Action 1.09

Routinely collecting process and outcome data, monitoring data for trends and reporting clinical alerts enables organisations to understand outcomes from service delivery, and to respond to deviations from the expected outcomes promptly.

Monitoring safety and quality performance data should include all clinical areas and cover all locations of service delivery to ensure a comprehensive picture of performance.

Clearly documented processes to ensure the accuracy, validity and comprehensiveness of information will increase the organisation’s confidence in data quality. Providing the governing body and the workforce with access to the organisation’s most important safety and quality metrics (indicators) will enable regular review of progress and will allow the organisation to respond to issues as they arise. Suitable metrics may include:

• Key relevant national priority indicators and regulatory requirements
• Those covering safety, clinical effectiveness, patient experience, access and efficiency across the organisation’s range of services and service locations
• Trends in reported adverse events, incidents and near misses
• Compliance with best-practice pathways.

Provide the governing body and management with regular, comprehensive safety and quality presentations and reports from managers and clinicians. Schedule data presentations following agreed criteria (for example, significance of risk, patient volume, organisational priority or focus).

Effective data presentations should cover:

• The design of the systems and processes being used
• Evaluation and management of risks
• The effectiveness of the risk management system
• Compliance with evidence-based practice
• Safety and quality outcomes, including consumer experience and patient-reported outcome measures
• Plans to improve safety and quality, and reduce risk.

In addition to providing data to the governing body, provide information to:

• The workforce, who should review the data to identify emerging safety and quality issues, or assess the impact of safety and quality initiatives
• Consumers and local community members as major stakeholders
• Other relevant health service organisations that may use the information in planning for patients who are referred to or from the organisation.

Examples of evidence

Select only examples currently in use:

• Reports on safety and quality performance data that are provided to the governing body, managers, committees, the workforce or consumers
• Committee and meeting records in which information on safety and quality indicators, data or recommendations by the governing body are discussed
• Committee and meeting records in which the appropriateness and accessibility of the health service organisation’s safety and quality performance information are discussed
• Communication strategy that describes processes for disseminating information on safety and quality performance to the community
• Communication with the workforce and consumers on the health service organisation’s safety and quality performance
• Records of safety and quality performance information published in annual reports, newsletters or other local media
• Reporting templates and calendars
• Reports provided to external organisations.

Routinely collecting process and outcome data, monitoring data for trends and reporting clinical alerts enables organisations to understand outcomes from service delivery, and to respond to deviations from the expected outcomes promptly.

Clearly documented processes to ensure the accuracy, validity and comprehensiveness of information will increase the organisation’s confidence in data quality. Providing the governing body and the workforce with access to the organisation’s most important safety and quality metrics (indicators) will enable regular review of progress and will allow the organisation to respond to issues as they arise. Suitable metrics may include:

• Key relevant national priority indicators and regulatory requirements
• Indicators covering safety, clinical effectiveness, patient experience, access and efficiency across the organisation’s services
• Trends in reported adverse events, incidents and near misses
• Compliance with best-practice pathways.

Provide the governing body and management with regular, comprehensive safety and quality presentations and reports from managers and clinicians. Schedule data presentations following agreed criteria (for example, significance of risk, patient volume, organisational priority or focus).

Effective data presentations should cover:

• The design of the systems and processes being used
• Evaluation and management of risks
• Compliance with evidence-based practice
• Safety and quality outcomes, including consumer experience and patient-reported outcome measures
• Plans to improve safety and quality, and reduce risk.

Some organisations may choose to participate in benchmarking groups, in which they submit clinical indicator data and are provided with benchmarking reports. This enables them to assess their performance against data collated from similar peer groups.

Examples of evidence

Select only examples currently in use:

• Reports on safety and quality performance data that are provided to the governing body, managers, committees, the workforce or consumers
• Committee and meeting records in which information on safety and quality indicators, data or recommendations by the governing body are discussed
• Committee and meeting records in which the appropriateness and accessibility of the health service organisation’s safety and quality performance information are discussed
• Communication strategy that describes processes for disseminating information on safety and quality performance to the community
• Communication with the workforce and consumers on the health service organisation’s safety and quality performance
• Records of safety and quality performance information published in annual reports, newsletters or other local media
• Reporting templates and calendars
• Reports provided to external organisations.

• Develop a reporting schedule that outlines the topic areas, format and frequency of reporting on safety and quality performance, and the effectiveness of the safety and quality systems
• Involve the workforce, consumers, local communities and other health service organisations in identifying the information, format and frequency of reporting to these groups on safety and quality performance, and the effectiveness of the safety and quality systems
• Routinely collect process and outcome data that include all clinical areas and cover all locations of service delivery, and monitor data for trends and reporting clinical alerts.

Suitable metrics may include:

• Key relevant national priority indicators and regulatory requirements
• Indicators covering safety, clinical effectiveness, patient experience, access and efficiency across the organisation’s services, and service locations
• Compliance with best-practice pathways.

Some organisations may choose to be involved in benchmarking groups, for which they submit clinical indicator data and are provided with benchmarking reports. This enables them to assess their performance against data collated from other similar peer groups.

Examples of evidence

Select only examples currently in use:

• Reports on safety and quality performance data that are provided to the governing body, managers, committees, the workforce or consumers
• Committee and meeting records in which information on safety and quality indicators, data or recommendations by the governing body are discussed
• Committee and meeting records in which the appropriateness and accessibility of the health service organisation’s safety and quality performance information are discussed
• Communication strategy that describes processes for disseminating information on safety and quality performance to the community
• Communication with the workforce and consumers on the health service organisation’s safety and quality performance
• Records of safety and quality performance information published in annual reports, newsletters or other local media
• Reporting templates and calendars
• Reports provided to external organisations.