a�framework�provided�by�the�central�authority.�In�smaller�jurisdictions�such�as�the�Australian�Capital�Territory�or�Northern�Territory,�responsibility�for�certain�aspects�may�rest�outside�the�organisation�within�a,�or�across�a�number�of,�government�departments�or�entities.�

The�corporate�and�clinical�functions�of�the�governing�body�have�been�defined�as:�

Corporategovernance–�“The�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�in�an�organisation”.3�It�influences�how�the�objectives�are�set�and�achieved,�how�risk�is�monitored�and�assessed�and�how�performance�is�optimised.4�

Clinicalgovernance�–�the�system�by�which�the�governing�body,�managers�and�clinicians�share�responsibility,�and�are�held�accountable�for�consumer�/�patient�safety,�minimising�risks�to�consumers�and�for�continuously�monitoring�and�improving�the�quality�of�clinical�care.5

Leadership and organisational cultureOrganisational�culture�refers�to�the�prevailing�pattern�of�beliefs,�attitudes,�values�and�behaviours�within�an�organisation6,�which�is�often�built�upon�underlying�assumptions.�Culture�incorporates�a�set�of�structures,�routines,�rules�and�norms�which�guide�and�constrain�behaviour.�It�is�shaped�by�relations�between�the�governing�body�and�management7,�as�well�as�broader�leadership�behaviour,�and�is�constantly�created�and�enacted�through�human�interactions.8

Strong�cultures�are�built�on�consistent,�visible�role�modelling�and�leadership,�consistent�feedback�on�both�positive�and�negative�performance,�and�constant�communication�and�sharing�of�experiences�around�what�is�important�to�the�organisation.9�For�example,�the�governing�body�may�lead�and�develop�a�culture�where�open�disclosure,�reporting�and�learning�from�errors�and�adverse�events,�and�clear�accountability�for�and�participation�in�safety�improvement�are�

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embedded�and�rewarded.�The�governing�body�and�senior�management�support�this�culture�by�resourcing�and�encouraging�Root�Cause�Analyses,�systems�review,�and�implementation�of�best�practice,�as�well�as�appropriate�education�and�training.10�This�may�be�reflected�in�the�development�of�a�‘just’�culture11,�a�values-supportive�model�of�shared�accountability�that�encourages�individuals�to�report�mistakes�so�that�the�precursors�to�errors�can�be�better�understood�in�order�to�fix�the�system�issues.�A�just�culture�holds�organisations�accountable�for�the�systems�they�design�and�for�how�they�respond�to�staff�behaviours�in�fair�and�just�ways.�In�turn,�staff�are�accountable�for�the�quality�of�their�choices�and�for�reporting�both�their�errors�and�system�vulnerabilities.

Prompt points

¼ How does the governing body set the tone of the organisational culture?

¼ What development opportunities are provided for leaders and managers and how do these support their role in promulgating organisational culture? Are cultural surveys administered regularly? How are results utilised to improve organisational culture?

¼ How is organisational culture measured and improvements made?

¼ How is application of the organisational culture by committees or other groups monitored? What documentation is audited?

¼ How are complaints from staff or consumers / patients regarding episodes that do not reflect organisation values managed?

¼ Are ‘whistleblower’ and respectful behaviour policies in place? How are staff protected?

Roles and responsibilities Governing�bodies�within�the�healthcare�context�are�responsible�for�both�corporate�and�clinical�governance.�The�governing�body�should�lead�an�effective�system�of�corporate�and�clinical�governance,�preferably�using�an�integrated�governance�model,�to�facilitate�quality�care�delivery�and�continuous�improvement�in�the�safety�and�quality�of�care.�The�governing�body�makes�certain�that�accountability�is�clear�and�creates�a�‘just’�culture�that�is�able�to�embrace�reporting�and�support�improvement.12�

Clinical�care�should�be�addressed�with�the�same�rigour�as�financial�and�business�issues�are�addressed�by�corporate�governance.�Clinical�governance�should�be�“rigorous�in�its�application,�organisation-wide�in�its�emphasis,�accountable�in�its�delivery,�developmental�in�its�thrust,�and�positive�in�its�connotations”.13�It�should�also�strive�to�balance�both�clinical�and�management�imperatives�with�a�focus�on�the�consumer�/�patient.�

The�governing�body�is�assisted�in�meeting�its�responsibilities�by�committees�and�appropriate�delegations.

Prompt points

¼ Which body carries legal accountability and/or scope of organisational responsibility for the governance functions? If this is shared, how are accountability and the various responsibilities delineated?

¼ How does the organisation ensure that roles, duties and responsibilities of the governing body are clearly defined and effective?

¼ How does the organisation ensure that the governing body members remain up-to-date and comply with relevant legislation?

¼ Does the organisation produce reports of reviews of governing body compliance with legislation?

¼ What methods does the governing body utilise to regularly and transparently communicate with stakeholders regarding non-confidential matters?

¼ How does the organisation evaluate the performance of the governing body and its members?

Orientation and education for the governing bodyTo�fulfil�their�responsibilities,�governing�body�members�need�to�exercise�care,�diligence�and�skill,�through�actions�such�as14:�

• taking�reasonable�steps�to�guide�and�monitor�the�management�of�the�organisation�including�its�approach�to�risk�management

• becoming�familiar�with�the�business�of�the�organisation�and�how�it�is�operated

• applying�their�minds�to�the�overall�position�of�the�organisation.�

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seCtion 5Standards, criteria, elements and guidelinesstandard 3.1:�The�governing�body�leads�the�organisation’s�strategic�direction�to�ensure�the�provision�of�quality,�safe�services

388  The ACHS EQuIP5 Guide  Book 2  Accreditation, Standards and Guidelines  Support and Corporate Functions

Criterion 3.1.2

Governance�is�assisted�by�formal�structures�and�delegation�practices�within�the�organisation.�(continued)

Members�should�also�be�oriented�regarding�appropriate�governance�dynamics�and�relations�that�support�constructive�interaction.�This�includes�governance�relations:

• amongst�governing�body�members�

• between�the�governing�body,�management7�and�senior�clinicians

• between�the�governing�body�and�members�of�external�governing�bodies�or�networks�to�facilitate�coordinated�planning�or�service�delivery.

Formal�orientation�and�ongoing�education�for�the�governing�body�will�assist�its�members�to�better�understand�their�governance�role�and�responsibilities.�As�many�governing�bodies�have�focused�largely�on�financial�performance�and�access�issues,�orientation�and�ongoing�education�should�focus�on�developing�the�broader�skills�needed�to�develop�the�specific�expertise�needed�in�risk�management,�quality�and�consumer�/�patient�safety�and�to�assume�a�more�‘corporate’�role.�Orientation�processes�should�introduce�a�new�member�to�the�roles�outlined�and�their�associated�responsibilities,�in�addition�to�the�more�subtle�politics,�influences�and�contexts�that�the�organisation�operates�within.�

Prompt points

¼ How does the organisation ensure that appropriate orientation and education is provided to governing body members?

¼ How are the requirements for ongoing education determined? Is a training needs analysis undertaken to identify gaps? How often does this occur?

¼ How does the content of orientation and education programs assist governing body members to undertake their role?

Governance structuresThe�governance�structure�specifies�the�distribution�of�rights�and�responsibilities�among�different�participants�of�the�organisation�such�as�governing�body�members,�managers�and�shareholders.1

Formal�organisational�structures�include:

• clarity�regarding�composition,�such�as�appointments�of�senior�managers�and�clinicians,�representation�of�disciplines,�professional�bodies�and�committee�structures

• delegation�of�authority�appropriate�to�individual�roles�and�responsibilities�within�the�organisation�for�the�operation�of�clinical�and��non-clinical�services

• linkages�with�stakeholders�and�facilities

• effective�clinical�governance�that15:�

– provides�an�environment�that�fosters�quality�

– monitors�the�quality�of�care�

– provides�a�regular�report�to�the�governing�body�on�the�quality�of�care�

– identifies�and�minimises�the�risk�of�deficiencies�in�the�quality�of�care�

– effectively�addresses�and�overcomes�these�deficiencies

• reporting�mechanisms�to�the�governing�body,�internally�within�the�organisation�and�to�stakeholders.

Organisations�should�regularly�review�their�governance�and�assurance�arrangements�to�assess�if�all�the�threads�of�quality,�performance�and�governance�are�aligned�and�integrated.�Consideration�should�be�given�to�whether�committee�structures,�their�terms�of�reference,�relationships�and�their�‘supports’�(staff,�advisors,�systems�and�processes)�are�all�fit�for�the�purpose�and�flexible�enough�to�cope�with�changing�priorities�and�risks.16�Steps�should�also�be�taken�to�assess�and�monitor�that�the�quality�of�meeting�minutes�and�other�documentation�supports�effective,�informed�and�meaningful�information�flow�and�decision�making.�

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October 2010  389

Prompt points

¼ What is in place to guide the governing body’s structure, roles and responsibilities, terms of reference, subcommittees, minutes of meetings and use of attendance registers?

¼ What Key Performance Indicators are in place and documented for the governing body, executive team, subcommittees, working groups, ‘meetings’ and advisory boards, etc.? How is progress measured and deficiencies addressed?

¼ How are committee structures, terms of reference and reporting lines determined and clearly defined? How are meeting minutes shared and with whom?

¼ How does the organisation ensure that governing body and committee meeting minutes are of high quality and comprehensively reflect discussions and decisions made?

¼ In what ways do the organisation’s annual reports reflect the organisation’s direction and activities?

Effective governance for quality and safetyWith�respect�to�safety�and�quality�of�care�in�healthcare�organisations,�ultimate�responsibility�and�authority�lies�with�the�governing�body.17�The�focus�of�the�governing�body�should�be�on�inquiry,�use�of�the�best�available�evidence,�innovation�and�systems�improvement.�

An�integrated�system�of�governance�can�be�utilised�to�actively�manage�consumer�/�patient�safety�and�quality�risks.�To�facilitate�this,�the�governing�body�should18:

• clearly�articulate�organisational�and�individual�accountabilities�for�safety�and�quality�throughout�the�organisation

• implement�planning�and�review�of�integrated�governance�systems�for�consumer�/�patient�safety�and�quality

• implement�and�maintain�systems,�materials,�education�and�training,�which�ensures�that�safe,�effective�and�reliable�health�care�is�delivered�

• facilitate�compliance�and�manage�performance�across�the�organisation�and�within�individual�areas�of�responsibility�

• model�behaviours�that�optimise�safety�and�high�quality�care�as�part�of�the�implementation�of�a�safety�culture�within�the�organisation

• consider�safety�and�quality�implications�in�decision-making�processes

• support�consumers�/�patients�to�exercise�their�healthcare�rights.

Structures�such�as�a�quality�committee�should�be�in�place,�along�with�associated�plans,�performance�measurement�and�monitoring�systems,�to�improve�quality�of�care�and�facilitate�the�management�and�reduction�of�serious�risks.10�To�facilitate�active�leadership�around�quality�and�safety,�the�governing�body�should�receive�and�consider�meaningful�reporting10�on�matters�such�as:

• progress�against�a�safety�and�quality�plan�

• adverse�events�and�progress�on�Root�Cause�Analysis�associated�with�sentinel�events�

• appropriateness�issues�such�as�overuse,�underuse�and�misuse�of�care,�including�utilisation�rates�for�high-volume,�high-cost�and�high-complaint�areas.�

The�governing�body�then�utilises�this�information�to�take�informed�and�appropriate�action.�

Prompt points

¼ What specific expertise in quality improvement and consumer / patient safety in health care or another industry is incorporated into membership of the governing body? If this capacity is lacking, what steps are being taken to attract and appoint members with such expertise?

¼ How does the organisation build and nurture effective relationships between the governing body, clinical staff and senior leadership?

¼ How is a quality and safety plan created?

¼ How does the organisation ensure that the governing body receives meaningful information, including trended and/or benchmarked performance reporting, on quality and consumer / patient safety?

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seCtion 5Standards, criteria, elements and guidelinesstandard 3.1:�The�governing�body�leads�the�organisation’s�strategic�direction�to�ensure�the�provision�of�quality,�safe�services

390  The ACHS EQuIP5 Guide  Book 2  Accreditation, Standards and Guidelines  Support and Corporate Functions

Criterion 3.1.2

Governance�is�assisted�by�formal�structures�and�delegation�practices�within�the�organisation.�(continued)

Delegation and accountabilityAppropriate�delegation�to�senior�executives�and�managers�for�the�operation�of�clinical�and�non-clinical�services�assists�them�to�fulfil�their�duties�and�meet�expectations�regarding�their�roles�and�the�implementation�of�governing�body�decisions.�Expectations�regarding�accountability�for�safety�and�quality�within�specified�areas�of�responsibility�should�be�clearly�outlined�and�linked�to�performance�measures.�A�formal�delegation�system�ensures�that�clear�lines�of�accountability�exist,�particularly�where�temporary�delegations�are�enacted.

Delegation�policies�may�include,�as�a�minimum:

• the�limits�of�delegation

• the�instrument�of�delegation

• how�the�policy�was�formulated

• implementation�and�compliance�monitoring.

Prompt points

¼ Is there a formal delegation system in operation? How are clear areas and scope of responsibility defined and documented, particularly for temporary delegations?

¼ When was the delegation system last reviewed, and what recommendations were implemented? Has this resulted in improvements?

¼ How is accountability monitored and addressed if standards are not being upheld? Is this undertaken within a climate of support and accountability?

¼ How does the governing body monitor implementation of its decisions?

¼ If there are delays in executing long-term governing body decisions, how does the organisation demonstrate that planning is underway?

Financial management The�organisation’s�financial�management�process�will�usually�include:

• appropriate�delegation�of�responsibility�for�the�management�of�financial�affairs

• planning�and�budget�preparation�with�the�participation�of�senior�management�and�staff

• a�risk�management�and�insurance�program�that�includes�appropriate�insurance�cover

• monitoring�of�financial�and�productivity�measures

• reporting�the�relationship�between�budget�and�actual�experience

• comprehensive�reporting�to�the�governing�body�and�senior�managers

• analysing�the�results�of�financial�reports

• internal�control

• preparation�of�accounts�that�meet�statutory�requirements

• independent�audit�if�required�by�statute

• management�follow-up�on�recommendations,�reports�and�related�feedback.

While�the�allocation�of�resources�may�not�be�determined�at�the�organisational�level�in�all�cases,�the�governing�body�has�responsibility�to�utilise�all�resources,�including�funding,�staff,�facilities�and�available�equipment�to�ensure�the�delivery�of�quality�and�safe�care�according�to�identified�service�requirements�and�in�line�with�strategic�and�operational�plans.�

Prompt points

¼ How are finances managed to facilitate the achievement of organisational goals, including the ability to provide quality care?

¼ What organisational values shape behaviour regarding financial management?

¼ How does the budget development and review process ensure the most equitable / just, efficient and effective use of resources?

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Ethical oversightEthical�decision�making�refers�to�the�way�in�which�an�organisation’s�ideals,�values�and�ethos�–�the�sum�of�ideals�which�define�an�overall�culture�–�are�translated�into�everyday�practice�through�the�actions�and�behaviour�of�people.19�

Ethical�issues�that�may�need�to�be�addressed�include:

• equity�of�access�to�services

• marketing�of�services

• recognition�of�cultural�or�religious�beliefs�that�affect�the�provision�of�care

• allocation�of�scarce�resources

• billing�and�charging�policies

• organ�donation

• withdrawal�/�continuation�of�life�support

• trialling�of�new�drugs�or�procedures

• conflicts�of�interest.

As�policies,�procedures�and�codes�of�conduct�may�not�always�provide�adequate�guidance�in�resolving�ethical�issues,�staff�may�need�a�more�formal�mechanism�to�govern�decision�making�with�ethical�implications.�This�promotes�a�consistent�approach�throughout�the�organisation�and�provides�staff�with�appropriate�support.�An�example�may�be�a�forum�where�staff�can�informally�discuss�and�explore�the�ethical�dimension�of�their�work�and�seek�collegial�guidance�and�support�not�only�for�clearly�contentious�decisions�that�may�carry�significant�associated�risk,�but�also�for�the�everyday�ethical�challenges�encountered�by�individual�staff.

Prompt points

¼ What ethical decision-making mechanism(s) is available to both clinical and non-clinical staff, particularly for everyday ethical challenges? How is this made known and promoted?

¼ How does the governing body receive, monitor and assess issues referred for ethical consideration?

¼ What arrangements are in place to address unanticipated ethical challenges, should they arise?

¼ How are the outcomes of clinical ethical issues reviewed and improvements made?

Evidence commonly presented

Consider whether the following will help to address criterion 3.1.2

¼ Measurement of and improvements to organisational culture

¼ Orientation and education program content and attendances by members of the governing body

¼ The structure of the governing body, its roles and responsibilities, terms of reference, minutes of meetings, attendance registers

¼ Organisational structure or chart

¼ Structures of committees, terms of reference, reporting lines, minutes of meetings

¼ Annual reports

¼ Reports of reviews of governing body compliance with legislation in its responsibilities

¼ Delegation documents or instruments

¼ Reports of reviews of the delegation documents

¼ Position descriptions

¼ Policies and procedures for budget development reviews

¼ Policies and procedures for financial management

¼ Reports of reviews of the financial system’s compliance with legislation

¼ Independent audit / sign-off of financial records, particularly matters that may be considered commercial-in-confidence

¼ Easy availability of ethical facts and information

¼ A forum where staff can discuss ethical issues, or a referral process for issues to be considered by the governing body

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seCtion 5Standards, criteria, elements and guidelinesstandard 3.1:�The�governing�body�leads�the�organisation’s�strategic�direction�to�ensure�the�provision�of�quality,�safe�services

392  The ACHS EQuIP5 Guide  Book 2  Accreditation, Standards and Guidelines  Support and Corporate Functions

Criterion 3.1.2

Governance�is�assisted�by�formal�structures�and�delegation�practices�within�the�organisation.�(continued)

Performance measurementThis�criterion�states�that:�“Governance�is�assisted�by�formal�structures�and�delegation�practices�within�the�organisation”.�The�organisation�should�be�able�to�demonstrate�that�it�has�a�structure�and�processes�in�place�to�ensure�effective�management,�delegation�and�communication,�and�that�these�support�the�delivery�of�quality�care�within�a�safe�and�ethical�culture.

Some�common�suggested�performance�measures�are�as�follows:

Number�of�new�governing�body�members�who�have�attended�an�orientation�program

Total number of new governing body members

Number�of�governing�body�members�educated�in�governance

Total number of governing body members

Number�of�recommendations�from�the�governing�body�implemented

Total number of recommendations from the governing body

Number�of�senior�management�and�staff�on�policy-making�and�organisational�committees

Total number of staff on policy-making and organisational committees

Number�of�committees�that�undertake�evaluation�by�members

Total number of committees

Number�of�committees�that�review�their�membership�every�X�years

Total number of committees

Comments:theorganisationtodefine‘X’

Number�of�committees�with�approved�terms�of�reference

Total number of committees

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October 2010  393

Number�of�communications�from�governing�body�/�leadership�team�highlighting�teamwork�/�quality�improvements�/�staff�successes

Total number of communications from governing body / leadership team

Number�of�complaints�receiving�highlighting�issues�in�violation�of�the�organisation’s�values

Total number of complaints received

References 1.� Organisation�for�Economic�Co-operation�and�Development�

(OECD).�OECDPrinciplesofcorporategovernance.�Paris�FR;�OECD;�2004.

2.� Braithwaite�J�and�Travaglia�JF.�An�overview�of�clinical�governance�policies,�practices�and�initiatives.�AustHealthRev2008;�32(1):�10-22.

3.� UK�Department�of�Health.�Afirstclassservice,qualityinthenewNHS.�London�UK;�National�Health�Service.�Accessed�from�http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4006902�on�1�September�2010.

4.� ASX�Corporate�Governance�Council.�Corporategovernanceprinciplesandrecommendations.�Sydney�NSW;�Australian�Securities�Exchange�(ASX);�2007.

5.� Australian�Council�on�Healthcare�Standards.�News�in�brief:�Clinical�governance�defined.�ACHSNews2004;�12�(Spring):�4.

6.� Forster�P.Queenslandhealthsystemsreview.Finalreport.Brisbane;�Queensland�Govt;�2005.

7.� Australian�Institute�of�Company�Directors�(AICD).�Module�9:�Achieving�Board�effectiveness.�AICDdirectorandboarddevelopment–companydirectorscourse.Sydney�NSW;�AICD;�2009-10.

8.� Schein�EH.�Organizationalcultureandleadership�San�Francisco�USA;�Jossey�Bass;�2004.�Accessed�from�http://books.google.com.au/books�on�12�April�2010.

9.� Mallak�LA,�Lyth�DM,�Olson�SDetal.�Culture,�the�built�environment�and�healthcare�organizational�performance.�ManagingServiceQuality2003;�13(1):�27-38.

10.� Victorian�Quality�Council.�Thehealthcareboard’sroleinclinicalgovernance.Melbourne�VIC;�Dept�of�Human�Services;�2004.

11.� Griffith�KS.�Error�prevention�in�a�just�culture�system�design�or�human�behavior?�JtCommPersp�2010;�10(6):�10-11.�Accessed�from�http://www.justculture.org/media/JustCultureColumn3.pdf�on�1�September�2010.

12.� Victorian�Department�of�Human�Services�(DHS).�Victorianclinicalgovernancepolicyframework–Enhancingclinicalcare.Melbourne�VIC;�DHS;�2008:�1-8.

13.� Scally�G�and�Donaldson�LJ.�Looking�forward:�Clinical�governance�and�the�drive�for�quality�improvement�in�the�new�NHS�in�England.�BrMedJ1998;�317(7150):�61-65.

14.� Wellington�H.�The�legal�framework.�VictorianHealthBoardsGovernanceprogramworkshopmaterials.Melbourne�VIC;�The�Nous�Group�for�Victorian�Department�of�Health;�2009.

15.� NSW�Health.�AframeworkformanagingthequalityofhealthservicesinNewSouthWales.�Sydney;�NSW�Health;�1999.

16.� National�Health�Service�(NHS).Integratedgovernancehandbook:Ahandbookforexecutivesandnon-executivesinhealthcareorganisations.London�UK;�Department�of�Health;�2006.

17.� Schyve�PM.Leadershipinhealthcareorganizations:AguidetoJointCommissionleadershipstandards.White�Paper.�San�Diego�USA;�The�Governance�Institute;�2009.

18.� Australian�Commission�on�Safety�and�Quality�in�Health�Care�(ACSQHC).�ConsultationpaperontheNationalSafetyandQualityHealthcareStandards.Sydney�NSW;�ACSQHC;�2009.

19.� Australian�Institute�of�Company�Directors�(AICD).�Module�1:�The�role�of�the�board�and�the�practice�of�directorship.�AICDdirectorandboarddevelopment–companydirectorscourse.Sydney�NSW;�AICD;�2009-10.

Further reading1.� National�Health�Service�(NHS).�Institute�for�Innovation�

and�Improvement.NHSleadershipqualitiesframework.London�UK;�NHS;�2006.

2.� Accreditation�Canada.�SustainableGovernance(Qmentumstandards).�Ottawa�Ontario;�Accreditation�Canada.�Accessed�from�http://www.accreditation.ca/accreditation-programs/qmentum/standards/sustainable-governance/�on�24�August�2010.

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seCtion 5Standards, criteria, elements and guidelinesstandard 3.1:�The�governing�body�leads�the�organisation’s�strategic�direction�to�ensure�the�provision�of�quality,�safe�services

394  The ACHS EQuIP5 Guide  Book 2  Accreditation, Standards and Guidelines  Support and Corporate Functions

Criterion LA – Awareness sA – implementationLA plus the following

MA – evaluationSA plus the following

eA – excellenceMA plus the following

oA – LeadershipEA plus the following

Criterion 3.1.3

Processesforcredentiallinganddefiningthescopeofclinicalpracticesupportsafe,qualityhealthcare.

this is a mandatory criterion

a)� The�governing�body�is�aware�of�its�responsibilities�for�ensuring�services�are�provided�by�competent�clinicians.

b)� There�is�an�organisational�policy�for�credentialling�clinicians�within�the�organisation.

c)� There�is�an�organisational�policy�for�defining�the�scope�of�clinical�practice�of�all�clinicians�within�the�organisation.

d)� Policy�exists�for�the�safe�introduction�of�new�interventions�and�treatments.

a)� There�is�a�credentialling�system�to�confirm�the�formal�qualifications,�training,�experience�and�clinical�competence�of�clinicians.

b)� The�process�for�assessing�the�credentials�of�applicants�is�consistent�with�national�standards�and�guidelines,�and�with�organisation�policy.

c)� Ongoing�monitoring�and�review�of�clinicians’�performance�is�linked�to�the�credentialling�system.

d)� The�process�for�recommending�the�scope�of�clinical�practice�is�consistent�with�national�standards�and�guidelines�and�organisation�policy.

e)� The�process�of�defining�the�scope�of�clinical�practice�is�organisation�or�facility�specific�and�relates�to�the�role�and�capabilities�of�the�organisation.

f)� A�process�for�reviewing�the�scope�of�clinical�practice�is�in�place�and�is�defined�as�part�of�the�appointment�process.

g)� Ongoing�monitoring�and�review�of�clinicians’�performance�is�linked�to�the�system�for�defining�the�scope�of�clinical�practice.

h)� A�system�exists�for�the�safe�introduction�of�new�interventions�and�treatments.

i)� The�clinician’s�credentials�are�reviewed�prior�to�the�introduction�of�new�services,�procedures�or�other�interventions.

a)� The�system�for�credentialling�clinicians�is�reviewed,�evaluated�and�improved�as�required.

b)� The�system�for�defining�the�scope�of�clinical�practice�for�clinicians�is�reviewed,�evaluated�and�improved�as�required.

c)� The�system�for�the�safe�introduction�of�new�interventions�and�treatments�is�evaluated�and�improved�as�required.

a)� The�system(s)�for�credentialling�and�defining�the�scope�of�clinical�practice�of�clinicians�is�compared�externally�and�improvements�are�made�to�ensure�better�practice.

and/or

b)� Research�on�credentialling�and�clinical�practices�is�used�by�the�organisation�to�inform�improvements.

and/or

c)� The�system�for�the�safe�introduction�of�new�interventions�is�compared�with�external�systems�and�improvements�are�made�to�ensure�better�practice.

(a)� The�organisation�demonstrates�that�it�is�a�leader�in�systems�for�credentialling�and�defining�the�scope�of�clinical�practice.

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Criterion LA – Awareness sA – implementationLA plus the following

MA – evaluationSA plus the following

eA – excellenceMA plus the following

oA – LeadershipEA plus the following

Criterion 3.1.3

Processesforcredentiallinganddefiningthescopeofclinicalpracticesupportsafe,qualityhealthcare.

this is a mandatory criterion

a)� The�governing�body�is�aware�of�its�responsibilities�for�ensuring�services�are�provided�by�competent�clinicians.

b)� There�is�an�organisational�policy�for�credentialling�clinicians�within�the�organisation.

c)� There�is�an�organisational�policy�for�defining�the�scope�of�clinical�practice�of�all�clinicians�within�the�organisation.

d)� Policy�exists�for�the�safe�introduction�of�new�interventions�and�treatments.

a)� There�is�a�credentialling�system�to�confirm�the�formal�qualifications,�training,�experience�and�clinical�competence�of�clinicians.

b)� The�process�for�assessing�the�credentials�of�applicants�is�consistent�with�national�standards�and�guidelines,�and�with�organisation�policy.

c)� Ongoing�monitoring�and�review�of�clinicians’�performance�is�linked�to�the�credentialling�system.

d)� The�process�for�recommending�the�scope�of�clinical�practice�is�consistent�with�national�standards�and�guidelines�and�organisation�policy.

e)� The�process�of�defining�the�scope�of�clinical�practice�is�organisation�or�facility�specific�and�relates�to�the�role�and�capabilities�of�the�organisation.

f)� A�process�for�reviewing�the�scope�of�clinical�practice�is�in�place�and�is�defined�as�part�of�the�appointment�process.

g)� Ongoing�monitoring�and�review�of�clinicians’�performance�is�linked�to�the�system�for�defining�the�scope�of�clinical�practice.

h)� A�system�exists�for�the�safe�introduction�of�new�interventions�and�treatments.

i)� The�clinician’s�credentials�are�reviewed�prior�to�the�introduction�of�new�services,�procedures�or�other�interventions.

a)� The�system�for�credentialling�clinicians�is�reviewed,�evaluated�and�improved�as�required.

b)� The�system�for�defining�the�scope�of�clinical�practice�for�clinicians�is�reviewed,�evaluated�and�improved�as�required.

c)� The�system�for�the�safe�introduction�of�new�interventions�and�treatments�is�evaluated�and�improved�as�required.

a)� The�system(s)�for�credentialling�and�defining�the�scope�of�clinical�practice�of�clinicians�is�compared�externally�and�improvements�are�made�to�ensure�better�practice.

and/or

b)� Research�on�credentialling�and�clinical�practices�is�used�by�the�organisation�to�inform�improvements.

and/or

c)� The�system�for�the�safe�introduction�of�new�interventions�is�compared�with�external�systems�and�improvements�are�made�to�ensure�better�practice.

(a)� The�organisation�demonstrates�that�it�is�a�leader�in�systems�for�credentialling�and�defining�the�scope�of�clinical�practice.

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seCtion 5Standards, criteria, elements and guidelinesstandard 3.1:�The�governing�body�leads�the�organisation’s�strategic�direction�to�ensure�the�provision�of�quality,�safe�services

396  The ACHS EQuIP5 Guide  Book 2  Accreditation, Standards and Guidelines  Support and Corporate Functions

Criterion 3.1.3

Processesforcredentiallinganddefiningthescopeofclinicalpracticesupportsafe,qualityhealthcare.(continued)

IntentThis�criterion�aims�to�ensure�that�the�organisation’s�processes�will�reflect�a�growing�understanding�of�the�role�of�credentialling�in�sound�clinical�governance�and�will�support�safe,�quality�health�care.�It�draws�upon�the�StandardforCredentiallingandDefiningtheScopeofClinicalPractice,�released�by�the�former�Australian�Council�for�Safety�and�Quality�in�Health�Care,�and�relevant�jurisdictional�policies.�

The�intent�of�this�criterion�is�to�ensure�that�the�skills�and�competence�of�all�clinicians�are�correctly�aligned�with�the�competence�of�a�healthcare�organisation,�so�that�the�right�clinicians�are�providing�the�right�care�and�services�in�the�right�healthcare�organisations.�

Relationships of 3.1.3 with other criteriaThe�organisation’s�processes�for�credentialling�and�defining�the�scope�of�clinical�practice�are�a�major�component�of�its�commitment�to�improving�performance�(Criterion�2.1.1)�and�ensuring�the�effective�management�of�corporate�and�clinical�risks�(Criterion�2.1.2).�These�processes�lie�within�the�purview�of�the�organisation’s�workforce�planning�(Criterion�2.2.1),�its�recruitment,�selection�and�appointment�system�(Criterion�2.2.2)�and�its�continuing�employment�and�development�system,�by�which�it�ensures�the�competence�of�staff�(Criterion�2.2.3).

Organisational responsibility and policyIn�a�healthcare�organisation,�members�of�the�governing�body�have�a�responsibility�for�the�quality�of�care�delivered�by�the�organisation,�and�this�accountability�is�shared�with�the�clinicians�providing�this�care.1

The�purpose�of�credentialling�and�defining�the�scope�of�clinical�practice�is�to�ensure�safe,�high�quality�health�care.�It�is�an�essential�component�of�any�consumer�/�patient�safety�or�clinical�governance�framework.

Credentialling�refers�to�the�formal�process�used�to�verify�the�qualifications,�experience,�professional�standing�and�other�relevant�professional�attributes�of�clinicians�for�the�purpose�of�forming�a�view�about�their�competence,�performance�and�professional�suitability�to�provide�safe,�high�quality�health�care�services�within�specific�organisational�environments.2�Competency�refers�to�specific�capabilities�and�is�made�up�of�knowledge,�skills�and�attitudes;�while�competence�refers�to�an�individual’s�overall�ability.3�It�is�important�to�acknowledge�that�competence�(the�ability�to�demonstrate�knowledge�or�a�skill)�is�not�always�translated�into�practice.�Performance�requires�competence�but�is�also�affected�by�system�and�individual�factors.4

Defining�the�scope�of�clinical�practice�follows�on�from�the�credentialling�of�medical�practitioners�and�other�clinicians,�and�involves�delineating�the�extent�of,�and�the�limits�to,�an�individual’s�clinical�practice�within�a�particular�organisation�based�on�that�individual’s�credentials,�competence,�performance�and�professional�suitability,�and�the�needs�and�the�capability�of�the�organisation�to�support�the�individual’s�scope�of�clinical�practice.2,�5

There�are�two�main�components�of�the�process�for�defining�the�scope�of�practice�of�a�clinician.�They�are6:

1.� Credentialling,�which�is�the�verification�of�the�clinician’s�credentials,�skills,�experience�and�competencies

2.� The�matching�of�these�with�the�role,�needs�and�capabilities�of�the�healthcare�organisation’s�level�of�service�provision,�staffing,�facilities�and�equipment,�and�support�systems�available.

The�governing�body�of�the�organisation�is�responsible�for�developing�and�implementing�a�policy�or�by-laws�on�credentialling�and�defining�the�scope�of�clinical�practice�for�all�clinicians.2�The�policy�or�by-laws�should:

• comply�with�all�relevant�legal�requirements

• allocate�responsibility�to�a�defined�organisational�committee�to�ensure�effective�processes�for�credentialling�and�for�continually�monitoring�the�clinical�practice

• identify�the�maximum�elapsed�time�following�which�the�processes�of�credentialling�and�defining�the�scope�of�clinical�practice�will�be�repeated

• specify�that�clinicians�who�are�required�to�be�registered�are�granted�rights�to�practise�within�the�organisation�contingent�at�all�times�upon�the�clinician�maintaining�appropriate�professional�registration

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• specify�the�extent�to�which,�and�to�whom,�the�organisation�will�disseminate�information�about�each�medical�practitioner’s�authorised�scope�of�clinical�practice

• specify�that�a�clinician’s�right�to�practise�within�the�organisation�will�be�concluded,�terminated�or�suspended�on�conclusion,�termination�or�suspension�of�the�clinician’s�appointment�to�the�organisation

• identify�the�circumstances�under�which�an�unplanned�review�of�a�clinician’s�credentials�and/or�scope�of�clinical�practice�may�be�initiated,�the�authorised�persons�and�bodies�within�or�outside�the�organisation�from�whom�a�request�for�an�unplanned�review�will�be�accepted,�and�how�the�results�of�such�a�review�will�be�implemented

• incorporate�an�appeals�committee�and�the�appeals�process;�if�responsibility�for�credentialling�/�scope�of�practice�decisions�lies�outside�the�organisation,�support�a�process�and�the�dissemination�of�information�so�that�staff�are�aware�of�the�mechanism�through�which�an�appeal�may�be�made�

• include�the�conditions,�if�any,�under�which�clinicians�may�administer�necessary�treatment�outside�their�authorised�scope�of�clinical�practice�in�emergency�situations�where�a�consumer�/�patient�may�be�at�risk�of�serious�harm�if�treatment�is�not�provided,�and�no�health�professional�or�medical�practitioner�with�an�appropriate�authorised�scope�of�clinical�practice�is�available

• include�provision�for�the�processes�of�credentialling�and�defining�the�scope�of�clinical�practice�to�be�undertaken�in�emergency�situations�where�clinical�expertise�is�required�on�a�temporary�basis,�and�clearly�identify�who�has�delegated�authority�to�undertake�these�processes.

Prompt points

¼ What statutory requirements and guidelines did the organisation consult in developing its policy / by-laws governing credentialling and defining the scope of practice?

¼ Under the terms of the organisation’s policy / by-laws, how often is credentialling carried out, and a clinician’s scope of practice redefined?

Credentialling and competency of cliniciansFor�the�purposes�of�credentialling�and�defining�the�scope�of�clinical�practice,�there�should�be�a�clear�definition�of�who�is�recognised�as�a�‘clinician’�within�the�organisation.�The�term�‘clinician’�used�in�the�context�of�this�guideline�applies�irrespective�of�legislated�requirements�for�registration,�and�encompasses�not�only�medical�practitioners,�but�all�trained�healthcare�providers�including�nurses,�dentists,�paramedics�and�all�allied�health�professionals,�except�for�those�required�to�work�under�supervision�(i.e.�junior�medical�officers�and�others�in�training).2�Credentials�are�the�formal�qualifications�attained�and�possessed�by�a�clinician,�and�may�be�demonstrated�in�the�first�instance�by�any�or�all�of:

• university�degrees

• fellowships�/�memberships�of�professional�colleges�or�associations

• registration�by�professional�bodies

• certificates�of�service

• certificates�of�completion�of�specific�courses

• verifiable�formal�instruction�or�supervised�training

• validated�competence

• confidential�professional�referee�reports.

The�process�for�assessing�the�credentials�of�an�applicant�is�outlined�by�theStandardforCredentiallingandDefiningtheScopeofClinicalPractice.2�Credentials�reflect�the�factors�that�may�contribute�to�a�clinician’s�performance,�but�provide�no�measure�of�actual�performance;�while�credentialling�involves�the�forming�of�an�opinion�about�a�clinician’s�performance�by�a�peer-level�committee�qualified�to�assess�that�performance.

An�important�aspect�of�credentialling�is�determining�the�competence�of�the�clinician,�which�has�been�defined�as�the�combination�of�skills,�knowledge,�values�and�abilities�that�underpin�effective�and/or�superior�professional�performance.7�The�clinician�will�be�expected�to�attain�certain�professional�competencies,�which�will�contribute�to�his�or�her�overall�competence.3�However,�competence�also�encompasses�“not�only�observable�behaviour�which�can�be�measured,�but�also�unobservable�attributes�including�attitudes,�values,�judgement�ability�and�personal�dispositions:�that�is�–�not�only�performance�but�capability”��(Worth-Butler�etal.,�quoted�in�2009�discussion�paper�on�health�workforce�principles3).�

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398  The ACHS EQuIP5 Guide  Book 2  Accreditation, Standards and Guidelines  Support and Corporate Functions

Criterion 3.1.3

Processesforcredentiallinganddefiningthescopeofclinicalpracticesupportsafe,qualityhealthcare.(continued)

Registration�is�a�regulatory�process�that�formalises�the�right�of�certain�clinicians�to�practise�health�care.�The�Australian�Health�Practitioner�Regulation�Agency�(AHPRA)8,�established�in�July�2010,�undertakes�the�professional�registration�and�accreditation�of�the�clinicians�within�its�ten�member�healthcare�professional�groups:�chiropractors,�dental�practitioners�and�specialists,�medical�practitioners�and�specialists,�nurses�and�midwives,�optometrists,�osteopaths,�pharmacists,�physiotherapists,�podiatrists�and�podiatric�specialists,�and�clinical�psychologists.�

Organisations�should�ensure�that�there�is�a�robust�system�in�place�to�investigate�the�credentials�of�overseas-trained�clinicians.�To�be�registered�to�practise�in�Australia�(in�professions�covered�by�AHPRA),�overseas-trained�clinicians�must�meet�requirements�for�English�language�proficiency,�qualifications�and/or�competence�as�described�by�the�relevant�professional�board.9�As�for�any�pre-employment�review,�care�should�be�made�to�check�claimed�work�experience,�additional�training,�references�and�employment�history�before�issuing�a�contract�or�commencing�immigration�processes.�The�review�of�previous�employment�is�not�necessarily�part�of�the�review�process�for�registration�of�overseas-trained�clinicians,�so�responsibility�for�the�integrity�of�this�process�may�rest�solely�with�the�organisation.�Where�verification�of�clinical�skills�is�difficult�or�uncertain,�an�extended�probationary�period�is�recommended.�The�findings�of�the�reviewer(s)�should�be�supported�by�all�appropriate�documentation.

Organisations�that�employ�junior�medical�officers�and�other�trainee�clinicians�should�have�policy�for�managing�their�supervision�and/or�for�ascertaining�skill�development�before�permitting�independent,�unsupervised�practice.�

Prompt points

¼ What credentials must a clinician present to the credentialling committee when being considered for appointment? How does the committee confirm those credentials?

¼ How does the credentialling committee determine the competence of clinicians?

¼ Does the committee’s process for investigating the qualifications of overseas-trained clinicians differ from that used for Australian-trained clinicians? If so, how?

¼ Does the organisation credential its junior medical officers? If not, how does the organisation ensure that its junior medical officers are appropriately supervised?

Defining the scope of clinical practiceDefining�the�scope�of�clinical�practice�is�the�outcome�of�matching�a�clinician’s�qualifications,�skills,�experience�and�competence�with�the�required�services�and�the�role�and�capabilities�of�the�organisation.�The�scope�of�practice�of�each�clinician�should�be�defined�in�the�context�of�the�organisation’s�facilities�and�clinical�and�non-clinical�support�services�to�be�provided�by�the�organisation,�to�enable�the�clinician�to�provide�safe,�high�quality�healthcare�services�in�the�specific�organisational�setting.�Defining�the�scope�of�clinical�practice�is�context-specific,�and�the�exact�process�may�therefore�be�unique�to�the�organisation�or�facility.�However,�the�process�must�be�transparent�and�details�made�available�to�all�staff.�The�scope�of�practice�for�all�clinicians�must�be�outlined�in�position�descriptions�and/or�employment�contracts�/�letters�of�appointment.�The�frequency�/�timing�of�reviews�of�scope�of�practice�should�also�be�included.

For�some�specific�staff�members,�it�may�be�appropriate�to�expand�their�scope�of�practice�in�line�with�their�professional�endorsements.�Endorsement�types�and�sub-types�vary�between�professions,�with�more�information�available�from�the�specific�AHPRA�boards.�As�an�example,�the�Board�of�Psychology�endorses�eight�different�types�of�practice,�including�clinical�psychology,�counselling�psychology,�and�education�and�developmental�psychology.

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Scope�of�practice�limitations�will�apply�due�to�the�level�of�training�and�experience�of�the�practitioner�and/or�the�defined�role�or�capability�of�the�site�and�extent�of�support�staff�expertise�and�technology�available.�For�clinicians�building�specialist�skills,�for�instance�in�surgery5,�anaesthesia10�or�obstetrics11,�there�must�be�clear�and�current�inclusion�and�exclusion�criteria�describing�those�procedures�that�can�be�performed�independently,�procedures�that�require�supervision�by�a�qualified�specialist,�and�procedures�that�must�be�performed�by�a�qualified�specialist.�The�inclusion�and�exclusion�criteria�for�each�clinician�must�be�readily�available�to�all�relevant�personnel.�However,�the�organisation�must�also�manage�the�dissemination�of�this�information�in�such�a�way�that�there�is�no�breach�of�legislation�relating�to�privacy,�trade�practices�or�defamation.

Prompt points

¼ Prior to writing a position description and inviting applicants, how is organisational need determined?

¼ How does the organisation ensure that scope of practice information is disseminated on a ‘need to know’ basis only?

Monitoring, redefining the scope of clinical practice and re-credentiallingThe�organisation�must�have�a�system�for�monitoring�the�ongoing�performance�of�clinicians,�and�this�will�factor�into�the�redefining�of�the�scope�of�practice.�The�system�should�include�a�means�for�ensuring�that�clinicians�work�within�their�defined�scope�of�practice.�In�many�cases,�the�system�will�be�outlined�by�the�organisational�policy,�which�will�provide�guidance�on�the�monitoring�of�performance�and�adherence�to�scope�of�practice.�The�organisation�should�work�with�clinicians�on�an�ongoing�basis�to�review�clinical�outcomes,�adverse�events,�and/or�complaints,�a�process�which�may�form�part�of�clinical�/�peer�review�meetings.�Close�attention�should�be�paid�to�any�indications�of�underperformance�such�as�persistence�with�outdated�practices,�clinical�disinterest�or�poor�procedural�outcomes.

As�well�as�demonstrating�that�all�relevant�registrations�and�memberships�have�been�maintained,�the�clinician�must�provide�details�of�any�further�endorsements�/�accreditations�achieved,�any�further�education�/�training�undertaken,�and�all�healthcare-related�activities�since�the�previous�credentialling.

The�process�for�re-credentialling�and�redefining�the�scope�of�practice�should�be�as�stringent�as�that�followed�for�the�initial�credentialling;�no�assumptions�should�be�made�about�a�clinician’s�qualifications�or�performance.�However,�the�process�should�also�be�non-punitive.�In�cases�where�there�are�any�areas�of�concern�about�competence�that�might�lead�to�restrictions�on�the�scope�of�practice,�these�should�be�addressed�as�soon�as�feasible�via�education�and�retraining.�

Apart�from�the�mandatory�period�review,�the�credentialling�committee�may�also�convene�if�there�is�substantive�change�in�the�work�environment�or�there�is�concern�about�the�performance�of�a�clinician.�A�clinician�has�the�right�to�appeal�a�decision�relating�to�his�or�her�credentialling�and/or�scope�of�practice.�The�organisation�must�establish�a�credentialling�and�scope�of�clinical�practice�appeals�committee�that�is�independent�of�the�original�credentialling�committee�whose�decision�is�being�appealed,�to�adjudicate�on�any�appealed�decision(s).�This�committee�should�be�peer-level,�and�its�members�should�have�a�demonstrated�understanding�of�the�processes�of�credentialling�and�defining�the�scope�of�practice,�and�have�the�necessary�skills�and�experience�to�provide�informed,�independent,�high�quality�advice.

All�decisions�and�actions�by�both�the�credentialling�committee�and�the�appeals�committee�should�be�comprehensively�documented.�Where�‘confidential’�referee�reports�are�involved,�there�is�a�possibility�that�the�applicant�may�see�the�report.�There�may�be�variations�between�jurisdictions�regarding�the�overriding�rights�in�these�instances,�so�committee�members�should�be�aware�of�any�legal�protections�for�their�decisions�and�documents.�Referees�should�be�forewarned�if�there�is�a�possibility�that�applicants�may�see�their�reports.�The�documents�should�be�securely�stored�and�copies�provided�to�the�clinician.

Prompt points

¼ What processes does the organisation use to monitor the ongoing competence of clinicians? What steps are taken in the event of an identified performance issue?

¼ What systems and processes would be followed if a decision of a credentialling and/or scope of clinical practice review was appealed?

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seCtion 5Standards, criteria, elements and guidelinesstandard 3.1:�The�governing�body�leads�the�organisation’s�strategic�direction�to�ensure�the�provision�of�quality,�safe�services

400  The ACHS EQuIP5 Guide  Book 2  Accreditation, Standards and Guidelines  Support and Corporate Functions

Criterion 3.1.3

Processesforcredentiallinganddefiningthescopeofclinicalpracticesupportsafe,qualityhealthcare.(continued)

New interventions and treatmentsThe�introduction�of�new�interventions�and�treatments�will�assist�organisations�to�provide�quality,�contemporary�care�and�services.�However,�the�safety�of�new�clinical�services,�procedures�or�other�interventions,�and�their�potential�to�improve�consumer�/�patient�outcomes,�are�the�overriding�considerations.2

Organisations�should�have�in�place�policy�for�the�introduction�of�new�interventions�and�treatments�that�operates�within�jurisdictional�legislation�and�is�linked�to�the�credentialling�and�scope�of�practice�policy.�

Policy�should:

• incorporate�a�definition�of�‘new�interventions�and�treatments’

• define�who�may�request�assessments�of�new�interventions�or�treatments,�and�the�process�by�which�they�may�submit�requests�for�those�assessments

• define�the�organisation’s�requirements�for�assessment�of�the�cost,�risks,�efficacy�and�cost-benefit�of�the�proposed�new�interventions�or�treatments,�including�whether�external�benchmarking�data�should�be�considered

• define�the�organisation’s�requirements�for�consideration�of�the�broader�healthcare�context�within�which�the�new�interventions�or�treatments�are�proposed�to�be�introduced

• define�the�individuals�or�committees�that�are�authorised�to�initiate�an�assessment�of�proposed�new�interventions�and�treatments

• define�the�individuals�or�committees�that�are�responsible�for�overseeing�the�assessment�of�proposed�new�interventions�and�treatments

• define�the�organisation’s�requirement�if�a�new�intervention�/�treatment,�which�had�not�yet�been�approved�and�therefore�remains�experimental,�was�referred�for�consideration�by�a�Human�Research�Ethics�Committee�or�a�Clinical�Ethics�Committee�(as�appropriate)

• formalise�the�monitoring�of�the�new�intervention�and�its�outcomes�against�predetermined�goals�for�a�specified�period�of�time�following�its�introduction.�

The�organisation�must�ensure�that�there�are�suitable�facilities�and�support�staff�for�the�safe�provision�of�the�new�service.�In�the�interest�of�consumers�/�patients,�clinicians�and�the�organisation,�the�adoption�of�new�interventions�and�treatments�must�be�carefully�managed�via�formal�approval�processes�that�are�effectively�applied.12

The�roll-out�of�a�new�service�should�be�documented�and�monitored.�Examination�of�the�challenges,�outcomes�and�any�adverse�events,�consumer�/�patient�feedback�and�costs�will�allow�decisions�regarding�the�continuation�or�refining�of�the�new�intervention�or�treatment�to�be�made�in�a�timely�and�informed�manner.�However,�the�review�process�should�not�be�used�to�limit�appropriate�professional�initiatives�or�to�inappropriately�restrict�measures�available�in�an�emergency�situation.�

Prompt points

¼ What role do clinicians play in the safe introduction of new interventions and treatments?

¼ How does the organisation assess applications for new interventions or treatments when new technology is involved?

¼ What evidence is there of consumer / patient involvement in the introduction and assessment of new interventions and treatments?

Evidence commonly presented

Consider whether the following will help to address criterion 3.1.3

¼ Evidence of compliance with policies on credentialling processes, introduction of new interventions, etc.

¼ Data on annual registration checks, including authentication and expiry date of licences / registrations

¼ By-laws that include credentialling committees

¼ Minutes of medical advisory council (MAC) meetings

¼ Credentialling policy and procedures, including the credentialling application and the monitoring and review process that comply with relevant State / Territory policies

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October 2010  401

¼ Staff lists listing the skills of clinicians against the capabilities of the organisation

¼ Policy and procedures for the introduction of new interventions and treatments that comply with relevant State / Territory policies

¼ Reports of data (outcomes, adverse events, incidents of non-compliance, feedback) used for monitoring the credentialling system and actions taken

¼ Reports of reviews of the introduction of new interventions and treatments including data on outcomes, adverse events, feedback, costs, etc.

Performance measurementThis�criterion�states�that:�“Processes�for�credentialling�and�defining�the�scope�of�clinical�practice�support�safe,�quality�health�care”.�The�organisation�should�be�able�to�demonstrate�that�it�has�in�place�effective�processes�for�credentialling�clinicians�and�defining�the�scope�of�their�clinical�practice,�and�for�managing�the�safe�introduction�of�new�interventions�and�treatments.

Some�common�suggested�performance�measures�are�as�follows:

Number�of�clinicians�who�have�their�scope�of�practice�reviewed�within�the�policy-documented�timeframe

Total number of staff defined within policy as ‘clinicians’

Number�of�scope�of�practice�reviews�that�incorporate�individual�clinicians’�performance�reviews

Total number of scope of practice reviews

Number�of�clinicians�with�current�registration�/�indemnity�cover�noted�in�their�personnel�files

Total number of clinicians

Number�of�new�interventions�/�treatments�introduced�after�assessment�according�to�organisational�policy�and�procedures

Total number of new interventions / treatments introduced

Number�of�clinicians�appointed�according�to�defined�and�documented�organisational�need

Total number of clinicians appointed

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seCtion 5Standards, criteria, elements and guidelinesstandard 3.1:�The�governing�body�leads�the�organisation’s�strategic�direction�to�ensure�the�provision�of�quality,�safe�services

402  The ACHS EQuIP5 Guide  Book 2  Accreditation, Standards and Guidelines  Support and Corporate Functions

Criterion 3.1.3

Processesforcredentiallinganddefiningthescopeofclinicalpracticesupportsafe,qualityhealthcare.(continued)

References1.� NSW�Health.�QualityofhealthservicesinNewSouthWales

–aframeworkformanaging–issued1999.Sydney;�NSW�Health;�2005.

2.� Australian�Council�for�Safety�and�Quality�in�Health�Care.�Standardforcredentiallinganddefiningscopeofclinicalpractice.�Canberra�ACT;�Australian�Council�for�Safety�and�Quality�in�Health�Care;�2004.

3.� Department�of�Human�Services.�Healthworkforcecompetencyprinciples:AVictoriandiscussionpaper.Melbourne;�Victorian�Government;�2009.

4.� Rethans�J,�Norcini�J,�Baron-Maldonado�M�etal.�The�relationship�between�competence�and�performance:�implications�for�assessing�practice�performance.�MedEduc2002;�36(30):�901-909.

5.� Royal�Australasian�College�of�Surgeons�(RACS).Positionpaper:Appointmentsandcredentialingcommitteesthatdefinescopeofpractice.Melbourne�VIC;�RACS;�2009.

6.� NSW�Health.�Delineationofclinicalprivilegesforvisitingpractitionersandstaffspecialists:Policyforimplementation.Sydney;�NSW�Health;�2005.

7.� ACT�Nursing�and�Midwifery�Board.�RequirementsformaintainingcompetenceandcontinuingprofessionaldevelopmentauditnursesandmidwivesregisteredintheACT.Canberra;�ACT�Nursing�and�Midwifery�Board;�2008.

8.� Australian�Health�Practitioner�Regulation�Agency�(AHPRA).�AboutAHPRA.�Canberra�ACT;�AHPRA.�Accessed�from�http://www.ahpra.gov.au/About-AHPRA.aspx�on�31�August�2010.

9.� Australian�Health�Practitioner�Regulation�Agency�(AHPRA).�Overseaspractitioners.�Canberra�ACT;�AHPRA.�Accessed�from�http://www.ahpra.gov.au/Registration/Registration-Process/Overseas-Practitioners.aspx�on�16�July�2010.

10.� Australian�&�New�Zealand�College�of�Anaesthetists�(ANZCA).�PS2Statementoncredentiallinganddefiningthescopeofclinicalpracticeinanaesthesia.�Sydney�NSW;�ANZCA;�2006.

11.� Royal�Australian�and�New�Zealand�College�of�Obstetricians�&�Gynaecologists�(RANZCOG).�StatementsoftheRANZCOG:Workforceandpracticeissues.Sydney�NSW;�RANZCOG.�Accessed�from�http://www.ranzcog.edu.au/gpdiploma/collegestatements.shtml�on�26�July�2010.

12.� Australian�Safety�&�Efficacy�Register�of�New�Interventional�Procedures�–�Surgical�(ASERNIP–S)�and�Royal�Australasian�College�of�Surgeons.�Areviewofpoliciesandprocessesfortheintroductionofnewinterventionalprocedures.�ASERNIP–S�Report�No�58.�Adelaide�SA;�Australian�Department�of�Health�and�Ageing;�2007.

Standards and guidelinesAustralian�Council�for�Safety�and�Quality�in�Health�Care.�Nationalguidelinesforcredentialsandclinicalprivileges.Melbourne�VIC;�Australian�Council�for�Safety�and�Quality�in�Health�Care;�2002.

Office�of�Safety�and�Quality�in�Healthcare.�Thepolicyforcredentiallinganddefiningthescopeofclinicalpracticeformedicalpractitioners�2nd�edn.�Perth�WA;�Department�of�Health�WA;�2009.

Queensland�Health.�CredentialinganddefiningthescopeofclinicalpracticeformedicalpractitionersinQueensland:Apolicyandresourcehandbook.�Brisbane;�Queensland�Government;�2009.

Quality�&�Safety�Branch�DHS.�CredentiallinganddefiningthescopeofclinicalpracticeformedicalpractitionersinVictorianhealthservices–apolicyhandbook.�Melbourne;�Vic�Dept�Human�Services;�2007.

Frommer�M,�Heinke�M�and�Barton�M.�ThecredentiallingofcancercliniciansinAustralia:Report.�Sydney�NSW;�Cancer�Council�Australia�and�Australian�Cancer�Network;�2005.

Holmboe�ES�and�Hawkins�RE�(eds).�Practicalguidetotheevaluationofclinicalcompetence.�Philadelphia�USA;�Mosby�Elsevier;�2008.

NSW�Health.�Theclinician’stoolkitforimprovingpatientcare.Sydney;�NSW�Health;�2001.

Department�of�Human�Services.CredentiallinganddefiningthescopeofclinicalpracticeformedicalpractitionersinVictorianhealthservices–apolicyhandbook.�Melbourne;�Victorian�Government;�2009.

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October 2010  403

Further readingChiarella�M.�AnoverviewofthecompetencymovementinAustraliannursingandmidwifery.�Sydney�NSW;�Nursing�and�Midwifery�Office,�NSW�Health;�2006.

Community�Services�and�Health�Industry�Training�Board�(CS&H�ITB).�CompetencystandardsforhealthandalliedhealthprofessionalsinAustralia.Melbourne�VIC;�CS&H�ITB;�2005.

Brand�CA,�Ibrahim�JE,�Cameron�PA�and�Scott�IA.�Standards�for�health�care:�a�necessary�but�unknown�quantity.�MedJAust2008;�189(5):�257-260.

Epstein�Ronald�M�and�Hundert�Edward�M.�Defining�and�assessing�professional�competence.�JAMA�2002;�287(2):�226-235.

Wass�Val,�van�der�Vleuten�Cees,�Shatzer�John�and�Jones�Roger.�Assessment�of�clinical�competence.�Lancet�2001;�357(9260):�945-949.

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seCtion 5Standards, criteria, elements and guidelinesstandard 3.1:�The�governing�body�leads�the�organisation’s�strategic�direction�to�ensure�the�provision�of�quality,�safe�services

404  The ACHS EQuIP5 Guide  Book 2  Accreditation, Standards and Guidelines  Support and Corporate Functions

IntentThe�intent�of�this�criterion�is�to�ensure�that�external�service�providers�are�managed�effectively,�so�that�they�provide�care�and�services�that�are�safe�and�of�the�highest�achievable�quality.

Relationships of 3.1.4 with other criteriaThe�organisation�may�arrange�for�certain�areas�of�operation�to�be�supplied�or�managed�by�external�service�providers.�Outsourcing�of�services�is�an�aspect�of�the�organisation’s�workforce�planning�(Criterion�2.2.1).�

It�is�likely�that�many�of�the�functions�performed�by�external�service�providers�will�fall�within�the�scope�of�other�criteria�–�for�example,�laundry�services�(Criterion�1.5.2),�food�preparation�and�delivery�(Criterion�1.5.7),�equipment�installation�and�maintenance�(Criterion�3.2.2),�waste�management�(Criterion�3.2.3)�and�

security�(Criterion�3.2.5).�It�is�the�responsibility�of�the�organisation�to�ensure�both�the�standard�of�the�services�provided,�and�that�any�contracted�personnel�are�given�all�necessary�orientation�and�safety�training�(Criterion�3.2.4).�The�use�of�external�service�providers�is�a�risk�that�must�be�managed�(Criterion�2.1.2)�in�order�to�avoid�incidents�(Criterion�2.1.3)�and�complaints�(Criterion�2.1.4).

PoliciesExternal�service�providers�may�supply�regular,�periodic�or�one-off�services�to�both�clinical�and�non-clinical�areas�of�the�healthcare�organisation.�Outsourced�services,�including�contracted�services,�may�be�governed�by�decisions�and�policy�from�a�higher�level,�such�as�a�head�office,�area�health�service�or�network.

Criterion LA – Awareness sA – implementationLA plus the following

MA – evaluationSA plus the following

eA – excellenceMA plus the following

oA – LeadershipEA plus the following

Criterion 3.1.4

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

a)� Policy�exists�for�the�management�of�external�service�providers.

a)� External�service�providers�can�demonstrate�compliance�with�relevant�regulatory�requirements.

b)� Services�provided�externally�are�consistent�with�specified�standards.

c)� There�are�documented�agreements�with�all�external�service�providers�that�include�performance�measures.

d)� External�service�providers�supply�evidence�of�internal�evaluation�for�the�services�that�they�are�providing�to�the�organisation.�

e)� Dispute�resolution�mechanisms�are�identified�and�communicated�to�the�external�provider.

a)� Agreements�with�external�service�providers�are�reviewed�and�improved�as�required.

b)� The�organisation�evaluates�the�performance�of�external�service�providers�through�agreed�performance�measures�including�clinical�outcomes�and�financial�performance�where�appropriate,�and�improvements�are�made�as�required.

a)� Agreements�with�external�service�providers�and�systems�for�monitoring�performance�are�compared�with�external�systems,�and�improvements�are�made�to�ensure�better�practice.

a)� The�organisation�demonstrates�it�is�a�leader�in�managing�external�service�providers.

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October 2010  405

To�ensure�standards�of�quality�and�integrity,�senior�managers�must�guarantee�that�probity�requirements�are�met�and�understand�the�structures�that�support�decision�making�in�relation�to�service�provision�to�facilitate�compliance.�For�example,�in�most�public�and�private�sector�organisations�there�will�be�an�identified�expenditure�above�which�services�will�be�tendered.

Many�States�/�Territories�have�prepared�public�sector�procurement�policies�and�guidelines�on�the�management�of�external�service�providers.1–3�In�addition,�organisations�should�have�a�delegation�manual�that�nominates�staff�with�the�delegated�authority�to�select�suppliers�of�specific�services.4�

Increasingly,�tendered�services�are�commissioned�using�online�processes;�policies�need�to�be�updated�to�reflect�this.�In�the�private�sector,�policies�should�reflect�jurisdictional�legislation�and�any�belief�systems,�structural�frameworks,�financial�drivers�or�other�goals�that�will�guide�service�provision�for�the�business.

Prompt points

¼ Is there policy / by-laws covering the appointment and management of external service providers?

¼ How does the organisation manage local service suppliers appointed through centralised tendering processes?

¼ Does the organisation maintain a register of external service providers? How is this cross-referenced with contracts or service agreements?

¼ What process determines KPIs for contracts? How are they monitored by the governing body?

Criterion LA – Awareness sA – implementationLA plus the following

MA – evaluationSA plus the following

eA – excellenceMA plus the following

oA – LeadershipEA plus the following

Criterion 3.1.4

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

a)� Policy�exists�for�the�management�of�external�service�providers.

a)� External�service�providers�can�demonstrate�compliance�with�relevant�regulatory�requirements.

b)� Services�provided�externally�are�consistent�with�specified�standards.

c)� There�are�documented�agreements�with�all�external�service�providers�that�include�performance�measures.

d)� External�service�providers�supply�evidence�of�internal�evaluation�for�the�services�that�they�are�providing�to�the�organisation.�

e)� Dispute�resolution�mechanisms�are�identified�and�communicated�to�the�external�provider.

a)� Agreements�with�external�service�providers�are�reviewed�and�improved�as�required.

b)� The�organisation�evaluates�the�performance�of�external�service�providers�through�agreed�performance�measures�including�clinical�outcomes�and�financial�performance�where�appropriate,�and�improvements�are�made�as�required.

a)� Agreements�with�external�service�providers�and�systems�for�monitoring�performance�are�compared�with�external�systems,�and�improvements�are�made�to�ensure�better�practice.

a)� The�organisation�demonstrates�it�is�a�leader�in�managing�external�service�providers.

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seCtion 5Standards, criteria, elements and guidelinesstandard 3.1:�The�governing�body�leads�the�organisation’s�strategic�direction�to�ensure�the�provision�of�quality,�safe�services

406  The ACHS EQuIP5 Guide  Book 2  Accreditation, Standards and Guidelines  Support and Corporate Functions

Criterion 3.1.4

External�service�providers�are�managed�to�maximise�quality,�safe�health�care�and�service�delivery.�(continued)

Documented agreements Contracts�and�agreements�need�to�abide�by�jurisdictional�legislation.�A�process�to�determine�which�contracts�need�legal�oversight�during�their�preparation�must�be�agreed�upon�and�documented�by�the�governing�body.�Agreements�with�high�value�or�risk�should�have�legal�oversight.�Many�government�departments�provide�templates�for�service�agreements,�and�these�will�vary�depending�upon�the�business�structures�entering�into�the�agreement.

Organisations�may�also�maintain�lists�of�preferred�suppliers�for�specific�projects.�This�is�most�common�for�tradesmen�who�may�be�needed,�but�not�always�available,�at�short�notice.�There�should�be�a�documented�process�for�the�selection�of�preferred�suppliers�and�a�process�to�review�the�outcome�of�the�service�provided.5�Care�must�be�taken�when�appointing�external�contractors,�particularly�where�a�conflict�of�interest�could�be�construed.

A�contract�or�service�agreement�is�important�for�both�the�healthcare�organisation�and�the�service�provider�to�ensure�quality�maintenance�of�the�service.�The�fundamental�responsibility�for�quality�rests�with�the�contracting�healthcare�organisation�and�its�governing�body.�In�establishing�the�legal�arrangement,�the�organisation�needs�to�include�the�level�of�service�expected�and�the�evidence�of�compliance�with�that�service’s�regulatory�or�industry�standards�required.�

Contracts�and�service�agreements�must�include�measures�and�timelines�against�expectations�of�service�provision.�Performance�indicators�and�their�measures�may�be�simple�or�complex,�but�must�be�specific,�achievable�and�relevant.�Examples�include�turnaround�times,�feedback,�survey�information�and�counts�of�services�provided.

Prompt points

¼ Is there a system to track agreements with external service providers, including those negotiated by head or regional offices or by networks? Does the system alert the organisation to agreements / contracts that have reached term or time for review?

¼ How is performance of external service suppliers managed?

¼ What dispute resolution mechanisms are in place for the organisation? Has the process and names of contact persons been communicated to service suppliers in the terms of the agreement or in other correspondence?

¼ Is performance against agreed performance measures reviewed before contracts for service provision are renewed or at predetermined times in long-term agreements? How is this information communicated to the governing body? What action is taken when performance fails to meet performance measures?

Standards and regulatory legislation complianceA�number�of�legislated�requirements�regulate�the�provision�of�certain�services�to�protect�public�health�and�safety.�When�commissioning�service�providers,�organisations�must�ensure�that�they�are�approved�to�provide�the�commissioned�service.�

Food�service�providers�should�follow�the�FoodStandardsAustraliaNewZealand(FSANZ)�standards�for�food�safety.6

Pathology�services�must�be�accredited�by�an�approved�body.7�There�are�also�standards�for�collection�stations�from�which�pathology�services�source�samples.8,�9

Tradesmen�must�be�appropriately�certified�to�perform�the�projects�assigned,�and�must�abide�by�legislated�requirements.�In�most�States�/�Territories,�the�Department�of�Consumer�Affairs�is�responsible�for�handling�queries�in�relation�to�licensing�of�tradesmen.�

Linen�services�should�meet�regulatory�requirements�for�infection�control,�as�outlined�in�AS�4146:2000�Laundrypractice.

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October 2010  407

Service�providers�may�provide�services�that�involve�many�different�staff�operating�on�the�organisation’s�premises.�Examples�include�security�guards,�cleaners�and�agency�nurses.�In�these�cases,�the�contract�will�require�clearly�delineated�responsibilities�regarding�access�to�organisational�facilities�and�the�provision�of�work-related�equipment.�In�addition,�it�is�important�that�contracts�clarify�the�role�of�the�contractor,�such�as�for�security�guards,�who�may�be�asked�to�restrain�aggressive�or�mentally�unstable�patients.10

The�organisation�should�retain�details�of�evidence�that�their�suppliers�fulfil�licensing�and�quality�standards�in�the�jurisdiction(s)�in�which�the�organisation�operates,�such�as�‘Working�with�Children’�and�police�checks.11�In�the�case�of�long-term�contracts,�this�evidence�should�be�rechecked�according�to�a�predetermined�timeframe.�

Prompt points

¼ In what areas is compliance with standards or retention of accreditation a condition for appointment or a performance measure on service providers’ contracts?

Evaluation of service providedEvaluation�and�monitoring�of�supplier�performance�may�relate�to�price,�service�and/or�quality,�and�the�measures�for�evaluation�should�be�decided�in�advance�and�recorded�in�the�contracted�agreement.�Monitoring�may�be�as�simple�as�sending�an�appropriately�qualified�person�to�check�the�satisfactory�completion�of�a�trades�job,�to�regular�audits�for�quality�and�accuracy�of�services�or�timeliness,�as�may�be�more�appropriate�for�ongoing�suppliers�of�food,�laundry�or�pathology�services.�Some�contracted�services�may�be�expected�to�provide�details�of�their�tasks�and�workloads,�particularly�where�fees�vary�with�the�volume�of�work.�For�example,�waste�disposal�services�may�report�on�volumes�of�different�classes�of�waste�and�any�aberrant�separation�of�classes�of�waste.�Pathology�services�might�list�services�by�type,�with�cost�and�volume.

Irrespective�of�whether�the�organisation�/�department�was�included�in�the�selection�of�its�service�providers,�it�should�monitor�the�service�received�and�have�channels�by�which�staff�can�feed�back�any�concerns.�Records�of�feedback�from�staff,�consumers�/�patients�and�visitors�regarding�service�provision�should�be�addressed�individually�as�appropriate,�and�retained�for�cumulative�review�against�the�agreed�standards�for�supply�of�the�service.

Examples�of�performance�measures�include:

• turnaround�times�for�recruitment�advertising,�haematology�samples�or�imaging

• feedback�forms�for�education�services�or�employment�assistance�schemes

• staff�survey�and/or�complaints�for�security�performance

• timeliness�and�numbers�moved�for�transport�services

• according�to�a�specific�standard�for�infection�control

• consumer�/�patient�surveys�and�complaints�for�food�and�food�service.�

Prompt points

¼ How is compliance with external standards and any other performance measures stated on contracts checked and maintained?

¼ How are a supplier’s reported service levels and costings cross-checked / audited?

¼ How does the organisation use education, incentives and/or hold providers to account, to improve the quality / value of service received from external suppliers?

¼ How is performance measured and reported to the senior management team?

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seCtion 5Standards, criteria, elements and guidelinesstandard 3.1:�The�governing�body�leads�the�organisation’s�strategic�direction�to�ensure�the�provision�of�quality,�safe�services

408  The ACHS EQuIP5 Guide  Book 2  Accreditation, Standards and Guidelines  Support and Corporate Functions

Performance measurementThis�criterion�states�that:�“External�service�providers�are�managed�to�maximise�quality,�safe�health�care�and�service�delivery”.�The�organisation�should�be�able�to�demonstrate�that�its�management�of�its�use�of�external�service�providers�ensures�that�all�services�provided�meet�the�necessary�and�contractually�agreed�standard.

Some�common�suggested�performance�measures�are�as�follows:

Number�of�external�service�providers�with�a�current�contract

Total number of external service providers

Number�of�contracts�with�external�service�providers�that�contain�performances�measures�/�indicators

Total number of external service provider contracts

Number�of�external�service�providers�that�supply�workers�compensation�and�insurance�information��to�the�organisation

Total number of external service providers

Criterion 3.1.4

External�service�providers�are�managed�to�maximise�quality,�safe�health�care�and�service�delivery.�(continued)

Evidence commonly presented

Consider whether the following will help to address criterion 3.1.4

¼ Policies relating to external service providers, including organisational information on service provision by service providers contracted through centralised processes

¼ Contracts with external service providers that include detailed task information and performance measures

¼ Administrative systems (or spreadsheets / databases) for coordinating the management of external service providers and staff who manage these systems

¼ Tender documents and advertising of tender

¼ Review meetings with subcontracted services – meeting records or correspondence

¼ Relevant questions on consumer / patient feedback survey forms and outcomes of surveys

¼ Audits of cleaning, or other specified performance markers such as infection control

¼ Documents demonstrating the handling of complaints about subcontracted services

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October 2010  409

Number�of�contracted�external�service�providers�reviewed�against�their�performance�measures�/�indicators

Number of contracted external service providers

Number�of�staff�and�consumers�/�patients�satisfied�with�services�provided�by�external�service�providers

Total number of staff and consumers / patients surveyed

References1.� NSW�Department�of�Commerce.NSWGovernment

procurementguidelines:Serviceproviderperformancemanagement.�Sydney;�NSW�Government�and�NSW�Treasury;�2007.

2.� Victorian�Auditor�General’s�Office�(VAGO).�Publicsectorprocurement:turningprinciplesintopractice.�Melbourne�VIC;�VAGO;�2007.

3.� Australian�Department�of�Finance.�AustralianGovernmentprocurementstatement.�Canberra�ACT;�Australian�Government;�2009.

4.� NSW�Health.�Delegationsmanual–Combined(Administrativefinancialstaff).�Sydney;�NSW�Health.�Accessed�from�http://www.health.nsw.gov.au/resources/policies/manuals/comb_delegations.asp�on�7�December�2009.

5.� Ombudsman�Victoria.�Probitycontrolsinpublichospitalsfortheprocurementofnon-clinicalgoodsandservices.Melbourne�VIC;�Ombudsman�Victoria;�2008.

6.� Food�Standards�Australia�New�Zealand�(FSANZ).�AustraliaNewZealandfoodstandardscode.Canberra�ACT;�FSANZ.�Accessed�from�http://www.foodstandards.gov.au/thecode/foodstandardscode/�on�25�January�2010.

7.� National�Pathology�Accreditation�Advisory�Council�(NPAAC).�Standardsforpathologylaboratoryparticipationinexternalproficiencytestingprograms.Canberra�ACT;�Australian�Dept�of�Health�and�Ageing.�Accessed�from��http://www.health.gov.au/internet/main/publishing.nsf/Content/npaac-stand-ext-test-toc�on�3�December.

8.� Department�of�Health�and�Ageing�(DoHA).�Guidelineforapprovedpathologycollectioncentres.Canberra�ACT;�DoHA;�2006.

9.� National�Pathology�Accreditation�Advisory�Council�(NPAAC).�Requirementsforapprovedcollectioncentres(NPAACTier3standard)(draftforsecondedn).Canberra�ACT;�NPAAC;�2009.

10.� Kemp�M.�Hospital�guards�defy�law�to�restrain�patients.�AdelaideNow�(6�May�2009).�Accessed�from�http://www.news.com.au/adelaidenow/story/0,27574,25441237-2682,00.html�on�4�December�2009.

11.� Australian�Institute�of�Family�Studies.�Pre-employment�screening:�Working�with�children�checks�and�police�checks.�Resourcesheet�2010;�13.�Accessed�from�http://www.aifs.gov.au/nch/resources/police/policechecks.html�on�1�September�2010.

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seCtion 5Standards, criteria, elements and guidelinesstandard 3.1:�The�governing�body�leads�the�organisation’s�strategic�direction�to�ensure�the�provision�of�quality,�safe�services

410  The ACHS EQuIP5 Guide  Book 2  Accreditation, Standards and Guidelines  Support and Corporate Functions

Criterion LA – Awareness sA – implementationLA plus the following

MA – evaluationSA plus the following

eA – excellenceMA plus the following

oA – LeadershipEA plus the following

Criterion 3.1.5

Documentedcorporateandclinicalpoliciesandproceduresassisttheorganisationtoprovidequality,safehealthcare.

this is a mandatory criterion

a)� The�organisation�is�aware�of�relevant:

� (i)� legislation

� (ii)� professional�guidelines

� (iii)� codes�of�practice�

� (iv)� Australian�standards

� (v)� codes�of�ethics.�

b)� Documented�corporate�and�clinical�policies�and�procedures�refer�to�by-laws,�operating�and�management�requirements.�

a)� A�framework�for�corporate�and�clinical�policy�and�procedure�development�and�review�is�in�place.

b)� Policies�and�procedures�reference:

� (i)� current�issues

� (ii)� Australian�standards

� (iii)� legislation

� (iv)� professional�guidelines

� (v)� codes�of�practice

� (vi)� codes�of�ethics

� (vii)�evidence.

c)� A�system�exists�that:�

� (i)� �audits�compliance�with�relevant�legislation

� (ii)� �informs�relevant�staff�of�new�or�amended�legislation

� (iii)� �educates�staff�on�relevant�legislation�applicable�to�their�area�of�responsibility.

d)� Stakeholders�including�staff�are�involved�in�the�development�of�local�policy�and�procedures.

e)� Changes�to�practice�and�service�in�clinical�and�non-clinical�areas�are�reflected�in�updated�policies�and�procedures.�

f)� A�system�for�document�control�is�implemented.

g)� A�process�for�the�distribution�and�implementation�of�new�and�reviewed�policies�and�procedures�is�in�place.

h)� There�is�adherence�to�by-laws,�operating�requirements�and�management�requirements.

i)� A�system�for�monitoring�compliance�with�policies�and�procedures�is�implemented.

a)� The�framework�for�policy�development�and�review�is�evaluated�and�improved�as�required.

b)� Policies�and�procedures�are�regularly�reviewed,�updated�and�improved�as�required.

c)� The�system�for�ensuring�implementation�of,�and�compliance�with,�key�or�amended�legislative�requirements�is�evaluated�and�improved,�as�required.�

a)� The�framework�for�corporate�and�clinical�policy�and�procedure�development�and�management�is�compared�with�internal�and�external�systems,�and�improvements�are�made�to�ensure�better�practice.

and/or

b)� Other�organisations�review�and�use�the�organisation’s�policies�and�procedures�as�a�framework�for�their�policy�implementation.�

a)� The�organisation�demonstrates�it�is�a�leader�in�corporate�and�clinical�policies�and�procedures.

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October 2010  411

Criterion LA – Awareness sA – implementationLA plus the following

MA – evaluationSA plus the following

eA – excellenceMA plus the following

oA – LeadershipEA plus the following

Criterion 3.1.5

Documentedcorporateandclinicalpoliciesandproceduresassisttheorganisationtoprovidequality,safehealthcare.

this is a mandatory criterion

a)� The�organisation�is�aware�of�relevant:

� (i)� legislation

� (ii)� professional�guidelines

� (iii)� codes�of�practice�

� (iv)� Australian�standards

� (v)� codes�of�ethics.�

b)� Documented�corporate�and�clinical�policies�and�procedures�refer�to�by-laws,�operating�and�management�requirements.�

a)� A�framework�for�corporate�and�clinical�policy�and�procedure�development�and�review�is�in�place.

b)� Policies�and�procedures�reference:

� (i)� current�issues

� (ii)� Australian�standards

� (iii)� legislation

� (iv)� professional�guidelines

� (v)� codes�of�practice

� (vi)� codes�of�ethics

� (vii)�evidence.

c)� A�system�exists�that:�

� (i)� �audits�compliance�with�relevant�legislation

� (ii)� �informs�relevant�staff�of�new�or�amended�legislation

� (iii)� �educates�staff�on�relevant�legislation�applicable�to�their�area�of�responsibility.

d)� Stakeholders�including�staff�are�involved�in�the�development�of�local�policy�and�procedures.

e)� Changes�to�practice�and�service�in�clinical�and�non-clinical�areas�are�reflected�in�updated�policies�and�procedures.�

f)� A�system�for�document�control�is�implemented.

g)� A�process�for�the�distribution�and�implementation�of�new�and�reviewed�policies�and�procedures�is�in�place.

h)� There�is�adherence�to�by-laws,�operating�requirements�and�management�requirements.

i)� A�system�for�monitoring�compliance�with�policies�and�procedures�is�implemented.

a)� The�framework�for�policy�development�and�review�is�evaluated�and�improved�as�required.

b)� Policies�and�procedures�are�regularly�reviewed,�updated�and�improved�as�required.

c)� The�system�for�ensuring�implementation�of,�and�compliance�with,�key�or�amended�legislative�requirements�is�evaluated�and�improved,�as�required.�

a)� The�framework�for�corporate�and�clinical�policy�and�procedure�development�and�management�is�compared�with�internal�and�external�systems,�and�improvements�are�made�to�ensure�better�practice.

and/or

b)� Other�organisations�review�and�use�the�organisation’s�policies�and�procedures�as�a�framework�for�their�policy�implementation.�

a)� The�organisation�demonstrates�it�is�a�leader�in�corporate�and�clinical�policies�and�procedures.

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seCtion 5Standards, criteria, elements and guidelinesstandard 3.1:�The�governing�body�leads�the�organisation’s�strategic�direction�to�ensure�the�provision�of�quality,�safe�services

412  The ACHS EQuIP5 Guide  Book 2  Accreditation, Standards and Guidelines  Support and Corporate Functions

Criterion 3.1.5

Documentedcorporateandclinicalpoliciesandproceduresassisttheorganisationtoprovidequality,safehealthcare.(continued)

IntentPolicy,�by-laws,�guidelines�and�procedures�represent�the�translation�of�legislation,�Australian�standards,�and�codes�of�practice�and�ethics�into�a�framework�that�allows�the�organisation�to�meet�its�obligations�to�the�community�it�serves.�The�intent�of�this�criterion�is�to�ensure�that�the�organisation�is�guided�by�well-constructed�and�effective�policy;�that�managers,�staff,�volunteers,�consumers�/�patients�and�other�stakeholders�are�informed�of�policy,�by-laws�and�guidelines�relevant�to�their�roles�within�the�organisation;�and�that�the�practical�implementation�of�policy�in�the�form�of�appropriate,�best�evidence-based�procedures�will�result�in�safe,�high�quality�health�care.

Relationships of 3.1.5 with other criteriaCorporate�and�clinical�policies�and�procedures�form�the�infrastructure�within�which�the�organisation�meets�its�obligation�to�provide�quality�care.�Consequently,�this�guideline�should�be�read�in�conjunction�with�all�other�criteria.

Organisational policyWithin�the�healthcare�system,�all�organisations�will�have�policies�to�which�they�adhere,�and�which�guide�operation�at�both�the�corporate�and�the�clinical�level.�Policies�usually�arise�from�overriding�legal�obligations,�and�outline�general�courses�of�action�designed�to�achieve�a�set�of�stated�outcomes.�They�will�include�specific�references�to�their�authority�and�a�statement�as�to�who�is�bound�by�them,�and�cover�a�significant�aspect�of�the�organisation’s�operation.

Corporate�policies�may�include:

• appointment�of�senior�staff

• delegation

• credentialling�/�scope�of�practice

• introduction�of�new�interventions

• committee�structures

• reporting�and�outcomes

• disciplinary�action

• recruitment�and�retention

• advertising

• secondary�employment

• information�management

• privacy�and�confidentiality

• conflict�of�interest

• declaration�of�private�interests

• acceptance�of�gifts�and�benefits

• Code�of�Conduct

• Occupational�Health�&�Safety

• security.

Clinical�policies�may�include:

• admissions�

• discharge�of�consumers�/�patients

• clinical�handover

• infection�control

• prevention�and�management�of�iatrogenic�wounds

• prevention�and�management�of�falls

• blood�and�blood�component�management

• management�of�specific�diseases

• medication�management

• correct�consumer�/�patient,�correct�procedure,�correct�site

• consent

• end-of-life�decision�making

• mortality�management.

While�State�/�Territory�health�departments�will�issue�policies,�the�size�and�nature�of�the�organisation�will�dictate�the�manner�in�which�the�requirements�of�these�policies�are�integrated�into�the�framework�of�operation.�Public�facilities�will�be�governed�by�area�or�regional�policies�based�upon�those�of�the�relevant�authority,�while�private�hospitals�and�other�independent�organisations�will�draft�their�own�policies�directly�from�State�/�Territory�directives�and�according�to�the�requirements�of�their�by-laws,�operating�requirements�and/or�management�requirements.�While�the�implementation�of�policy�is�not�discretionary,�the�translation�of�jurisdictional�policy�to�organisational�policy�does�allow�for�the�exercise�of�local�discretion�in�how�stated�outcomes�are�to�be�achieved.

Australian�standards,�professional�codes�of�practice,�codes�of�ethics�and�other�guidelines�are�rarely�legislated.�However,�there�is�an�expectation�that�the�organisation�will�reference�these�documents�in�its�policies,�and�that�compliance�will�be�demonstrated�through�evaluation�processes.�Policy�will�also�be�shaped�by�evidence�of�best�practice,�and�will�respond�to�issues�as�they�occur.

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October 2010  413

Prompt points

¼ For what aspects of the organisation’s operation do corporate policies exist? – clinical policies?

¼ What non-legislative documents are referenced within the organisation’s policies?

¼ Which of the organisation’s policies make reference to evidence-based practice?

Development and review of policies and proceduresA�framework�for�developing�policies�will�ensure�that�those�policies�are�consistent�across�the�organisation�and�that�all�of�the�essential�elements�are�included:�the�aim,�the�expected�outcome(s),�the�references�and�evidence�used�to�develop�the�policy,�how�and�when�the�outcomes�are�to�be�monitored,�reviewed�and�updated.

Policies�and�procedures�should�be�reviewed�at�least�once�within�the�EQuIP�cycle.�This�process�should�also�incorporate�a�review�of�the�framework�via�which�policies�are�developed�and�implemented,�and�improvements�made�to�the�systems,�the�delegation�of�responsibility�and/or�the�management�of�policy�development�as�required.�The�organisation�should�be�able�to�demonstrate�the�system(s)�by�which�it�obtains�the�most�current�information�about�legislation,�standards�and�evidence;�how�it�responds�to�this�information;�and�how�this�response�is�documented.�All�active�policies�and�procedures�should�reflect�current�legislation,�standards�and�evidence;�and�all�changes�that�are�made�to�existing�policies�and�procedures�and�the�reasons�for�them�should�be�thoroughly�documented.

Prompt points

¼ How does the organisation ensure that its policies and procedures are based upon the most current information?

¼ How does the organisation involve staff in the development of policies and procedures? What other stakeholders are involved?

¼ How often does the organisation review its policies and procedures?

Dissemination, implementation and complianceIt�is�essential�that�staff�at�all�levels�understand�their�responsibilities�with�respect�to�implementation�of,�and�compliance�with,�policies�and�procedures.�An�explanation�of�the�framework�under�which�policies�and�procedures�are�developed�and�reviewed�should�be�included�in�orientation�for�new�staff,�and�should�make�part�of�regular�education�‘refresher’�sessions�for�all�staff.�The�implementation�of�procedures�can�also�be�made�the�subject�of�sessions�targeted�at�particular�staff,�to�facilitate�understanding�of�the�relevant�legislation�and�compliance�on�the�part�of�those�individuals�operating�within�their�scope.�Staff�feedback�should�be�sought�to�assess�the�usefulness�of�these�sessions,�and�changes�made�to�the�content�or�approach�if�required.�Quality�care�cannot�be�provided�unless�there�is�a�system�that�ensures�that�the�organisation’s�policies�are�read�by�relevant�staff�and�that�a�sufficient�level�of�understanding�is�attained,�so�that�the�reasoning�behind�the�development�of�procedures�is�clear�and�correct�implementation�thus�facilitated.

Systems�to�disseminate�information�when�new�legislation�is�enacted�or�amendments�made�to�existing�legislation�/�standards�/�codes�/�guidelines�are�required�to�make�certain�that�staff�are�aware�of�their�legal�responsibilities,�that�all�active�procedures�are�in�accordance�with�the�most�current�information,�and�that�all�changes�made�to�procedures�are�reflected�in�the�altered�conduct�of�staff.�Along�with�the�policies�and�procedures�themselves,�the�organisation�should�review�the�means�by�which�material�is�disseminated,�to�ensure�that�all�necessary�information�reaches�all�relevant�staff�in�a�timely�manner,�and�make�changes�when�required.

Organisations�must�have�audit�systems�in�place�to�monitor�compliance�with�policies�and�procedures.�Organisations�may�wish�to�treat�instances�of��non-compliance�as�reportable�incidents,�particularly�in�the�case�of�high-risk�areas�such�as�mandatory�‘timeouts’�prior�to�surgery.�However,�incident�reporting�alone�is�not�a�sufficient�means�of�auditing�compliance.�Where�departures�from�policies�or�procedures�are�identified�via�spot-checks,�ongoing�monitoring,�reviews�of�incidents�and/or�staff�discussion�or�feedback,�analysis�of�the�reasons�for�the�non-compliance�will�allow�the�need�for�a�new�or�amended�policy�or�procedure�to�be�determined,�or�staff�behaviour�to�be�amended.�The�means�by�which�compliance�is�audited�should�also�be�subjected�to�regular�review,�to�make�certain�that�the�most�effective�processes�for�monitoring�and,�where�required,�improvement�are�in�place.

Page 168: Safety Quality Performance Version 2 · MA – evaluation. SA plus the following. eA – excellence. MA plus the following. oA – Leadership. EA plus the following. Criterion 2.1.1

seCtion 5Standards, criteria, elements and guidelinesstandard 3.1:�The�governing�body�leads�the�organisation’s�strategic�direction�to�ensure�the�provision�of�quality,�safe�services

414  The ACHS EQuIP5 Guide  Book 2  Accreditation, Standards and Guidelines  Support and Corporate Functions

Criterion 3.1.5

Documentedcorporateandclinicalpoliciesandproceduresassisttheorganisationtoprovidequality,safehealthcare.(continued)

Prompt points

¼ How does the organisation ensure that its staff are aware of their legal responsibilities with respect to policies and procedures?

¼ How are procedures implemented? How does the organisation monitor compliance with procedures? How does the organisation deal with identified instances of non-compliance?

Document controlThe�organisation’s�policies�and�procedures�must�be�managed�via�a�system�of�document�control�–�including�policy�and�procedures�for�the�preparation,�dissemination,�implementation�and�rescinding�of�policy�and�procedures.�There�are�various�ways�in�which�this�may�be�done,�and�the�form�and�the�scope�of�the�process�will�vary�according�to�the�size�and�complexity�of�the�facility.�It�is�imperative�that�the�most�current�documentation�is�circulated�and�implemented,�and�that�all�superseded�versions�are�withdrawn�and�archived.�Large�organisations�may�wish�to�employ�designated�document�controllers.�Decisions�must�be�made,�and�procedures�instigated,�to�manage�the�naming�and/or�numbering,�formatting�(hard�copy�and/or�electronic)�and�storage�of�documents.�Commercial�software�programs�are�available�to�assist�with�the�management�of�organisational�documentation,�which�may�be�extended�from�policies�and�procedures�to�include�other�relevant�documents�such�as�annual�reports,�standard�operating�procedures,�forms,�contracts,�etc.�Jurisdictional�legislation�and�policy�will�dictate�the�length�of�time�over�which�various�records�must�be�stored.�The�document�control�system�will�govern�and�facilitate�this�process.

Prompt points

¼ What system of document control does the organisation employ? Who is in charge of it?

¼ How does it ensure that the most current policies and procedures are available?

¼ What is the process for withdrawing earlier versions of documents?

¼ In what format(s) are earlier versions of policies and procedures stored?

Evidence commonly presented

Consider whether the following will help to address criterion 3.1.5

¼ Framework for the development of policies

¼ Corporate and clinical policies

¼ Schedule for review of policies and procedures

¼ Systems for identification and dissemination of information on new or amended legislation, Australian standards, codes of practice, guidelines, etc.

¼ Processes for incorporating legislation, Australian standards, codes of practice, guidelines, etc., into policies

¼ An example of the revision of existing policies / procedures due to new information

¼ Evaluation of compliance with policies and procedures

¼ Systems for retrieving superseded policies / procedures

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October 2010  415

GuidelinesAS/NZS�ISO�31000:2010�Riskmanagement—Principlesandguidelines.

AS�3806:2006Complianceprograms.Second�edn.

AS�ISO�10013:2003�Guidelinesforqualitymanagementsystemdocumentation.

Performance managementThis�criterion�states�that:�“Documented�corporate�and�clinical�policies�and�procedures�assist�the�organisation�to�provide�quality,�safe�health�care”.�The�organisation�should�be�able�to�demonstrate�that�its�development�of�policies�and�procedures�incorporates�the�most�current�information�on�legislation,�Australian�standards,�codes�of�practice�and�ethics,�guidelines�and�evidence�of�best�practice,�and�that�it�monitors�compliance�with�its�policies�and�procedures,�so�that�it�may�meet�its�obligations�to�the�community�it�serves�in�terms�of�the�provision�of�safe,�high�quality,�contemporary�health�care.

Some�common�suggested�performance�measures�are�as�follows:

Number�of�staff�attending�education�sessions�about�policies�and�procedures�per�calendar�year

Total number of staff

Number�of�policies�and�procedures�that�have�a�stated�review�date

Total number of policies and procedures

Number�of�policies�and�procedures�reviewed�within�the�required�timeframe

Total number of policies and procedures

Number�of�clinical�policies�reviewed�and�updated�to�reflect�current�clinical�practice

Total number of clinical policies

Number�of�staff�educated�on�legislation�related�to�their�area�of�responsibility

Total number of staff in that area of responsibility

Number�of�staff�in�compliance�with�a�specific�policy�or�procedure

Total number of staff working within the area to which that specific policy or procedure applies

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October 2010  417

3.2�Safe�Practice�and�Environment�Standard

The�standard�is:�The organisation maintains a safe environment for employees, consumers / patients and visitors.

The�intent�of�the�Safe�Practice�and�Environment�standard�is�to�ensure�that�the�healthcare�environment�is�safe�and�healthcare�providers�work�in�a�safe�manner.�Safe�Practice�and�Environment�criteria�all�require�the�systematic�application�of�risk�management�principles�to�determine�priorities�and�eliminate�risks�or�implement�controls.�

There�are�five�criteria�in�this�standard.�They�are:

3.2.1 Safety management systems ensuresafetyandwellbeingofconsumers/patients,staff,visitorsandcontractors.

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

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

3.2.4 Emergency and disaster management supportssafepracticeandasafeenvironment.

3.2.5� Security management supports�safe�practice�and�a�safe�environment.

seCtion 5Standards, criteria, elements and guidelines

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seCtion 5Standards, criteria, elements and guidelinesstandard 3.2:�The�organisation�maintains�a�safe�environment�for�employees,�consumers�/�patients�and�visitors

418  The ACHS EQuIP5 Guide  Book 2  Accreditation, Standards and Guidelines  Support and Corporate Functions

Criterion LA – Awareness sA – implementationLA plus the following

MA – evaluationSA plus the following

eA – excellenceMA plus the following

oA – LeadershipEA plus the following

Criterion 3.2.1

Safetymanagementsystemsensuresafetyandwellbeingofconsumers/patients,staff,visitorsandcontractors.

this is a mandatory criterion

a)� Documented�policies�for�safety�management�systems�are�in�accordance�with�relevant�jurisdictional�legislation�and�include:

� (i)� �workplace�health�and�safety

� (ii)� �workers�compensation

� (iii)� manual�handling

� (iv)� radiation�safety

� (v)� �management�of�dangerous�goods�and�hazardous�substances.

b)� Health�and�safety�risks�that�may�cause�harm�are�identified.

c)� Staff�are�educated�about�and�provided�with�information�on�workplace�health�and�safety�and�their�responsibilities.

d)� External�service�providers�are�supplied�with�relevant�information�and�comply�with�the�organisation’s�health�and�safety�requirements.

e)� Occupational�Health�&�Safety�(OH&S)�requirements�are�communicated�to�carers�and�visitors�as�required.

f)� There�are�documented�policies�and�procedures�on�the�procurement,�management�and�disposal�of�dangerous�goods�and�hazardous�substances,�and�a�register�of�hazardous�substances�is�maintained.

g)� A�register�is�kept�for�all�radioactive�substances,�safe�disposal�of�all�radioactive�waste�and�radiation�equipment.

h)� A�personal�radiation�monitoring�system�is�in�place,�together�with�any�relevant�area�monitoring.

a)� Safety�management�systems�are�managed�with�reference�to�any�relevant:

� (i)� Australian�standards

� (ii)� legislation

� (iii)� codes�of�practice

� (iv)� industry�guidelines.

b)� There�is�an�organisation-wide�system�to�assess�health�and�safety�risks,�determine�priorities�and�eliminate�the�risks�or�implement�controls.

c)� Service�planning�includes�health�and�safety�together�with�injury�prevention�strategies.

d)� Staff�are�involved�in�decisions�that�affect�workplace�health�and�safety�and�wellbeing.

e)� There�are�documented�safe�work�practices�/�safety�rules�for�all�relevant�procedures�and�tasks.

f)� A�hazards�identification�system�identifies�risks�and�implements�controls,�and�takes�corrective�action.

g)� Manual�handling�risks�in�both�clinical�and�non-clinical�areas�are�assessed�and�appropriate�controls�are�implemented.

h)� There�is�an�injury�management�program�that�reflects�legislation.

i)� Staff�with�formal�OH&S�responsibilities�are�appropriately�trained.

j)� There�is�a�radiation�safety�management�plan�which�is�coordinated�with�external�authorities.

k)� Consumer�/�patient�radiation�is�kept�to�a�minimum�whilst�maintaining�good�diagnostic�quality.

l)� Staff�exposure�to�radiation�is�kept�low�as�reasonably�achievable�(ALARA).

m)� A�radiation�safety�report�is�provided�to�the�ethics�committee�on�any�research�proposal�involving�irradiation�of�human�subjects.�

a)� The�safety�management�and�injury�management�systems�are�evaluated�and�improvements�are�made�to�support�safe�practice�and�a�safe�environment.

b)� The�design�and�layout�of�the�organisation’s�current�or�planned�physical�environment�are�evaluated.�

a)� Performance�indicators�for�safety�management�and�injury�management�systems�are�measured�and�compared�internally�and�with�external�systems,�and�improvements�are�made�to�ensure�better�practice.

a)� The�organisation�demonstrates�it�is�a�leader�in�safety�management�systems.

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October 2010  419

Criterion LA – Awareness sA – implementationLA plus the following

MA – evaluationSA plus the following

eA – excellenceMA plus the following

oA – LeadershipEA plus the following

Criterion 3.2.1

Safetymanagementsystemsensuresafetyandwellbeingofconsumers/patients,staff,visitorsandcontractors.

this is a mandatory criterion

a)� Documented�policies�for�safety�management�systems�are�in�accordance�with�relevant�jurisdictional�legislation�and�include:

� (i)� �workplace�health�and�safety

� (ii)� �workers�compensation

� (iii)� manual�handling

� (iv)� radiation�safety

� (v)� �management�of�dangerous�goods�and�hazardous�substances.

b)� Health�and�safety�risks�that�may�cause�harm�are�identified.

c)� Staff�are�educated�about�and�provided�with�information�on�workplace�health�and�safety�and�their�responsibilities.

d)� External�service�providers�are�supplied�with�relevant�information�and�comply�with�the�organisation’s�health�and�safety�requirements.

e)� Occupational�Health�&�Safety�(OH&S)�requirements�are�communicated�to�carers�and�visitors�as�required.

f)� There�are�documented�policies�and�procedures�on�the�procurement,�management�and�disposal�of�dangerous�goods�and�hazardous�substances,�and�a�register�of�hazardous�substances�is�maintained.

g)� A�register�is�kept�for�all�radioactive�substances,�safe�disposal�of�all�radioactive�waste�and�radiation�equipment.

h)� A�personal�radiation�monitoring�system�is�in�place,�together�with�any�relevant�area�monitoring.

a)� Safety�management�systems�are�managed�with�reference�to�any�relevant:

� (i)� Australian�standards

� (ii)� legislation

� (iii)� codes�of�practice

� (iv)� industry�guidelines.

b)� There�is�an�organisation-wide�system�to�assess�health�and�safety�risks,�determine�priorities�and�eliminate�the�risks�or�implement�controls.

c)� Service�planning�includes�health�and�safety�together�with�injury�prevention�strategies.

d)� Staff�are�involved�in�decisions�that�affect�workplace�health�and�safety�and�wellbeing.

e)� There�are�documented�safe�work�practices�/�safety�rules�for�all�relevant�procedures�and�tasks.

f)� A�hazards�identification�system�identifies�risks�and�implements�controls,�and�takes�corrective�action.

g)� Manual�handling�risks�in�both�clinical�and�non-clinical�areas�are�assessed�and�appropriate�controls�are�implemented.

h)� There�is�an�injury�management�program�that�reflects�legislation.

i)� Staff�with�formal�OH&S�responsibilities�are�appropriately�trained.

j)� There�is�a�radiation�safety�management�plan�which�is�coordinated�with�external�authorities.

k)� Consumer�/�patient�radiation�is�kept�to�a�minimum�whilst�maintaining�good�diagnostic�quality.

l)� Staff�exposure�to�radiation�is�kept�low�as�reasonably�achievable�(ALARA).

m)� A�radiation�safety�report�is�provided�to�the�ethics�committee�on�any�research�proposal�involving�irradiation�of�human�subjects.�

a)� The�safety�management�and�injury�management�systems�are�evaluated�and�improvements�are�made�to�support�safe�practice�and�a�safe�environment.

b)� The�design�and�layout�of�the�organisation’s�current�or�planned�physical�environment�are�evaluated.�

a)� Performance�indicators�for�safety�management�and�injury�management�systems�are�measured�and�compared�internally�and�with�external�systems,�and�improvements�are�made�to�ensure�better�practice.

a)� The�organisation�demonstrates�it�is�a�leader�in�safety�management�systems.

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seCtion 5Standards, criteria, elements and guidelinesstandard 3.2:�The�organisation�maintains�a�safe�environment�for�employees,�consumers�/�patients�and�visitors

420  The ACHS EQuIP5 Guide  Book 2  Accreditation, Standards and Guidelines  Support and Corporate Functions

Criterion 3.2.1

Safetymanagementsystemsensuresafetyandwellbeingofconsumers/patients,staff,visitorsandcontractors.(continued)

IntentThe�intent�of�this�criterion�is�to�ensure�that�healthcare�organisations�take�responsibility�for�the�health�and�safety�of�employees,�contractors,�management,�consumers�/�patients�and�visitors�via�a�comprehensive�and�integrated�safety�management�system.

Relationships of 3.2.1 with other criteriaThis�criterion�addresses�safety�management�systems�in�the�workplace�environment.�To�ensure�safe�management�systems,�staff�levels�need�to�be�commensurate�with�the�workload�(Criterion�2.2.1).�Organisational�systems�and�personal�responsibilities�for�workplace�safety�should�be�addressed�during�staff�orientation�(Criterion�2.2.2)�and�training�(Criterion�2.2.4).�The�design�of�the�facility�(Criterion�3.2.2)�will�impact�upon�specific�safety�issues,�such�as�falls�risk�(Criterion�1.5.4).�Safety�management�systems�will�operate�within�the�organisation’s�integrated�risk�management�framework�(Criterion�2.1.2).�Failure�to�implement�a�comprehensive�system�of�safety�management�may�lead�to�incidents�(Criterion�2.1.3)�and�complaints�(Criterion�2.1.4).

Safety management systemsA�safety�management�system�is�a�comprehensive�and�integrated�system�that�ensures�that�all�work�at�the�organisation�is�conducted�safely.�It�should�be�fully�documented,�accessible�and�comprehensible�to�those�that�need�to�use�it.�The�safety�management�system�recognises�the�potential�for�errors�and�establishes�control�measures�that�are�fully�implemented,�to�ensure�that�errors�do�not�result�in�incidents�or�near�misses.1�It�comprises�a�set�of�work�practices�and�procedures�for�monitoring�and�improving�the�safety�of�all�aspects�of�the�operation.

The�safety�management�system�includes:

• policy:�effective�health�and�safety�policies�set�a�clear�direction�for�the�organisation�to�follow

• planning:�an�effective�management�structure�and�arrangements�are�in�place�for�delivering�the�policy.�There�is�a�planned�and�systematic�approach�to�implementing�the�health�and�safety�policy.�Individual�responsibilities�should�be�clearly�outlined�and�may�be�stated�in�position�descriptions�or�similar�and�policies�and�procedures

• implementation:�the�policies,�procedures�and�resources�are�put�in�place�to�manage�all�aspects�of�the�control�measures�that�ensure�safe�operation�of�the�facility

• assessment:�performance�and�compliance�are�measured�against�agreed�standards�to�reveal�when�and�where�improvement�is�needed

• management�review:�the�organisation�learns�from�all�relevant�experience�and�applies�the�lessons.

The�organisation’s�implementation�of�its�safety�management�systems�will�be�carried�out�in�conjunction�with�its�design�and�layout�of�its�physical�environment.�While�the�physical�environment�is�in�part�an�outcome�of�the�organisation’s�planning�and�management�of�its�buildings�and�plant�(as�addressed�within�criterion�3.2.2),�the�concept�of�‘physical�environment’�also�encompasses�the�safe�and�effective�use�of�space�–�that�is,�it�addresses�issues�such�as�what�equipment�is�available�and�where�it�is�used,�the�design�and�placement�of�workstations,�how�workflow�is�organised�so�as�to�maintain�efficiency�and�meet�the�requirements�of�infection�control�procedures,�the�reduction�/�elimination�of�falls�risks,�and�so�forth.�The�design�and�layout�of�the�physical�environment�is�a�critical�aspect�of�the�organisation’s�management�of�Occupational�Health�&�Safety,�and�in�particular�of�manual�handling�/�task�(see�below).�The�organisation�should�not�only�regularly�evaluate�its�existing�systems,�making�improvements�as�required,�but�plan�ahead�for�any�anticipated�changes�in�service�delivery�and/or�the�size�and�composition�of�its�workforce.

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October 2010  421

Prompt points

¼ Do the safety policies and procedures address all the high-risk activities undertaken by the organisation? Wherever appropriate, do they separately consider the safety of staff, consumers / patients, carers, visitors and contractors?

¼ Are policies appropriately referenced to demonstrate awareness of regulatory obligations? Are they regularly reviewed and updated to reflect changes in regulations?

¼ What changes to the safety management system have been made in response to monitoring of reported incidents or other feedback? How was the implementation of the change managed? Are these processes, and any resulting changes, linked to risk management procedures, and the monitoring of risks (such as through the risk register)?

¼ How often does the organisation evaluate its current physical environment? What changes to design and layout have been made in response to anticipated changes in the organisation’s operation?

Occupational Health & Safety Depending�upon�their�size,�organisations�should�have�a�health�and�safety�officer�and/or�an�Occupational�Health�&�Safety�(OH&S)�committee�on�which�all�staff�groups�or�departments�are�represented,�as�required�by�legislation.�There�must�be�employee�representation�in�the�process,�not�only�representation�by�management.�Staff�who�accept�formal�OH&S�responsibilities�within�the�organisation�are�usually�required�to�undergo�accredited�training,�and�organisations�should�provide�access�to�such�training�and�allow�all�time�necessary�for�it�to�be�completed.�

Smaller�organisations�with�few�employees�may�seek�to�fulfil�their�staff�consultation�requirements�through�regular�team�meetings�where�OH&S�is�a�standing�agenda�item�and�staff�are�required�to�provide�input.�There�should�be�documented�evidence�of�the�consultative�process,�such�as�minutes.�Similarly,�there�should�be�documented�processes�that�ensure�that�issues�arising�within�the�Committee�are�notified�to�the�appropriate�executive�manager�or�board�/�executive�team.�Any�issues�raised�by�the�OH&S�Committee�that�require�a�response�should�be�documented�within�the�minutes�under�‘Business�Arising’�and�followed�through�for�a�decision.

There�should�be�a�process�to�ensure�that�all�staff�have�read�and�understood�health�and�safety�policies�and�procedures�and�this�should�be�part�of�the�induction�process.�Written�policies�for�health�and�safety�may�include:

• manual�handling�/�task

• radiation�safety

• slips�/�trips�/�falls

• electrical�safety

• noise�control

• hazardous�substances�and�dangerous�goods

• smoking

• ergonomics�–�assessments�of�all�working�environments�including�workstations�

• violence�and�aggression�

• management�of�incidents�and�near�misses

• staff�immunisation�–�a�risk-based�program�in�accordance�with�the�AustralianImmunisationHandbook2

• off-site�attendance�to�consumers�/�patients

• needlestick�injury�and�bodily�fluid�exposure�prevention

• provision�of�protective�clothing�and�equipment.

Prompt points

¼ Is there an OH&S system in place? Do policies, procedures, resources, communication processes and data link in a way that results in a ‘system’, rather than exist as stand-alone entities?

¼ Do staff understand their responsibilities in OH&S? Are there competency checks in key areas? What OH&S training is provided for staff? Is additional training available for OH&S representatives? Is attendance at training documented and non-attendance followed up?

¼ Are there records of meetings by the OH&S Committee (or any body with equivalent responsibilities)?

¼ How are major health and safety risks identified? How are incidents reported and managed? Are data collected and if so, how is it used? Is there a register of safe work method statements? Are these methods adopted by the staff?

¼ How are external service contractors made aware of policy and monitored for compliance with it?

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seCtion 5Standards, criteria, elements and guidelinesstandard 3.2:�The�organisation�maintains�a�safe�environment�for�employees,�consumers�/�patients�and�visitors

422  The ACHS EQuIP5 Guide  Book 2  Accreditation, Standards and Guidelines  Support and Corporate Functions

Criterion 3.2.1

Safetymanagementsystemsensuresafetyandwellbeingofconsumers/patients,staff,visitorsandcontractors.(continued)

Manual handling / taskThere�are�three�steps�to�reducing�manual�handling�/�task�incidents.�They�are:

1.� Identification

2.� Assessment�

3.� Control.

Identification: Manual�handling�tasks�should�be�identified�and�documented,�with�particular�attention�to�the�tasks�with�the�greatest�risk.�To�identify�these�tasks,�two�types�of�information�should�be�collected:�past�experiences�such�as�injury�statistics,�and�information�on�current�activities�gathered�by�staff�consultation�or�observation,�such�as�task�analysis.

Assessment: The�severity�of�the�risk�should�then�be�assessed.�For�example,�consumer�/�patient�lifting�in�a�surgical�or�orthopaedic�ward�would�pose�a�greater�risk�than�in�a�paediatric�ward.�While�both�require�manual�lifting�of�a�consumer�/�patient,�the�latter�would�normally�require�the�lifting�of�a�smaller�load�and�would�present�a�lower�risk.�Factors�to�consider�in�a�manual�handling�/�task�assessment�may�include�frequency�and/or�duration�of�task,�postural�factors,�weight�of�the�load,�load�characteristics,�environmental�factors�and�the�experience�of�the�staff�member.

The�risk�of�consumers�/�patients�having�a�fall�and�requiring�assistance�post-fall�applies�in�every�healthcare�organisation,�including�day�procedure�centres�and�community�health�centres.�The�use�of�anaesthesia�and�some�other�medications�increases�the�risk�of�a�fall�occurring�and�appropriate�risk�management�strategies�should�be�employed�to�minimise�identified�risk.�This�is�addressed�in�further�detail�within�criterion�1.5.4.

Control: The�National�Occupational�Health�and�Safety�Commission�(Australia)�Regulation�and�Codes3�and�some�additional�jurisdictional�requirements�call�for�risk�factors�to�be�controlled�by�redesigning�the�task�and�providing�general�training.�It�is�important�to�involve�the�staff,�the�OH&S�representative�/�committee�and�workplace�manager�in�any�redesigning�of�manual�handling�/�task�procedures.�The�use�of�consumer�/�patient�lifters�is�one�way�to�demonstrate�that�redesign�has�occurred.�

If�redesign�is�not�reasonably�practicable,�or�as�a�short-term�/�temporary�measure,�the�organisation�could�employ�team�lifting�or�provide�mechanical�aids�such�as�slide�sheets,�PAT�slides�and�trolleys,�and�training�and�supervision�in�the�use�of�these.�Often�the�best�solution�may�be�a�combination�of�one�or�more�of�these�controls.�Ergonomic�principles�should�be�considered�prior�to�the�purchase�of�any�equipment,�design�of�a�task�or�any�work�modifications.�There�should�be�procedures�for�the�use�and�trial�of�equipment�prior�to�use,�including�training�for�staff�using�the�equipment.�Records�of�these�equipment�trials�and�associated�training�should�be�retained�to�support�these�actions.

Policy�and�procedures�should�be�available�on�handling�bariatric�consumers�/�patients�to�avoid�injury�to�staff.�When�specialised�equipment�is�purchased,�training�in�the�use�of�that�equipment�should�be�performed�prior�to�its�implementation�and�should�also�become�a�part�of�orientation.

Injury and return-to-work managementThe�organisation�must�have�an�injury�management�policy�and�a�return-to-work�program�that�reflects�the�requirements�of�the�appropriate�State�/�Territory�legislation.�Correct�injury�management�ensures�the�prompt,�safe�and�durable�return-to-work�of�an�injured�worker.4�The�organisation’s�return-to-work�program�should�outline�the�policy�and�procedures�implemented�to�assist�injured�workers�with�their�return�to�the�workplace,�as�well�as�providing�all�other�relevant�information,�such�as�the�means�by�which�treatment�or�rehabilitation�may�be�accessed.�Staff�must�be�made�aware�of�the�return-to-work�program�(via�posters,�newsletters,�etc.),�and�all�related�information�must�be�freely�accessible.

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October 2010  423

Prompt points

¼ Is there a manual handling / task policy? When was it last reviewed?

¼ How are external service contractors made aware of the policy? How does the organisation monitor compliance by their external service contractors?

¼ Is there regular mandatory training in manual handling / task that meets specific staff / task needs? Is there a ‘no-lift’ policy?

¼ Does service planning include injury prevention strategies? Is there appropriate representation at strategic planning meetings?

¼ How do staff access the organisation’s injury management and return-to-work policies?

Sources of radiation and radiation safety systemsSources�of�radiation�are�essential�to�modern�health�care.�Radiation�is�a�vital�diagnostic�tool,�such�as�in�imaging�departments,�and�radiotherapy�may�be�used�to�the�treat�some�malignancies.5�Potential�exposure�needs�to�be�managed�and�according�to�the�relevant�code(s)�of�practice;�the�development�of�policy�and�procedures�to�support�this�management�will�be�a�requirement�for�a�large�group�of�organisations.

There�are�three�main�concepts�in�protecting�staff�from�radiation.�They�are:

• Time: The�amount�of�radiation�exposure�received�is�proportional�to�the�time�exposed.�Minimise�the�time�spent�handling�radioactive�substances�or�with�radiation�producing�equipment.�

• Distance: The�intensity�of�radiation�drops�rapidly�the�further�away�from�the�source.�Maximise�distance�from�sources�of�radiation�at�all�times.�This�includes,�for�example,�using�tongs�instead�of�hands�to�handle�radioactive�samples.�

• Shielding: Increasing�shielding�around�a�radiation�source�will�reduce�exposure.�

These�three�concepts�use�the�ALARA�(As�Low�As�Reasonably�Achievable)�principle�for�limiting�exposure�to�radiation�and�this�principle�should�be�considered�at�all�times�where�there�is�risk�of�exposure.

All�organisations�should�be�familiar�with�the�radiation�protection�standards�and�guidelines.�These�generally�pertain�to�exposure�and�dosage�and�can�be�found�on�the�Australian�Radiation�Protection�and�Nuclear�Safety�Agency�(ARPANSA)�website6,�where�guidelines,�codes�of�practice�and�other�relevant�information�are�available.�Control�of�radiation�exposure�is�governed�by�legislation�at�both�a�Federal�and�State�/�Territory�level.

In�organisations�where�lasers�are�used,�policies�and�procedures�should�reference�AS/NZS�4173:2004�Guidetothesafeuseoflasersinhealthcare.7�All�licences�and�safety�arrangements�should�be�in�place.

Depending�on�their�size,�organisations�should�have�a�radiation�safety�officer�and/or�a�radiation�safety�committee,�as�required�by�legislation.�A�radiation�management�plan�for�the�organisation�that�complies�with�the�ARPANSA�CodeofPracticeforRadiationProtectionintheMedicalApplicationsofIonizingRadiation8�should�be�implemented.

The�radiation�management�plan�should�note�those�persons�responsible�for�handling�and�purchase�of�any�radioactive�substances,�licences�and�compliance�with�any�standards�or�legislation.�There�should�be�a�register�of�radioactive�substances�and�relevant�equipment�on�site�at�any�time�that�is�regularly�updated.�

A�radiation�safety�report�should�be�provided�to�the�organisation’s�ethics�committee�(or�equivalent)�where�any�research�proposal�involves�irradiation�of�human�subjects,�in�accordance�with�the�ARPANSA�CodeofPracticefortheExposureofHumanstoIonizingRadiationforResearchPurposes.9�Where�required�by�the�State�/�Territory�regulatory�authority,�approval�for�the�research�is�also�sought�from�the�Radiation�Advisory�Council.�Staff�radiation�exposure�should�be�reviewed�by�the�radiation�safety�committee�or�the�alternative�relevant�authority�in�each�organisation.

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seCtion 5Standards, criteria, elements and guidelinesstandard 3.2:�The�organisation�maintains�a�safe�environment�for�employees,�consumers�/�patients�and�visitors

424  The ACHS EQuIP5 Guide  Book 2  Accreditation, Standards and Guidelines  Support and Corporate Functions

Criterion 3.2.1

Safetymanagementsystemsensuresafetyandwellbeingofconsumers/patients,staff,visitorsandcontractors.(continued)

Prompt points

¼ Are there risk identification and management reports, including for radiation? incident reports?

¼ Is there a radiation management program? Does the organisation have a Radiation Safety Officer and/or a Radiation Safety Committee? Do management / executives have a copy of the organisation’s Radiation Safety Plan?

¼ How does the organisation handle and dispose of radioactive waste?

¼ How often are the results of employee radiation exposure testing reviewed? How is this documented?

¼ How often is the radiation shielding (physical barriers and aprons) checked?

¼ Are Occupational Health and Safety reports, audits and/or meeting minutes available?

¼ Are results of external audits, numerical profiles, etc. trended, and implementation of recommendations made?

Hazardous substancesHazardous�substances�and�dangerous�goods�are�those�substances�that:

• are�referenced�in�the�National�Occupational�Health�and�Safety�Commission�ListofDesignatedHazardousSubstancesortheApprovedCriteriaforClassifyingHazardousSubstances�http://www.safeworkaustralia.gov.au/swa/HealthSafety/HazardousSubstances/FAQ/

• are�listed�in�the�Australian�Dangerous�Goods�(ADG)�Code�for�the�TransportofDangerousGoodsbyRoadandRail�http://www.infrastructure.gov.au/transport/australia/dangerous/�publications.aspx�

• meet�the�classification�criteria�of�the�ADG�Code.

The�application�of�risk�management�principles�and�compliance�with�each�State�/�Territory�hazardous�substances�code�of�practice�is�essential�in�ensuring�the�safety�and�wellbeing�of�consumers�/�patients,�staff�and�visitors�to�the�organisation.�Where�no�individual�policies�for�the�management�of�hazardous�materials�exist,�the�risk�management�policy�should�cover�areas�such�as:

• storage�/�security�/�isolation

• signage�/�information�/�labelling�/�identification�(including�information�from�provider)

• handling�/�use�

• spillage�(including�emergency�procedures)

• exposure�control,�monitoring�and�health�surveillance�(records�of�any�monitoring�or�health�surveillance�should�be�kept�for�30�years)

• personal�protective�equipment

• records

• transport

• disposal

• induction�and�training

• licensing

• maintenance�/�inspection�–�review�of�controls

• workplace�legislation�–�hazardous�substances,�dangerous�goods

• biological�hazards.

Material�Safety�Data�Sheets�(MSDSs)�should�be�available�for�staff�at�point�of�use�and�for�applicable�emergency�agencies�such�as�the�fire�brigade.�Hazardous�substances�are�to�be�properly�labelled�and�maintained�on�a�register�of�all�hazardous�substances�in�the�workplace.�Labels�should�never�be�altered�and�substances�should�be�stored�in�their�original�containers.

Chemicals�and�cleaning�solutions�bought�in�domestic�quantities�from�a�supermarket�or�other�supplier�should�be�handled�according�to�the�manufacturer’s�instructions.�Since�these�products�have�not�been�developed�specifically�for�healthcare�settings,�they�should�be�used�sparingly�within�the�organisation.�In�any�healthcare�organisation,�higher�standards�apply�than�in�the�home,�and�products�are�tested�accordingly.

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October 2010  425

Prompt points

¼ Are completed checklists and action plans to address identified deficiencies for each health industry hazard in line with State / Territory bodies available?

¼ Are there Occupational Health & Safety reports, audits and/or meeting minutes?

¼ Are Material Safety Data Sheets and a master index available to all staff?

¼ Are risk identification and management reports, including for radiation, available?

Evidence commonly presented

Consider whether the following will help to address criterion 3.2.1

¼ Completed checklist and action plan to address identified deficiencies for each health industry hazard, in line with State / Territory bodies

¼ Occupational Health and Safety reports, audits and/or meeting minutes

¼ Incident reports

¼ Availability of Material Safety Data Sheets and a master index

¼ Policies and procedures on safety management systems

¼ Risk identification and management reports

¼ Evidence of staff involvement in workplace health and safety

¼ Evidence of staff training and competency checks in workplace health and safety

¼ Register of safe work method statements

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seCtion 5Standards, criteria, elements and guidelinesstandard 3.2:�The�organisation�maintains�a�safe�environment�for�employees,�consumers�/�patients�and�visitors

426  The ACHS EQuIP5 Guide  Book 2  Accreditation, Standards and Guidelines  Support and Corporate Functions

Criterion 3.2.1

Safetymanagementsystemsensuresafetyandwellbeingofconsumers/patients,staff,visitorsandcontractors.(continued)

Performance measurementThis�criterion�states�that:�“Safety�management�systems�ensure�safety�and�wellbeing�of�consumers�/�patients,�staff,�visitors�and�contractors”.�The�organisation�should�be�able�to�demonstrate:�that�it�takes�responsibility�for�all�aspects�of�health�and�safety�via�the�implementation�of�appropriate�policies�and�procedures,�including�those�covering�injury�management�and�return-to-work;�its�proactive�attitude�to�risk�management;�its�response�to�the�occurrence�of�injuries�and�incidents,�including�near�misses;�and�an�ongoing�program�of�staff�education�that�includes�regular�competency�checks.

Some�common�performance�measures�are�as�follows:

Number�of�incidents�reported�that�relate�to�hazardous�substances�/�radiation�/�equipment�/��manual�handling�/�task

Total number of incidents

Comment:counttheincidentsforeachseparatecategory

Number�of�workers�compensation�claims�arising�from�a�manual�handling�/�task�incident

Total number of workers compensation claims

Number�of�staff�currently�on�workers�compensation

Total number of staff

Number�of�staff�working�hours�lost�to�workplace�injury

Total number of staff working hours

Number�of�staff�satisfied�with�the�organisation’s�return-to-work�program

Total number of staff who used the return-to-work program

Number�of�staff�who�completed�competencies�in�areas�such�as�dangerous�goods�/�hazardous�substances�/�radiation�/�manual�handling�/�task

Total number of staff undertaking competencies

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October 2010  427

Number�of�chemicals�that�have�a�current�Material�Safety�Data�Sheet

Total number of chemicals

Number�of�staff�satisfied�with�the�organisation’s�safety�strategies

Total number of staff surveyed

References1.� Government�of�South�Australia.�OccupationalHealth,

SafetyandWelfareRegulations1995.�In:�South�Australian�Consolidated�Regulations.�Adelaide;�Government�of�SA.�Accessed�from�www.austlii.edu.au�on�20�November�2008.

2.� Australian�Technical�Advisory�Group�on�Immunisation�(ATAGI)�and�National�Health�and�Medical�Research�Council�(NHMRC).�AustralianImmunisationHandbook.Canberra�ACT;�Australian�Dept�of�Health�and�Ageing.�Accessed�from�http://www.health.gov.au/internet/immunise/publishing.nsf/Content/Handbook-home�on�8�March�2010.

3.� Australian�Government.�NationalOccupationalHealthandSafetyCommissionRegulations.Canberra�ACT;�Attorney-General’s�Department;�2003.

4.� WorkCover�NSW.�Injurymanagementandreturn-to-workprograms:Factsheet2.�Sydney;�NSW�Government;�2008.

5.� Australian�Radiation�Protection�and�Nuclear�Safety�Agency�(ARPANSA).�Nationalstandardforlimitingoccupationalexposuretoionizingradiation.Radiation�Protection�Series�No.�1,�Republished�2002.�Canberra�ACT;�National�Occupation�Health�and�Safety�Commission;�1995.

6.� Australian�Radiation�Protection�and�Nuclear�Safety�Agency�(ARPANSA).�RadiationProtectionSeries.Melbourne�VIC;�Australian�Government.�Accessed�from�http://www.arpansa.gov.au/Publications/codes/rps.cfm�on�29�June�2010.

7.� AS/NZS�4173:2004�Guidetothesafeuseoflasersinhealthcare.

8.� Australian�Radiation�Protection�and�Nuclear�Safety�Agency�(ARPANSA).�Codeofpractice:Radiationprotectioninthemedicalapplicationsofionizingradiation.Radiation�Protection�Series�No.�14.�Canberra�ACT;�Australian�Government;�2008.

9.� Australian�Radiation�Protection�and�Nuclear�Safety�Agency�(ARPANSA).Codeofpractice:Exposureofhumanstoionizingradiationforresearchpurposes.Radiation�Protection�Series�No.�8.�Canberra�ACT;�Australian�Government;�2005.

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seCtion 5Standards, criteria, elements and guidelinesstandard 3.2:�The�organisation�maintains�a�safe�environment�for�employees,�consumers�/�patients�and�visitors

428  The ACHS EQuIP5 Guide  Book 2  Accreditation, Standards and Guidelines  Support and Corporate Functions

Criterion LA – Awareness sA – implementationLA plus the following

MA – evaluationSA plus the following

eA – excellenceMA plus the following

oA – LeadershipEA plus the following

Criterion 3.2.2

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

a)� Documented�policy�/�procedures�for:

� (i)� buildings�/�workplaces

� (ii)� plant

� (iii)� �medical�devices�and�equipment

� (iv)� other�equipment

� (v)� supplies

� (vi)� utilities

� (vii)� consumables

� (viii)�workplace�design�

� address�health,�safety�and�service�requirements.

b)� Medical�devices�are:

� (i)� selected

� (ii)� installed�

� (iii)� operated�

� (iv)� maintained�

� (v)� repaired�

� (vi)� calibrated�where�necessary

� by�competent,�qualified�people.

c)� Plant�and�other�equipment�are�installed�and�operated�in�accordance�with�manufacturer�specifications.

d)� Plant�logs�exist�and�are�in�accordance�with�manufacturer�requirements.

e)� There�is�a�cleaning�schedule�for�all�areas�of�the�buildings�and�for�equipment.

f)� Purchase�and�supply�procedures�ensure�that�products�are�available�or�that�appropriate�alternatives�are�supplied.

g)� There�is�clear�external�signage�at�appropriate�locations.

h)� The�organisation�has�identified�disability�and�cultural�signage�needs.

i)� Disability�access�and�facilities�meet�legislative�requirements�where�they�exist,�and/or�are�based�on�recognised�guidelines.

j)� The�organisation�has�procedures�that�ensure�the�efficient�and�sustainable�use�of�energy�and�water.

a)� There�is�a�system�to�plan,�manage�and�operate:

� (i)� buildings�/�workplaces

� (ii)� plant

� (iii)� �medical�equipment�/�devices

� (iv)� other�equipment

� (v)� supplies

� (vi)� utilities

� (vii)� consumables.

b)� Buildings,�plant,�medical�devices�and�equipment,�utilities,�consumables�and�supplies�are�managed�with�reference�to�any�relevant:

� (i)� Australian�standards

� (ii)� legislation

� (iii)� codes�of�practice

� (iv)� industry�guidelines.

c)� Relevant�staff�are�trained�in�the�safe�and�appropriate�use�of�medical�devices�and�equipment.

d)� There�is�a�documented,�planned�and�coordinated�preventative�maintenance�system.

e)� The�organisation�provides�resources�that�support�cleaning�requirements.

f)� Services�/�departments�are�sign�posted�appropriate�to�the�needs�of�the�community�and�the�organisation.

g)� Sign�posting�reflects�the�use�of�multilingual�/�international�symbols�appropriate�to�the�community’s�needs.

a)� The�safety�and�accessibility�of�the�buildings�/�workplace,�and�the�safe�and�consistent�operation�of�plant�and�equipment,�is�evaluated,�and�improvements�are�made�to�reduce�risk.

b)� The�acquisition,�use,�maintenance�and�storage�of�medical�devices�/�medical�equipment�is�monitored�and�evaluated.

c)� Maintenance�and�replacement�of�buildings,�plant,�medical�and�other�equipment�is�planned,�prioritised�and�budgeted�for.

d)� Incidents�and�hazards�associated�with�building,�plant,�medical�devices,�equipment,�utilities,�consumables�and�supplies�are�documented,�evaluated,�and�action�is�taken�to�reduce�risk.

e)� The�quality�of�cleaning�practices�is�evaluated�and�improved�as�required.

f)� The�organisation�regularly�evaluates�whether�the�signage�meets�community�needs�and�makes�necessary�improvements.

g)� Energy�and�water�use�is�evaluated�annually�and�improvements�are�made�to�enhance�efficiency.

a)� Management�systems�related�to�buildings,�plant,�equipment,�medical�devices,�consumables�and�supplies�are�measured�and�compared�internally�and�externally,�and�improvements�are�made�to�ensure�better�practice.

and/or

b)� Signage�and�physical�access�are�compared�with�available�published�standards�and�external�data,�and�improvements�are�made�to�ensure�better�practice.�

and/or

c)� Utilities�are�monitored�over�time,�and�efforts�made�to�ensure�efficient,�effective�and�sustainable�use�of�energy�and�water�resources.

a)� The�organisation�demonstrates�it�is�a�leader�in�the�management�of�buildings,�signage,�plant,�medical�devices,�equipment,�supplies,�utilities�and�consumables.

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October 2010  429

Criterion LA – Awareness sA – implementationLA plus the following

MA – evaluationSA plus the following

eA – excellenceMA plus the following

oA – LeadershipEA plus the following

Criterion 3.2.2

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

a)� Documented�policy�/�procedures�for:

� (i)� buildings�/�workplaces

� (ii)� plant

� (iii)� �medical�devices�and�equipment

� (iv)� other�equipment

� (v)� supplies

� (vi)� utilities

� (vii)� consumables

� (viii)�workplace�design�

� address�health,�safety�and�service�requirements.

b)� Medical�devices�are:

� (i)� selected

� (ii)� installed�

� (iii)� operated�

� (iv)� maintained�

� (v)� repaired�

� (vi)� calibrated�where�necessary

� by�competent,�qualified�people.

c)� Plant�and�other�equipment�are�installed�and�operated�in�accordance�with�manufacturer�specifications.

d)� Plant�logs�exist�and�are�in�accordance�with�manufacturer�requirements.

e)� There�is�a�cleaning�schedule�for�all�areas�of�the�buildings�and�for�equipment.

f)� Purchase�and�supply�procedures�ensure�that�products�are�available�or�that�appropriate�alternatives�are�supplied.

g)� There�is�clear�external�signage�at�appropriate�locations.

h)� The�organisation�has�identified�disability�and�cultural�signage�needs.

i)� Disability�access�and�facilities�meet�legislative�requirements�where�they�exist,�and/or�are�based�on�recognised�guidelines.

j)� The�organisation�has�procedures�that�ensure�the�efficient�and�sustainable�use�of�energy�and�water.

a)� There�is�a�system�to�plan,�manage�and�operate:

� (i)� buildings�/�workplaces

� (ii)� plant

� (iii)� �medical�equipment�/�devices

� (iv)� other�equipment

� (v)� supplies

� (vi)� utilities

� (vii)� consumables.

b)� Buildings,�plant,�medical�devices�and�equipment,�utilities,�consumables�and�supplies�are�managed�with�reference�to�any�relevant:

� (i)� Australian�standards

� (ii)� legislation

� (iii)� codes�of�practice

� (iv)� industry�guidelines.

c)� Relevant�staff�are�trained�in�the�safe�and�appropriate�use�of�medical�devices�and�equipment.

d)� There�is�a�documented,�planned�and�coordinated�preventative�maintenance�system.

e)� The�organisation�provides�resources�that�support�cleaning�requirements.

f)� Services�/�departments�are�sign�posted�appropriate�to�the�needs�of�the�community�and�the�organisation.

g)� Sign�posting�reflects�the�use�of�multilingual�/�international�symbols�appropriate�to�the�community’s�needs.

a)� The�safety�and�accessibility�of�the�buildings�/�workplace,�and�the�safe�and�consistent�operation�of�plant�and�equipment,�is�evaluated,�and�improvements�are�made�to�reduce�risk.

b)� The�acquisition,�use,�maintenance�and�storage�of�medical�devices�/�medical�equipment�is�monitored�and�evaluated.

c)� Maintenance�and�replacement�of�buildings,�plant,�medical�and�other�equipment�is�planned,�prioritised�and�budgeted�for.

d)� Incidents�and�hazards�associated�with�building,�plant,�medical�devices,�equipment,�utilities,�consumables�and�supplies�are�documented,�evaluated,�and�action�is�taken�to�reduce�risk.

e)� The�quality�of�cleaning�practices�is�evaluated�and�improved�as�required.

f)� The�organisation�regularly�evaluates�whether�the�signage�meets�community�needs�and�makes�necessary�improvements.

g)� Energy�and�water�use�is�evaluated�annually�and�improvements�are�made�to�enhance�efficiency.

a)� Management�systems�related�to�buildings,�plant,�equipment,�medical�devices,�consumables�and�supplies�are�measured�and�compared�internally�and�externally,�and�improvements�are�made�to�ensure�better�practice.

and/or

b)� Signage�and�physical�access�are�compared�with�available�published�standards�and�external�data,�and�improvements�are�made�to�ensure�better�practice.�

and/or

c)� Utilities�are�monitored�over�time,�and�efforts�made�to�ensure�efficient,�effective�and�sustainable�use�of�energy�and�water�resources.

a)� The�organisation�demonstrates�it�is�a�leader�in�the�management�of�buildings,�signage,�plant,�medical�devices,�equipment,�supplies,�utilities�and�consumables.

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seCtion 5Standards, criteria, elements and guidelinesstandard 3.2:�The�organisation�maintains�a�safe�environment�for�employees,�consumers�/�patients�and�visitors

430  The ACHS EQuIP5 Guide  Book 2  Accreditation, Standards and Guidelines  Support and Corporate Functions

Criterion 3.2.2

Buildings,�signage,�plant,�medical�devices,�equipment,�supplies,�utilities�and�consumables�are�managed�safely�and�used�efficiently�and�effectively.�(continued)

IntentThe�intent�of�this�criterion�is�to�ensure�that�all�buildings,�signage,�plant,�medical�devices,�equipment,�supplies,�utilities�and�consumables�owned�or�used�by�the�organisation�are�managed�in�a�way�that�will�support�the�creation�and�maintenance�of�a�safe�healthcare�environment.

Relationships of 3.2.2 with other criteriaThe�organisation’s�management�of�its�buildings,�signage,�plant,�medical�devices,�equipment,�utilities,�supplies�and�consumables�is�an�aspect�of�its�responsibility�to�ensure�the�safety�of�consumers�/�patients,�staff,�visitors�and�contractors�(Criterion�3.2.1)�and�to�manage�risk�(Criterion�2.1.2).�It�must�reflect�the�organisation’s�commitment�to�safe�practice�and�a�safe�environment,�as�per�its�emergency�and�disaster�management�policies�(Criterion�3.2.4),�while�also�providing�for�those�consumers�/�patients�and�carers�with�diverse�needs�and�from�diverse�backgrounds�(Criterion�1.6.3).�The�implementation�of�efficient�cleaning�practices,�as�well�as�water�usage�and�the�choice�of�electrical�goods,�will�fall�under�the�organisation’s�responsibility�for�providing�a�safe�and�sustainable�environment�(Criterion�3.2.3)�and�may�be�influenced�by�its�management�of�infection�control�(Criterion�1.5.2).�A�failure�in�the�efficiency�and/or�effectiveness�of�management�of�its�buildings,�signage,�plant,�medical�devices,�equipment,�supplies,�utilities�and�consumables�may�lead�to�incidents�and�complaints�(Criteria�2.1.3�and�2.1.4).

Planning and developmentThe�organisation’s�management�of�its�buildings,�plant�and�equipment�requires�the�development�of�policy�and�procedures�drawn�from�relevant�legislation,�codes�of�practice�and�Australian�standards,�and�which�address�how�the�organisation�will�maximise�the�safety�and�comfort,�and�supply�the�needs,�of�the�community�it�serves.�The�Australasian�Health�Infrastructure�Alliance�(formerly�the�Health�Capital�Asset�Managers’�Consortium�of�Australia�and�New�Zealand)�has�developed�the�Australasian�Health�Facilities�Guideline�(AusHFG)1,�a�comprehensive�guide�to�the�planning,�design,�building�and�refurbishment�of�healthcare�facilities.�It�also�covers�the�planning,�selection�and�installation�of�plant�and�equipment,�aspects�of�sustainability,�access�features�for�those�with�special�needs,�and�workplace�design�and�ergonomics.�The�AusHFG�is�intended�to�promote�a�best-practice�approach�to�health�facility�planning,�and�is�subjected�to�a�continuous�review�process�to�ensure�that�the�content�reflects�contemporary�models�of�care�and�health�planning�practice.�It�also�lists�all�appropriate�jurisdictional�legislation,�including�Occupational�Health�&�Safety�legislation,�and�relevant�Australian�standards.�

In�November�2007,�the�AusHFG�was�officially�endorsed�for�use�by�Australian�States�/�Territories�and�by�the�Ministry�of�Health,�New�Zealand.�Using�this�document�as�its�guide,�organisations�should�develop�policy�and�procedures�that�will�provide�an�effective�managerial�framework.

In�existing�facilities,�or�where�an�area�is�designated�for�a�new�purpose,�it�can�be�difficult�to�redesign�workspaces�without�major�renovation.�If�the�organisation�intends�to�adapt�an�existing�space�for�a�new�purpose,�it�should�plan�the�changes�and�manage�the�area�so�as�to�ensure�compliance�with�relevant�Occupational�Health�&�Safety�legislation.

The�organisation’s�planning�and�development�should�also�strive�for�continual�improvements�to�the�environment�and�for�a�reduction�in�risk,�by�evaluating�the�workplace�and�making�changes�as�necessary.�As�part�of�its�system�of�planning,�organisations�should�recognise�that�over�time,�buildings,�plant,�medical�devices�and�other�equipment�may�require�maintenance�and/or�repair,�or�to�be�replaced.�Events�such�as�these�should�be�expected,�prioritised�and�budgeted�for,�in�order�to�ensure�that�safety�of�the�environment�is�not�compromised.�Success�or�the�need�for�improvement�in�the�area�of�workplace�planning�/�design�may�be�gauged�by�surveying�consumers�/�patients,�visitors�and�staff.

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October 2010  431

Prompt points

¼ Was the workplace purpose-built, or was an existing facility adapted? If an existing facility was adapted, what measures were taken to ensure that the environment was appropriate to the work?

¼ What legislation / guidelines were consulted when planning for disabled access to the facility?

¼ If dangerous goods and/or hazardous substances are stored onsite, what legislation / codes of practice were consulted in planning for their storage?

¼ How did considerations of ergonomics influence the design and layout of the workplace?

¼ Highlight some improvements made to the workplace after it was re-evaluated?

¼ How does the organisation prioritise maintenance, repairs and/or replacement of buildings, plant, medical devices and other equipment?

Plant, equipment, vehicles, supplies and consumablesPlant,�equipment,�vehicles,�supplies�and�consumables�purchased�by�the�organisation�should�support�the�provision�of�care�and�services,�and�protect�the�health�and�safety�of�consumers�/�patients,�staff�and�others�within�the�organisation.�Effective�planning�and�assessment�of�equipment�may�include�reviewing�the�community’s�needs,�involving�staff�who�use�the�equipment,�and�seeking�opinions�of�those�consumers�/�patients�who�use�the�equipment.�The�process�for�assessment�of�new�plant,�equipment,�supplies�and�vehicles�should�include:

• compliance�with�relevant�legislative�requirements,�codes�of�practice,�Australian�standards�and�guidelines

• intended�use�and�user�and�consumer�/�patient�needs

• cost�benefits

• safety,�including�manual�handling�/�task�issues

• infection�control,�including�waste�management�issues

• energy�efficiency�and�environmental�sustainability

• training�needs

• storage�and�distribution.

Installation�of�plant�and�equipment�should�be�in�accordance�with�the�manufacturers’�specifications,�with�the�plant�/�equipment�appropriately�tested�and�commissioned�and�all�necessary�licences�obtained.�Current�information�and�scientific�data�from�manufacturers�relating�to�their�products’�requirements�should�be�available�for�reference�and�guidance�for�both�the�operation�and�maintenance�of�plant�and�equipment.

Plant�logs�and�maintenance�processes�should�ensure�that�plant�/�equipment�is�maintained�and�serviced�by�people�trained�in�maintenance�of�that�equipment�and�in�accordance�with�manufacturer�specifications�and�relevant�standards,�including�maintenance�on�high-risk�plant�such�as�cooling�towers�and�pressure�vessels.�Documented�processes�for�procurement,�upgrading�and�replacing�equipment�and�supplies�should�be�in�place.�The�organisation�may�address�issues�of�planning,�purchasing�and�provision�through�a�comprehensive�asset�management�system.�A�program�to�address�breakdown�or�any�planned,�deferred�and/or�outstanding�maintenance�requirements�should�be�developed.

The�safe�operation�of�electrically�operated�equipment�used�in�health�care�should�be�monitored�in�regard�to�electrical�shock,�thermal,�radiant�and�mechanical�hazards.�Organisations�should�refer�to�State�/�Territory�legislation,�Australian�standards,�and�any�other�relevant�guidelines.�Specialised�equipment�should�only�be�operated�by�trained�staff�to�minimise�the�likelihood�of�injury�and�to�obtain�the�best�results.

Vehicles,�according�to�their�use�and/or�location,�may�be�considered�as�either�a�workplace�or�as�plant.�It�is�the�responsibility�of�the�organisation�to�maintain�all�owned,�operated�and�leased�vehicles.�

Efficient�management�of�supplies�and�consumables�requires�that�systems�of�ordering,�storage,�distribution,�and�control�of�inventory�be�implemented�by�the�organisation.�Items�designed�for�single�use�should�not�be�reused�unless�the�organisation�has�specific�policies�and�guidelines�for�safe�reuse�incorporating�relevant�statutory�requirements,�codes�of�practice�and�Australian�standards.�There�should�also�be�a�system�to�manage�the�recall�of�any�supply�or�consumable,�as�per�bulletins�from�the�Therapeutic�Goods�Administration.

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seCtion 5Standards, criteria, elements and guidelinesstandard 3.2:�The�organisation�maintains�a�safe�environment�for�employees,�consumers�/�patients�and�visitors

432  The ACHS EQuIP5 Guide  Book 2  Accreditation, Standards and Guidelines  Support and Corporate Functions

Criterion 3.2.2

Buildings,�signage,�plant,�medical�devices,�equipment,�supplies,�utilities�and�consumables�are�managed�safely�and�used�efficiently�and�effectively.�(continued)

Prompt points

¼ For what plant / equipment / vehicles are logs kept? Who updates the logs?

¼ How did considerations of efficiency and environmental sustainability influence the purchase of plant / equipment / vehicles?

¼ What plant / equipment / vehicles within the organisation require the operator(s) to be licensed? How is correct licensing of operators, including drivers of vehicles, monitored?

¼ Who carries out maintenance on the organisation’s plant / equipment / vehicles? How often is it carried out? What records are kept?

¼ In the event of the recall of a consumable by the Therapeutic Goods Administration, what is the organisation’s procedure?

Medical devicesA�medical�device�is�“any�instrument,�apparatus�or�appliance,�including�software,�whether�used�alone�or�in�combination,�together�with�any�accessories�necessary�for�correct�operation,�which�makes�physical�or�electrical�contact�with�the�patient,�or�transfers�energy�to�or�from�the�patient,�or�detects�such�energy�transfer�to�or�from�the�patient,�or�is�intended�to�diagnose,�treat�or�monitor�a�patient”.2

The�term�‘medical�device’�applies�to�all�equipment�used�in�treatment,�diagnostic�activities,�monitoring,�and�direct�consumer�/�patient�care.�This�includes,�but�is�not�limited�to,�devices�used�for:

• life�support:�anaesthesia�machines,�ventilators,�heart-lung�machines,�etc.

• monitoring:�bedside�monitors,�telemetry�monitors,�etc.

• treatment:�lasers,�electrosurgery,�diathermy,�etc.

• diagnostics:�pathology�laboratory�analysers,�radiology�equipment,�endoscopes,�etc.

• patient�support:�hospital�beds,�specialty�beds,�etc.

An�organisation�should�have�documented�management�strategies�for�all�medical�devices�used�within�its�facilities�including:

• medical�devices�owned,�leased�or�rented�by�the�organisation

• medical�devices�on�short,�medium�or�long-term�loan�to�the�organisation

• medical�devices�being�trialled�by�the�organisation

• medical�devices�prescribed�by�the�organisation’s�staff�to�consumers�/�patients.�

The�planning�for�and�procurement�of�medical�devices�should�support�the�provision�of�clinical�services�and�quality�care,�reflect�the�organisation’s�commitment�to�the�health,�wellbeing�and�safety�of�consumers�/�patients,�and�meet�the�community’s�expectations.�The�process�for�assessment�of�new�medical�devices�should�include�consideration�of�their�clinical�efficacy�and�effectiveness,�human�factors,�Occupational�Health�&�Safety,�infection�control,�cost�of�ownership�and�clinical�life,�and�should�be�undertaken�in�consultation�with�all�relevant�staff.�

Many�medical�devices�require�specific�training�and�some�require�licensing�of�the�individuals�who�will�operate�the�device.�The�organisation�must�ensure�that�all�those�involved�in�the�operation�of�medical�devices�have�undergone�all�necessary�training,�are�competent,�and�that�where�required,�all�correct�licences�have�been�obtained.

Increasingly,�medical�devices�are�utilising�elements�of�information�and�communications�technology�(I&CT).�A�growing�number�of�medical�devices�are�in�essence�a�desktop�computer,�notebook�or�network�server�running�dedicated�medical�software,�or�a�system�incorporating�a�desktop(s),�notebook(s)�or�server(s).�However,�the�organisation�should�manage�all�such�devices�as�medical�devices,�not�as�I&CT.�

Installation,�calibration,�maintenance�and,�finally,�decommissioning�and�disposal�of�medical�devices�should�be�carried�out�by�registered�and/or�appropriately�qualified,�trained�and�competent�individuals.�Records�should�be�kept�of�all�medical�device�maintenance.

Responsibility�should�also�be�assigned�for�the�cleaning,�sterilisation�and/or�recommissioning�of�each�individual�device,�as�this�is�a�specialised�task�that�does�not�fall�within�the�province�of�the�organisation’s�general�cleaning�staff.3

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October 2010  433

Prompt points

¼ What processes exist within the organisation to ensure broad consultation during medical device procurement?

¼ In managing medical devices within the organisation, how does the biomedical engineering department ensure appropriate engagement on I&CT issues?

¼ What processes and approval mechanisms can the organisation demonstrate with respect to the management of medical devices, including record keeping, risk evaluation, scope of routine testing programs, contract management and resource availability?

¼ In the event of a recall of a medical device by the Therapeutic Goods Administration, what is the organisation’s procedure?

Signage and special needsClear�signage�is�an�important�aspect�of�any�healthcare�organisation.�In�an�emergency,�an�individual’s�ability�to�determine�quickly�the�location�of�the�organisation�and/or�how�to�access�the�required�department�can�be�critical,�while�at�any�time�clear�signage�will�ensure�that�the�consumer�/�patient�and�the�visitor�alike�can�find�their�way�around�easily,�and�that�a�visit�to�the�organisation�is�not�attended�by�confusion,�stress�or�unnecessary�loss�of�time.�Installation�of�signage�upon�the�roads�surrounding�the�healthcare�organisation�will�need�to�be�organised�in�consultation�with�local�councils�and�the�appropriate�roads�authority.

The�organisation’s�external�signage�should�provide�the�following�information:

• appropriate�routes�of�access

• hours�of�access

• after-hours�access�(where�applicable)

• telephone�numbers

• details�of�other�healthcare�organisations�in�the�area,�particularly�the�nearest�accident�/�emergency�facility.

External�signage�may�also�relate�to�such�management�issues�as�designated�parking�/�non-parking�zones,�ambulance�bays,�and�the�enforcement�of�a�non-smoking�policy.

Internal�signage�must�provide�clear�directions�to�specific�areas�of�the�organisation,�as�well�as�providing�health�and�safety�information�including�non-smoking�areas,�restricted�mobile�phone�usage�and�the�presence�of�any�hazards.�All�exits�must�be�clearly�marked.

Clear,�effective,�well-positioned�signage�is�an�important�aspect�of�the�efficient�operation�of�any�healthcare�organisation,�and�one�that�should�be�monitored�and�reassessed�according�to�changes�in�the�community�being�serviced�and�the�level�of�satisfaction�expressed�by�consumers�/�patients�and�visitors.�Surveys�may�be�used�to�assess�satisfaction�levels.

Prompt points

¼ Is the organisation’s signage language-based or symbol-based? What factors influenced this choice?

¼ Does the organisation provide signage in languages other than English? How were the other languages chosen?

¼ What special needs signage is found within this organisation?

¼ How often are the organisation’s signage arrangements reassessed? On what basis are changes to the signage made?

UtilitiesUtilities�are�the�basic�services�that�the�organisation�uses�to�function,�including�water,�power,�ventilation,�medical�gases�and�suction�systems,�and�communications�systems.�Supplies�and�consumables�are�generally�commodities�with�a�shorter�life�while�in�use�than�items�that�would�remain�in�inventory�after�distribution�or�assignment�for�use,�such�as�dressings,�syringes,�disposable�gloves,�catheters,�etc.

Policies�governing�the�use�of�utilities�should�cover�emergency�and�disaster�management.�The�organisation�should�also�have�procedures�to�ensure�that�the�use�of�energy�and�water�is�efficient�and�sustainable.�These�should�address�considerations�such�as�purchasing�electrical�equipment�with�a�high�energy�rating,�and�programs�to�conserve�energy�and�water�(switching�off�equipment,�good�plumbing�maintenance,�etc.).�The�organisation’s�energy�and�water�use�should�be�assessed�annually,�and�efforts�made�to�improve�efficiency.

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seCtion 5Standards, criteria, elements and guidelinesstandard 3.2:�The�organisation�maintains�a�safe�environment�for�employees,�consumers�/�patients�and�visitors

434  The ACHS EQuIP5 Guide  Book 2  Accreditation, Standards and Guidelines  Support and Corporate Functions

Criterion 3.2.2

Buildings,�signage,�plant,�medical�devices,�equipment,�supplies,�utilities�and�consumables�are�managed�safely�and�used�efficiently�and�effectively.�(continued)

Prompt points

¼ How has the organisation improved the efficiency of its energy and water usage?

Cleaning, maintenance and hazard managementIn�order�to�be�efficient�and�effective,�the�organisation’s�management�of�its�buildings,�signage,�plant,�equipment,�utilities,�supplies�and�consumables�should�be�supported�by�a�well-planned�and�well-resourced�system�of�cleaning,�maintenance�and�hazard�control.

In�order�to�ensure�thorough�cleaning,�there�should�be�a�schedule�that�clearly�describes�all�areas�to�be�cleaned,�as�well�as�the�specific�surfaces�/�objects�to�be�cleaned�(e.g.�floors,�toilets,�desk�tops,�computer�screens).�This�schedule�should�also�specify�which�surfaces�/�objects�are�not�to�be�touched�(e.g.�medical�devices).�Cleaning�is�not�only�crucial�in�its�own�right�but�a�vital�component�of�the�organisation’s�infection�control�and�waste�management�systems.�It�is�the�organisation’s�responsibility�to�ensure�that�cleaning�is�sufficiently�staffed�and�resourced,�and�that�cleaning�products�are�stored�and�used�as�per�manufacturer’s�instructions�and�relevant�OH&S�policies.�The�frequency�of�cleaning�of�specific�areas�should�be�related�to�a�risk�assessment.

Maintenance�is�also�an�essential�aspect�of�the�organisation’s�management�of�its�buildings,�plant,�equipment�and�vehicles.�However,�maintenance�should�not�merely�be�reactive:�the�organisation�should�implement�a�planned�and�coordinated�system�of�preventive�maintenance,�in�order�to�retain�all�assets�in�good�working�order,�to�extend�the�working�life�of�critical�and�expensive�equipment,�and�to�reduce�the�risk�associated�with�poorly�operating�equipment.�All�stages�of�preventive�maintenance,�from�planning�to�completion,�should�be�documented.�Any�instance�of�deferred�maintenance,�that�is,�maintenance�that�should�be�performed,�but�is�not,�for�reasons�ranging�from�budgetary�constraints�to�staffing�limitations,�should�also�be�recorded�and�an�explanation�provided.

Well-implemented�systems�of�cleaning,�preventive�maintenance�and�hazard�reduction�are�fundamental�to�the�organisation’s�efficient�and�effective�management�of�its�buildings,�signage,�plant,�equipment,�utilities,�supplies�and�consumables,�and�the�quality�and�efficacy�of�the�systems�should�be�regularly�evaluated,�and�improvements�made�as�required.

Prompt points

¼ How does the organisation ensure that its cleaning requirements are sufficiently resourced?

¼ How and by whom is the organisation’s program of preventive maintenance planned?

¼ How does the organisation encourage the reporting of near misses within its management of its buildings, signage, plant, equipment, utilities, supplies and consumables?

¼ What improvements have been made to the organisation’s cleaning, maintenance and hazard reduction systems, and why were they made?

Evidence commonly presented

Consider whether the following will help to address criterion 3.2.2

¼ Risk ratings / assessments

¼ Preventive maintenance plan, including deferred maintenance records

¼ Preventive maintenance plan review

¼ Systems for handling recalled goods or devices

¼ Incident reports, including near misses

¼ Evidence of disability and cultural needs identification

¼ Policies on:

– purchase and supply – buildings, signage, plant, equipment,

utilities, supplies and consumables – workplace design

¼ Asset register

¼ Contracts, including biomedical and IT contracts

¼ Results of mandatory plant / equipment testing

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October 2010  435

Performance measurementThis�criterion�states�that:�“Buildings,�signage,�plant,�medical�devices,�equipment,�supplies,�utilities�and�consumables�are�managed�safely�and�used�efficiently�and�effectively”.�The�organisation�should�be�able�to�demonstrate�that�it�has�policies�and�procedures�for�the�safe�and�efficient�use�of�its�assets,�that�it�proactively�maintains�them,�and�replaces�them�as�needed;�and�that�it�meets�all�standard�and�jurisdictional�requirements�for�the�procurement,�operation�and�maintenance�of�its�medical�devices.

Some�common�suggested�performance�measures�are�as�follows:

Number�of�incidents�resulting�in�loss�of�critical�services

Total number of incidents

Number�of�injuries�sustained�by�staff�relating�to�the�use�of�equipment�or�medical�devices

Total number of injuries sustained by staff

Number�of�incidents,�including�complaints,�relating�to�building�defects��(trip�hazards,�lighting�problems,�insufficient�or�incorrect�signage,�etc.)

Total number of incidents and complaints

Number�of�scheduled�preventative�maintenance�services�completed�on�time

Total number of scheduled preventative maintenance services

Number�of�vehicle�accidents�/�breakdowns

Total number of vehicles

Number�of�Root�Cause�Analysis�recommendations�implemented

Total number of Root Cause analysis recommendations

Number�of�consumers�/�patients�satisfied�with�the�organisation’s�signage

Total number of consumers / patients surveyed

Number�of�staff�and�consumers�/�patients�who�are�satisfied�with�the�design�/�layout�of�the�organisation

Total number of staff and consumers / patients surveyed

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seCtion 5Standards, criteria, elements and guidelinesstandard 3.2:�The�organisation�maintains�a�safe�environment�for�employees,�consumers�/�patients�and�visitors

436  The ACHS EQuIP5 Guide  Book 2  Accreditation, Standards and Guidelines  Support and Corporate Functions

Criterion 3.2.2

Buildings,�signage,�plant,�medical�devices,�equipment,�supplies,�utilities�and�consumables�are�managed�safely�and�used�efficiently�and�effectively.�(continued)

References1.� Australasian�Health�Infrastructure�Alliance.�Australasian

healthfacilityguidelines(AusHFG).�Sydney�NSW;�Centre�for�Health�Assets�Australasia,�UNSW;�2009.

2.� AS/NZS�3551:2004�Technicalmanagementprogramsformedicaldevices.

3.� AS/NZS�4187:2003�Cleaning,disinfectingandsterilizingreusablemedicalandsurgicalinstrumentsandequipment,andmaintenanceofassociatedenvironmentsinhealthcarefacilities.

StandardsAustralian�Building�Codes�Board�(ABCB).BuildingCodeofAustralia.�Canberra�ACT;�ABCB.�Accessed�from�http://www.abcb.gov.au�on�2�June�2010.�� �Volume�One�(Class�2�to�Class�9�Buildings)�

Volume�One�Appendices�(Variations�&�Additions)��Volume�Two�(Class�1�&�Class�10�Buildings).

ISO�7001:2007�Graphicalsymbols–Publicinformationsymbols.

AS�2342:1992�Development,testingandimplementationofinformationandsafetysymbolsandsymbolicsigns.

AS/NZS�2500:2004�Guidetothesafeuseofelectricityinpatientcare.

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seCtion 5Standards, criteria, elements and guidelinesstandard 3.2:�The�organisation�maintains�a�safe�environment�for�employees,�consumers�/�patients�and�visitors

438  The ACHS EQuIP5 Guide  Book 2  Accreditation, Standards and Guidelines  Support and Corporate Functions

IntentHealthcare�organisations�are�accountable�for�their�waste�from�the�point�of�its�generation�to�its�final�disposal.�The�intent�of�this�criterion�is�to�ensure�that�organisations�demonstrate�both�a�safe�practice�and�a�responsible�environmental�approach�to�waste�management.

Relationships of 3.2.3 with other criteriaGeneration�of�waste�is�an�unavoidable�consequence�of�the�delivery�of�health�care,�and�one�that�must�be�carefully�managed.�Due�to�the�nature�of�the�waste�produced�within�healthcare�organisations,�all�waste�management�policies�must�be�shaped�with�reference�to�considerations�of�infection�control�(Criterion�1.5.2).�The�risks�associated�with�each�of�the�various�categories�of�waste�generated�must�be�managed�(Criterion�2.1.2),�and�failure�to�do�so�may�result�in�incidents�and�complaints�(Criteria�2.1.3�and�2.1.4).�The�collection�and�disposal�of�waste�may�be�outsourced�to�external�service�providers�(Criterion�3.1.4),�and�this�process�must�be�managed�by�the�organisation.

Criterion LA – Awareness sA – implementationLA plus the following

MA – evaluationSA plus the following

eA – excellenceMA plus the following

oA – LeadershipEA plus the following

Criterion 3.2.3

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

a)� There�is�an�organisation-wide�waste�and�environmental�management�policy.

b)� Waste�management�streams�are�identified�and�signage�is�displayed.

c)� Staff�are�instructed�in,�and�provided�with,�information�on�their�responsibilities�in�waste�and�environmental�management.

d)� External�service�providers�comply�with�any�requirements�for�the�handling,�transport�and�disposal�of�waste.

e)� There�is�a�policy�to�reduce�carbon�emissions�and�improve�environmental�sustainability.

a)� Waste�is�managed�with�reference�to�any�relevant:

� (i)� Australian�standards

� (ii)� legislation

� (iii)� codes�of�practice

� (iv)� industry�guidelines.

b)� Controls�are�implemented�covering�identification,�handling,�separation�and�segregation�of�clinical,�radioactive�and�hazardous�waste,�and�non-clinical�waste.

c)� There�is�a�system�to�assess,�separate,�handle,�transport�and�dispose�of�all�waste�streams.

d)� Waste�management�systems�are�coordinated�with�external�authorities.

e)� Recycling,�reducing�and�reusing�processes�support�resource�conservation�and�waste�and�environmental�management.�

f)� The�system�to�reduce�carbon�emissions�and�improve�environmental�sustainability�is�implemented.

a)� The�waste�and�environmental�management�system�is�evaluated,�and�improved�as�required.

b)� The�system�to�reduce�carbon�emissions�and�improve�environmental�sustainability�is�monitored�over�time,�and�improvements�are�implemented�as�required.

a)� Performance�indicators�for�the�management�of�waste�are�measured�and�compared�internally�and�with�external�systems,�and�improvements�are�made�to�ensure�better�practice.

and/or

b)� There�are�processes�in�place�to�advocate�/�promote�awareness�of�environmental�sustainability.

a)� The�organisation�demonstrates�it�is�a�leader�in�waste�and�environmental�management,�supporting�safe�practice�and�a�safe�and�sustainable�environment.

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October 2010  439

Waste management policiesWithin�a�healthcare�organisation,�waste�management�requires�not�only�the�collection�and�disposal�of�waste,�but�also�control�of�all�associated�risks,�including�that�of�infection.�A�variety�of�different�forms�of�waste�will�be�generated�by�any�organisation�within�the�healthcare�system.�Segregation,�or�the�division�of�waste�into�various�categories�according�to�its�nature,�source�and�hazard�level,�allows�simultaneously�for�the�control�of�risk,�and�for�financial�gain�through�both�the�recovery�of�reusable�and�recyclable�materials�and�the�avoidance�of�unnecessary�handling�/�destruction�of�non-hazardous�material.�At�both�Federal�and�State�/�Territory�levels,�policies�of�sustainability�have�been�embraced�in�Australia;�these�are�shaped�around�strategies�aimed�at�environmental,�social�and�financial�gain�through�greater�responsibility�in�the�use�of�resources.1�The�expression�‘greenhouse�

gas’�in�fact�refers�to�a�combination�of�six�gases,�of�which�carbon�dioxide�(CO

2)�is�a�major�one;�the�term�

‘carbon�emission’�usually�refers�to�the�generation�of�all�gases�that�contribute�to�global�warming�and�climate�change.2�Apart�from�producing�solid�waste,�healthcare�organisations�also�contribute�to�carbon�emissions�through�such�actions�as�the�combustion�of�fossil�fuels,�the�use�of�transportation,�the�consumption�of�electricity�and�paper,�and�the�production�of�refrigerants.�Organisations�should�have�a�policy�in�place�to�reduce�carbon�emissions�based�upon�the�principles�of�avoidance,�modification,�and�reduction�of�usage.3�Electronic,�or�‘e-waste’,�refers�to�the�disposal�of�superseded�computers,�mobile�phones,�televisions,�and�other�electronic�and�battery-operated�devices4,�which�at�the�present�time�are�considered�another�form�of�hazardous�waste.5

Criterion LA – Awareness sA – implementationLA plus the following

MA – evaluationSA plus the following

eA – excellenceMA plus the following

oA – LeadershipEA plus the following

Criterion 3.2.3

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

a)� There�is�an�organisation-wide�waste�and�environmental�management�policy.

b)� Waste�management�streams�are�identified�and�signage�is�displayed.

c)� Staff�are�instructed�in,�and�provided�with,�information�on�their�responsibilities�in�waste�and�environmental�management.

d)� External�service�providers�comply�with�any�requirements�for�the�handling,�transport�and�disposal�of�waste.

e)� There�is�a�policy�to�reduce�carbon�emissions�and�improve�environmental�sustainability.

a)� Waste�is�managed�with�reference�to�any�relevant:

� (i)� Australian�standards

� (ii)� legislation

� (iii)� codes�of�practice

� (iv)� industry�guidelines.

b)� Controls�are�implemented�covering�identification,�handling,�separation�and�segregation�of�clinical,�radioactive�and�hazardous�waste,�and�non-clinical�waste.

c)� There�is�a�system�to�assess,�separate,�handle,�transport�and�dispose�of�all�waste�streams.

d)� Waste�management�systems�are�coordinated�with�external�authorities.

e)� Recycling,�reducing�and�reusing�processes�support�resource�conservation�and�waste�and�environmental�management.�

f)� The�system�to�reduce�carbon�emissions�and�improve�environmental�sustainability�is�implemented.

a)� The�waste�and�environmental�management�system�is�evaluated,�and�improved�as�required.

b)� The�system�to�reduce�carbon�emissions�and�improve�environmental�sustainability�is�monitored�over�time,�and�improvements�are�implemented�as�required.

a)� Performance�indicators�for�the�management�of�waste�are�measured�and�compared�internally�and�with�external�systems,�and�improvements�are�made�to�ensure�better�practice.

and/or

b)� There�are�processes�in�place�to�advocate�/�promote�awareness�of�environmental�sustainability.

a)� The�organisation�demonstrates�it�is�a�leader�in�waste�and�environmental�management,�supporting�safe�practice�and�a�safe�and�sustainable�environment.

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Criterion 3.2.3

Waste�and�environmental�management�supports�safe�practice�and�a�safe�and�sustainable�environment.�(continued)

Healthcare�organisations�generate�both�clinical�and�non-clinical�(general)�waste.�Furthermore,�changes�in�the�approach�to�infection�control�have�resulted�in�a�significant�increase�in�the�volume�of�waste�generated,�due�to�the�shift�towards�single-use,�disposable�clinical�products.�Health�care,�like�other�industries,�must�now�also�deal�with�the�problem�of�e-waste.�Strict�policies�and�procedures�in�waste�management�are�necessary�in�order�to:

• protect�the�health�and�safety�of�the�public

• provide�a�safe�work�environment

• reduce�waste�handling�and�disposal�volumes�/�costs�without�compromising�health�care

• minimise�the�environmental�impact,�including�as�a�result�of�carbon�emissions,�of�waste�generation,�treatment�and�disposal.

Prompt points

¼ What legislation / polices / standards were referenced in the shaping of the organisation’s waste management policy?

¼ How does the organisation act to reduce its environmental impact?

Classification, segregation and minimisation of wasteThe�healthcare�industry�produces�a�wide�variety�of�waste,�some�of�which�poses�a�hazard�to�staff,�consumers�/�patients,�the�public�and�those�employed�to�transport�and�dispose�of�the�waste.�

Hazardous�waste�can�be�generated�in�any�healthcare�setting�and�must�be�appropriately�managed.�Waste�management�streams�should�be�identified�and�indicated�via�suitable�signage.�The�segregation�and�disposal�of�clinical�waste�must�be�managed�with�accordance�with�State�/�Territory�requirements,�and�must�conform�to:

• relevant�statutory�requirements

• codes�of�practice

• Australian�standards

• Occupational�Health�&�Safety�guidelines

• the�requirements�of�the�relevant�environmental�protection�agencies�and�health�departments

• any�requirements�of�local�government.

Wherever�appropriate�collection�/�processing�facilities�are�available,�a�recycling�program�should�be�a�major�aspect�of�the�organisation’s�waste�minimisation�strategy.�At�both�a�Federal�and�State�/�Territory�level,�guidelines�for�sustainability�require�that�organisations�pursue�a�policy�of�reduce,reuse,recycle.6�

However,�in�implementing�such�a�policy,�the�duty�of�care�must�always�take�precedence;�and�the�organisation�should�therefore�shape�its�strategy�around�its�obligations�in�the�management�of�hazardous�waste�and�infection�control,�and�its�guidelines�for�the�safe�use�of�equipment,�which�should�include�a�process�for�reporting�faults.�Furthermore,�the�use�of�reusable�items�should�be�considered�only�where�it�does�not�compromise�consumer�/�patient�safety,�and�is�suitable�for�the�size�and�location�of�the�organisation.

Prompt points

¼ What different forms of waste are produced by the organisation?

¼ What is the organisation doing to minimise its waste production?

¼ What proportion of the waste is recycled rather than discarded to landfill?

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Management, training and educationWithin�the�organisation,�all�staff�will�generate�waste,�and�all�staff�must�take�responsibility�for�the�correct�identification,�segregation�and�disposal�of�waste.�The�organisation�should�not�assume�that�staff�will�be�able�to�correctly�classify�any�given�form�of�waste,�nor�rely�entirely�upon�its�signage,�but�should�provide�instruction�as�to�the�correct�procedures.�The�content�of�this�instruction�should�be�refined�over�time�to�ensure�that�all�necessary�information�is�being�provided.

The�collection,�storage�and�disposal�of�certain�kinds�of�waste,�such�as�radioactive,�cytotoxic�or�pharmaceutical�waste,�may�require�specific�training�and�even�licensing�of�the�individuals�concerned�in�its�handling.�It�is�the�organisation’s�responsibility�to�ensure�that�staff�are�made�aware�of�their�obligations�in�this�respect,�to�provide�access�to�the�appropriate�training�/�licensing,�and�to�supply�all�appropriate�personal�protective�equipment.�The�organisation�must�also�ensure�that�untrained�and/or�unlicensed�individuals�are�not�permitted�to�handle�the�waste�in�question.

All�staff�must�be�made�aware�of�their�responsibilities�with�regard�to�sustainability�and�the�reduction�of�carbon�emissions.�The�organisation�must�work�continually�towards�improving�its�environmental�management,�and�may�wish�to�encourage�staff�to�suggest�and/or�implement�their�own�changes�and�improvements�to�existing�workplace�systems.

As�a�means�of�calculating�an�organisation’s�energy�and�emissions�data,�and�measuring�the�success�of�its�environmental�management�policies,�the�Federal�Government’s�Department�of�Climate�Change�offers�an�Online�System�for�Comprehensive�Activity�Reporting�(OSCAR)�(http://www.climatechange.gov.au/government/initiatives/oscar.aspx).

Prompt points

¼ How does the organisation instruct staff as to their responsibilities in waste management?

¼ How does the organisation ensure that its waste management policies and procedures are being implemented?

¼ Does the organisation generate waste that requires those handling it to be licensed? How is the licensing achieved?

¼ How are staff encouraged to assist in the organisation’s environmental management?

¼ Does the organisation develop and use an annual waste management plan?

External service providers and transport of wasteThe�organisation’s�waste�management�system�will�typically�include�the�use�of�external�service�providers,�or�contractors,�who�will�collect,�transport�and�dispose�of�accumulated�waste�of�all�kinds.�It�is�the�responsibility�of�the�organisation�to�ensure�that�all�waste�is�correctly�segregated,�packaged�and�identified�prior�to�off-site�transportation;�and�also�to�ensure�that�all�those�involved�in�the�management�of�waste�are�correctly�licensed�and�operating�according�to�all�relevant�legislation�and�codes�of�practice.�One�option�available�to�management�is�an�audit.�The�company’s�premises�may�be�audited,�as�may�the�collected�waste,�to�ensure�the�correct�provision�of�services.

The�transportation�of�waste�is�governed�by�legislation,�codes�of�practice�and�guidelines,�which�should�be�consulted�where�applicable,�including�the�Australian�Code�for�the�Transport�of�Dangerous�Goods�by�Road�and�Rail.7�A�list�of�the�relevant�competent�authorities�may�be�found�at�the�website�of�the�Department�of�Infrastructure,�Transport,�Regional�Development�and�Local�Government,�which�“works�with�the�States�and�Territories,�and�the�National�Transport�Commission,�to�promote�best�practice�and�internationally�harmonised�legislation�for�the�land�transport�of�dangerous�goods�in�Australia”.8

Prompt points

¼ Does the organisation use an external service provider for the collection, transport and/or disposal of clinical and related waste? How was the provider chosen?

¼ How does the organisation ensure that the external service provider is compliant with the requirements of the relevant authorities?

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Criterion 3.2.3

Waste�and�environmental�management�supports�safe�practice�and�a�safe�and�sustainable�environment.�(continued)

Evidence commonly presented

Consider whether the following will help to address criterion 3.2.3

¼ Policies and procedures on waste and environmental management

¼ Waste identification strategies and evidence of their effectiveness

¼ Waste reduction strategies

¼ Waste minimisation promotion strategies

¼ Results of waste audits

¼ Evidence of staff education

¼ Contracts with external service providers such as waste removal contracts

¼ Waste management performance indicator reports

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Performance measurementThis�criterion�states�that:�“Waste�and�environmental�management�supports�safe�practice�and�a�safe�and�sustainable�environment”.�Various�aims�are�encompassed�within�this�criterion.�The�organisation�should�measure�its�performance�both�in�terms�of�its�duty�of�care,�and�with�respect�to�its�commitment�to�environmental�sustainability.�The�organisation�should�also�be�mindful�that�some�of�the�critical�aspects�of�waste�management,�in�particular�the�correct�segregation�of�waste,�may�only�be�demonstrated�via�official�auditing.

Some�common�suggested�performance�measures�are�as�follows:

Weight�or�volume�of�clinical�waste

Weight or volume of all waste

Weight�or�volume�of�general�waste

Weight or volume of all waste

Weight�or�volume�of�recycling�waste

Weight or volume of all waste

Number�of�bins�/�receptacles�overfilled�at�time�of�audit

Total number of bins / receptacles at time of audit

Number�of�bins�/�receptacles�containing�incorrectly�segregated�waste�at�time�of�audit

Total number of bins / receptacles at time of audit

Reams�of�paper�purchased�during�the�previous�year

Reams of paper purchased during the current year

Organisation’s�greenhouse�gas�emissions�during�the�previous�year

Organisations greenhouse gas emissions during current year

Number�of�staff�satisfied�with�the�organisation’s�waste�and�environmental�conservation�strategies

Total number of staff surveyed

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Criterion 3.2.3

Waste�and�environmental�management�supports�safe�practice�and�a�safe�and�sustainable�environment.�(continued)

References1.� Department�of�Environment,�Water,�Heritage�and�the�

Arts.�Nationalwastepolicy:lesswaste,moreresources.National�waste�policy�fact�sheet.�Canberra�ACT;�Australian�Government;�2009.

2.� Queensland�Department�of�Environment�and�Resource�Management.�It’sacarbonjungleoutthere:Asurvivalguideforbusiness.�ClimateSmart�Business.�Brisbane;�Queensland�Government;�2009.

3.� Victorian�Environment�Protection�Authority�(EPA).�Draftcarbonmanagementprinciples–EPAdiscussionpaper.Melbourne;�Victorian�Government;�2007.

4.� Hyder�Consulting.�WasteandrecyclinginAustralia.Canberra�ACT;�Australian�Department�of�Environment,�Water,�Heritage�and�the�Arts;�2008.

5.� Canberra�Environment�and�Sustainability�Resource�Centre.�Electronicwastemanagementandminimisationforlocalgovernments:Aneducationandtrainingprogram.�Canberra�ACT;�Australian�Department�of�Environment,�Water,�Heritage�and�the�Arts;�2009.

6.� Sustainability�Victoria.Recyclingandreusinginyourworkplace.ResourceSmart.�Melbourne;�Victorian�Government;�2008.

7.� National�Transport�Commission�(NTC)�Australia.�AustralianCodefortheTransportofDangerousGoodsbyRoadAndRail(ADGCode).�Vol.�1,�7th�edn.�Melbourne�VIC;�Australian�Government;�2007.

8.� Australian�Department�of�Infrastructure,�Transport,�Regional�Development�and�Local�Government.TransportinAustralia–Dangerousgoods.Canberra�ACT;�Australian�Government.�Accessed�from�http://www.infrastructure.gov.au/transport/australia/dangerous/index.aspx�on�5�May�2010.

Standards and guidelinesProductivity�Commission.Wastemanagement–Inquiryoverview.Melbourne�VIC;�Australian�Government;�2006.

Waste�Policy�Taskforce.�Anationalwastepolicy:Managingwasteto2020.�Canberra�ACT;�Australian�Department�of�the�Environment,�Water,�Heritage�and�the�Arts;�2009.

Australia�and�New�Zealand�Clinical�Waste�Management�Group.�Industrycodeofpracticeforthemanagementofclinicalandrelatedwaste.�5th�edn.�Sydney�NSW;�Waste�Management�Association�of�Australia;�2007.

NSW�Health.�Wastemanagementguidelinesforhealthcarefacilities.PD2005_132.�Sydney;�NSW�Health;�1998.

AS/NZS�3816:1998�Managementofclinicalandrelatedwastes.

AS�4031:1992/Amdt�1-1996�Non-reusablecontainersforthecollectionofsharpmedicalitemsusedinhealthcareareas.

AS/NZS�4261:1994/Amdt�1-1997�Reusablecontainersforthecollectionofsharpitemsusedinhumanandanimalmedicalapplications.

Advisory�Committee�on�the�Transport�of�Dangerous�Goods�Competent�Authorities�Sub-Committee.�GuidancenotesforthetransportofClass6.2(InfectiousSubstances)Dangerousgoods.Canberra�ACT;�Federal�Office�of�Road�Safety;�1997.

Further readingNSW�Dept�of�Environment�and�Climate�Change.�Wasteavoidanceandresourcerecoverystrategy,2007.Sydney;�NSW�Government;�2007.

Department�of�Environment,�Water,�Heritage�and�the�Arts.�Hazardoussubstancesandhazardouswaste.National�Waste�Policy�Fact�Sheet.�Canberra�ACT;�Australian�Government;�2009.

Waste�audits�as�a�management�tool�–�Robyn�Pearson�shows�us�how.�WME(WasteManagementandEnvironment),�2002;�October:�25-28.

Queensland�Department�of�Environment�and�Resource�Management.�Top10workplacetips.Acarboncutting,costsavingsurvivalguideforbusiness.�Brisbane,�QLD;�Queensland�Government;�2009.

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October 2010  445

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seCtion 5Standards, criteria, elements and guidelinesstandard 3.2:�The�organisation�maintains�a�safe�environment�for�employees,�consumers�/�patients�and�visitors

446  The ACHS EQuIP5 Guide  Book 2  Accreditation, Standards and Guidelines  Support and Corporate Functions

Criterion LA – Awareness sA – implementationLA plus the following

MA – evaluationSA plus the following

eA – excellenceMA plus the following

oA – LeadershipEA plus the following

Criterion 3.2.4

Emergencyanddisastermanagementsupportssafepracticeandasafeenvironment.

this is a mandatory criterion

a)� There�is�an�organisation-wide�policy�for�emergency�and�disaster�management�and�business�continuity.

b)� Likely�emergencies�are�identified�and�response�and�evacuation�plans�are�prominently�displayed.

c)� Staff�are�educated�and�trained�at�orientation�and�annually�in�response�to�emergencies�and�in�evacuation.

d)� Emergency�practice�/�drill�exercises�including�fire�and�evacuation�are�regularly�conducted.

e)� External�service�providers�comply�with�the�organisation’s�requirements�for�the�prevention�of�emergencies.

f)� There�is�documented�evidence�that�an�authorised�external�provider�undertakes�a�full�fire�report�on�the�premises�at�least�once�within�each�EQuIP�cycle�and�in�accordance�with�jurisdictional�legislation.�

a)� There�is�evidence�that�the�systems�to�manage�emergencies�operate�with�reference�to�any�relevant:

� (i)� Australian�standards

� (ii)� legislation

� (iii)� codes�of�practice

� (iv)� industry�guidelines.

b)� Business�continuity�plans�have�been�developed�to�cover�disasters�/�emergencies.

c)� There�are�systems�for�prevention,�preparedness,�response�and�recovery�in�emergencies,�including�triage�and�deployment�of�medical�teams�where�appropriate.

d)� Internal�and�external�emergency�and�disaster�management�plans�are�developed�and�reviewed�in�consultation�with�relevant�authorities.

e)� Communication�systems�are�in�place�to�manage�any�emergencies�or�disasters.

f)� Relevant�staff�have�access�to�first�aid�equipment�and�supplies�and�are�trained�in�their�use.

g)� There�is�an�appropriately�trained�fire�officer.

h)� There�is�a�documented�plan�to�implement�recommendations�from�the�fire�action�plan.

a)� Emergency�and�disaster�management�systems�are�evaluated,�and�improved�as�required.

b)� Staff�training�and�competence�in�managing�emergency�procedures,�including�evacuation,�is�evaluated�and�improvements�are�made�as�required.

a)� Performance�indicators�for�emergency�preparedness�and�disaster�management�are�measured�and�compared�internally�and�with�external�systems,�and�improvements�are�made�to�ensure�better�practice.

and/or

b)� Innovative�processes�which�prepare�for�any�disasters�are�demonstrated�by�the�organisation.

and/or

c)� Major�incident�management�plans�integrate�with�those�of�other�services�within�the�community.

a)� The�organisation�demonstrates�it�is�a�leader�in�emergency�and�disaster�management.

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October 2010  447

Criterion LA – Awareness sA – implementationLA plus the following

MA – evaluationSA plus the following

eA – excellenceMA plus the following

oA – LeadershipEA plus the following

Criterion 3.2.4

Emergencyanddisastermanagementsupportssafepracticeandasafeenvironment.

this is a mandatory criterion

a)� There�is�an�organisation-wide�policy�for�emergency�and�disaster�management�and�business�continuity.

b)� Likely�emergencies�are�identified�and�response�and�evacuation�plans�are�prominently�displayed.

c)� Staff�are�educated�and�trained�at�orientation�and�annually�in�response�to�emergencies�and�in�evacuation.

d)� Emergency�practice�/�drill�exercises�including�fire�and�evacuation�are�regularly�conducted.

e)� External�service�providers�comply�with�the�organisation’s�requirements�for�the�prevention�of�emergencies.

f)� There�is�documented�evidence�that�an�authorised�external�provider�undertakes�a�full�fire�report�on�the�premises�at�least�once�within�each�EQuIP�cycle�and�in�accordance�with�jurisdictional�legislation.�

a)� There�is�evidence�that�the�systems�to�manage�emergencies�operate�with�reference�to�any�relevant:

� (i)� Australian�standards

� (ii)� legislation

� (iii)� codes�of�practice

� (iv)� industry�guidelines.

b)� Business�continuity�plans�have�been�developed�to�cover�disasters�/�emergencies.

c)� There�are�systems�for�prevention,�preparedness,�response�and�recovery�in�emergencies,�including�triage�and�deployment�of�medical�teams�where�appropriate.

d)� Internal�and�external�emergency�and�disaster�management�plans�are�developed�and�reviewed�in�consultation�with�relevant�authorities.

e)� Communication�systems�are�in�place�to�manage�any�emergencies�or�disasters.

f)� Relevant�staff�have�access�to�first�aid�equipment�and�supplies�and�are�trained�in�their�use.

g)� There�is�an�appropriately�trained�fire�officer.

h)� There�is�a�documented�plan�to�implement�recommendations�from�the�fire�action�plan.

a)� Emergency�and�disaster�management�systems�are�evaluated,�and�improved�as�required.

b)� Staff�training�and�competence�in�managing�emergency�procedures,�including�evacuation,�is�evaluated�and�improvements�are�made�as�required.

a)� Performance�indicators�for�emergency�preparedness�and�disaster�management�are�measured�and�compared�internally�and�with�external�systems,�and�improvements�are�made�to�ensure�better�practice.

and/or

b)� Innovative�processes�which�prepare�for�any�disasters�are�demonstrated�by�the�organisation.

and/or

c)� Major�incident�management�plans�integrate�with�those�of�other�services�within�the�community.

a)� The�organisation�demonstrates�it�is�a�leader�in�emergency�and�disaster�management.

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seCtion 5Standards, criteria, elements and guidelinesstandard 3.2:�The�organisation�maintains�a�safe�environment�for�employees,�consumers�/�patients�and�visitors

448  The ACHS EQuIP5 Guide  Book 2  Accreditation, Standards and Guidelines  Support and Corporate Functions

Criterion 3.2.4

Emergencyanddisastermanagementsupportssafepracticeandasafeenvironment.�(continued)

IntentThe�intent�of�this�criterion�is�to�ensure�that�healthcare�organisations�have�systems,�policies,�procedures�and�training�programs�in�place�that�identify�and�manage�potential�emergency�situations�that�may�arise�either�internally�or�externally,�in�terms�of�consequence,�exposure,�probability�and�preventative�actions.�Organisations�should�demonstrate�development�and�implementation�of�appropriate�emergency�response�systems�in�consultation�with�external�emergency�response�organisations�and�other�relevant�bodies.

Relationships of 3.2.4 with other criteriaSuccessful�emergency�and�disaster�management�requires�a�multifaceted,�organisation-wide�program�of�policies,�procedures,�education�and�training�in�which�a�range�of�critical�situations,�both�internal�and�external�to�the�organisation�itself,�are�anticipated�and�planned�for.�The�development,�implementation�and�regular�re-evaluation�of�such�a�program�is�a�part�of�the�organisation’s�overall�safety�management�system�(Criterion�3.2.1),�including�the�design�and�safe�management�of�its�buildings,�plant�and�equipment,�and�the�approach�to�signage�(Criterion�3.2.2).�This�criterion�also�falls�within�the�scope�of�the�integrated�risk�management�framework�(Criterion�2.1.2)�and�management�of�security�(Criterion�3.2.5).

Emergency and disaster management systems and plansAn�emergency�or�a�disaster�is�“a�serious�disruption�to�community�life�that�threatens�or�causes�death�or�injury�in�that�community,�and/or�damage�to�property,�which�is�beyond�the�day-to-day�capacity�of�the�prescribed�statutory�authorities,�and�which�requires�special�mobilisation�and�organisation�of�resources�other�than�those�normally�available�to�those�authorities”.1�The�difference�between�an�emergency�and�a�disaster�is�usually�considered�to�be�one�of�scale;�a�disaster�is�an�emergency�that�overwhelms�the�immediate�capabilities�of�the�authorities�and�services�that�must�respond�to�it.�The�seriousness�of�the�event�must�be�gauged�relative�to�where�it�occurs�and�the�capacity�of�the�organisation(s)�that�must�respond�to�it;�what�might�be�an�emergency�to�a�large�city�hospital�could�be�considered�a�disaster�by�a�small�rural�hospital.�

An�external�emergency�or�disaster�may�necessitate�preparation�for�the�reception�of�a�significant�number�of�victims�and/or�the�allocation�and�transport�of�personnel�and�resources�to�an�external�site.2�An�internal�emergency�or�disaster�can�be�caused�by�factors�that�may�be�internal�or�external�to�the�organisation,�may�adversely�affect�consumers�/�patients,�visitors�and�staff�and�require�an�immediate�response.2

Disaster�and�emergency�management�within�the�health�system�is�overseen�at�a�Federal�level,�although�the�immediate�response�is�primarily�the�responsibility�of�State�and�Territory�governments,�with�the�Commonwealth�lending�assistance.�The�Emergency�Management�Australia�Division�of�the�Attorney-General’s�Department3�is�responsible�for�crisis�coordination�and�management�undertaken�when�requests�for�assistance�are�received�from�the�States�and�Territories,�and�encourages�an�integrated�‘all�hazards,�all�agencies’�strategy�for�disaster�management.�This�comprehensive�approach�was�identified�as�essential�in�the�Council�of�Australian�Governments’�NaturalDisastersinAustralia:Reformingmitigation,reliefandrecoveryarrangementsreport4,�and�is�now�reflected�in�the�State�/�Territory�legislation�governing�emergency�and�disaster�response,�which�should�guide�organisations�in�their�own�emergency�planning.�

Evacuation�plans�should�be�developed�for�each�facility�within�the�organisation�and�prominently�displayed,�ideally�as�a�diagram(s)�showing�exit�paths.�Staff�must�be�made�aware�of�the�significance�of�the�various�alarms�used�by�their�organisation,�and�trained�in�the�correct�reactions�and�their�assembly�points.�Evacuation�drills�should�be�planned�and�carried�out�so�that�all�staff,�from�all�facilities�and�through�all�shifts,�are�familiar�with�the�proper�course�of�action.�

Emergency�planning�should�include�a�provision�for�regular�updating�and�posting�of�consumer�/�patient�lists,�senior�hospital�staff�and�staff�on�duty,�to�facilitate�a�rapid�response.

Fire�safety�is�a�key�aspect�of�the�organisation’s�emergency�and�disaster�planning,�and�must�be�managed�so�that�consumers�/�patients,�staff�and�others�are�not�placed�at�undue�risk.�Organisations�should�develop�an�appropriate�fire�management�plan�and�specific�policies�and�procedures�that�consider�all�people�and�all�areas�of�the�organisation.�Fire�plans�should�cover:

• identification�of�fire�and�explosion�risks

• fire�safety�and�preventative�strategies

• fire�and�explosion�emergency�procedures�for�preparedness,�response�and�recovery

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October 2010  449

• raising�the�alarm

• effective�arrangements�for�a�fire�response�team

• an�emergency�communication�system,�including�methods�for�activating�external�services�such�as�fire-fighting�authorities,�ambulance,�etc.

• assignment�of�personnel�to�specific�tasks�and�responsibilities

• information�readily�available�for�staff�throughout�the�organisation

• emergency�services

• fire-fighting�response

• evacuation�from�all�parts�of�all�buildings

• staff�training�/�education,�and�regular�fire�and�evacuation�drills.

Preparedness�is�critical�to�responding�to�an�emergency�in�an�appropriate�and�timely�manner.�Emergency�and�disaster�management�systems�must�be�regularly�reviewed�and�updated�in�light�of�current�best-practice�evidence,�as�well�as�internal�factors�such�as�alterations�to�buildings�and�changes�in�staffing�or�services�provided.�

Should�the�organisation�experience�or�be�involved�in�an�emergency,�inevitably�there�will�be�lessons�to�be�learned�about�its�systems�and�procedures.�Every�aspect�of�the�review�that�follows�such�an�incident�should�be�thoroughly�documented,�to�demonstrate�the�resultant�changes�made�to�any�or�all�aspects�of�the�pre-existing�plan,�including�evacuation�plans,�staff�training�and�communication�systems.

Prompt points

¼ How is the ‘all hazards, all agencies’ approach to emergency and disaster management reflected in the organisation’s systems? Are any specific disasters or emergencies highlighted in its planning? Why?

¼ Under what legislation, codes of practice and/or Australian standards were the plan(s) developed? What civil authorities were consulted?

Developing plans in consultation with relevant authoritiesPlanning�should�be�carried�out�in�consultation�with�relevant�regional�and�local�authorities,�and�include�testing�of�major�emergency�plans.�Relevant�authorities�may�vary�between�jurisdictions�but�would�include�the�local�council,�the�police,�ambulance,�and�fire�and�emergency�services.�Where�appropriate,�community�partners�should�also�be�consulted;�communities�that�are�actively�engaged�in�the�process�of�emergency�planning�and�management�show�greater�resilience�and�better�recovery�in�the�event�of�an�actual�emergency.5–7

The�following�points�may�be�useful�in�developing�a�coordinated�plan�in�response�to�potential�emergencies:

• the�use�of�colour-coding�for�emergencies�in�line�with�acceptable�international�/�national�guidelines�or�standards

• identification�of�key�responsibilities�and�accountabilities

• specification�of�division�of�duties�in�an�emergency

• development�of�critical�operating�procedures

• development�of�a�communication�infrastructure

• development�of�a�crisis�response�infrastructure

• ensuring�the�availability�of�appropriate�drugs,�supplies�and�equipment�for�various�medical�emergencies�to�assist�a�rapid�and�effective�response

• planning�for�deployment�of�medical�teams,�where�appropriate

• development�of�an�evacuation�plan�and�procedures,�including�drills�and�debriefing�processes

• regular�training�and�exercises�for�a�range�of�potential�threats.

Specific�circumstances�may�warrant�the�development�of�plans�for�chemical,�biological�and/or�radiological�events.

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seCtion 5Standards, criteria, elements and guidelinesstandard 3.2:�The�organisation�maintains�a�safe�environment�for�employees,�consumers�/�patients�and�visitors

450  The ACHS EQuIP5 Guide  Book 2  Accreditation, Standards and Guidelines  Support and Corporate Functions

Criterion 3.2.4

Emergencyanddisastermanagementsupportssafepracticeandasafeenvironment.�(continued)

Prompt points

¼ If the organisation becomes aware of a disaster, who manages the allocation of duties? What policies / procedures allow the coordinator to reallocate staff to an alternative role? How would this be tracked?

¼ Has the organisation planned for the dispatch of a medical team? If so, what preparations have been made for the dispatch?

¼ Does the organisation have an assigned role in regional plans for emergencies? If it participates, what role does the organisation play in regional emergency / disaster planning?

Business continuityBusiness�continuity�is�defined�as�management�and�planning�for�the�continued�availability�of�essential�services�during�and�after�an�emergency,�including�all�the�functions�and�resources�associated�with�the�provision�of�these�services.8�Business�continuity�planning�should�focus�upon�the�analysis�of�risk,�and�then�address�those�threats�most�likely�to�interrupt�services.�Good�risk�management�will�increase�the�organisation’s�resilience,�and�minimise�potential�downtime.9

The�response�of�an�organisation�to�a�disaster�/�emergency�will�depend�upon�the�type�of�organisation,�the�severity�of�the�incident�and�the�number�of�staff�affected.�When�planning�for�continuity�of�business�during�a�state�of�emergency,�an�organisation�with�inpatients�should�consider�developing�separate�scenarios�for:

1.� continuing�business�as�usual,�while�managing�any�interruptions�to�staffing,�consumer�/�patient�flow�and/or�supplies

2.� ceasing�elective�admissions,�with�ongoing�management�of�admitted�consumers�/�patients�

3.� ceasing�elective�admissions,�and�transferring�admitted�consumers�/�patients�to�another�facility.

Prompt points

¼ In the event of drastic understaffing, due to natural disaster or epidemic, how does the organisation plan to ensure continuity of care?

¼ In the event of an emergency that impacts directly upon the organisation, how does its business continuity plan ensure ongoing access to medical gases?

¼ What steps has the organisation taken towards self-sufficiency in the event of an emergency?

¼ If a natural disaster or an epidemic left the organisation drastically understaffed, how would it assess whether it could maintain services for consumers / patients already admitted?

Policies, procedures, systems and processesIn�public�hospitals,�emergency�and�disaster�management�policies�may�be�developed�on�a�State�/�Territory-wide�or�regional�basis�and�will�integrate�with�centralised�responses�coordinated�through�groups�such�as�the�Emergency�Management�Australia�Division�of�the�Attorney-General’s�Department.3

In�response,�organisations�will�need�to�consider�how�those�policy�decisions�will�be�applied�and�actioned,�down�to�a�facility,�building�or�department�level.�It�is�of�primary�importance�that�procedures�are�updated�regularly�and�in�response�to�impacting�factors,�such�as:

• changes�to�the�overriding�policy

• personnel�changes,�particularly�first�aid�officers�and�fire�wardens

• departmental�relocations�or�reconfigurations�of�patient�care�areas

• access�to�the�proposed�evacuation�route�or�assembly�area.

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October 2010  451

Organisations�in�areas�at�risk�of�bushfires�or�whose�community�includes�such�areas�should�consider�providing�guidance�to�staff�(policies�and�procedures)�on�appropriate�precautions�for�days�of�extreme�fire�risk.�For�instance,�on�these�days,�the�emergency�coordinating�staff�at�the�organisation�might�be�provided�with�a�copy�of�the�community�worker’s�schedule�and�kept�informed�of�their�progress�as�they�move�around�the�district�during�the�day,�so�they�can�be�contacted�and/or�traced�in�case�fire�risk�circumstances�change.

Prompt points

¼ What jurisdictional legislation, codes of practice and standards does the organisation’s emergency policies and procedures refer to?

Communication systemsState�/�Territory�plans�include�information�about�communication�and�coordination�of�action�in�the�event�of�a�disaster.�At�the�local�level,�the�organisation�will�decide�upon�the�most�suitable�emergency�communication�system�for�its�size�and�specific�needs;�it�should�ensure�there�are�effective�methods�for�activating�external�services�such�as�fire-fighting�authorities.�

An�organisational�communication�system�usually�comprises�an�Emergency�Warning�Intercommunications�System�(EWIS),�a�Fire�Indicator�Panel�(FIP)�and�a�Warden�Intercom�Phone�(WIP),�supplemented�by�appropriate�individual�alarms�and�mobile�phones.�However,�when�integrating�mobile�phones�into�the�emergency�system,�organisations�should�exercise�caution;�if�the�power�supply�were�disrupted,�it�might�not�be�possible�to�recharge�phones�when�needed.�Consideration�should�be�given�to�satellite�phones�and/or�battery�rechargers�where�appropriate.�Responsibility�for�portable�devices�employed�within�an�emergency�communication�system�and�the�conditions�of�their�use�should�be�clearly�defined�within�the�organisation’s�communications�plan.

Prompt points

¼ What are the components of the organisation’s emergency communication system?

¼ How would key communications be affected if the power supply were disrupted?

Fire report and fire action planWithin�the�scope�of�this�criterion,�the�expression�‘full�fire�report’�is�used�to�describe�an�inspection�that�includes�a�review�of�fire�safety�risks�associated�with�a�building.�The�terms�used�to�describe�building�fire�safety�certificates�and�reports�vary�between�jurisdictions.

A�‘full�fire�report’�is�required�at�least�once�within�the�EQuIP5�cycle,�or�according�to�notified�jurisdictional�variations;�for�example,�the�maximum�accepted�time�since�the�last�review�for�Victorian�healthcare�facilities�is�five�years,�though�in�other�States�/�Territories�it�is�four�years.�The�assessor�who�prepares�the�‘full�fire�report’�should�use�the�Building�Code�of�Australia�(BCA)�as�a�guide�for�their�review�of�fire�safety�risk�and�should�report�their�findings�in�relation�to�the�building’s�structure,�its�safety�installations�/�measures,�their�performance�and�maintenance.�

The�person�preparing�the�‘full�fire�report’�should:

• have�experience�and/or�a�qualification�that�includes�building�fire�safety�risk�mitigation

• be�familiar�with�the�BCA�

• be�external�to�the�organisation.�

In�some�jurisdictions,�assessors�may�be�aligned�to�the�jurisdictional�fire�authority.�A�listing�of�consultants�and�organisations�working�in�different�areas�of�fire�risk�protection�is�maintained�by�the�Fire�Protection�Association�of�Australia,�http://www.fpaa.com.au/providers/.�

Note:�the�external�fire�inspection�report�demonstrating�BCA�compliance�and�any�subsequent�action�plan�must�be�forwarded�to�the�ACHS�six�weeks�prior�to�the�onsite�survey.�Experience�indicates�that�it�may�take�several�months�for�organisations�to�obtain�all�the�necessary�documentation.�For�this�reason,�it�is�strongly�recommended�that�organisations�initiate�the�fire�inspection�cycle�12�months�prior�to�the�onsite�survey.

Prompt points

¼ When was the organisation’s last cycle of inspection and maintenance on essential safety measures undertaken?

¼ What actions were taken in response to the last full fire report? What actions are proposed in the future?

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seCtion 5Standards, criteria, elements and guidelinesstandard 3.2:�The�organisation�maintains�a�safe�environment�for�employees,�consumers�/�patients�and�visitors

452  The ACHS EQuIP5 Guide  Book 2  Accreditation, Standards and Guidelines  Support and Corporate Functions

Criterion 3.2.4

Emergencyanddisastermanagementsupportssafepracticeandasafeenvironment.�(continued)

External service providers in precautions and preventionIn�planning�for�emergencies,�organisations�must�ensure�that�external�service�providers�are�aware�of�their�responsibilities�and�act�in�compliance�with�the�organisation’s�policies�and�procedures.

External�service�providers,�such�as�contractors�and�agency�nurses,�should�undergo�a�site�orientation�to�ensure�they�are�aware�of�the�organisational�requirements.�Contract�staff�members�working�in�consumer�/�patient�care�areas�must�be�briefed�on�the�emergency�communication�system�and�evacuation�procedures�from�the�location�in�which�they�are�working.�

Night�shifts,�school�holiday�periods�and�during�the�‘flu�season�are�times�when�numbers�of�consumer�/�patient�care�staff�who�have�completed�full�fire�training�may�be�low.�The�organisation�must�ensure�that�at�all�times,�staff�on�duty�are�familiar�with�the�location�and�correct�operation�of�the�fire�walls�and�doors,�and�contingency�plans�for�protecting�consumers�/�patients�if�an�emergency�arises.

Prompt points

¼ What systems / processes are used to ensure that tradesmen do not inadvertently cause or contribute to an emergency situation?

¼ How does the organisation ensure that any external suppliers can be traced outside the building if an evacuation has been called?

¼ Regardless of whether they are permanent staff or contractors, what guidance is provided to operating theatre staff on the appropriate response to an alarm during surgery?

Fire officersFire�safety�officers,�or�fire�wardens,�as�appropriate�to�the�size�and�type�of�the�organisation,�should�be�appointed�from�amongst�the�staff.�In�a�small�organisation�a�single�warden�may�be�sufficient,�while�larger�organisations�/�facilities�will�require�the�involvement�of�more�individuals�with�differing�levels�of�responsibility�(for�example,�Floor�Warden,�Deputy�Chief�Fire�Warden,�Chief�Fire�Warden).�

Various�companies�provide�accredited�training�for�those�individuals�willing�to�accept�the�position�of�fire�warden,�and�the�organisation�should�provide�the�funds�and�the�time�for�such�training�to�be�completed.�The�identity�and�internal�contact�details�of�all�fire�wardens�should�be�clearly�posted�within�all�areas�of�the�organisation.

Prompt points

¼ How many fire wardens / safety officers does the organisation have? Where are the wardens’ details posted?

First aidHealthcare�organisations�must�meet�jurisdictional�requirements�in�terms�of�numbers�of�trained�first�aid�officers�and�access�to�appropriate�first�aid�kits.�Kits�should�reflect�the�type�and�level�of�risk�in�that�workplace�and�should�be�regularly�checked�to�ensure�items�are�replenished�and�within�their�expiry�dates.

First�aid�supplies�and�trained�personnel�should�be�available�to�all�facilities�in�the�organisation,�including�non-clinical�areas.�Availability�and�positioning�of�the�kits�is�of�particular�importance�in�areas�distant�from�consumer�/�patient�care�areas�and�where�there�is�a�risk�of�physical�injury,�such�as�kitchens,�sterilising�departments,�maintenance�workshops,�gardening�sheds�and�laundries.

Prompt points

¼ Where are first aid kits situated within the organisation?

¼ Who is responsible for checking them?

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October 2010  453

Staff training in case of an emergencyThe�organisation�must�not�only�plan�for�emergencies�and�disasters,�but�ensure�that�its�staff,�and�any�other�individuals�working�on�the�premises�while�employed�by�a�different�organisation,�are�educated�in�all�aspects�of�those�plans,�and�trained�in�putting�them�into�effect.�Emergency�procedures�as�reflected�in�the�organisation’s�fire�safety�plan�should�be�presented�to�all�staff�at�orientation,�and�at�least�annually�in�education�sessions.�The�training�should�reiterate�the�components�of�the�various�plans�and�the�stages�of�response.�Education�of�all�staff,�regardless�of�designation,�location�or�shift,�in�the�correct�responses�to�an�emergency�situation�is�a�vital�component�of�the�organisation’s�preparedness,�with�theoretical�exercises�supported�by�regular�practical�training�and�drills.�Compliance�is�crucial,�and�comprehensive�records�should�be�kept�of�staff�completion�of�both�the�theoretical�and�practical�aspects�of�evacuation�and�emergency�response�training,�including�first�aid�certification.

Prompt points

¼ What emergency rehearsals does the organisation use to ensure preparedness? What staff take part in these rehearsals? How does the organisation ensure that night shift and contract staff are adequately trained in emergency and evacuation procedures?

¼ How does the organisation ensure that all staff are familiar with the components of its fire safety plan, including the communications system and the position and correct use of fire walls / doors?

¼ Did all of the organisation’s staff complete fire drill and fire-fighting training within the last calendar year? How is non-compliance followed up and what action is taken? What actions ensure that casual and visiting staff are familiar with the emergency response and their responsibilities within the area that they are working?

Evidence commonly presented

Consider whether the following will help to address criterion 3.2.4

¼ Disaster management plan

¼ Policies, including information on both internal and external emergencies

¼ Appointment of personnel in preparation for an emergency, for example, fire wardens

¼ Staff education, including:

– fire training – CPR training

¼ Evidence of full fire inspection

¼ Annual essential services reports

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454  The ACHS EQuIP5 Guide  Book 2  Accreditation, Standards and Guidelines  Support and Corporate Functions

Criterion 3.2.4

Emergencyanddisastermanagementsupportssafepracticeandasafeenvironment.�(continued)

Performance managementThis�criterion�states�that:�“Emergency�and�disaster�management�supports�safe�practice�and�a�safe�environment”.�The�organisation�should�be�able�to�demonstrate�its�preparedness�in�terms�of�policies�and�procedures,�staff�education�and�training,�business�continuity�planning�and�other�contingency�arrangements,�that�will�allow�it�to�continue�to�meet�its�duty�of�care�and�maintain�a�safe�environment�even�in�the�event�of�an�emergency.�

Some�common�suggested�performance�measures�are�as�follows:

Average response time to emergency calls

Comment:considerdefiningbyemergencycodesuchasRED,BLACK,BLUEcodes

Number�of�staff�who�have�attended�fire�training,�including�an�evacuation�drill

Total number of staff

Number�of�staff�who�have�demonstrated�their�understanding�of�emergency�procedures

Total number of staff

Number�of�false�fire�alarms�during�designated�period

Total number of fire alarms during designated period

Comment:organisationtodefinetimeframe

Number�of�separate�facilities�/�areas�within�the�organisation�for�which�one�or�more�fire�drills�have�been�conducted

Total number of separate facilities / areas within the organisation

Number�of�designated�fire�wardens�who�have�completed�specialised�fire�training

Total number of designated fire wardens

Number�of�emergency�/�disaster�plans�developed�in�consultation�with�relevant�external�authorities

Total number of emergency / disaster plans

Number�of�first�aid�kits�audited�within�appropriate�timeframe

Total number of first aid kits

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October 2010  455

References1.� Emergency�Management�Australia.TheAustralian

emergencymanagementglossary.�Canberra�ACT;�Australian�Government;�1998.

2.� AS�4083:1997�Planningforemergencies–healthcarefacilities.

3.� Attorney-General’s�Department.�EmergencymanagementAustralia.Canberra�ACT;�Australian�Government.�Accessed�from�http://www.ag.gov.au/www/agd/agd.nsf/Page/OrganisationalStructure_EmergencyManagementAustralia�on�7�July�2010.

4.� Dept�of�Transport�and�Regional�Services.�NaturalDisastersinAustralia:Reformingmitigation,reliefandrecoveryarrangements.�A�report�to�the�Council�of�Australian�Governments�by�a�high�level�officials’�group.�Canberra�ACT;�Council�of�Australian�Governments�(COAG);�2004.

5.� Paton�D�and�Johnston�D.�Disasters�and�communities:�vulnerability,�resilience�and�preparedness.�DisasterPrevandMgmt�2001;�10�(4):�270-277.

6.� Government�of�Western�Australia.�Emergencymanagementstrategicframework2006–2011.�Perth�WA;�State�Emergency�Management�Committee;�2006.

7.� Bushfire�Cooperative�Research�Centre�(CRC).�Resilienceattheurbaninterface:astudyofNewSouthWalesfirebrigadescommunityfireunits.�Vol.�21.�Melbourne�VIC;�Bushfire�CRC;�2007.

8.� Attorney-General’s�Department.�EmergencymanagementinAustralia:Businesscontinuity.Canberra�ACT;�Australian�Government.�Accessed�from�http://www.ema.gov.au/www/emaweb/emaweb.nsf/Page/Emergency_ManagementPreparing_for_EmergenciesBusiness_Continuitiy�on�7�July�2010.

9.� Itzwerth�RL,�Macintyre�CR,�Shah�S�and�Plant�AJ.�Pandemic�influenza�and�critical�infrastructure�dependencies:�possible�impact�on�hospitals.MedJAust2006;�185(10):�S70-S72.

Standards and guidelinesAS�3745�(incorporating�Amdt�Nos�1�and�2):2002�Emergencycontrolorganizationandproceduresforbuildings,structuresandworkplaces.�Third�edn.

AS�1670.4:2004Firedetection,warning,controlandintercomsystems–Systemdesign,installationandcommissioning–Soundsystemsandintercomsystemsforemergencypurposes.

Standards�Australia�HB221:2004�Handbook:�Businesscontinuitymanagement.Second�edn.

Further readingNSW�State�Emergency�Management�Committee.�On-siteemergencyplanning.�Aguidetohelporganisationsdevelopon-siteemergencyplansinaheightenedsecurityenvironment.�Sydney;�NSW�Office�of�Emergency�Services;�2004.

Aged�and�Community�Services�WA.�Pandemicinfluenza.Businesscontinuityplan.AguideforagedcareprovidersPerth�WA;�Aged�and�Community�Services;�2006.

Emergency�Management�Australia.Hazards,disastersandyourcommunity.�7th�edn.�Canberra�ACT;�Australian�Government;�2006.

Richardson�DB�and�Kumar�S.�Emergency�response�to�the�Canberra�bushfires.�MedJAust2004;�181(1):�40-42.

Bartley�BH,�Stella�JB�and�Walsh�LD.�What�a�disaster?!�Assessing�utility�of�simulated�disaster�exercise�and�educational�process�for�improving�hospital�preparedness.�PrehospitalDisasterMed2006;�21(4):�249-255.

Rosenfeld�JV,�Fitzgerald�M,�Kossman�T�etal.�Is�the�Australian�hospital�system�adequately�prepared�for�terrorism?�MedJAust2005;�183(11/12):�567-570.

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456  The ACHS EQuIP5 Guide  Book 2  Accreditation, Standards and Guidelines  Support and Corporate Functions

Criterion LA – Awareness sA – implementationLA plus the following

MA – evaluationSA plus the following

eA – excellenceMA plus the following

oA – LeadershipEA plus the following

Criterion 3.2.5

Security�management�supports�safe�practice�and�a�safe�environment.

a)� There�is�an�organisation-wide�security�policy.

b)� Major�security�risks�are�identified.

c)� Staff�are�educated�and�provided�with�information�in�relation�to�security�risks�and�responsibilities.

d)� External�service�providers�are�supplied�with�relevant�information�and�comply�with�the�organisation’s�security�controls.

a)� There�is�an�organisation-wide�system�to�assess�security�risks,�determine�priorities�and�eliminate�risks�or�implement�controls.

b)� The�system�to�manage�security�risks�and�violence�and�aggression�prevention�operates�with�reference�to�any�relevant:

� (i)� Australian�standards

� (ii)� legislation�

� (iii)� codes�of�practice

� (iv)� industry�guidelines.

c)� Service�planning�includes�strategies�for�security�management.

d)� Staff�are�consulted�in�decision�making�that�affects�organisational�and�personal�risks.

e)� There�is�an�organisation-wide�violence�and�aggression�prevention�program.

f)� Security�management�plans�are�coordinated�with�relevant�external�authorities.

a)� Performance�indicators�are�used�to�evaluate�the�security�management�system,�and�improvements�are�made�as�required.

b)� The�violence�and�aggression�prevention�program�is�evaluated,�and�improved�as�required.

a)� Performance�indicators�for�security�and�violence,�and�aggression�prevention�management�are�measured�and�compared�internally�and�with�external�systems,�and�improvements�are�made�to�ensure�better�practice.

and/or

b)� The�organisation�demonstrates�that�security,�and�violence�and�aggression�prevention�systems�ensure�that�security�breaches�and�incidents�are�minimised.

a)� The�organisation�demonstrates�it�is�a�leader�in�security�management.

IntentThe�intent�of�this�criterion�is�to�ensure�that�the�organisation�manages�all�aspects�of�security�so�as�to�meet�its�commitment�to�support�best�practice�and�to�maintain�a�safe�environment�for�employees,�consumers�/�patients�and�visitors.

Relationships of 3.2.5 with other criteriaMaintenance�of�a�safe�environment�by�the�organisation�compliments�its�implementation�of�employee�support�systems�(Criterion�2.2.5).�It�is�also�a�part�of�the�organisation’s�management�of�its�buildings,�plant�and�equipment�(Criterion�3.2.2).�Some�aspects�of�security�management�will�require�the�utilisation�of�information�and�communication�technology�(Criterion�2.3.4).�Security�management,�particularly�the�management�of�physical�security,�is�an�important�aspect�of�the�

organisation’s�integrated�risk�management�framework�(Criterion�2.1.2).�Failure�to�manage�security�so�as�to�maintain�a�safe�environment�may�result�in�incidents�and�complaints�(Criteria�2.1.3�and�2.1.4).�

Procedural securitySecurity�can�be�divided�into�four�broad�areas.�Procedural�security�concerns�the�policies�and�procedures�put�in�place�by�the�organisation�to�provide�an�environment�that�enhances�the�safety�of�employees,�consumers�/�patients�and�visitors.�Physical�security�refers�to�the�steps�taken�to�prevent�and/or�minimise�the�incidence�of�verbal�and�physical�acts�of�aggression�and�violence�within�the�workplace,�either�by�or�towards�employees,�consumers�/�patients�and�visitors.�Personal�security,�in�a�healthcare�setting,�refers�to�the�right�of�consumers�/�patients�and�visitors�to�be�confident�of�

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October 2010  457

Criterion LA – Awareness sA – implementationLA plus the following

MA – evaluationSA plus the following

eA – excellenceMA plus the following

oA – LeadershipEA plus the following

Criterion 3.2.5

Security�management�supports�safe�practice�and�a�safe�environment.

a)� There�is�an�organisation-wide�security�policy.

b)� Major�security�risks�are�identified.

c)� Staff�are�educated�and�provided�with�information�in�relation�to�security�risks�and�responsibilities.

d)� External�service�providers�are�supplied�with�relevant�information�and�comply�with�the�organisation’s�security�controls.

a)� There�is�an�organisation-wide�system�to�assess�security�risks,�determine�priorities�and�eliminate�risks�or�implement�controls.

b)� The�system�to�manage�security�risks�and�violence�and�aggression�prevention�operates�with�reference�to�any�relevant:

� (i)� Australian�standards

� (ii)� legislation�

� (iii)� codes�of�practice

� (iv)� industry�guidelines.

c)� Service�planning�includes�strategies�for�security�management.

d)� Staff�are�consulted�in�decision�making�that�affects�organisational�and�personal�risks.

e)� There�is�an�organisation-wide�violence�and�aggression�prevention�program.

f)� Security�management�plans�are�coordinated�with�relevant�external�authorities.

a)� Performance�indicators�are�used�to�evaluate�the�security�management�system,�and�improvements�are�made�as�required.

b)� The�violence�and�aggression�prevention�program�is�evaluated,�and�improved�as�required.

a)� Performance�indicators�for�security�and�violence,�and�aggression�prevention�management�are�measured�and�compared�internally�and�with�external�systems,�and�improvements�are�made�to�ensure�better�practice.

and/or

b)� The�organisation�demonstrates�that�security,�and�violence�and�aggression�prevention�systems�ensure�that�security�breaches�and�incidents�are�minimised.

a)� The�organisation�demonstrates�it�is�a�leader�in�security�management.

the�credentials�and�background�of�the�individuals�with�whom�they�interact�in�that�setting.�Logical�security�is�that�aspect�of�security�management�that�utilises�communications,�information�technology�(IT)�and�information�management�(IM).

Security�management�is�a�vital�and�wide-ranging�issue�in�any�healthcare�setting,�encompassing�not�only�the�physical�and�emotional�safety�of�individuals,�but�the�protection�of�buildings,�plant,�equipment�and�other�assets.�Policy�should�consider�the�following�issues:

• security�and�safety�of�staff,�consumers�/�patients�and�visitors

• security�of�information

• security�of�staff�off-site,�for�example�on�home�visits

• security�in�geographically�remote�areas�or�in�isolation

• security�of�personal�belongings

• security�of�assets

• security�of�pharmaceuticals

• security�of�payroll

• defined�responsibilities�for�management�and�staff,�and�delegated�responsibility�for�the�security�system

• security�assessment,�as�required�by�jurisdictional�guidelines,�undertaken�by�an�accredited�consultant.

Organisations�are�required�to�identify�their�major�security�risks.�Consideration�needs�to�be�given�to�the�environment,�work�practices,�work�arrangements�and�equipment�used.

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458  The ACHS EQuIP5 Guide  Book 2  Accreditation, Standards and Guidelines  Support and Corporate Functions

Criterion 3.2.5

Security�management�supports�safe�practice�and�a�safe�environment.�(continued)

When�identifying�where�the�organisation�may�be�at�risk,�the�nature�and�source�of�the�harm�that�could�occur�needs�to�be�identified.�Organisations�should�consider:

• What�could�happen�(or�what�could�go�wrong)?

• How�would�it�happen?

• What�harm�would�it�cause?

• Who�or�what�would�be�harmed?

Information�to�assist�organisations�on�identification,�risk�rating,�elimination�or�control�of�risks�and�monitoring�is�available�in�the�ACHS�RiskManagementHandbook1,�available�from�the�ACHS�website:�http://www.achs.org.au�and�AS�4485:1997�Securityforhealthcarefacilities.2

Strategies�for�security�management�should�be�included�in�service�planning.�This�will�involve�allowing�for�the�resources�needed�to�ensure�the�organisation’s�security,�such�as�provision�of�personal�/�duress�alarms,�installation�of�panic�buttons�and�their�connection�to�police�or�a�security�company,�appropriate�lighting,�video�surveillance�and/or�the�provision�of�security�staff�if�needed.

Healthcare�organisations�should�consider�architectural�design3�that�improves�surveillance�of�critical�service�areas�such�as�plant�rooms,�and�the�protection�of�personnel,�for�example�service�counter�design�and�access�to�treatment�rooms,�as�well�as�the�location�of�other�security�risks�areas�such�as�ATMs�and�pharmacies.

Prompt points

¼ What legislation / standards / codes of practice are referenced in the organisation’s security policy?

¼ How often is the organisation’s risk register updated?

¼ How does the organisation ensure that confidential information is secure?

¼ Does the organisation have staff who work off-site? How does it manage their safety?

Physical and personal securityOrganisations�should�have�an�effective�risk�management�plan�to�address�violence�and�aggression�in�the�workplace.�The�focus�should�be�on�prevention.�However,�when�a�violent�incident�does�occur,�action�should�be�taken�to�minimise�its�impact�and�prevent�its�recurrence�as�far�as�possible,�regardless�of�its�source.�Appropriate�support�should�be�provided�for�affected�staff,�such�as�debriefing,�and�encouragement�to�access�professional�counselling�and�assistance�from�the�organisation’s�employee�support�program.

The�term�‘violence�and�aggression’�encompasses�any�incident�in�which�an�individual�is�abused,�threatened�or�assaulted.�Such�an�incident�may�involve�verbal,�physical�or�psychological�abuse,�threats�or�other�intimidating�behaviours,�intentional�physical�attacks,�aggravated�assault,�threats�with�an�offensive�weapon,�sexual�harassment,�or�sexual�assault.

A�policy�of�zero�tolerance�should�be�adopted�by�the�organisation.�Zero�tolerance�means�that�in�all�violent�or�aggressive�incidents,�appropriate�action�will�be�taken�to�protect�staff,�consumers�/�patients�and�visitors�from�the�effects�of�such�behaviour.4

Organisations�should�have�in�place�a�violence�and�aggression�prevention�program.�This�program�should�include:

• policies�addressing�zero�tolerance,�internal�(intra-organisational)�violence,�aggression�and�bullying,�between�staff�at�all�levels�as�well�as�visitors

• a�focus�on�the�elimination�of�violent�behaviour�and,�where�risks�cannot�be�eliminated,�the�reduction�of�risk�to�the�lowest�possible�level

• control�strategies�for�violence�and�aggression,�developed�in�consultation�with�staff

• protocols�for�reporting�violent�incidents

• a�working�environment�that�supports�zero�tolerance�and�management�commitment�to�the�program

• staff�education�about�responding�to�violent�incidents.

Physical�security�includes�alarms,�guards,�lighting,�locks,�safes,�closed�circuit�television�(CCTV),�etc.�As�part�of�its�commitment�to�providing�a�safe�working�environment,�the�organisation�should�ensure�that�lighting�is�adequate�in�areas�such�as�car�parks,�corridors,�access�paths�and�storage�facilities.�An�access�control�system�for�registering,�managing�and�monitoring�individual�levels�of�access,�including�the�allocation�and�use�of�key�and/or�swipe�cards,�should�be�in�place,�kept�up�to�date�and�regularly�reviewed.

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Access�controls�to�specific�areas,�including�locks�on�drug�storage�areas,�reduced�face-to-face�contact�during�supply�of�pharmaceuticals,�designated�escape�routes,�and�swipe�card�access�for�relevant�individuals�can�improve�the�physical�safety�of�staff.

Where�CCTV�is�in�use,�a�large�sign�indicating�that�the�site�is�being�monitored�continuously�should�be�displayed.

Personal�security�includes�pre-employment�checking�and�human�resources�policies�and�procedures.�Relevant�credentials�should�be�provided�by�all�staff�and�copies�kept�in�personal�records.�In�settings�where�staff�are�working�with�or�in�contact�with�children,�appropriate�checks�should�be�completed.5�Identification�should�be�worn�by�all�staff,�including�volunteers.�Identification�should�consider�visibility,�culture,�safety,�security�and�customer�focus.

Logical securityThe�term�logical�security�refers�to�those�security�features�that�are�built�into�communications,�IT�and�IM�systems.�More�extensive�information�about�logical�security�and�its�implementation�and�management�can�be�found�in�criterion�2.3.4.

Prompt points

¼ When a violent incident is reported, what is the average response time? Is a risk assessment subsequently undertaken and an action plan developed?

¼ Does the organisation have areas to which access is restricted? How is access to those areas monitored and/or controlled? For example, if consumers / patients or carers can access the main facility after hours, is the kitchen secure? Are knives or other potential weapons secured?

¼ If the organisation has an Emergency Department, how are consumers / patients and in particular, carers, contained within the ED after hours, when staffing and other resources are limited?

Education, consultation and procedural reviewSecurity�and�consumer�/�patient�safety�are�key�concerns�in�any�healthcare�organisation.�Management�should�demonstrate�its�support�for�zero�tolerance�to�all�levels�of�staff�through�a�commitment�to�education�and�training,�and�an�effective�response�when�incidents�are�reported.�The�integrity�of�policies�and�procedures�can�only�be�assured�by�the�methods�employed�to�train�staff�in�current�procedures�and�by�continuously�reviewing�and�updating�those�procedures�as�required�following�consultation�with�staff.�The�procedures�developed�in�any�organisation�must�be�understood,�with�relevant�staff�training�provided�where�necessary.�A�mechanism�to�guarantee�that�policies�and�procedures�have�been�read�and�understood�should�be�in�place.�This�can�be�in�the�form�of�a�register�or�part�of�the�annual�review�of�key�performance�indicators.

The�organisation’s�responsibility�to�provide�a�safe�working�environment�extends�to�all�individuals�entering�the�workplace,�including�any�external�service�providers�or�contractors.�The�organisation�must�provide�these�individuals�with�all�relevant�security�information,�both�in�order�that�they�may�be�protected,�and�to�ensure�that�in�turn�they�comply�with�all�security�policies�and�procedures.

The�issue�of�staff�working�alone�should�be�considered�under�Occupational�Health�&�Safety�legislation,�and�other�relevant�Regulations,�Acts�and�codes�of�practice.�Employers�must�take�all�reasonably�practicable�steps�to�protect�the�health�and�safety�at�work�of�all�employees.�The�best�way�to�ensure�that�all�reasonably�practicable�steps�have�been�taken�is�to�apply�a�consultative�risk�management�process�to�the�identification,�assessment�and�control�of�risks�involved�in�working�alone�or�in�remote�areas.�National,�State�and�Territory�legislation�requires�that�employers�consult�with�employees�to�identify�hazards,�assess�the�risk,�determine�and�implement�control�measures,�develop�policies�and�procedures�to�minimise�the�risk,�decide�on�training�requirements�and�supervise�and�monitor�the�risk�control�measures.�

When�staff�are�required�to�visit�consumers�/�patients�in�their�own�homes,�a�risk�assessment�that�occurs�over�the�phone�may�not�be�sufficient�to�identify�all�of�the�risks�involved�in�that�visit.�Apart�from�risks�within�the�home�environment,�such�as�pets,�other�persons�/�residents�in�attendance,�and�the�physical�environment,�there�are�also�risks�in�the�surrounding�area�or�complex�where�the�consumer�/�patient�resides.�

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460  The ACHS EQuIP5 Guide  Book 2  Accreditation, Standards and Guidelines  Support and Corporate Functions

Criterion 3.2.5

Security�management�supports�safe�practice�and�a�safe�environment.�(continued)

Organisations�need�to�ensure�that:

• there�is�a�risk�management�policy�and�procedure�in�place�that�addresses�risks�to�employees�who�visit�consumers�/�patients�in�their�own�homes

• the�risk�management�policy�and�procedure�has�been�developed�in�consultation�with�the�employees�performing�that�function

• risk�assessments�of�consumers�/�patients�occur,�with�alternate�care�options�provided�for�those�who�are�excluded�on�the�basis�of�risk�assessment�or�those�where�a�risk�assessment�is�not�an�option�due�to�time�constraints

• risks�and�risk�control�strategies�that�are�implemented�are�communicated�to�staff

• the�effectiveness�of�the�policies�and�the�controls�that�are�in�place�is�demonstrated

• policies�and�procedures�to�support�staff�in�these�situations�are�in�place�and�monitored

• appropriate�training�for�staff�occurs�including�training�in�aggressive�behaviour�management�and�manual�handling�/�task,�commensurate�with�the�working�conditions�of�the�employee

• back-up�protocols�are�in�place�to�support�staff�on�consumer�/�patient�home�visits,�taking�into�consideration�issues�such�as�roadside�assistance�for�vehicle�travel;�‘call�in’�to�staffed�office�with�monitoring�of�return�times;�or�in�remote�locations,�GPS�monitoring�and�duress�alarm�availability�connected�to�a�24�hour�monitoring�centre�(such�as�a�commercial�security�contractor)�and�emergency�response�times

• appropriate�emergency�support�equipment,�such�as�mobile�phones�or�other�communication�equipment,�is�made�available�to�staff�suitable�to�the�location�of�the�service.

Prompt points

¼ How does the organisation educate its staff about security matters? How often is this information updated and disseminated?

¼ How often are staff consulted regarding matters of security in the workplace? What form does this consultation take?

¼ How does the organisation ensure that external service providers act in compliance with the organisation’s security policies?

¼ What back-up protocols are in place for staff undertaking home visits? How is the safety of staff in remote areas ensured?

Evidence commonly presented

Consider whether the following will help to address criterion 3.2.5

¼ Evidence of pre-employment checks

¼ Identification of security risks and plans to manage those risks

¼ Security audits (internal, e.g. OH&S Committee, as well as external)

¼ Evidence of violence and aggression prevention plans

¼ Reported incidents and action taken on:

– aggression – theft – breaches of secure areas

¼ Policies and procedures

¼ Evidence of staff training

¼ Evidence of staff consultation

¼ Privacy audits

¼ Property and property check audits

¼ Security licences

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Performance measurementThis�criterion�states�that:�“Security�management�supports�safe�practice�and�a�safe�environment”.�The�organisation�should�demonstrate�its�commitment�to�maintaining�a�safe�environment�via�its�implementation�of�security�policies�and�procedures,�its�adoption�of�a�zero�tolerance�approach�towards�workplace�violence�and�aggression,�the�provision�of�appropriate�education�to�its�staff,�and�its�consultation�with�staff�during�its�evaluation�and�improvement�of�its�security�program.

Some�common�suggested�performance�measures�are�as�follows:

Number�of�reported�incidents�that�relate�to�theft�/�risk�/�security

Total number of reported incidents

Number�of�reported�incidents�that�relate�to�aggression

Total number of reported incidents

Number�of�reported�breaches�of�security�doors

Total number of security incidents

Number�of�workers�compensation�claims�related�to�aggression

Total number of workers compensation claims

Number�of�incidents�involving�staff�working�off-site

Total number of reported incidents

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seCtion 5Standards, criteria, elements and guidelinesstandard 3.2:�The�organisation�maintains�a�safe�environment�for�employees,�consumers�/�patients�and�visitors

462  The ACHS EQuIP5 Guide  Book 2  Accreditation, Standards and Guidelines  Support and Corporate Functions

Criterion 3.2.5

Security�management�supports�safe�practice�and�a�safe�environment.�(continued)

References1.� Australian�Council�on�Healthcare�Standards�(ACHS).�Risk

managementandqualityimprovementhandbook.Sydney�NSW;�ACHS;�2007.�Accessed�from�http://www.achs.org.au/RiskMgmtQIHandbook/�on�27�July�2010.

2.� AS�4498.1:1997�Securityforhealthcarefacilities.Part1:Generalrequirements.

3.� AHIA�(formerly�Health�Capital�and�Asset�Management�Consortium)�and�University�of�NSW�Centre�for�Health�Assets�Australasia.�AustralasianHealthFacilityGuidelines(AusHFG).Sydney;�UNSW.�Accessed�from�http://www.healthfacilityguidelines.com.au/guidelines.htm�on�11�December�2009.

4.� NSW�Health.Zerotolerance.ResponsetoviolenceintheNSWhealthworkplace.Policyandframeworkguidelines.Sydney;�NSW�Health;�2003.

5.� Australian�Institute�of�Family�Studies.�Pre-employment�screening:�Working�with�children�checks�and�police�checks.Resourcesheet2010;�13.�Accessed�from�http://www.aifs.gov.au/nch/resources/police/policechecks.html�on�1�September�2010.

Standards and guidelinesAS/NZS�ISO�31000:2010�Riskmanagement–Principlesandguidelines.

AS�4485.1:1997�Securityforhealthcarefacilities.Part1:Generalrequirements.

AS�4485.2:1997�Securityforhealthcarefacilities.Part2:Proceduresguide.

Victorian�Department�of�Human�Services.�PreventingoccupationalviolenceinVictorianhealth�services.�A�policy�framework�and�resource�kit.�Melbourne;�Victorian�Government�2007.

Further readingDepartment�of�Commerce.�Handbookforworkplaces.Preventionandmanagementofaggressioninhealthservices.Perth�WA;�Government�of�Western�Australia;�2009.

Forster�JA,�Petty�MT,�Schleiger�C�and�Waters�HC.�kNOw�workplace�violence:�Developing�programs�for�managing�the�risk�of�aggression�in�the�health�care�setting.�MedJAust2005;�183(7):�357-361.

Remote�Health�Branch,�NT�Department�of�Health�and�Families.Aggressionmanagementpolicy.Information�sheet.�Darwin�NT;�Northern�Territory�Government;�2005.

Comcare.�TheCommonwealthoccupationalhealthandsafetyjurisdiction.Canberra�ACT;�Commonwealth�government.�Accessed�from�http://www.comcare.gov.au/forms__and__publications/fact_sheets/the_commonwealth_occupational_health_and_safety_jurisdiction�on�14�September�2010.

Comcare.�Laws&regulations.Canberra�ACT;�Australian�Government.�Accessed�from�http://www.comcare.gov.au/laws__and__regulations�on�14�September�2010.

SafeWork�SA.�Safeworkforhomeandcommunityworkers.Adelaide�SA;�Government�of�South�Australia.�Accessed�from�http://www.safework.sa.gov.au/contentPages/Industry/AgedCare/agedHomeCommunityWorkers.htm�on�14�September�2010.

Worksafe�Victoria.�Ahandbookforworkplaces:Workingsafelyinvisitinghealthservices.�Melbourne�VIC;�Worksafe;�2006.

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October 2010  463

Definitions in this glossary are for use in the context of the ACHs eQuiP5 standards, criteria, elements and guidelines.

access the�various�pathways�and�processes�via�which�the�consumer�/�patient�may�enter�the�health�system�and�obtain�required�services�

accessibility the�ability�of�consumers�/�patients�or�potential�consumers�/�patients�to�obtain�required�or�available�services�when�needed�within�an�appropriate�time1

accountability responsibility�and�requirement�to�answer�for�tasks�or�activities.�This�responsibility�may�not�be�delegated�and�should�be�transparent1

accreditation a�public�recognition�by�a�healthcare�accreditation�body�of�the�achievement�of�accreditation�standards�by�a�healthcare�organisation,�demonstrated�through�an�independent�external�peer�assessment�of�that�organisation’s�level�of�performance�in�relation�to�the�standards1

advance care plan / directive

instructions�that�consent�to,�or�refuse,�the�future�use�of�specified�medical�treatments.�It�becomes�effective�in�situations�where�the�consumer�/�patient�no�longer�has�the�capacity�to�make�treatment�decisions2

AC60: Advanced Completion in 60 days survey

in�the�context�of�EQuIP5:�

an�opportunity�for�an�organisation�to�promptly�address�outstanding�issues�to�achieve�an�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�criteria

admission the�point�in�the�care�journey�at�which�an�organisation�acknowledges�a�consumer�/�patient�as�a�client,�and�accepts�responsibility�for�his�or�her�care3;�in�some�contexts,�the�term�‘registration’�may�be�used�rather�than�admission.�The�point�at�which�admission�is�considered�to�have�occurred,�and�the�processes�by�which�it�happens,�vary�considerably�according�to�the�nature�of�an�organisation.

In�the�first�instance,�admission�refers�to�the�administrative�process�by�which�an�individual’s�details�are�entered�into�the�organisation’s�systems�so�that�the�care�journey�may�begin.�However,�it�is�important�to�recognise�that,�depending�upon�the�nature�and�sector�of�the�organisation,�admission�does�not�necessarily�require�the�provision�of�accommodation,�or�access�to�a�specific�facility.

adverse event an�incident�that�results�in�harm�to�a�consumer�/�patient,�where�harm�includes�disease,�injury,�suffering,�disability�and�death4

adverse reaction unexpected�harm�arising�from�a�justified�treatment5

agreement a�mutually�agreed�arrangement�describing�the�scope�for�cooperative�ventures�between�parties�and�documenting�relevant�responsibilities

analysis presentation�of�the�essential�features�into�simple�elements,�such�as�a�summary,�outline�or�identification�of�the�essence�of�an�issue

antimicrobial a�chemical�substance�that�inhibits�or�destroys�bacteria,�fungi�or�parasites.4�These�include�antibiotics,�antivirals�and�disinfectants

appropriate service�that�is�consistent�with�a�consumer�/�patient’s�expressed�requirements�and�is�provided�in�accordance�with�current�best�practice1

in�the�context�of�EQuIP5:�is�suitable,�or�fitting,�to�do

seCtion 6Glossary

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seCtion 6Glossary

appropriateness doing�what�is�necessary,�and�not�doing�what�is�not�necessary.�Occurs�when�consumers�/�patients�receive�appropriate�and�necessary�care,�interventions�and�services�in�the�most�appropriate�setting

artificial nutritional support

parenteral�and/or�enteral�nutrition�therapy6

(parenteral�nutrition:�intravenous�administration�of�nutrients�into�a�central�or�peripheral�vein.�Enteral�nutrition:�feeding�provided�through�the�gastrointestinal�tract�via�a�tube,�catheter,�or�stoma�that�delivers�nutrients�distal�to�the�oral�cavity)6

as required when�required�by�obligation

assessment a�process�by�which�the�characteristics�and�needs�of�consumers�/�patients,�groups�or�situations�are�evaluated�or�determined�so�that�they�can�be�addressed.�Assessment�forms�the�basis�of�a�plan�for�services�or�action.1�While�assessment�may�be�known�by�different�names�and�occurs�in�a�broad�variety�of�contexts,�such�as�triage�in�an�emergency�department,�comprehensive�assessment�by�an�Aged�Care�Assessment�Service,�or�screening�and�intake�by�a�community�health�or�outreach�service,�the�process�remains�consistent�and�as�defined�above

‘at-risk’ consumer / patient

a�consumer�/�patient�characterised�by�a�high�risk�or�susceptibility�to�a�disease7�or�event,�e.g.�falls�

Australian standards national�standards�developed�by�Standards�Australia

benchmarking the�continuous�measurement�of�a�process,�product,�or�service�compared�to�those�of�the�toughest�competitor,�to�those�considered�industry�leaders,�or�to�similar�activities�in�the�organisation,�in�order�to�find�and�implement�ways�to�improve�it.�One�of�the�foundations�of�both�total�quality�management�and�continuous�quality�improvement.�Internal�benchmarking�occurs�when�similar�processes�within�the�same�organisation�are�compared.�Competitive�benchmarking�occurs�when�an�organisation's�processes�are�compared�with�best�practices�within�the�industry.�Functional�benchmarking�refers�to�benchmarking�a�similar�function�or�process,�such�as�scheduling,�in�another�industry6

best practice an�approach�that�has�been�shown�to�produce�superior�results,�selected�by�a�systematic�process,�and�judged�as�exemplary,�or�demonstrated�as�successful.�It�is�then�adapted�to�fit�a�particular�organisation1

blood homologous�and�autologous�whole�blood,�blood�including�red�blood�cells,�platelets,�fresh�frozen�plasma,�cryoprecipitate�and�cryo-depleted�plasma4

blood component fresh�blood�components�including�red�cells,�platelets,�fresh�frozen�plasma,�cryoprecipitate�and�cryodepleted�plasma8

blood products plasma�derivatives�and�recombinant�products�

business plan the�current�action�plan�for�achieving�organisation�goals1

by-laws rules,�regulations�or�legislation�adopted�by�the�organisation�for�the�regulation�of�both�its�internal�and�external�affairs

carbon emissions generally�an�abbreviation�of�emissions�of�greenhouse�gases.�Greenhouse�gases�are�a�number�of�different�gases�that�all�have�the�ability�to�influence�the�global�energy�balance�of�the�Earth;�the�greenhouse�effect9

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care plan the�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�date10

carers / support persons people�who�provide�unpaid�care�and�support�to�family�members�and�friends�who�have�a�disability,�mental�illness,�chronic�condition,�terminal�illness�or�who�are�frail.11�Carers�include�parents�and�guardians�caring�for�children4.�

in�the�context�of�EQuIP5:�

a�carer�/�support�person�is�any�person�elected�by�a�consumer�/�patient�to�accompany�or�assist�the�consumer�/�patient�during�an�episode�of�care

change management the�process�of�managing�the�effective�implementation�of�organisational�strategies,�ensuring�that�permanent�changes�in�goals,�behaviours,�relationships,�processes�and�systems�are�achieved�to�the�organisation’s�advantage.�It�is�the�key�competence�required�for�managing�all�strategic�initiatives

clinical audit a�systematic�independent�examination�and�review�to�determine�whether�actual�activities�and�results�comply�with�planned�arrangements1

clinical classification the�process�of�translating�data,�such�as�for�diseases,�conditions,�injuries�and�interventions,�from�a�consumer�/�patient�record�into�a�coded�format�using�a�relevant�classification�system

clinical governance the�system�by�which�the�governing�body,�managers�and�clinicians�share�responsibility�and�are�held�accountable�for�consumer�/�patient�care,�minimising�risks�to�consumers�/�patients�and�for�continuously�monitoring�and�improving�the�quality�of�clinical�care12�

clinical handover the�transfer�of�professional�responsibility�and�accountability�for�some�or�all�aspects�of�care�for�a�consumer�/�patient,�or�group�of�consumers�/�patients,�to�another�person�or�professional�group�on�a�temporary�or�permanent�basis.4,�13�The�efficient�and�effective�transfer�of�high�quality�clinical�information�from�one�healthcare�provider�to�another�facilitates�safe�transfer�of�care14�

clinical indicator a�measure�of�the�clinical�management�and/or�outcome�of�care�that�should�screen,�flag�or�draw�attention�to�a�specific�clinical�issue.�Clinical�indicators�identify�the�rate�of�occurrence�of�an�event�and�are�used�to�assess,�compare�and�determine�the�potential�to�improve�care.�They�assist�in�assessing�whether�or�not�a�standard�in�consumer�/�patient�care�is�being�met�by�indicating�potential�problems�that�might�need�addressing15�

clinical pathway sometimes�called�a�care�map,�a�consumer�/�patient�management�tool�that�organises,�sequences�and�times�the�major�care�activities�and�interventions�of�the�entire�interdisciplinary�team�for�a�consumer�/�patient�with�a�particular�diagnosis�or�need�for�a�procedure16�

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seCtion 6Glossary

clinician a�healthcare�provider,�trained�as�a�health�professional.�Clinicians�include�registered�and�non-registered�practitioners,�or�a�team�of�health�professionals�providing�health�care�who�spend�the�majority�of�their�time�providing�direct�clinical�care.4�The�term�encompasses�medical�practitioners,�nurses,�dentists,�paramedics�and�allied�health�professionals�such�as�physiotherapists,�occupational�therapists,�speech�pathologists,�dieticians,�radiographers,�social�workers,�psychologists,�pharmacists�and�all�others�in�active�clinical�practice17,�but�excludes�clinicians-in-training�and�junior�practitioners�who�must�work�under�supervision18

code of practice a�published�document�that�sets�out�commonly�agreed�sets�of�guidelines�and�informs�all�parties�of�responsibilities�and�expectations�under�the�code.�Codes�of�practice�can�be19:

• voluntary�agreements�where�a�group�of�companies�or�an�industry�sector�agree�to�abide�by�a�particular�code

• quasi-regulation�where�the�code�may�be�developed�by�industry�in�cooperation�with�government

• co-regulation�where�the�code�describes�required�performance�or�behaviour,�or�specifies�acceptable�means�of�meeting�broader�performance-based�obligations,�and�where�there�are�penalties�for�non-compliance�with�the�code

community a�group�of�people�who�share�a�common�interest�or�background�(e.g.�cultural,�social,�political,�economic,�health),�which�may�also�be,�but�is�not�necessarily,�geographic20

competence a�guarantee�that�an�individual’s�knowledge�and�skills�are�appropriate�to�the�service�provided�and�an�assurance�that�the�knowledge�and�skill�levels�are�regularly�evaluated1

complaint expression�of�a�problem,�an�issue,�or�dissatisfaction�with�services�that�may�be�verbal�or�in�writing1

conditional survey in�the�context�of�EQuIP5:�

an�additional�survey�that�is�undertaken�one�year�following�an�Organisation-Wide�Survey�or�a�Periodic�Review,�during�which�issues�were�identified�as�needing�to�be�addressed�rapidly.�A�recommendation�for�a�Conditional�Survey�is�made�for�issues�for�which�a�60-day�framework�is�too�short�to�achieve�the�level�of�change�required,�and�provides�the�organisation�with�an�opportunity�to�address�issues�that�require�some�time�and�resources�in�order�to�achieve�an�acceptable�level�of�performance.

A�Conditional�Survey�may�be�offered�to�an�organisation�in�up�to�two�criteria�in�order�to�address:

• High�Priority�Recommendations�(HPRs),�and/or

• an�SA�rating�in�mandatory�criteria

In�addition,�a�Conditional�Survey�may�be�offered�to�an�organisation�in�order�to�address:

• LA/SA�ratings�in�from�six�to�eleven�non-mandatory�criteria

confidentiality guaranteed�limits�on�the�use�and�distribution�of�information�collected�from�individuals�or�organisations1�

consent, informed a�process�of�communication�between�a�consumer�/�patient�and�his�or�her�medical�officer�that�results�in�the�consumer�/�patient’s�authorisation�or�agreement�to�undergo�a�specific�medical�intervention.�This�communication�should�ensure�the�consumer�/�patient�has�an�understanding�of�all�the�available�options�and�the�expected�outcomes�such�as�the�success�rate�and/or�side�effects�for�each�option4

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consent, acknowledgement of

in�the�absence�of�a�completed�consent�form,�an�acknowledgement�of�consent�form�should�be�present�in�the�health�record,�signed�by�the�consumer�/�patient�and,�when�appropriate,�the�treating�physician,�stating�that�the�proposed�treatment,�the�benefits�and�risks�and�any�costs�involved�have�been�explained�to�the�consumer�/�patient

consumer / patient a�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�This�encompasses�consumers�/�patients�receiving�health�care�from�a�clinician4,�those�with�specific�health�needs,�or�who�may�at�some�time�have�them,�and�those�who�have�a�general�interest�in�the�health�system�and�health�funding.�Many�consumers�/�patients�also�have�an�indirect�influence�upon�the�health�system�in�the�capacity�of�taxpayers�

consumer / patient participation

the�process�of�involving�consumers�/�patients�and�the�community�meaningfully�in�decision�making�about�their�own�health�care,�health�service�planning,�policy�development,�setting�of�priorities�and�quality�issues�in�the�delivery�of�services23

continuity of care the�ability�to�provide�uninterrupted,�coordinated�care�or�services�across�programs,�practitioners,�organisations�and�levels�over�time20

contract a�mutual�agreement�between�two�or�more�competent�parties�that�creates�a�legally�supportable�obligation�to�do�or�not�do�something�specified

coordinate to�bring�together�in�a�common,�ordered�and�harmonious�action�or�effort

corporate governance the�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�in�an�organisation.24�It�influences�how�objectives�are�set�and�achieved,�how�risk�is�monitored�and�assessed�and�how�performance�is�optimised25

credentialling the�formal�process�used�to�verify�the�qualifications,�experience,�professional�standing�and�other�relevant�professional�attributes�of�clinicians�for�the�purpose�of�forming�a�view�about�their�competence,�performance�and�professional�suitability�to�provide�safe,�high�quality�healthcare�services�within�specific�organisational�environments26

credentials documentation�that�an�individual’s�knowledge,�skills,�competence�and�qualifications�comply�with�specific�requirements1

criteria specific�steps�to�be�taken�or�activities�to�be�done,�to�reach�a�decision�or�a�standard1

cultural competence the�processes�and�practices�implemented�by�an�organisation�that�foster�inclusiveness�and�establish�the�progression�of�learning�about�diversity�and�differences,�and�their�impact�on�the�way�services�are�delivered,�received,�accessed�and�promoted.�In�the�context�of�health�care,�cultural�competence�focuses�on�the�capacity�of�the�organisation�to�improve�health�and�wellbeing�for�the�individual�and�the�community�by�integrating�culture�into�the�delivery�of�health�services27

culture, organisational the�prevailing�pattern�of�beliefs,�attitudes,�values�and�behaviours�within�an�organisation28

data unorganised�facts�from�which�information�can�be�generated

data collection a�store�of�data�captured�in�an�organised�way�for�a�specific�defined�purpose

data integrity accuracy,�consistency�and�completeness�of�data

data security protection�of�data�from�intentional�or�unintentional�destruction,�modification�or�disclosure

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seCtion 6Glossary

defining the scope of clinical practice

the�process�that�follows�on�from�the�credentialling�of�medical�practitioners�and�other�clinicians,�which�involves�delineating�the�extent�of,�and�limits�to,�an�individual’s�clinical�practice�within�a�particular�organisation,�based�on�that�individual’s�credentials,�competence,�performance�and�professional�suitability,�and�the�needs�and�the�capability�of�the�organisation�to�support�the�individual’s�scope�of�clinical�practice26,�29

delegation the�devolution�of�authority�appropriate�to�individual�roles�and�responsibilities�within�an�organisation�for�the�operation�of�clinical�and�non-clinical�services.�A�formal�delegation�system�ensures�that�clear�lines�of�accountability�exist,�particularly�where�temporary�delegations�are�enacted�

deteriorating consumer / patient

a�consumer�/�patient�whose�physiological�condition�is�deteriorating.�May�apply�to�any�consumers�/�patients�receiving�medical,�surgical,�maternity�or�mental�health�care�and�is�determined�by�observing�and�documenting�changes�in�their�clinical�circumstances.�This�includes�both�the�absolute�change�in�physiological�measurements�and�abnormal�observations,�as�well�as�the�rate�of�change�over�time�for�an�individual30

disaster recovery a�disaster�recovery�strategy�is�a�set�of�pre-determined�procedures�that�provides�for�substitute�operations�and�a�quick�return�to�normal�after�any�disruption�

discharge / transfer of care

the�release�of�a�consumer�/�patient�from�care7�or�movement�of�a�consumer�/�patient�from�one�setting�of�care�to�another31

document control system a�planned�system�for�controlling�the�release,�change�and�use�of�important�documents�within�an�organisation,�particularly�policies�and�procedures.�The�system�requires�each�document�to�have�a�unique�identification,�and�to�show�dates�of�issue,�updates�and�authorisation.�Issue�of�documents�in�the�organisation�is�controlled�and�all�copies�of�all�documents�are�readily�traceable�and�obtainable32

diverse background the�breadth�of�social,�economic�and�cultural�factors�that�influence�an�individual�consumer�/�patient’s�experience�and�perspective.�This�encompasses�culturally�and/or�linguistically�diverse�backgrounds�

diverse needs the�range�of�consumer�/�patient�needs�that�may�be�found�within�the�community�that�an�organisation�serves,�and�which�may�form�a�barrier�to�health�care�if�not�addressed�by�the�organisation�in�meeting�its�duty�of�care.�Such�needs�may�be�cultural,�physical,�linguistic,�economic�or�health-status�related�

education systematic�instruction�and�learning�activities�to�develop�or�bring�about�change�in�knowledge,�attitudes,�values�or�skills1

effective producing�the�desired�result

effectiveness care,�intervention�or�action�that�is�relevant�to�the�consumer�/�patient’s�needs�and�based�on�established�standards.�This�care,�intervention�or�action�achieves�the�desired�outcome20

efficiency achieving�desired�results�with�the�most�cost-effective�use�of�resources20

electronic records a�record�on�electronic�storage�media�that�is�produced,�communicated,�maintained�and/or�accessed�by�means�of�electronic�equipment.�An�Electronic�Health�Record�(EHR)�is�a�repository�of�information�regarding�the�health�status�of�a�consumer�/�patient,�in�computer-processable�form33

elements in�the�context�of�EQuIP5:�

elements�identify�what�should�be�in�place�to�achieve�the�criterion�at�a�certain�rating�level:�a�description�of�what�is�required�to�achieve�the�criterion.�These�provide�prompts�for�improvement�and�best�practice

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employee assistance program

a�proven�strategy�for�assisting�employees�and�their�families�with�personal�and�work-related�problems,�difficulties�and�concerns�which�they�may�experience�from�time�to�time�and�which�can�affect�work�performance

entry a�process�by�which�a�consumer�/�patient�comes�into�a�healthcare�organisation�to�receive�healthcare�services

end-of-life care a�quality�management�approach�that�evaluates�the�individual�holistic�needs�of�a�consumer�/�patient,�his�or�her�family�and/or�carers,�and�coordinates�appropriate�care�at�the�end�of�life.�It�recognises�the�interdependent�physical,�social,�emotional,�cultural�and�spiritual�aspects�of�care�and�includes�the�combination�of�broad�health�and�community�services�that�care�for�a�person�at�the�end�of�his�or�her�life34

environmental sustainability

development�that�meets�the�needs�of�the�present�without�compromising�the�ability�of�future�generations�to�meet�their�own�needs.�The�ability�to�maintain�the�balance�between�resources,�such�as�water,�timber�and�solar�energy,�and�living�organisms�such�as�humans,�animals�and�plants35,�36

error unintentionally�being�wrong�in�conduct�or�judgement.�Errors�may�occur�by�doing�the�wrong�thing�(commission)�or�by�failing�to�do�the�right�thing�(omission)37

ethics acknowledged�set�of�principles�which�guide�professional�and�moral�conduct

evaluation assessment�of�the�degree�of�success�in�meeting�the�goals�and�expected�results�(outcomes)�of�the�organisation,�services,�program�or�consumers�/�patients1

evidence data�and�information�used�to�make�decisions.�Evidence�can�be�derived�from�research,�experimental�learning,�indicator�data,�and�evaluations.�Evidence�is�used�in�a�systematic�way�to�evaluate�options�and�make�decisions1

evidence-based the�use�of�systematically�reviewed�appraised�clinical�research�findings�to�aid�the�delivery�of�optimum�clinical�care�to�consumers�/�patients38;�the�transfer�of�knowledge�from�research�into�healthcare�practice

external entity a�body�/�establishment�external�to�the�organisation

externally based references

reference�and�research�information�generated�outside�the�organisation,�such�as�journals,�internet�information,�research�databases,�library�resources,�etc.

feedback a�communication�from�a�consumer�/�patient�relaying�how�delivered�products,�services�and�information�compare�with�consumer�/�patient�expectations

flexible work practices working�arrangements�that�assist�employees�to�meet�personal�responsibilities,�such�as�caring�for�a�child�or�other�family�member.�These�may�include39:

• changes�in�hours�of�work

• changes�in�patterns�of�work

• changes�in�location�of�work

follow-up processes�and�actions�taken�after�a�service�has�been�completed1

formalised follow-up documented�processes�and�actions�taken�after�a�service�has�been�completed

governance the�set�of�relationships�and�responsibilities�established�by�a�healthcare�organisation�between�its�executive,�workforce�and�stakeholders�(including�consumers).�It�incorporates�the�set�of�processes,�customs,�policy�directives,�laws,�and�conventions�affecting�the�way�a�healthcare�organisation�is�directed,�administered�or�controlled.�Governance�arrangements�specify�the�mechanisms�for�monitoring�performance4

governing body a�body�that�carries�legal�accountability�and/or�scope�of�organisational�responsibility�for�the�services�provided,�such�as�an�individual�owner�or�a�group�of�senior�managers,�a�governing�body�of�directors,�a�board,�a�group�of�senior�managers��and/or�a�chief�executive�appointed�by�a�government�agency�

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seCtion 6Glossary

guidelines principles�guiding�or�directing�action.1�Clinical�practice�guidelines�are�systematically�developed�statements�to�assist�practitioner�and�consumer�/�patient�decisions�about�appropriate�health�care�for�specific�circumstances.40�Guidelines�in�the�EQuIP5�Guide�provide�essential�information�for�the�achievement�of�the�EQuIP5�standards

healthcare-associated infections

infections�acquired�in�healthcare�facilities�(nosocomial�infections)�and�infections�that�occur�as�a�result�of�healthcare�interventions�(iatrogenic�infections),�and�which�may�manifest�after�people�leave�the�healthcare�facility41

healthcare provider a�team�or�individuals�who,�in�cooperation�with�the�consumer�/�patient,�assume�responsibility�for�all�aspects�of�an�episode�of�care�in�response�to�the�diagnosis�and�needs�of�the�consumer�/�patient

health priority areas identified�health�areas�which�contribute�significantly�to�the�burden�of�illness�and�injury,�which�have�potential�for�health�gains�and�reduction�in�the�burden�of�disease.�These�priorities�sit�under�the�overarching�framework�of�the�National�Chronic�Disease�Strategy42–44

health record term�used�to�describe�many�types�of�data�and�reports�about�a�consumer�/�patient�stored�in�different�media45

health workforce the�workforce�that�provides�health�care�to�consumers�/�patients;�ranging�from�workers�with�no�formal�qualifications�providing�support�services�in�home-based�settings�through�to�highly�qualified�specialists�working�in�technology�intensive��super-acute�hospital�settings

High Priority Recommendation (HPR)

in�the�context�of�EQuIP5:�

a�recommendation�where�there�is�an�area�of�high�risk�identified�by�the�surveying�team�when:

• consumer�/�patient�care�is�compromised,�and/or

• the�safety�of�consumers�/�patients�and/or�staff�is�jeopardised

The�HPR�is�a�trigger�for�the�organisation�to�address�the�issue�either�at�an��AC60�or�at�a�Conditional�Survey

home ward outlier consumer / patient

a�consumer�/�patient�who�is�being�treated�in�an�area�of�the�organisation�that�normally�treats�a�different�casemix,�for�example,�a�consumer�/�patient�with�a�medical�condition�such�as�diabetes�who�may�be�admitted�to�a�surgical�ward�due�to�a�lack�of�available�medical�beds

iatrogenic arising�from�or�associated�with�health�care�rather�than�an�underlying�disease�or�injury37

ICD – 10 – AM a�system�of�codes,�from�a�set�of�defined�categories,�which�are�used�to�categorise�activity�in�a�consistent�and�systemised�way:�the�International�Classification�of�Diseases,�10th�Revision,�Australian�modification

incident an�event�or�circumstance�which�could�have�or�did�lead�to�unintended�and/or�unnecessary�harm�to�a�person,�and/or�complaint,�loss�or�damage4

include(s) a�list�that�provides�examples�and�is�not�limiting

indicator performance�measurement�tool,�screen�or�flag�that�is�used�as�a�guide�to�monitor,�evaluate,�and�improve�the�quality�of�services.�Indicators�relate�to�structure,�process�and�outcomes1

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infection control management plan

a�documented�plan�that�outlines�the�structure�of�an�infection�control�program,�its�overall�aims�and�objectives,�associated�quality�management�activities,�program�evaluation�criteria�and�timeframes�for�review.46�The�document�should�address�the�governance�of�infection�control�and�identify:

• who�is�at�risk�and�from�what

• the�hazards�involved

• the�procedures�for�minimising�risk

• appropriate�measures�for�infection�control,�based�on�standard�precautions�and�when�required,�additional�precautions

information management the�process�of�planning,�organising,�analysing�and�controlling�data�and�information.�The�management�of�information�applies�to�both�computer-based�and�manual�systems

information privacy the�right�of�a�person�to�control�the�use�and�disclosure�of�information�that�reveals�his�or�her�identity,�health�information�or�health�status

information system a�system�that�provides�access�to�information�using�hardware,�software,�supplies,�policies,�procedures�and�people�

information technology (IT)

mechanical�and�electronic�devices�designed�for�the�collection,�storage,�manipulation,�presentation�and�dissemination�of�information

integrated governance an�additional�approach�that�aims�to�strengthen�and�streamline�healthcare�organisation�governance�arrangements�by�focusing�on�quality4�as�the�driver�of�change�and�placing�clinical�governance�at�the�heart�of�governance�arrangements.�Considered�a�key�building�block�of�good�governance�in�health�care47

integrity, data the�characteristic�of�data�and�information�being�accurate�and�complete

interoperability the�ability�of�information�systems�to�reliably�exchange�information�without�error33

intervention any�act�performed�to�prevent�harming�of�a�consumer�/�patient�or�to�improve�the�mental,�emotional�or�physical�function�of�a�consumer�/�patient48

IT cost management a�mechanism�to�manage�IT�costs

IT security a�tangible�set�of�physical�and�logical�mechanisms�used�to�protect�information�held�in�hard�copy,�computer�systems�and�information,�and�telecommunication�infrastructure�from�unauthorised�access

IT system a�group�of�interacting,�interrelated�or�interdependent�elements�forming�or�regarded�as�forming�a�collective�entity

leadership the�ability�to�provide�direction�and�cope�with�change.�It�involves�establishing�a�vision,�developing�strategies�for�producing�the�changes�needed�to�implement�the�vision,�aligning�people,�and�motivating�and�inspiring�people�to�overcome�obstacles1�

legibility data�or�information�that�is�decipherable�or�readable16

legislation the�body�of�laws�made�by�Parliament.�These�consist�of:�acts�of�parliament;�and�regulations,�ordinances�and�rules�which�are�also�called�‘subordinate’�or�‘delegated’�legislation49

magnet hospital a�term�coined�in�the�United�States�from�research�that�sought�to�understand�why�certain�hospitals�were�able�to�attract�and�retain�staff�

management setting�targets�or�goals�for�the�future�through�planning�and�budgeting,�establishing�processes�for�achieving�those�targets�and�allocating�resources�to�accomplish�those�plans.�Ensuring�that�plans�are�achieved�by�organising,�staffing,�controlling�and�problem�solving1

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seCtion 6Glossary

mandatory criterion in�the�context�of�EQuIP5:

one�where�it�is�considered�that�without�Marked�Achievement�(evaluation),�the�quality�of�care�or�the�safety�of�people�within�the�organisation�could�be�at�risk

malnutrition a�state�of�nutrition�in�which�a�deficiency�or�excess�(or�imbalance)�of�energy,�protein,�and�other�nutrients�causes�measurable�adverse�effects�on�tissue�/�body�form�(shape,�size�and�composition)�and�function�and�clinical�outcome50

manual handling / task a�task�comprised�wholly�or�partly�by�any�activity�requiring�a�person�to�use�any�part�of�their�musculoskeletal�system�in�performing�their�work.�These�tasks�can�include51:

• lifting,�lowering,�pushing,�pulling,�carrying�or�otherwise�moving,�holding�or�restraining�any�person,�animal�or�item

• repetitive�actions

• sustained�work�postures

• exposure�to�vibration

medication error any�preventable�event�that�may�cause�or�lead�to�inappropriate�medication�use�or�consumer�/�patient�harm�while�the�medication�is�in�the�control�of�the�healthcare�professional�or�consumer�/�patient4

medication management the�processes�of�dispensing,�prescribing,�storing,�administering�and�monitoring�the�effects�of�medicines4

medico legal requirements

requirements�of�or�relating�to�both�medicine�and�law7

mission a�broad�written�statement�in�which�an�organisation�states�what�it�does�and�why�it�exists.�The�mission�sets�apart�one�organisation�from�another1

monitor to�check,�supervise,�observe�critically,�measure�or�record�the�progress�of�an�activity,�action�or�system�on�a�regular�basis�in�order�to�identify�change�and/or�track�change37

morbidity a�diseased�state�or�symptom�or�the�incidence�of�disease;�the�rate�of�sickness�in�a�specified�community�or�group7

mortality the�number�of�deaths�in�a�given�time�or�place�or�the�proportion�of�deaths�to�a�given�population7

multidisciplinary care�or�a�service�given�with�input�from�more�than�one�discipline�or�profession

National Chronic Disease Strategy

the�overarching�framework�of�national�direction�for�improving�chronic�disease�prevention�and�care�across�Australia.�A�nationally�agreed�agenda�to�encourage�coordinated�action�in�response�to�the�growing�impact�of�chronic�disease�on�the�health�of�Australians�and�the�healthcare�system42

near miss an�incident�that�did�not�cause�harm,�but�had�the�potential�to�do�so4

needs physical,�mental,�emotional,�social�or�spiritual�requirement�for�wellbeing.�Needs�may�or�may�not�be�perceived�or�expressed�by�those�in�need.�They�must�be�distinguished�from�demands,�which�are�expressed�desires,�not�necessarily�needs1

non-clinical information information�that�is�not�direct,�personal�consumer�/�patient�information

non-surgical wounds in�the�context�of�EQuIP5:

wounds�that�may�arise�following�admission�to�a�health�service�and�only�whilst�the�consumer�/�patient�is�admitted.�This�encompasses�pressure�ulcers,�or�ulcers�that�may�develop�by�other�means;�skin�tears,�caused�by�friction�and/or�tearing;�skin�infections,�etc.�This�does�not�include�wounds�that�would�be�the�purpose�of�the�admission,�such�as�burns,�wounds�related�to�cancers,�radiation�injuries�etc.

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nutrition care interventions,�monitoring,�and�evaluation�designed�to�facilitate�appropriate�nutrient�intake�based�upon�the�integration�of�information�from�the�nutrition�assessment6,�52

nutrition screening the�process�of�identifying�consumers�/�patients�with�characteristics�commonly�associated�with�nutrition�problems�who�may�require�comprehensive�nutrition�assessment�and�may�benefit�from�nutrition�intervention50

nutrition assessment a�comprehensive�approach�to�gathering�pertinent�data�in�order�to�define�nutritional�status�and�identify�nutrition-related�problems.�The�assessment�often�includes�consumer�/�patient�history,�medical�diagnosis�and�treatment�plan,�nutrition�and�medication�histories,�and�nutrition-related�physical�examination�including�anthropometry,�nutritional�biochemistry,�psychological,�social,�and�environmental�aspects50

objective target�that�must�be�reached�if�the�organisation�is�to�achieve�its�goals.�It�is�the�translation�of�the�goals�into�specific,�concrete�terms�against�which�results�can�be�measured1

ongoing care the�active�and�supportive�management�of�care�for�people�with�chronic�or�complex�conditions�as�well�as�the�process�that�follows�an�admission�to�a�healthcare�organisation�

open disclosure the�open�discussion�of�incidents�that�resulted�in�harm�to�a�consumer�/�patient�while�receiving�health�care.�The�criteria�of�open�disclosure�are�an�expression�of�regret,�a�factual�explanation�of�what�happened�and�the�potential�consequences,�and�the�steps�being�taken�to�manage�the�event�and�prevent�recurrence4

operational plan a�short-term�plan�that�details�how�aspects�of�a�strategic�plan�will�be�accomplished

organisation all�sites�/�locations�under�the�governance�of,�and�accountable�to,�the�governing�body�/�owner(s)1

orientation a�formal�process�of�informing�and�training�staff�on�entry�into�a�position�or�organisation,�covering�the�policies,�processes�and�procedures�applicable�to�that�healthcare�organisation4

outcome results�that�may�or�may�not�have�been�intended�that�occur�as�a�result�of�a�service�or�intervention

palliative care plan a�written�statement�developed�for�a�consumer�/�patient�who�is�suffering�from�a�life-limiting�illness,�with�little�or�no�prospect�of�a�cure,�and�for�whom�the�primary�treatment�goal�is�quality�of�life,�which�states�the�nursing�and�other�interventions�to�be�undertaken,�the�health�outcomes�to�be�achieved�and�the�review�of�care�which�will�occur�at�regular�intervals53

pathway a�multidisciplinary�plan�of�care�that�commences�before�or�on�admission�and�finishes�at�discharge�

patient master index permanent�listing�or�register�of�health�information�held�by�an�organisation�on�consumers�/�patients�who�have�received�or�are�scheduled�to�receive�services4�

performance measure in�the�context�of�EQuIP5:�

suggested�indicators�at�the�end�of�each�criterion�in�the�Guide�provided�to�assist�organisations�to�identify,�or�‘flag’,�an�issue�that�may�need�further�investigation�and�to�assist�in�the�evaluation�of�processes.�These�measures�are�distinct�from�clinical�indicators,�available�to�organisations�through�the�ACHS�Clinical�Indicator�Program

personal information information�or�an�opinion�(including�information�or�an�opinion�forming�part�of�a�database),�whether�true�or�not,�and�whether�recorded�in�a�material�form�or�not,�about�an�individual�whose�identity�is�apparent,�or�can�reasonably�be�ascertained,�from�the�information�or�opinion54

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seCtion 6Glossary

policy written�statement(s)�which�acts�as�a�guideline�and�reflects�the�position�and�values�of�the�organisation�on�a�given�subject.1�All�procedures�and�protocols�should�be�linked�to�a�policy�statement4

pressure ulcer a�localised�injury�to�the�skin�and/or�underlying�tissue,�usually�over�a�bony�prominence�and�caused�by�unrelieved�pressure,�friction�or�shear.�Pressure�ulcers�occur�most�commonly�on�the�sacrum�and�heel�but�can�develop�anywhere�on�the�body.�Pressure�injury�is�a�synonymous�term�for�pressure�ulcer4

prevention and management

a�systematic�approach�adopted�by�all�sections�of�an�organisation�to�ensure�appropriate�identification�and�actions�for�consumers�/�patients�at�risk�of�an�illness�or�condition

procedure a�set�of�documented�instructions�conveying�the�approved�and�recommended�steps�for�a�particular�act�or�sequence�of�acts

process a�series�of�actions,�changes�or�functions�that�bring�about�an�end�or�a�result

psycho-social pertaining�to�a�combination�of�psychological�and�social�factors48

quality activities activities�which�measure�performance,�identify�opportunities�for�improvement�in�the�delivery�of�care�and�service,�and�include�actions�and�follow-up

quality framework an�overarching�approach�to�quality�improvement�that�promotes�integration�of�risk�management�with�quality�improvement�strategies�and�informs�decision�making�and�planning55

quality improvement ongoing�response�to�quality�assessment�data�about�a�service�in�ways�that�improve�the�processes�by�which�services�are�provided�to�consumers�/�patients1

quality use of medicines the�judicious,�appropriate,�safe�and�effective�use�of�medicines56

records all�records�within�the�organisation,�clinical�and�non-clinical

records management field�of�management�responsible�for�the�efficient�and�systematic�control�of�the�creation,�receipt,�maintenance,�use�and�disposition�of�records57

record safety the�physical�safety�of�records�such�as�from�light,�humidity,�vermin,�fire�and�moisture

record storage the�function�of�storing�records�for�future�retrieval�and�use57

recruitment and selection process�used�to�attract,�choose�and�appoint�qualified�staff32

referral the�process�of�directing�or�redirecting�a�consumer�/�patient�to�an�appropriate�specialist�or�agency�for�definitive�treatment7

relevant in�the�context�of�EQuIP�standards:

when�something�is�connected�with�a�matter;�when�there�is�a�logical�connection

research an�active,�diligent�and�systematic�process�of�inquiry�in�order�to�discover,�interpret�or�revise�facts,�events,�behaviours,�or�theories,�or�to�make�practical�applications�with�the�help�of�such�facts,�laws�or�theories�

risk the�effect�of�uncertainty�on�objectives�which�may�be�positive�and/or�negative.�Objectives�can�have�different�aspects,�such�as�financial,�health�and�safety,�and�environmental�goals�and�can�apply�at�different�levels,�such�as�strategic,�organisation-wide,�project,�product�and�process.�Risk�is�often�expressed�in�terms�of�a�combination�of�the�consequences�of�an�event�and�the�associated�likelihood�of�occurrence58

risk management coordinated�activities�to�direct�and�control�an�organisation�with�regard�to�risk,�such�as�activities�that�identify,�control�and�minimise�threats�to�the�ongoing�efficiency,�effectiveness�and�success�of�its�operations�to�deliver�desired�outcomes4,�58�

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October 2010  475

risk management framework

a�set�of�components�that�provide�the�foundations�and�organisational�arrangements�for�designing,�implementing,�monitoring,�reviewing�and�continually�improving�risk�management�throughout�the�organisation.�The�framework�should�be�embedded�within�the�organisation's�overall�strategic�and�operational�policies�and�practices58

root cause analysis (RCA)

a�systematic�process�whereby�the�factors�which�contributed�to�an�incident�are�identified37

sample blood�samples�collected�from�a�consumer�/�patient�for�purposes�of�blood�or�blood�product�/�component�transfusion�/�infusion

sampling the�collection�of�a�sample�from�a�consumer�/�patient

scope of clinical practice the�extent�of�an�individual�medical�practitioner’s�clinical�practice�within�a�particular�organisation,�based�on�the�individual’s�credentials,�competence,�performance�and�professional�suitability,�and�the�needs�and�the�capability�of�the�organisation�to�support�the�medical�practitioner’s�scope�of�clinical�practice.59�This�is�delineated�after�the�process�of�credentialling

self identified Aboriginal or Torres Strait Islander person

a�person�of�Aboriginal�or�Torres�Strait�Islander�descent�who�identifies�as�an�Aboriginal�or�Torres�Strait�Islander�and�is�accepted�as�such�by�the�community�in�which�he�or�she�lives60

sentinel event an�unexpected�occurrence�involving�death�or�serious�physical�or�psychological�injury,�or�the�risk�thereof.�Serious�injury�specifically�includes�loss�of�limb�or�function.�The�phrase�"or�the�risk�thereof"�includes�any�process�variation�for�which�a�recurrence�would�carry�a�significant�chance�of�a�serious�adverse�outcome.�Such�events�signal�the�need�for�immediate�investigation�and�response6

services products�of�the�organisation�delivered�to�consumers�/�patients,�or�units�of�the�organisation�that�deliver�products�to�consumers�/�patients1

skillmix the�mix�of�posts,�grades�or�occupations�within�a�unit�/�organisation.�It�may�also�refer�to�the�combinations�of�activities�or�skills�needed�for�each�job�within�the�organisation61�

specialty ward area in�the�context�of�EQuIP5:

an�area�of�an�organisation�that�normally�treats�consumers�/�patients�with�a�specific�casemix,�for�example,�an�orthopaedic�ward,�a�paediatric�ward,�a�maternity�ward,�etc.

staff term�which�includes�employed,�visiting,�sessional,�contracted�or�volunteer�personnel

stakeholder individuals,�organisations�or�groups�that�have�an�interest�or�share�in�services1

standard a�desired�and�achievable�level�of�performance�against�which�actual�performance�is�measured1

statutory notifications any�notification�required�by�an�act�of�parliament�

statutory requirements any�requirement�laid�down�by�an�act�of�parliament�

strategic plan a�formalised�plan�that�establishes�an�organisation’s�overall�objectives�and�that�seeks�to�position�the�organisation�in�terms�of�its�environment1

strategy a�long-term�plan�of�action�designed�to�achieve�a�particular�objective

surveillance the�ongoing,�systematic�collection,�analysis�and�interpretation�of�health-related�data�essential�to�the�planning,�implementation�and�evaluation�of�public�health�practice62,�closely�integrated�with�the�timely�dissemination�of�these�data�to�those�responsible�for�prevention�and�control63

survey external�peer�review�which�measures�the�performance�of�the�organisation�against�an�agreed�set�of�standards32

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476  The ACHS EQuIP5 Guide  Book 2  Accreditation, Standards and Guidelines  Support and Corporate Functions

seCtion 6Glossary

References1.� International�Society�for�Quality�in�Health�Care�(ISQua).�

TheISQuasurveyortrainingstandardsprogramme.Dublin�IRL;�ISQua;�2009.

2.� NSW�Health.Guidelinesforend-of-lifecareanddecision-making.�Sydney;�NSW�Health;�2005.

3.� Queensland�Health,�Admitted�Patient�Data�Collection�(QHAPDC).�QueenslandHealthAdmissionpolicy.AppendixF:Criteriaforadmission.�Brisbane;�Qld�Health.�Accessed�from�http://www.health.qld.gov.au/hic/qhapdc2006/Appendix_F.pdf�on�20�August�2010.

4.� Australian�Commission�on�Safety�and�Quality�in�Health�Care.�ConsultationpaperonthedraftNationalSafetyandQualityHealthcareStandards,August2010.Sydney�NSW;�ACSQHC;�2010.

5.� World�Health�Organization.�Finaltechnicalreport:TheconceptualframeworkfortheInternationalClassificationforPatientSafety,Version1.1.�Geneva�CH;�WHO;�2009.

6.� Joint�Commission�on�Accreditation�of�Healthcare�Organisations�(JCAHO).�Sentineleventglossaryofterms.Oakbrook�Terrace�USA;�JCAHO.�Accessed�from�http://www.jointcommission.org/SentinelEvents/se_glossary.htm�on�9�September�2010.

7.� MedlinePlus�Medical�Dictionary.�MedicalDictionary.Merriam-Webster.�Accessed�from�http://www.merriam-webster.com/medlineplus/at%20risk�on�12�August�2010.

8.� National�Blood�Authority�(NBA).�Nationalhaemovigilancedatadictionary:AguideforformattinghaemovigilancedatafortheAustraliannationalhaemovigilancedataset.3rd�edn.�Canberra�ACT;�NBA;�2010.

9.� Energy�Australia.�Whatarecarbonemissions?�In:�University�of�Sydney�Integrated�Sustainability�Analysis�Group.�Carbonemissions&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.�Victorianservicecoordinationpracticemanual.�Melbourne;�Victorian�Department�of�Human�Services;�2009.

11.� Australian�Commission�on�Safety�and�Quality�in�Health�Care�(ACSQHC).�ConsultationPaperontheNationalSafetyandQualityHealthcareStandards(Draft).Sydney�NSW;�ACSQHC;�2009.

12.� Australian�Council�on�Healthcare�Standards�(ACHS).�News�in�brief:�Clinical�governance�defined.�ACHSNews,�2004;�12(Spring):�4.

13.� Australian�Commission�on�Safety�and�Quality�in�Health�Care�(ACSQHC).�Windowsintosafetyandqualityinhealthcare2008.�Sydney�NSW;�ACSQHC;�2008.

14.� Sydney�South�West�Area�Health�Service.�Guideline:clinicalhandover.�Sydney;�NSW�Health;�2007.

system the�resources,�policies,�processes�and�procedures�that�are�organised,�integrated,�regulated�and�administered�to�accomplish�an�objective4

tracking creating,�capturing�and�maintaining�information�about�the�movement�and�use�of�records57

training the�development�of�practical�skills�that�should�be�related�to�the�professional�development�needs�of�the�individual�and�organisation�and�may�be�incorporated�into�professional�development�programs4

unique identifier universal�number�or�code�that�uniquely�identifies�a�person�or�other�discrete�entity33

validation to�make�sound,�ratify,�confirm,�substantiate�or�to�give�legal�force�to.�Validity�deals�with�the�relationship�of�the�data�obtained�to�the�purpose�for�which�it�accomplishes,�or�measures�what�it�seeks�to�measure

values principles�and�beliefs�that�guide�an�organisation�and�may�involve�social�or�ethical�issues

vision description�of�what�the�organisation�would�like�to�be1

waiting list a�register�which�contains�essential�details�about�consumers�/�patients�who�have�been�assessed�as�needing�elective�care

when required required�at�the�time

where required required�in�certain�circumstances

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October 2010  477

15.� ACHS�Performance�and�Outcomes�Service.�ACHSclinicalindicatorprograminformation2010.�Sydney�NSW;�Australian�Council�on�Healthcare�Standards�(ACHS);�2010.

16.� Abdelhak�M,�Grostick�S,�Hanken�MA�and�Jacobs�E.�Healthinformation:Managementofastrategicresource.2nd�edn.�Philadelphia�USA;�Saunders;�2001.

17.� Frommer�M,�Heinke�M�and�Barton�M.�Credentiallingofcancerclinicians:AguideforAustralianhealthcareorganisations.Sydney�NSW;�Cancer�Council�Australia�and�the�Australian�Cancer�Network;�2005.

18.� Australian�Health�Practitioner�Regulation�Agency�(AHPRA).�Registrationprocess.�Canberra�ACT;�AHPRA.�Accessed�from�http://www.ahpra.gov.au/Registration/Registration-Process.aspx�on�16�July�2010.

19.� South�Australian�Government�and�Northern�Territory�Government.�Australiancodesofpracticedatabase.Accessed�from�http://codes.bli.net.au/Codes.asp?Section=90�on�10�September�2010.

20.� National�Health�Information�Standards�and�Statistics�Committee�(NHISSC).Nationalhealthperformanceframework.2nd�edn.�Canberra�ACT;�AIHW;�2009.

21.� Gregory�J.�ConsumerengagementinAustralianhealthpolicy:FinalreportoftheAIHPSresearchproject.Melbourne�VIC;�Australian�Institute�of�Health�Policy�Studies�(AIHPS);�2008.

22.� SA�Health.�Consumerandcommunityparticipationpolicydirective.�Adelaide;�Government�of�South�Australia;�2009.

23.� Austin�Health.�Consumerandcommunityparticipation.Heidelberg�VIC;�Austin�Health.�Accessed�from�http://www.austin.org.au/Page.aspx?ID=138�on�9�June�2010.

24.� UK�Department�of�Health.Afirstclassservice,qualityinthenewNHS.�London�UK;�National�Health�Service.�Accessed�from�http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4006902�on�1�September�2010.

25.� ASX�Corporate�Governance�Council.�Corporategovernanceprinciplesandrecommendations.�Sydney�NSW;�Australian�Securities�Exchange�(ASX);�2007.

26.� Australian�Council�for�Safety�and�Quality�in�Health�Care.Standardforcredentiallinganddefiningscopeofclinicalpractice.Canberra�ACT;�Australian�Council�for�Safety�and�Quality�in�Health�Care;�2004.

27.� Stewart�S.�Culturalcompetenceinhealthcare.Sydney�NSW;�Diversity�Health�Institute,�SWAHS;�2006.

28.� Forster�P.�Queenslandhealthsystemsreview.FinalreportBrisbane;�Queensland�Govt;�2005.

29.� Royal�Australasian�College�of�Surgeons�(RACS).�Positionpaper:Appointmentsandcredentialingcommitteesthatdefinescopeofpractice.�Melbourne�VIC;�RACS;�2009.

30.� Australian�Commission�on�Safety�and�Quality�in�Health�Care�(ACSQHC).�NationalConsensusStatement:essentialelementsforrecognisingandrespondingtoclinicaldeterioration.�Sydney�NSW;�ACSQHC;�2010.

31.� Ma�E,�Coleman�E,�Fish�Retal.Quantifying�posthospital�care�transitions�in�older�patients.�JAmMedDirAssoc2004;�5(2):�71-74.

32.� Shaw�CD�and�ISQua�toolkit�working�group.�Toolkitforaccreditationprograms:Someissuesinthedesignandredesignofexternalhealthcareassessmentandimprovementsystems.Melbourne�VIC;�ISQua;�2004.

33.� National�E-Health�Transition�Authority�(NEHTA).�Acronyms,abbreviations&glossaryofterms.�Sydney�NSW;�NEHTA;�2005.

34.� Palliative�Care�Australia�(PCA).�Palliativecare–Glossaryofterms.Melbourne�VIC;�PCA;�2008.

35.� Green�Times,�your�online�green�journal�and�directory.�Environmentalsustainability.�Sydney�NSW;�Sierra�Marketing.�Accessed�from�http://www.greentimes.com.au/glossary/categories/lifestyle/environmental-sustainability.html�on�14�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�and�definitions�for�safety�and�quality�concepts.�MedJAust2006;�184(10�Suppl):�S41-S43.

38.� Rosenberg�W�and�Donald�A.�Evidence-based�medicine:�an�approach�to�clinical�problem�solving.�BMJ�1995;�310(6987):�1122-1126.

39.� Fair�Work�Australia�and�Fair�Work�Ombudsman.�Fairworkonline.�Canberra�ACT,�Australian�Government.�Accessed�from�http://www.fairwork.gov.au/Pages/default.aspx�on�17�March�2010.

40.� Field�MJ,�Lohr�KN�and�the�Committee�to�Advise�the�Public�Health�Service�on�Clinical�Practice�Guidelines,�Institute�of�Medicine�(eds).�Clinicalpracticeguidelines:Directionsforanewprogram.�Washington�DC�USA;�National�Academies�Press;�1990.

41.� National�Health�and�Medical�Research�Council�(NHMRC).�Australianguidelinesforthepreventionandcontrolofinfectioninhealthcare(ConsultationDraft).Canberra�ACT;�Australian�Government;�2010.

42.� National�Health�Priority�Action�Council�(NHPAC).�Nationalchronicdiseasestrategy.Canberra�ACT;�Australian�Health�Ministers’�Advisory�Council�(AHMAC);�2005.

43.� Australian�Institute�of�Health�&�Welfare�(AIHW).�Chronicdisease:Nationalchronicdiseasestrategy.�Canberra�ACT;�AIHW.�Accessed�from�http://www.health.gov.au/internet/main/publishing.nsf/Content/pq-ncds-strat�on�17�August�2010.

44.� Australian�Institute�of�Health�&�Welfare�(AIHW).NationalHealthPriorityAreaFAQs.Canberra�ACT;�Australian�Government.�Accessed�from�http://www.aihw.gov.au/nhpa/faqs.cfm#NHPA_what�on�10�September�2010.

45.� United�Medical�Protection�(UMP).�Medico-legalhandbook:Aguidetolegalissuesinmedicalpractice.Sydney�NSW;�UMP;�2003.

46.� Queensland�Communicable�Diseases�Unit.Infectioncontrolguidelines–extract.�2nd�edn.�Brisbane;�Queensland�Health;�2001.

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478  The ACHS EQuIP5 Guide  Book 2  Accreditation, Standards and Guidelines  Support and Corporate Functions

seCtion 6Glossary

47.� National�Health�Service�(NHS).�Integratedgovernancehandbook:Ahandbookforexecutivesandnon-executivesinhealthcareorganisations.London�UK;�Department�of�Health;�2006.

48.� Harris�PG,�Nagy�S�and�Vardaxis�N�(eds).Mosby’sdictionaryofmedicine,nursingandhealthprofessions.Sydney�NSW;�Mosby�Elsevier;�2010.

49.� Law�Reform�Commission�NSW�(NSW�LRC).�DiscussionPaper30(1993)–ReviewoftheAnti-DiscriminationAct1977(NSW).Lawlink�NSW.�Sydney�NSW;�NSW�LRC.�Accessed�from�http://www.lawlink.nsw.gov.au/lrc.nsf/pages/DP30TOR�on�16�September�2010.

50.� Dietitians�Association�of�Australia.�Evidence�based�practice�guidelines�for�the�nutritional�management�of�malnutrition�in�adult�patients�across�the�continuum�of�care.�Nutr�Diet�2009;�66(Suppl.):�S1-S34.

51.� Australian�Safety�and�Compensation�Council�(ASCC).�Nationalstandardformanualtasks.Canberra�ACT;�ASCC;�2007.

52.� American�Society�for�Parenteral�and�Enteral�Nutriton�(ASPEN).�Definitionofterms.Silver�Spring�USA;�ASPEN.�Updated:�November�2009.�Accessed�from�http://www.nutritioncare.org/lcontent.aspx?id=546�on�14�September�2010.

53.� Palliative�Care�Australia�(PCA).�StandardsforprovidingqualitypalliativecareforallAustralians.�Canberra�ACT;�PCA;�2005.

54.� PrivacyAct�(1988)(Cth.)

55.� Australian�Council�on�Healthcare�Standards�(ACHS).�Riskmanagementandqualityimprovementhandbook.Sydney�NSW:�ACHS;�2007.�Accessed�from�http://www.achs.org.au/RiskMgmtQIHandbook/�on�27�July�2010.

56.� Australian�Council�for�Safety�and�Quality�in�Health�Care.�Thenationalstrategyforqualityuseofmedicines.Canberra�ACT;�Department�of�Health�and�Ageing;�2002.

57.� AS�ISO�15489.1:2002�Recordsmanagement:General.

58.� AS/NZS�ISO�31000:2010�Riskmanagement—Principlesandguidelines.

59.� Queensland�Health.�CredentialinganddefiningthescopeofclinicalpracticeformedicalpractitionersinQueensland:Apolicyandresourcehandbook.�Brisbane;�Queensland�Government;�2009.

60.� ‘The�Commonwealth�Definition’,�High�Court�judgement�in�the�case�of�CommonwealthvTasmania(1983)�46�ALR�625.

61.� Buchan�J�and�Dal�Poz�MR.�Skill�mix�in�the�health�care�workforce:�reviewing�the�evidence.�BullWorldHealthOrgan�2002;�80:�575-580.

62.� World�Health�Organization�(WHO).Publichealthsurveillance.�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�surveillance�in��the�United�States.�Epidemiol�Rev�1988;�10:�164-190.

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A

ACHS Australian�Council�on�Healthcare�Standards

ADG Australian�Dangerous�Goods

AEC Animal�Ethics�Committee

AHMC Australian�Health�Ministers’�Conference

AHRQ Agency�for�Healthcare�Research�and�Quality

ALARA As�Low�As�Reasonably�Possible

ANZCMHN Australian�and�New�Zealand�College�of�Mental�Health�Nurses

ANZICS Australian�and�New�Zealand�Intensive�Care�Society

ANZSBT Australian�and�New�Zealand�Society�of�Blood�Transfusion

APAC Australian�Pharmaceutical�Advisory�Council

ARCBS Australian�Red�Cross�Blood�Service

ASERNIP-S Australian�Safety�and�Efficacy�Register�of�New�Interventional�Procedures–Surgical

ARPANSA Australian�Radiation�Protection�and�Nuclear�Safety�Agency�

AS/NZS Australian�and�New�Zealand�Standard

B

C

CABG Coronary�Artery�Bypass�Graft(s)

CCTV Closed�Circuit�Television

CEO Chief�Executive�Officer

CI Clinical�Indicator�

CIAP Clinical�Information�Access�Program

CJD Creutzfeldt-Jakob�Disease

CPD Continuing�Professional�Development

CPI Clinical�Practice�Improvement

CQI Continuous�Quality�Improvement

CPR Cardiopulmonary�Resuscitation�

CSM Customer�Services�Manager�

D

DNA Deoxyribonucleic�Acid

DRG Diagnosis�Related�Group

E

EA Excellent�Achievement�(EQuIP�Rating)

EAP Employee�Assistance�Program

ED Emergency�Department

EEO Equal�Employment�Opportunities

EPA Environmental�Protection�Authority�

EQuIP Evaluation�and�Quality�Improvement�Program

seCtion 6EQuIP5 Acronyms

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seCtion 6EQuIP5 Acronyms

F

FTE Full�Time�Equivalent

G

g / L Haemoglobin�is�measured�in�grams�(g)�per�litre�(L)

GP General�Practitioner

H

HACC Health�and�Ageing�Home�and�Community�Care

Hb Haemoglobin

HIV Human�Immunodeficiency�Virus

HREC Human�Research�Ethics�Committee

HRM Human�Resources�Management

HSANZ Haematology�Society�of�Australia�&�New�Zealand

I

I&CT Information�and�Communication�Technology

ICMP Infection�Control�Management�Plan

ICU Intensive�Care�Unit

IM Information�Management

ISO International�Organization�for�Standardization

IT Information�Technology

J

JMO Junior�Medical�Officer

K

KPI Key�Performance�Indicator

L

LA Little�Achievement�(EQuIP�Rating)

LMCA Left�Main�Coronary�Artery

M

MA Marked�Achievement�(EQuIP�Rating)

MET Medical�Emergency�Team

MSDS Material�Safety�Data�Sheets

N

NA Not�Applicable

NATA National�Association�of�Testing�Authorities

NBA National�Blood�Authority

NCDDD National�Cardiovascular�Disease�and�Diabetes�Register

NEHTA National�E-Health�Transition�Authority

NFR Not�For�Resuscitation�

NHMRC National�Health�and�Medical�Research�Council

NHPA National�Health�Priority�Areas

NICS National�Institute�of�Clinical�Studies

NOHSC National�Occupational�Health�and�Safety�Commission

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NPAAC National�Pathology�Accreditation�Advisory�Council

NPP National�Privacy�Principles

NPS National�Prescribing�Service

NSQHS (STANDARDS)

National�Safety�and�Quality�Health�Service�(Standards)

O

OA Outstanding�Achievement�(EQuIP�Rating)

OH&S Occupational�Health�and�Safety

OWS Organisation-Wide�Survey�(ACHS�EQuIP�survey)

P

PBS Pharmaceutical�Benefits�Scheme

PDCA Plan,�Do,�Check,�Act

PDSA Plan,�Do,�Study,�Act

POS Performance�Outcomes�Service�(ACHS)

PR Periodic�Review�(ACHS�EQuIP�survey)

Q

QA Quality�Assurance

QI Quality�Improvement

QUM Quality�Use�of�Medicine

R

RACP Royal�Australasian�College�of�Physicians

RACS Royal�Australasian�College�of�Surgeons

RAND Corporation,�the�name�of�which�was�derived�from�a�contraction��of�the�termresearchanddevelopment

RANZCA Royal�Australian�and�New�Zealand�College�of�Anaesthetists

RCA Root�Cause�Analysis

RCBS Red�Cross�Blood�Service

RCNA Royal�College�of�Nursing,�Australia

S

SA Some�Achievement�(EQuIP�Rating)

SHPA Society�of�Hospital�Pharmacists�of�Australia

SIDS Sudden�Infant�Death�Syndrome

T

TQM Total�Quality�Management

U

UCLA University�of�California,�Los�Angeles

V

VA Veterans’�Affairs

VMO Visiting�Medical�Officer

VTE Venous�Thromboembolism

WXYZ

WHO World�Health�Organization

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seCtion 6Acknowledgements

482  The ACHS EQuIP5 Guide  Book 2  Accreditation, Standards and Guidelines  Support and Corporate Functions

The�revision�of�the�Evaluation�and�Quality�Improvement�Program�(EQuIP)�is�a�major�undertaking�that�extends�over�several�years.�EQuIP5�represents�the�culmination�of�dedication�and�commitment�by�many�organisations�and�individuals�to�the�promotion�of�safety�and�quality�in�health�care.�

The�Australian�Council�on�Healthcare�Standards�(ACHS)�acknowledges�the�individuals�who�committed�their�knowledge,�experience�and,�more�significantly,�their�time�to�this�complex�task.

The�revision�of�EQuIP�programs�is�led�by�the�ACHS�Standards�Committee,�whose�role�it�is�to�steer�the�direction�and�content�of�the�standards�review�and�to�advise�on�the�applicability�of�the�standards�for�implementation�and�accreditation.�The�Standards�Committee�is�a�subcommittee�of�the�ACHS�Board�and�reports�its�recommendations�directly�to�the�ACHS�Board.�

The�development�of�EQuIP5�involved�the�formation�of�nine�working�groups,�each�chaired�by�a�member�of�the�Standards�Committee.�The�membership�of�the�working�groups�also�included�representation�from�a�broad�cross-section�of�member�organisations,�and�an�ACHS�Customer�Services�Manager�(CSM).

In�addition,�Specialist�Reference�Groups�were�established�to�review�specific�EQuIP5�criteria�and�guidelines�and�assist�in�their�development.

ACHS Board of Directors Assoc Prof Peter Woodruff (President)MBBS, ChM, FRCS, FRACS, FACS

Ms Karen Linegar (Vice President)RN, RM, BAppSc(Nurs), BBus, MHA, Dip Comm Law, FRCNA, JP

Mr John Smith PSM (Treasurer)MHA, Grad Dip HSM, AFCHSM, CHE, FAHSFMA, AFAHRI, AFAIM, FHFM, FAICD

Ms Jennie Baker BHSc(Mgt), BBus(IR), MLegSt, MIR, FCHSM, CHE

Ms Helen DowlingBPharm, Dip Hosp Pharm (Admin), Grad Dip QI HCare, CHP, FSHP, AICD

Dr David Lord MBBS, DPM, FRANZCP

Mr Russell McGowan BA

Ms Kae MartinRN, RM, BHSc(Nurs), MHA, LLB, AFCHSM

Dr Leonard Notaras AMLLB, BA, Dip Comm, BMed, MHA, MA, AFCHSM

Dr Robert PorterMBBS, FRACGP, FRACMA, AFCHSE

Mr Michael RoffGrad Cert Mgt

Dr Dana Wainwright MBBS, FRACP

Mr Stephen Walker Ass Dip Eng, BBus, Grad Dip Acc, AFCHSM, AICD

ACHS Standards CommitteeMs Helen Dowling (Chair)BPharm, Dip Hosp Pharm (Admin), Grad Dip QI HCare, CHP, FSHP, AICDStandards�Committee�Chair�(2008–),�ACHS�Board�Member,�ACHS�SurveyorArea�Director�of�Pharmacy,�Hunter�New�England�Health,�NSW�

Ms Jackie BullockRN, BA(Govt Studies) Quality�Improvement�Manager,�Hollywood�Private�Hospital,�WA

Ms Margo CarberryRN, C&FHN, AFAAQHCACHS�Surveyor,�Acting�Community�Health�Manager,�Hunter�New�England�Health�Service,�NSW�

Assoc Prof Brett EmmersonMBBS, MHA, FRANZCP, FRACMAACHS�Councillor,�ACHS�SurveyorExecutive�Director,�Division�of�Mental�Health�Services,�Metropolitan�North�Service�District,�Qld�

Dr Philip HoyleMBBS, MHA, FRACMAACHS�SurveyorMedical�Director,�Royal�Adelaide�Hospital,�SA

Mr John KennyBSc, Grad Dip QAConsultant,�Representative�of�Quality�Health�New�Zealand,�NZ

Ms Maralyn MastersRN, Grad Dip HSMACHS�CouncillorDirector�of�Nursing,�Adelaide�Day�Surgery,�SA

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October 2010  483

Ms Sue McKeanMHSc(Risk Man), Grad Dip OHS, Dip OHSCorporate�Risk�&�Quality�Manager,�UnitingCare�Health,�Qld

Ms Alison McMillanRN, BEd, MBAACHS�CouncillorDirector,�Quality,�Safety�&�Patient�Experience,�Department�of�Health,�Vic

Ms Sandra MillerBHSc(MRA), Grad Dip HSc (Epi & Bio)Director,�Safety�&�Quality�Performance,�Sir�Charles�Gairdner�Hospital,�WA

Mr Stephen Walker Ass Dip Eng, BBus, Grad Dip Acc, AFCHSM, AICDACHS�Board�memberChief�Executive�Officer,�St�Andrew’s�Hospital,�SA

Ms Patricia WarnBA Representative,�Consumers’�Health�Forum,�NSW�

Assoc Prof Peter Woodruff MBBS, ChM, FRCS, FRACS, FACSACHS�PresidentACHSI�Board�member�Director�of�Vascular�Surgery,�Princess�Alexandra�Hospital,�Qld�(2003–2009)

Working Group 1: Continuum of CareCriteria 1.1.1, 1.1.2, 1.1.3, 1.1.4, 1.1.5, 1.1.6, 1.1.7

Working Group Chair: Ms Helen Dowling

Ms�Brigitte�Kaiser,�CSM

Ms�Vijia�Chain,�Consultant,�NSW

Ms�Karen�Edwards,�ACHS�Surveyor.�Chief�Executive�Officer,�Calvary�Health�Care,�Sydney,�NSW

Assoc�Prof�Brett�Emmerson,�ACHS�Surveyor.�Executive�Director,�Division�of�Mental�Health�Services,�Metropolitan�North�Service�District,�Qld

Ms�Jacqueline�Flynn,�Director�of�Nursing�Services,�Christchurch�Hospital,�NZ

Mr�David�Henderson,�ACHS�Surveyor,�Qld

Ms�Beth�Hooper,�Clinical�Manager–Anaesthetics/Recovery,�Ashford�Hospital,�SA

Mr�Ahmed�Jamal,�Clinical�Practice�Improvement�Coordinator,�Westmead�Hospital,�NSW

Ms�Michaela�Kelleher,�Clinical�Nurse�Consultant–Renal�Services,�Prince�of�Wales�Hospital,�Randwick,�NSW

Ms�Denise�Lippiatt,�Acting�Quality�and�Risk�Manager,�Concord�General�Hospital,�NSW

Dr�Chris�Maxwell,�ACHS�Surveyor.�Clinical�Director,�ACHS�Performance�and�Outcomes�Service.�Director�Clinical�Services,�The�Northern�Hospital,�Vic

Ms�Janne�McMahon,�ACHS�Consumer�Surveyor.�Representative�of�the�Private�Mental�Health�Consumer�Carer�Network,�SA

Ms�Cheryl�McWilliams,�Education�Coordinator,�Mater�Private�Hospital,�Qld

Mr�Sasha�Mikulich,�Manager,�Medicolegal�Claims,�Royal�Perth�Hospital,�WA

Ms�Kerry�Plumer,�Director,�Child�and�Family�Community�Health,�Sydney�South�West�Area�Health�Service,�NSW

Ms�Kate�Roberts,�Allied�Health�Quality�and�Research�Coordinator,�Hampstead�Rehabilitation�Centre,�Royal�Adelaide�Hospital,�SA

Ms�Patricia�Warn,�ACHS�Standards�Committee.�Representative�of�Consumers’�Health�Forum,�NSW

Ms�Peta�Welten,�Community�Clinician�Nurse�Manager,�Child�and�Adolescent�Community�Health�(CACH),�Riverlands�Region�South�Inland�Zone,�WA

Ms�Tiffany�Whittington,�Clinical�Services�Coordinator,�Noarlunga�Health�Service,�SA

Working Group 2: Access, Appropriateness and EffectivenessCriteria 1.2.1., 1.2.2, 1.3.1, 1.4.1

Working Group Chair: Ms Alison McMillan

Ms�Anne�O’Loughlin,�CSM

Ms�Fiona�Allsop,�Divisional�Manager,�Medicine,�Emergency�And�Intensive�Care,�Northern�Beaches�Health�Service,�Northern�Sydney�and�Central�Coast�Area�Health�Service,�NSW�

Ms�Julie�Ashwell,�ACHS�Surveyor.�Regional�Quality�Coordinator�(Community),�Blue�Care�Southern�Region,�Qld�

Ms�Aileen�Bradley,�Nursing�Director,�Darling�Downs�–�West�Moreton�Health�Service�District,�Qld

Ms�Darlene�Cox,�Executive�Director,�Health�Care�Consumers’�Association,�ACT

Ms�Leonie�Hobbs,�ACHS�Surveyor.�Director,�Nursing�and�Midwifery�Services,�Logan-Beaudesert,�Qld

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seCtion 6Acknowledgements

484  The ACHS EQuIP5 Guide  Book 2  Accreditation, Standards and Guidelines  Support and Corporate Functions

Ms�Vicki�Hutchinson,�Clinical�Services�Coordinator,�Quality�Assurance�Coordinator,�Mental�Health�Repatriation�General�Hospital,�SA

Ms�Nanette�Jemmeson,�Accreditation�Coordinator,�Primary�&�Community�Networks�&�Mental�Health�Services,�Hunter�New�England�Health,�NSW

Mr�Paul�R�Kachel,�ACHS�Surveyor,�Qld

Ms�Ruth�Melville,�Nurse�Unit�Manager,�Operating�Theatre,�Nambour�General�Hospital,�Qld

Ms�Christine�Mitchell,�Quality�Projects�Manager,�Castlemaine�Health,�Vic�

Ms�Linda�Nolte,�Quality�Improvement�Manager,�Peter�MacCallum�Cancer�Centre,�Vic

Ms�Sally�Percy,�ACHS�Surveyor.�Manager,�Quality�and�Risk�Management�Coordinator,�Royal�District�Nursing�Service,�Vic

Ms�Cindi�Rees,�ACHS�Surveyor.�Mission�Australia,�NSW�

Mr�Hugh�Stern,�Quality�Manager,�Mental�Health,�Southern�Health,�Vic

Ms�Deirdre�Watson,�Quality�Manager,�Southern�Health,�Vic�

Working Group 3: Safety ManagementCriteria 1.5.1. 1.5.2, 1.5.3, 1.5.4, 1.5.5, 1.5.6

Working Group Chair: Dr Philip Hoyle

Ms�Cathy�Cavanagh,�CSM

Ms�Kim�Brookes,�Acting�Clinical�Quality�Manager,�St�George�Hospital,�NSW

Ms�Christine�Ceely,�Patient�Safety�Manager,�The�Children’s�Hospital,�Westmead,�NSW

Ms�Julianne�Clift,�Quality�Manager,�Lower�Hunter�Cluster,�Hunter�New�England�Area�Health�Service,�NSW

Ms�Jennifer�Dickson,�Quality�Manager,�Peninsula�Health,�Vic

Ms�Roisin�Dunne,�Service�Improvement�Coach,�Mater�Private�Hospital,�Qld

Ms�Pauline�Gaetani,�Southern�Hospitals�Network�Accreditation�Manager,�Wollongong�Hospital�and�Community�Health�Services,�NSW

Assoc�Prof�Robert�Gibberd,�Director�Health�Services�Research�Group�(HSRG),�University�of�Newcastle,�NSW�

Mr�David�Gunderson,�ACHS�Surveyor.�Principal�Project�Officer,�Centre�for�Healthcare�Related�Infection�Surveillance�and�Prevention�(CHRISP),�Qld�

Mr�James�Harrison,�Manager,�Clinical�Services,�St�Lukes�Health,�Tas

Ms�Nicole�Jones,�Advanced�Clinical�Services�Coordinator�Anaesthetics,�Royal�Adelaide�Hospital,�SA

Ms�Beth�McErlean,�Acting�Regional�Director,�Quality�Safety�&�Performance,�Southern�Area�Health�Service,�SA

Ms�Susan�McGregor,�Transfusion�Clinical�Nurse�Consultant,�Western�Health,�Vic

Mr�Russell�McGowan,�ACHS�Board�member,�ACHS�Surveyor.�Representative�of�Consumers’�Health�Forum,�ACT�

Ms�Patricia�Nicholson,�Coordinator�Postgraduate�Specialist�Programs,�Perioperative�Stream�Coordinator,�School�of�Nursing�and�Social�Work,�University�of�Melbourne,�Vic

Ms�Gaynor�Taylor,�Clinical�Nurse�Manager,�Mercy�Hospital,�WA

Ms�Solly�Toefy,�ACHS�Surveyor.�Nurse�Manager,�Vista�Eye�Clinics,�NSW

Ms�Jenny�Tuffin,�ACHS�Surveyor.�Vice�President,�Australasian�Association�for�Quality�in�Health�Care�(AAQHC),�Tas

Working Group 4: Consumers & Risk ManagementCriteria: 1.6.1, 1.6.2, 1.6.3, 2.1.1, 2.1.2, 2.1.3

Working Group Chair: Ms Sue McKean

Ms�Jo�Heaney,�CSM

Ms�Chen�Anderson,�Group�Clinical�Risk�Coordinator,�St�John�of�God�Healthcare,�WA

Ms�Elizabeth�Apps,�Clinical�Governance�Coordinator,�Alfred�Health,�Vic

Dr�Catherine�Crock,�ACHS�Surveyor.�Physician,�Adolescent�Health,�The�Royal�Children’s�Hospital,�Vic

Ms�Lynnette�Ford,�ACHS�Surveyor.�Quality�and�Accreditation�Coordination�Team�Leader,�Patient�Safety�&�Quality�Unit,�ACT�Health,�ACT

Ms�Mary�Fullick,�Quality�Improvement�&�Accreditation�Manager,�Northern�Beaches�Health�Service,�NSW

Mr�Allan�Hall,�Director�Clinical�Governance,�Sydney�South�West�Area�Health�Service,�Area�Mental�Health�Service,�NSW

Ms�Paula�Hanlon,�ACHS�Surveyor.�Coordinator�Consumer�Participation�Services,�North�Shore-Ryde�Mental�Health�Services,�NSW

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October 2010  485

Ms�Wendy�James,�Quality�Manager�/�Consumer�Advocate,�Wimmera�Health�Care�Group,�Vic

Ms�Cathy�Jones,�National�Manager,�Quality�&�Compliance,�Healthscope�Ltd,�Vic�

Ms�Lynn�Kerr,�Safety�Quality�Project�Consultant,�Central�Northern�Adelaide�Health�Service,�SA

Ms�Helen�McDonald,�Senior�Consultant,�Quality�and�Consumer�Safety,�Mental�Health�Services,�Department�of�Health�and�Human�Services,�Tas

Mr�Joseph�Pendon,�Manager,�Area�Clinical�Governance,�South�Eastern�Sydney�Illawarra�Area�Health�Service,�NSW

Dr�Astrid�Perry,�Area�Manager�Multicultural�Health,�South�Eastern�Sydney�Illawarra�Area�Health�Service,�NSW

Ms�Robyn�Ware,�Quality�Coordinator,�St�Andrew’s�Hospital,�SA

Ms�Christine�Webb,�Transfusion�Medicine�Improvement�Projects,�Greater�Southern�Area�Health�Service,�NSW�

Ms�Shirleen�Wickham,�Director,�Safety�&�Quality,�Royal�Hobart�Hospital,�Tas

Mr�Allan�Wilson,�National�Risk�Manager,�Sisters�of�Charity�Health�Service,�Qld

Working Group 5: Human RelationsCriteria: 2.2.1, 2.2.2, 2.2.3, 2.2.4, 2.2.5

Chair: Mr John Kenny

Ms�Brigitte�Kaiser,�CSM

Ms�Christine�Arnold,�Quality�Manager�and�Director�of�Nursing,�Mercy�Health,�NSW

Ms�Melissa�Condon,�Clinical�Services�Coordinator,�Roxby�Downs�Health�Services,�Woomera�Community�Hospital,�SA�

Mr�Eric�Daniels,�Director�of�Nursing�and�Midwifery,�Wagga�Wagga�Base�Hospital,�Greater�Southern�Area�Health�Service,�NSW�

Ms�Kate�Furlong,�Nurse�Unit�Manager,�Neurosciences�Unit,�Melbourne�Private�Hospital,�Vic

Ms�Alison�Garrett,�Administration�Manager,��The�Hobart�Clinic,�Tas

Ms�Sheryl�Hampson,�Director�of�Nursing,�Lithgow�Community�Private�Hospital,�NSW

Ms�Angela�Hand,�Clinical�Nurse�Educator,�Ballarat�Health�Service,�Vic

Ms�Roslyn�Hewlett,�Associate�Clinical�Service�Coordinator,�Central�Northern�Adelaide�Health�Service,�SA

Ms�Kathy�Huett,�Chief�Executive�Officer,�Edenhope�&�District�Memorial�Hospital,�Vic

Ms�Veronica�Jamison,�Director,�Support�Services,�Southern�Health,�Vic

Dr�Helen�McArdle,�Medical�Adviser,�Safety�and�Quality,�Department�of�Health�and�Human�Services,�Tas

Dr�John�Monagle,�ACHS�Surveyor.�Director�Anaesthesia�and�Perioperative�Medicine,�Southern�Health,�Vic

Ms�Joan�Murphy,�Manager,�Community�&�Allied�Health,�Wellington�Health�Service,�NSW

Ms�Jane�O’Shannessy,�Quality�&�Risk�Management,�Mater�Misericordiae�Hospital,�Mackay,�Qld

Ms�Leanne�Sice,�Regional�Clinical�Practice�Improvement�Coordinator,�Manager�Workforce�Development,�Western�Australian�Country�Health�Service�Midwest,�WA

Working Group 6: Information ManagementCriteria: 1.1.8, 2.3.1, 2.3.2, 2.3.3, 2.3.4

Chair: Ms Sandra Miller

Ms�Karen�Walkerden,�CSM

Mr�Rick�Austin,�ACHS�Surveyor,�Qld

Mr�Cameron�Barnes,�Manager�and�Privacy�Officer,�Health�Information�Services,�The�Royal�Children’s�Hospital,�Vic

Ms�Roslyn�Chataway,�Risk�Manager,�Acting�Manager,�Safety,�Quality�&�Risk�Management�Unit,�The�Queen�Elizabeth�Hospital,�SA

Ms�Maren�Jones,�Physiotherapy�Manager,�Rehabilitation,�Aged�&�Extended�Care�Services,�Port�Kembla�Hospital,�NSW

Ms�Tracy�Kerle,�Nurse�Manager,�Operating�Suite,�Gosford�Hospital,�NSW

Ms�Julia�Logan,�Head�of�Department,�Patient�Information�Management�Services,�Child�and�Adolescent�Health�Service,�WA

Ms�Tanya�Merinda,�Program�Manager,�Network�of�Alcohol�and�other�Drug�Agencies�(NADA),�NSW

Dr�Pam�Montgomery,�Director,�Fellowship�and�Standards,�Royal�Australasian�College�of�Surgeons,�Vic

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seCtion 6Acknowledgements

486  The ACHS EQuIP5 Guide  Book 2  Accreditation, Standards and Guidelines  Support and Corporate Functions

Ms�Carol�Moore,�Quality�Coordinator,�Program�Manager,�Adelaide�Community�Healthcare�Alliance,�SA

Ms�Kate�Morrissy,�Senior�Project�Officer,�Victorian�Quality�Council,�Vic

Ms�Catherine�O’Neill,�Acting�Clinical�Nurse�Manager,�Child�and�Adolescent�Health�Service,�South�Inland�Zone,�WA

Ms�Marilyn�Sneddon,�ACHS�Surveyor.�Consultant,�Vic

Dr�Susan�Shea,�Quality�Coordinator�Medical�Services,�Ballarat�Health�Service,�Vic

Ms�Jenny�Smith,�Clinical�Business�Analyst,�Clinical�Information�Systems,�Information�Management�Division,�Mater�Health�Services,�Qld

Ms�Karen�Steinhoff,�Service�Improvement�Project�Officer,�The�Children’s�Hospital,�Westmead,�NSW

Ms�Denyse�Stephens,�Quality�and�Risk�Manager,�Sydney�South�West�Area�Mental�Health�Service,�NSW

Ms�Belinda�Westlake,�Health�Information�and�Quality�Manager,�Moyne�Health�Service,�Vic

Working Group 7: GovernanceCriteria: 2.5.1, 3.1.1, 3.1.2, 3.1.3, 3.1.4, 3.1.5

Chair: Mr Stephen Walker

Ms�Karen�Walkerden,�CSM

Dr�Cathy�Balding,�ACHS�Surveyor.�Director,�Quality�Works,�Vic

Ms�Christina�Bygrave,�Program�Manager,�Department�of�Health,�WA

Mr�Wesley�Carter,�Chief�Executive�Officer,�Tallangatta�Health�Service,�Vic

Ms�Tracy�Cooke,�Risk�Manager,�Country�Health,�Whyalla�Eastern�Eyre�and�Far�North�Health�Services,�Whyalla�Hospital�and�Health�Services,�SA

Mr�Paul�Clenaghan,�Cluster�Manager,�Sydney�South�West�Area�Health�Service,�NSW

Ms�Marie�Dickinson,�Quality�Manager,�Tresillian�Family�Centres,�NSW

Ms�Margrit�Fleck,�Corporate�Quality�and�Accreditation�Manager,�Ramsay�Health�Care,�NSW

Ms�Eleri�Griffiths,�Manager,�Surgical�Services,�Armadale�Health�Services,�WA

Ms�Melissa�Harvey,�Accreditation�Coordinator,�Greater�Newcastle�Acute�Hospital�Network,�Hunter�New�England�Area�Health�Service,�NSW

Mr�Barrington�Kinnaird,�Director,�Planning,�Partnerships�and�Performance,�Sydney�South�West�Area�Mental�Health�Service,�NSW

Margaret�Lloyd-Jones,�Executive�Officer,�Mater�Hospitals,�Rockhampton,�Yeppoon,�Gladstone,�Qld

Dr�Christopher�May,�ACHS�Surveyor.�Director�of�Emergency�Services�(Bayside),�Metro�South�Health�Service�District,�Qld

Mr�Russell�McGowan,�ACHS�Board�member,�ACHS�Surveyor.�Representative�of�Consumers’�Health�Forum,�ACT

Ms�Karin�Mulligan,�Quality�Manager,�Department�of�Health�and�Families,�NT

Ms�Jenny�Rance,�ACHS�Surveyor.�National�Quality�and�Compliance�Officer,�Healthscope�Ltd,�Vic

Ms�Meredith�Rooke,�Perioperative�Services�Manager,�Cairns�Private�Hospital,�Qld

Ms�Anne�Young,�Director,�Quality�and�Risk�Management�Unit,�St�Vincent’s�Hospital,�NSW

Working Group 8: Workplace and EnvironmentCriteria: 3.2.1, 3.2.2, 3.2.3, 3.2.4, 3.2.5

Chair: Ms Jackie Bullock

Ms�Linda�Brennan,�CSM

Mr�Chris�Bone,�Director�of�Nursing,�Armadale�Health�Service,�WA

Ms�Vivienne�Bush,�Environmental�Risk�Manager,�Concord�Repatriation�General�Hospital,�NSW

Mr�John�England,�Manager,�Quality�and�Safety,�North�West�Regional�Hospital,�Tas

Ms�Josephine�Maprock,�ACHS�Surveyor.�Director,�HealthKare�Intelligence,�Vic

Dr�Forbes�McGain,�Anaesthetist,�Intensive�Care�Unit,�Western�Hospital,�Vic

Ms�Tonia�Naylor,�Nurse�Manager,�Emergency�Preparedness,�Swan�Kalamunda�Health�Service,�North�Metropolitan�Health�Service,�WA

Mr�Trevor�Nowak,�Director�of�Nursing�&�Midwifery,�Country�Health,�Barossa�Health,�SA

Ms�Jenny�Owen,�Manager,�Emergency�Management,�Southern�Health,�Vic

Ms�Sudha�Raju,�Clinical�Safety�and�Quality�Coordinator,�Sydney�West�Area�Health�Service�Oral�Health�Network,�NSW

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October 2010  487

Ms�Di�Slater,�Quality�&�Risk�Manager,�Infection�Control�Coordinator,�Rehabilitation�&�RTW�Coordinator,�Caloundra�Private�Hospital,�Qld

Assoc�Prof�Richard�Smart,�Radiation�Safety�Officer,�St�George�Hospital�&�Community�Health�Service,�South�Eastern�Sydney�and�Illawarra�Area�Health�Service,�NSW

Ms�Carole�Steiner,�Nurse�Manager,�Quality�&�Safety,�Fremantle�Hospital�and�Health�Service,�WA

Mr�Phillip�Thorburn,�Director,�Biomedical�Engineering,�Royal�Adelaide�Hospital,�SA�

Ms�Karen�Wheeler,�Quality�and�Safety�Coordinator,�The�Hobart�Clinic,�Tas

Ms�Kim�White,�Human�Resources,�Quality�&�Safety�Manager,�St�John�of�God�Hospital,�Warrnambool,�Vic

Ms�Christine�Wolstenholme,�National�Occupation�Health�and�Safety�Officer,�Healthscope,�Qld

Working Group 9: Health PromotionCriterion: 2.4.1

Chair: Ms Margo Carberry

Ms�Anne�O’Loughlin,�CSM

Mr�Michael�Curry,�Clinical�Practice�Consultant,�Infectious�Diseases�Unit,�Internal�Medicine�Services,�Royal�Adelaide�Hospital,�SA

Ms�Melissa�Day,�Acting�Clinical�Practice�Consultant,�Multidisciplinary�Ambulatory�Consulting�Services,�Royal�Adelaide�Hospital,�SA

Ms�Kim�Gossage,�Zone�Director,�Community�Health,�Department�of�Health,�WA

Ms�Anne-Marie�Hayes,�Director,�Community�Health�Division,�Primary�and�Population�Health�Directorate,�Children,�Youth�and�Women’s�Health,�SA

Ms�Catherine�Hugo,�Information�Services�Manager,�Clinical�Nurse�Consultant,�Surveillance�and�Monitoring,�Hunter�New�England�Population�Health,�NSW

Ms�Gretchen�Long,�Primary�Health�Care�Coordinator,�North�Eastern�Soldiers�Memorial�Hospital�(NESM),�Scottsdale,�Tas

Ms�Jo�Anne�Rash,�Continuous�Improvement�–�Acute,�Latrobe�Regional�Hospital,�Vic

Ms�Dianne�Rudeforth,�Acting�After�Hours�Hospital�Coordinator,�Carnarvon�Hospital,�WA

Ms�Sharon�Simpson,�Health�Service�Manager,�Narrabri�Health�Service,�NSW

Mr�Robert�Stirling,�Senior�Project�Officer,�Network�of�Alcohol�and�other�Drugs�Agencies�(NADA),�NSW

Ms�Sandy�Thomson,�ACHS�Surveyor.�Consultant�/�Administrator,�Mount�Lawley�Private�Hospital,�WA

Pilot organisationsThe following healthcare organisations and facilities generously participated in the trialling of the standards as pilot organisations and provided invaluable information during the development of EQuIP5:

National�Capital�Private�Hospital�–�Healthscope�Ltd.,�Canberra,�ACT�(onsite�survey)

Calvary�Health�Care,�Sydney,�NSW�(onsite�survey)

Albury�Wodonga�Health�Service�(Wodonga�Campus),�Vic�(onsite�survey)

Greater�Newcastle�Acute�Hospital�Network,�NSW

Royal�District�Nursing�Service,�Melbourne,�Vic

Timboon�and�District�Healthcare�Service,�Vic

Child�and�Adolescent�Health�Service,�Perth,�WA

Lyell�McEwin�Hospital,�Adelaide,�SA

The�Prince�Charles�Hospital,�Brisbane,�Qld

The following ACHS surveyors kindly provided their knowledge and expertise to the onsite pilot surveys

Mr�Mark�Avery,�Qld

Mr�Sid�Ducket,�Vic

Dr�David�Henderson,�Qld

Ms�Kaye�Hogan,�ACT

Mr�Ian�Paterson,�NSW

Ms�Ros�Pearson,�Vic

Ms�Lesley�Seigloff,�SA

Ms�Maria�Stickland,�Vic

The EQuIP5 Guidelines were reviewed by a number of people, including relevant experts, surveyors, Chairs of the Working Groups, private hospital representatives and ACHS surveyors.

The ACHS gratefully acknowledges the generous contribution and dedication to quality in health of the following people and organisations that assisted in the review of the EQuIP5 guidelines:

Rev�Carl�Aiken,�President,�Spiritual�Care�Australia,�SA

Ms�Nicola�Askham,�Quality�Manager,�Toowong�Private�Hospital,�Qld�

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seCtion 6Acknowledgements

488  The ACHS EQuIP5 Guide  Book 2  Accreditation, Standards and Guidelines  Support and Corporate Functions

Dr�Cathy�Balding,�ACHS�Surveyor.�Director,�Quality�Works,�Vic

Mr�Cameron�Barnes,�Manager�and�RCH�Privacy�Officer,�Health�Information�Services,�The�Royal�Children’s�Hospital�Melbourne�/�Director,�Health�Information�Services,�Cabrini�Health,�Vic

Dr�Jenny�Bartlett,�Program�Clinical�Lead,�Quality�and�Safety,�National�E-Health�Transition�Authority�(NEHTA),�Vic

Ms�Debbie�Blanchfield,�Clinical�Nurse�Consultant�(Wound�Care),�Southern�Hospital�Network,�South�Eastern�Sydney�and�Illawarra�Area�Health�Service,�NSW

Mr�Beress�Brooks,�Executive�Director,�Safety,�Quality�&�Performance,�North�Metropolitan�Area�Health�Service,�WA

Ms�Olly�Campbell,�Manager,�Governance�and�Performance,�Safety,�Quality�and�Performance�Unit,�North�Metropolitan�Area�Health�Service,�WA

Ms�Julianne�Clift,�Quality�Manager,�Lower�Hunter�Cluster,�Hunter�New�England�Area�Health�Service,�NSW

College�of�Biomedical�Engineering�representatives,�Royal�Adelaide�Hospital,�SA

Cooperative�Research�Centre�for�Aboriginal�Health,�Improving�the�Culture�of�Hospitals�Project,�La�Trobe�University,�Vic

Ms�Lyn�David,�Acting�Director�of�Safety�&�Quality,�Department�of�Health,�WA

Mr�Sam�Dodd,�Director�of�Clinical�Services,�Linacre�Private�Hospital,�Vic

Ms�Tanya�Gawthorne,�Manager,�Clinical�Quality,�Office�of�Safety�and�Quality�in�Healthcare,�Performance�Activity�&�Quality�Division,�Department�of�Health,�WA

Mr�David�Gunderson,�ACHS�Surveyor.�Principal�Project�Officer,�Centre�for�Healthcare�Related�Infection�Surveillance�and�Prevention�(CHRISP),�Qld�

Ms�Sarah�Harper,�Senior�Project�Officer,�Clinical�Engagement,�Quality,�Safety�and�Patient�Experience,�Department�of�Health,�Vic

Prof�Ken�Hillman,�Professor�of�Intensive�Care,�University�of�NSW,�Director,�The�Simpson�Centre�for�Health�Services�Research,�NSW

Ms�Kaye�Hogan,�ACHS�Surveyor,�ACT

Rev�Cheryl�Holmes,�Chief�Executive�Officer,�Healthcare�Chaplaincy�Council�of�Victoria�Inc.,�Vic

Dr�Susan�Hooper,�Rehabilitation�Medical�Officer,�Brain�Injury�Rehabilitation�Unit,�Hampstead�Rehabilitation�Centre,�SA

Ms�Toni�Howell,�Quality�Use�of�Medicines�Pharmacist,�Quality�and�Safety�Manager,�Pharmacy�Department,�The�Royal�Melbourne�Hospital,�Vic

Dr�Paul�Hyland,�Assistant�Director,�Systems�and�Data�Development,�Blood�Sector�Clinical�Development,�National�Blood�Authority,�ACT�

Dr�Daryl�Jones,�Consultant�Intensive�Care�Specialist,�Austin�Health,�Vic

Ms�Sharon�Kendall,�Director�of�Business�Operations,�St�Andrews�Hospital,�SA

Ms�Lian�Kwa,�Coordinator,�Quality�and�Accreditation,�Child�and�Adolescent�Health�Service,�WA�

Ms�Lina�Lim,�Quality�&�Risk�Manager,��St�Vincent’s�Hospital,�Brisbane,�Qld

Ms�Julia�Logan,�Head�of�Department,�Patient�Information�Management�Services,�Child�and�Adolescent�Health,�WA

Dr�Yvonne�Luxford,�Chief�Executive�Officer,�Palliative�Care�Australia,�ACT

Ms�Mary�Ellen�Mickle,�Quality,�Risk�and�OH&S�Manager,�Executive,�Linacre�Private�Hospital,�Vic

Ms�Beth�McErlean,�Acting�Regional�Director,�Quality,�Safety�&�Performance,�Southern�Area�Health�Service,�SA

Dr�Forbes�McGain,�Anaesthetist,�Intensive�Care,�Western�Hospital,�Vic

Ms�Susan�McGregor,�Clinical�Nurse�Consultant,�Transfusion�Practice,�Western�Health,�Vic

Ms�Wendy�McIntosh,�Program�Manager,�WA�Country�Health�Service,�WA

Ms�Alison�McMillan,�Director,�Quality,�Safety�&�Patient�Experience,�Department�of�Health,�Vic�

Ms�Belinda�Newley,�Clinical�Governance�Officer,�Clinical�Safety�&�Quality�Unit,�Mater�Health�Services,�Qld

Dr�Gerry�O’Callaghan,�National�Medical�Director,�Australian�Organ�and�Tissue�Donation�and�Transplantation�Authority,�SA

Ms�Lyndall�Olsen,�Quality�Improvement�Coordinator,�Clinical�Quality�and�Safety�Unit,�Mater�Health�Services,�Qld

Ms�JoAnne�Oosen,�Quality�and�Risk�Manager,�Belmont�Private�Hospital,�Qld

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October 2010  489

Mr�Glen�Pang,�Network�Manager�–�Nutrition,�Greater�Metropolitan�Clinical�Taskforce,�NSW

Dr�Astrid�Perry,�Area�Manager,�Multicultural�Health,�South�Eastern�Sydney�Illawarra�Area�Health�Service,�NSW

Dr�Grant�Phelps,�Clinical�Lead,�Clinical�Engagement�Program,�Victorian�Department�of�Health,�Vic

Mr�Paul�Philcox,�Nurse�Clinical�Services�Coordinator,�Orthopaedic,�Amputee�and�Burns�Rehabilitation�Unit,�Hampstead�Rehabilitation�Centre,�SA

Ms�Sandra�Polmear,�Performance�Evaluation�Manager,�Armadale�Health�Service,�WA

Ms�Jill�Porteous,�Director,�Safety�Quality�&�Performance,�WA�Country�Health�Service,�WA

Dr�Beverleigh�Quested,�Senior�Transfusion�Nurse�Educator,�Australian�Red�Cross,�SA

Ms�Trudi�Ruane,�Director�Safety,�Quality�and�Performance,�Child�and�Adolescent�Health�Service,�WA�

Ms�Carolyn�Saunders,�Manager,�South�Metropolitan�Area�Health�Service�Policy�Unit,�Royal�Perth�Hospital,�WA

Ms�Di�Slater,�Quality�&�Risk�Manager,�Infection�Control�Co-ordinator,�Rehabilitation�&�Return�to�Work�Coordinator,�Caloundra�Private�Hospital,�Qld

Assoc�Prof�Richard�Smart,�Radiation�Safety�Officer,�St�George�Hospital�&�Community�Health�Service,�South�Eastern�Sydney�and�Illawarra�Area�Health�Service,�NSW

Dr�Amanda�Thomson,�Expert�Working�Group,�Patient�Blood�Management�Guidelines,�National�Health�and�Medical�Research�Council�(NHMRC);�Representative�and�Co-Chair,�Australian�and�New�Zealand�Society�of�Blood�Transfusion�(ANZSBT),�National�Blood�Authority�(NBA),�NSW�

Ms�Lesley�Townsend,�Coordinator,�Research�Development�Office,�Royal�Prince�Alfred�Hospital,�NSW

Dr�Janet�Wale,�Representative�of�Consumers’�Health�Forum,�The�Cochrane�Collaboration�Consumer�Network,�Vic

Mr�Robert�Walsh,�ACHS�Surveyor.�Chief�Executive�Officer,�St.�Vincent’s�Private�Hospital,�Lismore,�NSW

Ms�Robyn�Ware,�Quality�Coordinator,�St�Andrews�Hospital,�SA

Mr�John�Willis,�Aboriginal�Health�Coordinator�and�Mission�Liaison,�St�Vincent’s�Hospital�Melbourne,�Vic

Mr�Allan�Wilson,�National�Risk�Manager,��Sisters�of�Charity�Health�Service,�Qld

The ACHS also gratefully acknowledges the generous contribution and dedication to quality in health of the following ACHS surveyors who assisted in the review of the EQuIP5 guidelines:

Mr�Mark�Avery,�ACHS�Surveyor.�Health�Services�and�Management�Consultant,�The�Consultancy�Bureau,�Qld

Mr�Peter�Barber,�ACHS�Surveyor.�Director�of�Nursing�&�Midwifery,�Executive�Officer,�Gloucester�District�Health�Service,�Hunter�New�England�Area�Health�Service,�NSW

Mr�Grant�Carey-Ide,�ACHS�Surveyor.�Executive�Director,�Aged�Care�&�Rehabilitation�Service,�ACT�Health,�ACT

Ms�Val�Coughlin-West,�ACHS�Surveyor,�Qld

Dr�Catherine�Crock,�ACHS�Surveyor.�Physician�Adolescent�Health,�The�Royal�Children’s�Hospital,�Vic

Ms�Karen�Edwards,�ACHS�Surveyor.�Chief�Executive�Officer,�Calvary�Health�Care,�Sydney,�NSW

Dr�Jacki�Flynn,�ACHS�Surveyor.�Director�of�Clinical�Services,�St�Vincent’s�Hospital,�Lismore,�NSW

Ms�Lynnette�Ford,�ACHS�Surveyor.�Quality�and�Accreditation�Coordination�Team�Leader,�Patient�Safety�&�Quality�Unit,�ACT�Health,�ACT

Mr�Vince�Gagliotti,�ACHS�Surveyor.�Manager,�Quality�and�Improvement,�Clinical�Governance�Unit,�St�Vincent’s�Hospital,�Melbourne,�Vic

Ms�Sharon�Godleman,�ACHS�Surveyor.�Executive�Officer,�Director�of�Nursing,�Country�Health,�SA

Ms�Robyn�Goffe,�ACHS�Surveyor,�NSW

Dr�Deane�Golding,�ACHS�Surveyor.�Clinical�Consultant,�Dental�&�Eyecare�Practices�AHM�(Australian�Health�Management),�NSW

Dr�Rob�Griffin,�ACHS�Surveyor.�Director�of�Medical�Services,�Calvary�Health�Care,�ACT

Dr�Lee�Gruner,�ACHS�Surveyor.�Director,�Quality�Directions�Australia,�Vic

Ms�Garda�Hemming,�ACHS�Surveyor.�Redevelopment�Manager�/�Administrator,�Townsville�Health�Service�District,�Qld

Ms�Marion�Holden,�ACHS�Surveyor.�Chief�Executive�Officer�/�Director�of�Nursing,�Whyalla�Aged�Care�Inc.,�SA

Ms�Judy�Hoskins,�ACHS�Surveyor.�Nursing�and�Healthcare�Consultant,�Qld

Mr�Graeme�Houghton,�ACHS�Surveyor,�Vic.�Hospital�Standards�&�Accreditation�Advisor,�Department�of�Health,�PNG

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seCtion 6Acknowledgements

490  The ACHS EQuIP5 Guide  Book 2  Accreditation, Standards and Guidelines  Support and Corporate Functions

Mr�Peter�Hurst,�ACHS�Surveyor,�NSW

Ms�Lesley�Innes,�ACHS�Surveyor.�Senior�Management�and�Leadership�Development�Consultant,�Centre�for�Education�and�Workforce�Development,�Sydney�South�West�Area�Health�Service,�NSW

Dr�Peter�Kendall,�ACHS�Surveyor.�Clinical�Assoc�Prof,�Respiratory�Medicine,�Fremantle�Hospital;�Clinical�Lead,�Health�Networks�Branch,�Department�of�Health;�Medical�Adviser,�Clinical�Governance,�South�Metropolitan�Area�Health�Service,�WA

Ms�Dianne�Knight,�ACHS�Surveyor,�Qld�

Dr�David�Lord,�ACHS�Board,�ACHS�Surveyor,�WA

Mr�Stuart�MacKinnon,�ACHS�Surveyor.�Commissioning�Manager,�Orange�Health�Service�Redevelopment,�Bloomfield�Hospital,�NSW

Ms�Jill�Michelson,�ACHS�Surveyor.�Operations�Manager,�Marie�Stopes�International,�SA

Ms�Helen�Milne,�ACHS�Surveyor.�Director�Innovation�and�Reform,�Hunter�New�England�Area�Health�Service,�NSW

Ms�Rosalind�O’Sullivan,�ACHS�Surveyor.�Clinical�Group�Manager,�South�Eastern�Sydney�and�Illawarra�Area�Health�Service,�NSW

Ms�Ros�Pearson,�ACHS�Surveyor.�Consultant,�Vic

Ms�Sally�Percy,�ACHS�Surveyor.�Manager,�Quality�and�Risk�Management�Coordinator,�Royal�District�Nursing�Service,�Vic

Mr�David�Plunkett,�ACHS�Surveyor.�Executive�Director�Nursing,�Access�&�Patient�Support�Services�(Chief�Nursing�&�Midwifery�Officer),�Eastern�Health,�Vic

Ms�Monica�Seth,�ACHS�Surveyor.�Community�Care�Manager,�Central�Queensland�Cluster,�Bluecare,�Qld

Ms�Susan�Shaw,�ACHS�Surveyor.�Manager�of�Corporate�Systems�Review�and�Redesign,�Consultant�to�the�Eastern,�Central�&�Western�Clusters�–�Mental�Health�&�Drug�&�Alcohol�Program,�Sydney�West�Area�Health�Service,�NSW

Ms�Lesley�Siegloff,�ACHS�Surveyor.�Associate�Dean,�Practice�Development,�Senior�Lecturer,�Nursing�&�Aged�Care,�School�of�Nursing�and�Midwifery,�Faculty�of�Health�Sciences,�Flinders�University,�SA

Ms�Heather�Brown,�ACHS�Surveyor.�Accreditation�/�Quality�Coordinator,�Quality�Improvement,�Royal�Prince�Alfred�Hospital,�NSW

Ms�Marilyn�Sneddon,�ACHS�Surveyor.��MSPS�Project�Services�(Consultancy),�Vic

Ms�Jean�Spurge,�ACHS�Surveyor,�NSW

Ms�Rosie�Taylor,�ACHS�Surveyor,�SA

Ms�Sandy�Thomson,�ACHS�Surveyor.�Consultant�/�Administrator,�Mount�Lawley�Private�Hospital,�WA

Ms�Wendy�Wood,�ACHS�Surveyor.�Deputy�Chief�Executive�Officer�/�Director�of�Cancer�Nursing,�Peter�MacCallum�Cancer�Centre,�Vic

Reference GroupsBlood

Ms�Sally�Francis,�Clinical�Nurse�Consultant,�Transfusion�Medicine,�Northern�Sydney�Central�Coast�Area�Health�Service,�NSW

Ms�Jo�Main,�Transfusion�Nurse�Consultant,�Peter�MacCallum�Cancer�Centre,�Vic�

Ms�Jennifer�Roberts,�Director,�Blood�Counts,�National�Blood�Authority,�Vic

Ms�Lisa�Stevenson,�Transfusion�Clinical�Nurse�Consultant,�Blood�Matters�–�better�safer�transfusion�program,�Statewide�Quality�Branch,�Department�of�Human�Services;�Australian�Red�Cross�Blood�Service,�Vic

Dr�Beverleigh�Quested,�Transfusion�Nurse�Educator,�BloodSafe,�Australian�Red�Cross�Blood�Services,�SA.

Ms�Kaye�Hogan,�ACHS�Surveyor,�ACT

Prof�James�Isbister,�University�of�Sydney,�Adj�Prof,�University�of�Technology,�Sydney;�Emeritus�Consultant�Haematologist,�Royal�North�Shore�Hospital,�NSW

Dr�Peter�Flanagan,�National�Medical�Director,�New�Zealand�Blood�Service,�past�President�Council�of�Australian�and�New�Zealand�Society�of�Blood�Transfusion,�NZ

Dr�James�Thyer,�Senior�Advisor�Blood�Governance�and�Policy,�Red�Cross�Australia,�Vic

infection control

Mr�David�Gunderson,�ACHS�Surveyor.�Principal�Project�Officer,�Centre�for�Healthcare�Related�Infection�Surveillance�and�Prevention�(CHRISP),�Qld

Ms�Judith�Flis,�Clinical�Nurse�Consultant,�Infection�Control,�Sydney�South�West�Area�Health�Service�Oral�Health�Service,�NSW

Ms�Di�Slater,�Quality�&�Risk�Manager,�Infection�Control�Co-ordinator,�Rehabilitation�&�Return�to�Work�Coordinator,�Caloundra�Private�Hospital,�Qld

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October 2010  491

Ms�Sandra�Polmear,�Asst�Manager�Performance�Review,�SQuIRes�Project�Manager,�Department�of�Health,�WA�

Ms�Mary-Rose�Godsell,�South�West�Infection�Control�Nurse�Consultant,�Country�Health�Service�–�South�West,�WA�

nutrition

Ms�Rhonda�Matthews,�Nutrition�Matters�Program�Manager,�Clinical�Governance�Unit,�Northern�Sydney�Central�Coast�Health;�Co-chair�Nutrition�in�Hospitals�Group,�Greater�Metropolitan�Clinical�Taskforce,�Royal�North�Shore�Hospital,�NSW

Mr�Glen�Pang,�Network�Manager�–�Nutrition,�Greater�Metropolitan�Clinical�Taskforce,�NSW

Dr�Merrilyn�Banks,�Director,�Nutrition�&�Dietetics,�Royal�Brisbane�&�Women’s�Hospital;�Honorary�Fellow,�School�of�Public�Health,�Queensland�University�of�Technology,�Qld

Ms�Marie�Smith,�Director�of�Nutrition,�Calvary�Health�Care,�ACT

Assoc�Prof�Judy�Bauer,�Nutrition�Services�Manager,�The�Wesley�Hospital;�Assoc�Professor,�School�of�Human�Movement�Studies,�University�of�Queensland,�Qld

Ms�Cheryl�Watterson,�Director�of�Nutrition�and�Dietetics,�Greater�Newcastle�Acute�Hospital�Network,�John�Hunter�Hospital;�Conjoint�Lecturer,�School�of�Health�Sciences,�Faculty�of�Health,�University�of�Newcastle,�NSW

Ms�Kay�Gibbons,�Manager,�Nutrition�&�Food�Services,�The�Royal�Children’s�Hospital,�Vic�

Ms�Linda�Nolte,�Quality�Improvement�Manager,�Peter�MacCallum�Cancer�Centre,�Vic

Ms�Jacquie�Krassie,�Dietitian�and�Food�Service�Consultant,�Vic�

Dr�Karen�Walton,�Acting�Coordinator�Nutrition�and�Dietetics�Programs,�School�of�Health�Sciences,�University�of�Wollongong,�NSW

Dr�Elizabeth�Isenring,�Senior�Lecturer,�University�of�Queensland,�Qld

Ms�Vicki�Barrington,�Food�Services�Dietitian,�Peter�MacCallum�Cancer�Centre,�Vic�

Ms�Carolyn�Hankins,�Senior�Dietitian�–�Foodservice,�Repatriation�General�Hospital,�SA

Ms�Joanne�Prendergast,�Manager,�Nutrition�and�Dietetics,�Royal�North�Shore�Hospital,�NSW

Ms�Karen�Storer,�Senior�Dietitian,�St�Vincent’s�Hospital,�NSW

Ms�Rhonda�Anderson,�Manager,�Nutrition�and�Dietetics,�Concord�Hospital,�NSW

Ms�Dawn�Vanderkroft,�Manager,�Nutrition�and�Dietetics,�Gosford�Hospital,�NSW

Ms�Tanya�Hazlewood,�Manager,�Nutrition�and�Dietetics,�Liverpool�Hospital,�NSW

ACHS Executive Mr�Brian�Johnston,�Chief�Executive

Ms�Darlene�Hennessy,�Executive�Director�–�Development

Ms�Laurie�Leigh,�Executive�Director�–�Customer�Services

Ms�Lena�Low,�Executive�Director�–�Corporate�Services

ACHS EQuIP5 project teamMs�Darlene�Hennessy,�Executive�Director�–�Development

Ms�Deborah�Jones,�Senior�Project�Officer,�EQuIP5�Project�Manager,�Standards�and�Program�Development

Dr�Jen�Bichel-Findlay,�Coordinator,�Performance�and�Outcomes�Service

Ms�Bronwyn�Fleming,�Project�Officer,�Standards�and�Program�Development

Ms�Elizabeth�Kingsley,�Project�Officer,�Standards�and�Program�Development

Ms�Natasha�Lo,�Project�Officer,�Standards��and�Program�Development

Ms�Anne�McIntosh,�Project�Officer,�Development�Unit

Ms�Phoebe�Zhang,�Project�Officer,�Performance��and�Outcomes�Service

ACHS EQuIP5 project administrationMs�Lesley�Bateman�

Ms�Blanche�Wiseman�

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Contact and Information

Inquiries regarding EQuIP5, other ACHS accreditation programs and program education and support, should be directed to:

The Australian Council on Healthcare Standards (ACHS) 5 Macarthur Street Ultimo NSW 2007 Australia

+61 2 9281 9955

+61 2 9211 9633

[email protected]

www.achs.org.au

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strive for excellence | framework for maintaining quality care and service | focus on the customer | developing strong leadership | striving for best practice | standards | criterion | guidelines | safety, quality performance | strive for excellence | framework for maintaining quality care and service | focus on the customer | developing strong leadership | striving for best practice | standards | criterion | guidelines | safety, quality performance | strive for excellence | framework for maintaining quality care and service | focus on the customer | developing strong leadership | striving for best practice | standards | criterion | guidelines | safety, quality performance | strive for excellence | framework for maintaining quality care and service | focus on the customer | developing strong leadership | striving for best practice | standards | criterion | guidelines | safety, quality performance | strive for excellence | framework for maintaining quality care and service | focus on the customer | developing strong leadership | striving for best practice | standards | criterion | guidelines | safety, quality performance | strive for excellence | framework for maintaining quality care and service | focus on the customer | developing strong leadership | striving for best practice | standards | criterion | guidelines | safety, quality performance | strive for excellence | framework for maintaining quality care and service | focus on the customer | developing strong leadership | striving for best practice | standards | criterion | guidelines | safety, quality performance | strive for excellence | framework for maintaining quality care and service | focus on the customer | developing strong leadership | striving for best practice | standards | criterion | guidelines | safety, quality performance | strive for excellence | framework for maintaining quality care and service | focus on the customer | developing strong leadership | striving for best practice | standards | criterion | guidelines | safety, quality performance | strive for excellence | framework for maintaining quality care and service | focus on the customer | developing strong leadership | striving for best practice | standards | criterion | guidelines | safety, quality performance | strive for excellence | framework for maintaining quality care and service | focus on the customer | developing strong leadership | striving for best practice | standards | criterion | guidelines | safety, quality performance | strive for excellence | framework for maintaining quality care and service | focus on the customer | developing strong leadership | striving for best practice | standards | criterion | guidelines | safety, quality performance | strive for excellence | framework for maintaining quality care and service | focus on the customer | developing strong leadership | striving for best practice | standards | criterion | guidelines | safety, quality performance | strive for excellence | framework for maintaining quality care and service | focus on the customer | developing strong leadership | striving for best practice | standards | criterion | guidelines | safety, quality performance | strive for excellence | framework for maintaining quality care and service | focus on the customer | developing strong leadership | striving for best practice | standards | criterion | guidelines | safety, quality performance | strive

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