Action 2.01

The Clinical Governance Standard has specific actions relating to health service organisations’ safety and quality systems.

• Action 1.07 – policies and procedures
• Action 1.10 – risk management systems
• Actions 1.19, 1.20 and 1.21 – education and training

Health service organisations should:

• Use these and other established safety and quality systems to support policies and procedures, risk management and training for partnering with consumers
• Ensure that current versions of all relevant policies and procedures are readily available and accessible to clinicians.

Clinical policies may be developed or adapted at different levels within the organisation. However, all policy documents should be incorporated into a single, coherent set to maximise the effectiveness of the policy development process.

Establish governance for partnering with consumers

For Action 2.01, the health service organisation should ensure that all actions in the Partnering with Consumers Standard have appropriate governance structures and support from the governing body and management.

Actions 2.11, 2.12, 2.13 and 2.14 outline strategies for partnering with consumers in discussions and decisions regarding the design, implementation and evaluation of health policies, programs and services.

Implement policies and procedures

Ensure that organisational policies and procedures are in place that cover:

• Healthcare rights
• Informed consent, including financial consent
• Shared decision making and planning care
• Health literacy and effective communication with patients, carers, families and consumers
• Partnering with consumers in governance.

Manage risks

Use the organisation’s risk management systems (see Action 1.10) to identify, monitor, manage and review risks associated with partnering with consumers. Develop processes to manage clinical risks for different populations served within the organisation, clinical and workplace risks for the workforce, and organisational risks.

Use information from measurement and quality improvement systems, adverse events, clinical outcomes and patient experiences to inform and update risk assessments and the risk management system.

Identify training requirements

Assess the competency and training needs of the workforce in line with the requirements of Actions 1.19, 1.20 and 1.21. Perform a risk assessment to inform the training schedule and to set priorities for the members of the workforce who require training. Develop, or provide access to, training and education resources to meet the needs of the workforce with regard to partnering with consumers

Education and training to support understanding and awareness of the value of partnerships with consumers can include training on person-centred care, shared decision making, communication techniques and health literacy. It may also involve consumer input through stories, presentations or advice on the development of training materials.

Consider the training the workforce may need to effectively use the incident management and investigation system to inform risk management, and to plan and implement quality improvement processes to mitigate risks.

The Clinical Governance Standard has specific actions relating to health service organisations’ safety and quality systems.

• Action 1.07 – policies and procedures
• Action 1.10 – risk management systems
• Actions 1.19, 1.20 and 1.21 – education and training

Health service organisations should:

• Use these and other established safety and quality systems to support policies and procedures, risk management and training for partnering with consumers
• Ensure that current versions of all relevant policies and procedures are readily available and accessible to clinicians.

Clinical policies may be developed or adapted at different levels within the organisation. However, all policy documents should be incorporated into a single, coherent set to maximise the effectiveness of the policy development process.

Establish governance for partnering with consumers

For Action 2.01, the health service organisation should ensure that all actions in the Partnering with Consumers Standard have appropriate governance structures and support from the governing body and management.

Actions 2.11, 2.12, 2.13 and 2.14 outline strategies for partnering with consumers in discussions and decisions regarding the design, implementation and evaluation of health policies, programs and services.

Implement policies and procedures

Ensure that organisational policies and procedures are in place that cover:

• Healthcare rights
• Informed consent, including financial consent
• Shared decision making and planning care
• Health literacy and effective communication with patients, carers, families and consumers
• Partnering with consumers in governance.

Manage risks

Use the organisation’s established risk management systems (see Action 1.10) to identify, monitor, manage and review risks associated with partnering with consumers. Develop processes to manage clinical risks for different populations served within the organisation, clinical and workplace risks for the workforce, and organisational risks.

Use information from measurement and quality improvement systems, adverse events, clinical outcomes and patient experiences to inform and update risk assessments and the risk management system.

Identify training requirements

Assess the competency and training needs of the workforce in line with the requirements of Actions 1.19, 1.20 and 1.21. Perform a risk assessment to inform the training schedule and to set priorities for the members of the workforce who require training. Develop, or provide access to, training and education resources to meet the needs of the workforce with regard to partnering with consumers

Education and training to support understanding and awareness of the value of partnerships with consumers can include training on person-centred care, shared decision making, communication techniques and health literacy. It may also involve consumer input through stories, presentations or advice on the development of training materials.

Consider the training the workforce may need to effectively use the incident management and investigation system to inform risk management, and to plan and implement quality improvement processes to mitigate risks.

Examples of evidence

Select only examples currently in use:

• Policy documents that describe the health service organisation’s processes for partnering with consumers, including the
  • mechanisms available to engage with consumers
  • financial and physical resources that are available to support consumer participation and input at the governance level
• Observation of clinicians’ practice that demonstrates use of the health service organisation’s processes for partnering with consumers
• Records of interviews with clinicians that show that they understand the health service organisation’s processes for partnering with consumers
• Organisational structure that identifies where and how consumers are engaged
• Committee and meeting records that show clinician and consumer involvement in the discussion of consumer engagement strategies, including implementing policy, managing risk, and building skills and capacity for partnering with consumers
• Data from the health service organisation’s risk management and reporting systems on risks associated with partnering with consumers and risk mitigation strategies
• Training documents that include information on the value of consumer engagement, and the potential roles for consumer partners in clinical governance and strategic leadership
• Documented examples of consumer engagement in workforce recruitment or review of recruitment processes
• Feedback from consumers, consumer representatives, consumer organisations and carers on their experience of engagement with the health service organisation in clinical governance.

The Clinical Governance Standard has specific actions relating to health service organisations’ safety and quality systems.

• Action 1.07 – policies and procedures
• Action 1.10 – risk management systems
• Actions 1.19, 1.20 and 1.21 – education and training

Health service organisations should:

• Use these and other established safety and quality systems to support policies and procedures, risk management and training for partnering with consumers
• Ensure that current versions of all relevant policies and procedures are readily available and accessible to clinicians.

Clinical policies may be developed or adapted at different levels within the organisation. However, all policy documents should be incorporated into a single coherent set to maximise the effectiveness of the policy development process.

Establish governance for partnering with consumers

For Action 2.01, the health service organisation should ensure that all actions in the Partnering with Consumers Standard have appropriate governance structures and support from the governing body and management.

Actions 2.11, 2.12, 2.13 and 2.14 outline strategies for partnering with consumers in discussions and decisions regarding the design, implementation and evaluation of health policies, programs and services.

Implement policies and procedures

MPSs or small hospitals that are part of a local health network or private hospital group should adopt or adapt and use the existing policies and procedures for partnering with consumers.

Small hospitals that are not part of a local health network or private hospital group should develop or adapt policies and procedures that cover:

• Healthcare rights
• Informed consent, including financial consent
• Shared decision making and planning care
• Health literacy and effective communication with patients, carers, families and consumers
• Partnering with consumers in governance.

Manage risks

Use the organisation’s established risk management systems (Action 1.10) to identify, monitor, manage and review risks associated with partnering with consumers. Develop processes to manage clinical risks for different populations served within the organisation, clinical and workplace risks for the workforce, and organisational risks.

Use information from measurement and quality improvement systems, adverse events, clinical outcomes and patient experiences to inform and update risk assessments and the risk management system.

Identify training requirements

Assess the competency and training needs of the workforce in line with the requirements of Actions 1.19, 1.20 and 1.21. Perform a risk assessment to inform the education plan and to set priorities for the members of the workforce who require training. Develop, or provide access to, training and education resources to meet the needs of the workforce with regard to partnering with consumers

Education and training to support understanding and awareness of the value of partnerships with consumers can include training on person-centred care, shared decision making, communication techniques and health literacy. It may also involve consumer input through stories, presentations or advice on the development of training materials.