Action 1.27 states
The health service organisation has processes that:
- Provide clinicians with ready access to best-practice guidelines, integrated care pathways, clinical pathways and decision support tools relevant to their clinical practice
- Support clinicians to use the best available evidence, including relevant clinical care standards developed by the Australian Commission on Safety and Quality in Health Care
Intent
The clinical workforce is supported to use the best available evidence.
Reflective questions
How does the health service organisation decide which best-practice guidelines, integrated care pathways, clinical pathways, decision support tools and clinical care standards are to be used?
How does the health service organisation support and monitor clinicians’ use of these tools?
Key tasks
- Evaluate the extent to which documented clinical guidelines or pathways have been formally adopted by the clinical workforce, and whether opportunities exist to adopt clinical guidelines or pathways as a quality improvement activity.
- Review how compliance with, and variations of practice from, evidence-based clinical guidelines or pathways are monitored, especially for high-volume or high-risk conditions.
Strategies for improvement
Hospitals
Use clinical guidelines and pathways
Good clinical governance promotes clinical practice that is effective and evidence based.1 Provide clinicians with ready access to best-practice guidelines, integrated care pathways, clinical pathways, decision support tools, and the clinical care standards developed by the Commission relevant to their clinical practice.
The introduction, use, monitoring and evaluation of evidence-based clinical pathways support effective care, and promote an organisational culture in which evaluation of organisational and clinical performance, including clinical audit, is expected in every clinical service.2
Promote clinical effectiveness by developing or adopting guidelines and protocols for particular diseases and clinical interventions. The National Health and Medical Research Council’s clinical practice guidelines portal provides links to clinical practice guidelines developed for use in Australian healthcare settings.
Promote accountability of clinicians for their practice, including compliance with accepted clinical guidelines or pathways. Overseeing clinical practice should enable the early identification and management of practices that place patients at risk of harm.3
Effective quality improvement systems identify the extent of variation from agreed clinical guidelines or pathways, and how such variation is managed. Use audits to monitor the proportion of care that is provided following clinical guidelines or pathways, and communicate this to the workforce, managers and the governing body.
The governing body and management should periodically review compliance with, and variations from, evidence-based practice, to provide assurance of appropriate care and identify quality improvement opportunities.
Use clinical care standards
Clinical care standards support the delivery of appropriate care, reduce unwarranted variation in care, and promote shared decision making between patients, carers and clinicians.4 Clinical care standards target key areas and provide opportunities to better align clinical practice with the best evidence.
Clinical care standards are designed to:
- Inform patients about the care they can expect to receive
- Provide guidance to clinicians on delivering appropriate, high-quality care
- Identify the systems that organisations need to have in place to support and monitor appropriate care.
Clinical guidelines form the evidence base for the clinical care standards. It is recommended that clinical care standards are used by health service organisations when they apply to services being provided.
If appropriate, build the requirements of the clinical care standard into the organisation’s policies, processes or protocols, and give clinicians access to relevant clinical care standards.
Each clinical care standard includes nationally agreed quality statements outlining key areas of care.
In complex organisations, or the private health sector, the care described in the quality statements may not be offered or delivered by one care provider. Identify which of the quality statements are the responsibility of the health service organisation and which other service providers may be responsible for care set out in the quality statements. Establish formal agreements on responsibility for implementing the quality statements with any other organisations or service providers delivering care.
Action 3.15 and Action 5.29 include strategies related to the Antimicrobial Stewardship Clinical Care Standard and the Delirium Clinical Care Standard.
Support evidence-based practice
Ensure that systems are in place to periodically review compliance with, and variations from, evidence-based practice, and report to the governing body, to provide assurance of appropriate care and identify quality improvement opportunities.
Strategies to support clinicians to use the best available evidence and limit unwarranted variations in care may include:
- Adopting clinical guidelines, pathways or clinical care standards where they are appropriate
- Identifying or establishing the committees or individuals with responsibility for approving and reviewing the use of best-practice guidelines, integrated care pathways, clinical pathways, clinical care standards and decision support tools, and for communicating this information to the workforce
- Making resources available to implement clinical guidelines, pathways or clinical care standards
- Establishing processes that enable peer-based feedback to the clinical workforce about compliance with evidence and management of variation
- Monitoring compliance with the clinical care standards being used, and informing clinicians if unwarranted variation is detected.
Examples of evidence
Select only examples currently in use:
- Policy documents about access to, and use of, best-practice guidelines, pathways, decision support tools and clinical care standards that reflect best available evidence and are appropriately referenced
- Committee and meeting records in which decisions about the implementation and use of best-practice guidelines, pathways, decision support tools and clinical care standards were discussed
- Training documents about best-practice guidelines, pathways, decision support tools and clinical care standards
- List of procedures with agreed clinical pathways available to the workforce
- List of web addresses for the workforce to use, and electronic copies of best-practice guidelines, pathways, decision support tools and clinical care standards
- Audit results of healthcare records for adherence to available best-practice guidelines, pathways, decision support tools and clinical care standards
- Observation of best-practice guidelines, pathways, decision support tools and clinical care standards in clinical areas.
Day Procedure Services
Use clinical guidelines and pathways
Good clinical governance promotes clinical practice that is effective and evidence based.1 Provide clinicians with ready access to best-practice guidelines, integrated care pathways, clinical pathways, decision support tools, and the clinical care standards developed by the Commission relevant to their clinical practice.
The introduction, use, monitoring and evaluation of evidence-based clinical pathways support effective care, and promote an organisational culture in which evaluation of organisational and clinical performance, including clinical audit, is expected in every clinical service.2
Promote clinical effectiveness by developing or adopting guidelines and protocols for particular diseases and clinical interventions. The National Health and Medical Research Council’s clinical practice guidelines portal provides links to clinical practice guidelines developed for use in Australian healthcare settings.
Promote accountability of clinicians for their practice, including compliance with accepted clinical guidelines or pathways. Overseeing clinical practice should enable the early identification and management of practices that place patients at risk of harm.3
Effective quality improvement systems identify the extent of variation from agreed clinical guidelines or pathways, and how such variation is managed. Use audits to monitor the proportion of care that is provided following clinical guidelines or pathways, and communicate this to the workforce, managers and the governing body.
The governing body and management should periodically review compliance with, and variations from, evidence-based practice, to provide assurance of appropriate care and identify quality improvement opportunities.
Use clinical care standards
Clinical care standards support the delivery of appropriate care, reduce unwarranted variation in care, and promote shared decision making between patients, carers and clinicians.4 Clinical care standards target key areas and provide opportunities to better align clinical practice with the best evidence.
Clinical care standards are designed to:
- Inform patients about the care they can expect to receive
- Provide guidance to clinicians on delivering appropriate, high-quality care
- Identify the systems that organisations need to have in place to support and monitor appropriate care.
Clinical guidelines form the evidence base for the clinical care standards. It is recommended that clinical care standards are used by health service organisations when they apply to services being provided.
If appropriate, build the requirements of the clinical care standard into the organisation’s policies, processes or protocols, and give clinicians access to relevant clinical care standards.
Each clinical care standard includes nationally agreed quality statements outlining key areas of care.
In complex organisations, or the private health sector, the care described in the quality statements may not be offered or delivered by one care provider. Identify which of the quality statements are the responsibility of the health service organisation and which other service providers may be responsible for care set out in the quality statements. Establish formal agreements on responsibility for implementing the quality statements with any other organisations or service providers delivering care.
Action 3.15 and Action 5.29 include strategies related to the Antimicrobial Stewardship Clinical Care Standard and the Delirium Clinical Care Standard.
Support evidence-based practice
Ensure that systems are in place that periodically review compliance with, and variations from, evidence-based practice, and report to the governing body, to provide assurance of appropriate care and identify quality improvement opportunities.
Strategies to support clinicians to use the best available evidence and limit unwarranted variations in care may include:
- Adopting clinical guidelines, pathways or clinical care standards where they are appropriate
- Identifying or establishing committees or individuals with responsibility for approving and reviewing the use of best-practice guidelines, integrated care pathways, clinical pathways, clinical care standards and decision support tools, and for communicating this information to the workforce
- Making resources available to implement clinical guidelines, pathways or clinical care standards
- Establishing processes that enable peer-based feedback to the clinical workforce about compliance with evidence and management of variation
- Monitoring compliance with clinical care standards being used, and informing clinicians if unwarranted variation is detected.
Examples of evidence
Select only examples currently in use:
- Policy documents about access to, and use of, best-practice guidelines, pathways, decision support tools and clinical care standards that reflect best available evidence and are appropriately referenced
- Committee and meeting records in which decisions about the implementation and use of best-practice guidelines, pathways, decision support tools and clinical care standards were discussed
- Training documents about best-practice guidelines, pathways, decision support tools and clinical care standards
- List of procedures with agreed clinical pathways available to the workforce
- List of web addresses for the workforce to use, and electronic copies of best-practice guidelines, pathways, decision support tools and clinical care standards
- Audit results of healthcare records for adherence to available best-practice guidelines, pathways, decision support tools and clinical care standards
- Observation of best-practice guidelines, pathways, decision support tools and clinical care standards in clinical areas.
MPS & Small Hospitals
MPSs or small hospitals that are part of a local health network or private hospital group should adapt or adopt the established clinical guidelines and pathways.
Small hospitals that are not part of a local health network or private hospital group should identify and endorse clinical guidelines and pathways appropriate to the service type and context, and:
- Evaluate the extent to which documented clinical guidelines or pathways have been formally adopted by the clinical workforce, and whether opportunities exist to adopt clinical guidelines or pathways as a quality improvement activity
- Review how compliance with, and variations of practice from, evidence-based clinical guidelines or pathways are monitored, especially for high-volume or high-risk conditions.
Good clinical governance promotes clinical practice that is effective and evidence based.1 Provide clinicians with ready access to best-practice guidelines, integrated care pathways, clinical pathways, decision support tools, and the clinical care standards developed by the Commission relevant to their clinical practice.
The National Health and Medical Research Council’s clinical practice guidelines portal provides links to clinical practice guidelines developed for use in Australian healthcare settings.
Clinical care standards support the delivery of appropriate care, reduce unwarranted variation in care, and promote shared decision making between patients, carers and clinicians. Clinical care standards are designed to:
- Inform patients about the care they can expect to receive
- Provide guidance to clinicians on delivering appropriate, high-quality care
- Identify the systems that organisations need to have in place to support and monitor appropriate care.
Clinical guidelines form the evidence base for the clinical care standards.
If appropriate, build the requirements of the clinical care standard into the organisation’s policies, processes or protocols, and give clinicians access to relevant clinical care standards.
Each clinical care standard includes nationally agreed quality statements outlining key areas of care.
In complex organisations, or the private health sector, the care described in the quality statements may not be offered or delivered by one care provider. Identify which of the quality statements are the responsibility of the health service organisation and which other service providers may be responsible for care set out in the quality statements. Establish formal agreements on responsibility for implementing the quality statements with any other organisations or service providers delivering care.
Action 3.15 and Action 5.29 include strategies related to the Antimicrobial Stewardship Clinical Care Standard and the Delirium Clinical Care Standard.
Examples of evidence
Select only examples currently in use:
- Policy documents about access to, and use of, best-practice guidelines, pathways, decision support tools and clinical care standards that reflect best available evidence and are appropriately referenced
- Committee and meeting records in which decisions about the implementation and use of best-practice guidelines, pathways, decision support tools and clinical care standards were discussed
- Training documents about best-practice guidelines, pathways, decision support tools and clinical care standards
- List of procedures with agreed clinical pathways available to the workforce
- List of web addresses for the workforce to use, and electronic copies of best-practice guidelines, pathways, decision support tools and clinical care standards
- Audit results of healthcare records for adherence to available best-practice guidelines, pathways, decision support tools and clinical care standards
- Observation of best-practice guidelines, pathways, decision support tools and clinical care standards in clinical areas.
Hospitals
Use clinical guidelines and pathways
Good clinical governance promotes clinical practice that is effective and evidence based.1 Provide clinicians with ready access to best-practice guidelines, integrated care pathways, clinical pathways, decision support tools, and the clinical care standards developed by the Commission relevant to their clinical practice.
The introduction, use, monitoring and evaluation of evidence-based clinical pathways support effective care, and promote an organisational culture in which evaluation of organisational and clinical performance, including clinical audit, is expected in every clinical service.2
Promote clinical effectiveness by developing or adopting guidelines and protocols for particular diseases and clinical interventions. The National Health and Medical Research Council’s clinical practice guidelines portal provides links to clinical practice guidelines developed for use in Australian healthcare settings.
Promote accountability of clinicians for their practice, including compliance with accepted clinical guidelines or pathways. Overseeing clinical practice should enable the early identification and management of practices that place patients at risk of harm.3
Effective quality improvement systems identify the extent of variation from agreed clinical guidelines or pathways, and how such variation is managed. Use audits to monitor the proportion of care that is provided following clinical guidelines or pathways, and communicate this to the workforce, managers and the governing body.
The governing body and management should periodically review compliance with, and variations from, evidence-based practice, to provide assurance of appropriate care and identify quality improvement opportunities.
Use clinical care standards
Clinical care standards support the delivery of appropriate care, reduce unwarranted variation in care, and promote shared decision making between patients, carers and clinicians.4 Clinical care standards target key areas and provide opportunities to better align clinical practice with the best evidence.
Clinical care standards are designed to:
- Inform patients about the care they can expect to receive
- Provide guidance to clinicians on delivering appropriate, high-quality care
- Identify the systems that organisations need to have in place to support and monitor appropriate care.
Clinical guidelines form the evidence base for the clinical care standards. It is recommended that clinical care standards are used by health service organisations when they apply to services being provided.
If appropriate, build the requirements of the clinical care standard into the organisation’s policies, processes or protocols, and give clinicians access to relevant clinical care standards.
Each clinical care standard includes nationally agreed quality statements outlining key areas of care.
In complex organisations, or the private health sector, the care described in the quality statements may not be offered or delivered by one care provider. Identify which of the quality statements are the responsibility of the health service organisation and which other service providers may be responsible for care set out in the quality statements. Establish formal agreements on responsibility for implementing the quality statements with any other organisations or service providers delivering care.
Action 3.15 and Action 5.29 include strategies related to the Antimicrobial Stewardship Clinical Care Standard and the Delirium Clinical Care Standard.
Support evidence-based practice
Ensure that systems are in place to periodically review compliance with, and variations from, evidence-based practice, and report to the governing body, to provide assurance of appropriate care and identify quality improvement opportunities.
Strategies to support clinicians to use the best available evidence and limit unwarranted variations in care may include:
- Adopting clinical guidelines, pathways or clinical care standards where they are appropriate
- Identifying or establishing the committees or individuals with responsibility for approving and reviewing the use of best-practice guidelines, integrated care pathways, clinical pathways, clinical care standards and decision support tools, and for communicating this information to the workforce
- Making resources available to implement clinical guidelines, pathways or clinical care standards
- Establishing processes that enable peer-based feedback to the clinical workforce about compliance with evidence and management of variation
- Monitoring compliance with the clinical care standards being used, and informing clinicians if unwarranted variation is detected.
Examples of evidence
Select only examples currently in use:
- Policy documents about access to, and use of, best-practice guidelines, pathways, decision support tools and clinical care standards that reflect best available evidence and are appropriately referenced
- Committee and meeting records in which decisions about the implementation and use of best-practice guidelines, pathways, decision support tools and clinical care standards were discussed
- Training documents about best-practice guidelines, pathways, decision support tools and clinical care standards
- List of procedures with agreed clinical pathways available to the workforce
- List of web addresses for the workforce to use, and electronic copies of best-practice guidelines, pathways, decision support tools and clinical care standards
- Audit results of healthcare records for adherence to available best-practice guidelines, pathways, decision support tools and clinical care standards
- Observation of best-practice guidelines, pathways, decision support tools and clinical care standards in clinical areas.
Day Procedure Services
Use clinical guidelines and pathways
Good clinical governance promotes clinical practice that is effective and evidence based.1 Provide clinicians with ready access to best-practice guidelines, integrated care pathways, clinical pathways, decision support tools, and the clinical care standards developed by the Commission relevant to their clinical practice.
The introduction, use, monitoring and evaluation of evidence-based clinical pathways support effective care, and promote an organisational culture in which evaluation of organisational and clinical performance, including clinical audit, is expected in every clinical service.2
Promote clinical effectiveness by developing or adopting guidelines and protocols for particular diseases and clinical interventions. The National Health and Medical Research Council’s clinical practice guidelines portal provides links to clinical practice guidelines developed for use in Australian healthcare settings.
Promote accountability of clinicians for their practice, including compliance with accepted clinical guidelines or pathways. Overseeing clinical practice should enable the early identification and management of practices that place patients at risk of harm.3
Effective quality improvement systems identify the extent of variation from agreed clinical guidelines or pathways, and how such variation is managed. Use audits to monitor the proportion of care that is provided following clinical guidelines or pathways, and communicate this to the workforce, managers and the governing body.
The governing body and management should periodically review compliance with, and variations from, evidence-based practice, to provide assurance of appropriate care and identify quality improvement opportunities.
Use clinical care standards
Clinical care standards support the delivery of appropriate care, reduce unwarranted variation in care, and promote shared decision making between patients, carers and clinicians.4 Clinical care standards target key areas and provide opportunities to better align clinical practice with the best evidence.
Clinical care standards are designed to:
- Inform patients about the care they can expect to receive
- Provide guidance to clinicians on delivering appropriate, high-quality care
- Identify the systems that organisations need to have in place to support and monitor appropriate care.
Clinical guidelines form the evidence base for the clinical care standards. It is recommended that clinical care standards are used by health service organisations when they apply to services being provided.
If appropriate, build the requirements of the clinical care standard into the organisation’s policies, processes or protocols, and give clinicians access to relevant clinical care standards.
Each clinical care standard includes nationally agreed quality statements outlining key areas of care.
In complex organisations, or the private health sector, the care described in the quality statements may not be offered or delivered by one care provider. Identify which of the quality statements are the responsibility of the health service organisation and which other service providers may be responsible for care set out in the quality statements. Establish formal agreements on responsibility for implementing the quality statements with any other organisations or service providers delivering care.
Action 3.15 and Action 5.29 include strategies related to the Antimicrobial Stewardship Clinical Care Standard and the Delirium Clinical Care Standard.
Support evidence-based practice
Ensure that systems are in place that periodically review compliance with, and variations from, evidence-based practice, and report to the governing body, to provide assurance of appropriate care and identify quality improvement opportunities.
Strategies to support clinicians to use the best available evidence and limit unwarranted variations in care may include:
- Adopting clinical guidelines, pathways or clinical care standards where they are appropriate
- Identifying or establishing committees or individuals with responsibility for approving and reviewing the use of best-practice guidelines, integrated care pathways, clinical pathways, clinical care standards and decision support tools, and for communicating this information to the workforce
- Making resources available to implement clinical guidelines, pathways or clinical care standards
- Establishing processes that enable peer-based feedback to the clinical workforce about compliance with evidence and management of variation
- Monitoring compliance with clinical care standards being used, and informing clinicians if unwarranted variation is detected.
Examples of evidence
Select only examples currently in use:
- Policy documents about access to, and use of, best-practice guidelines, pathways, decision support tools and clinical care standards that reflect best available evidence and are appropriately referenced
- Committee and meeting records in which decisions about the implementation and use of best-practice guidelines, pathways, decision support tools and clinical care standards were discussed
- Training documents about best-practice guidelines, pathways, decision support tools and clinical care standards
- List of procedures with agreed clinical pathways available to the workforce
- List of web addresses for the workforce to use, and electronic copies of best-practice guidelines, pathways, decision support tools and clinical care standards
- Audit results of healthcare records for adherence to available best-practice guidelines, pathways, decision support tools and clinical care standards
- Observation of best-practice guidelines, pathways, decision support tools and clinical care standards in clinical areas.
MPS & Small Hospitals
MPSs or small hospitals that are part of a local health network or private hospital group should adapt or adopt the established clinical guidelines and pathways.
Small hospitals that are not part of a local health network or private hospital group should identify and endorse clinical guidelines and pathways appropriate to the service type and context, and:
- Evaluate the extent to which documented clinical guidelines or pathways have been formally adopted by the clinical workforce, and whether opportunities exist to adopt clinical guidelines or pathways as a quality improvement activity
- Review how compliance with, and variations of practice from, evidence-based clinical guidelines or pathways are monitored, especially for high-volume or high-risk conditions.
Good clinical governance promotes clinical practice that is effective and evidence based.1 Provide clinicians with ready access to best-practice guidelines, integrated care pathways, clinical pathways, decision support tools, and the clinical care standards developed by the Commission relevant to their clinical practice.
The National Health and Medical Research Council’s clinical practice guidelines portal provides links to clinical practice guidelines developed for use in Australian healthcare settings.
Clinical care standards support the delivery of appropriate care, reduce unwarranted variation in care, and promote shared decision making between patients, carers and clinicians. Clinical care standards are designed to:
- Inform patients about the care they can expect to receive
- Provide guidance to clinicians on delivering appropriate, high-quality care
- Identify the systems that organisations need to have in place to support and monitor appropriate care.
Clinical guidelines form the evidence base for the clinical care standards.
If appropriate, build the requirements of the clinical care standard into the organisation’s policies, processes or protocols, and give clinicians access to relevant clinical care standards.
Each clinical care standard includes nationally agreed quality statements outlining key areas of care.
In complex organisations, or the private health sector, the care described in the quality statements may not be offered or delivered by one care provider. Identify which of the quality statements are the responsibility of the health service organisation and which other service providers may be responsible for care set out in the quality statements. Establish formal agreements on responsibility for implementing the quality statements with any other organisations or service providers delivering care.
Action 3.15 and Action 5.29 include strategies related to the Antimicrobial Stewardship Clinical Care Standard and the Delirium Clinical Care Standard.
Examples of evidence
Select only examples currently in use:
- Policy documents about access to, and use of, best-practice guidelines, pathways, decision support tools and clinical care standards that reflect best available evidence and are appropriately referenced
- Committee and meeting records in which decisions about the implementation and use of best-practice guidelines, pathways, decision support tools and clinical care standards were discussed
- Training documents about best-practice guidelines, pathways, decision support tools and clinical care standards
- List of procedures with agreed clinical pathways available to the workforce
- List of web addresses for the workforce to use, and electronic copies of best-practice guidelines, pathways, decision support tools and clinical care standards
- Audit results of healthcare records for adherence to available best-practice guidelines, pathways, decision support tools and clinical care standards
- Observation of best-practice guidelines, pathways, decision support tools and clinical care standards in clinical areas.
Certification and re-certification of practising colonoscopists
Certification (of training) and Re-certification (of ongoing competency) in adult colonoscopy are now mandatory for all practitioners working in health service organisations being assessed to the second edition of the NSQHS Standards.
Resources
References
- Starey N. What is clinical governance? Fordham (UK): Hayward Medical Communications; 1999.
- Office of Safety and Quality in Health Care WA. Clinical governance standards for Western Australian health services. Perth: WA Department of Health; 2005.
- Hyde JK, Shortell SM. The structure and organization of local and state public health agencies in the US: a systematic review. Am J Prevent Med 2012;42(5 Suppl 1):S29–41.
- Australian Commission on Safety and Quality in Health Care. Clinical care standards. Sydney: ACSQHC; 2017 [cited 2017 Mar 22].