Action 5.02

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

• Action 1.08 – quality improvement systems
• Action 1.09 – reporting
• Action 1.11 – incident management and investigation systems

Health service organisations should use these and other established safety and quality systems to support monitoring, reporting and implementation of quality improvement strategies for comprehensive care.

Monitor effectiveness and performance

Use the organisation’s quality improvement systems to identify and set priorities for the organisational and clinical strategies to deliver comprehensive care and minimise patient harm.

Review these systems to ensure that they include requirements for:

• Intermittent audits of documentation on screening and assessment processes, patient preferences and goals, and shared decision making

• Ongoing data collection about processes such as patient admission and discharge, hourly rounding, multidisciplinary team rounds and meetings, clinical handover, and discharge planning

• Ongoing data collection about outcomes such as length of stay, the alignment of documented patient preferences with actual care, patient experiences, and the prevalence of adverse events associated with this standard (for example, falls, pressure injuries, delirium, restraint)

• Periodic surveys of workforce attitudes and patient experiences of using the system for comprehensive care

• Regular, informal quality checks of patient, carer and family experiences and perspectives (for example, conducting five-minute interviews at the bedside or in the waiting room).

Implement quality improvement strategies

Use the results of monitoring activities to show improvements or areas in which improvement is required. If appropriate, use quality improvement activities that are consistent and measurable across the corporate group, network or health service.

Use the results of organisational risk assessments to identify gaps, plan, and set priorities for areas for investigation or action.

When adverse events occur, specifically investigate to identify any issues in the performance or use of the system for comprehensive care. Use this information to make improvements.

Report outcomes

Report evaluation findings to the governing body and the workforce. Use the data to work with consumers, the workforce, clinical leaders and managers to identify and implement improvements to the system for comprehensive care.

Strategies for monitoring, preventing and minimising specific risks of harm can be found in the Minimising patient harm criterion of this standard.

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

• Action 1.08 – quality improvement systems
• Action 1.09 – reporting
• Action 1.11 – incident management and investigation systems

Health service organisations should use these and other established safety and quality systems to support monitoring, reporting and implementation of quality improvement strategies for comprehensive care.

Monitor effectiveness and performance

Use the organisation’s quality improvement systems to identify and set priorities for the organisational and clinical strategies to deliver comprehensive care and minimise patient harm.

Review these systems to ensure that they include requirements for:

• Intermittent audits of documentation on screening and assessment processes, patient preferences and goals, and shared decision making
• Ongoing data collection about indicators such as clinical deterioration, cancellation of procedures on the day, delayed discharges, unplanned transfers or overnight stays, and returns to theatre¹
• Periodic surveys of workforce attitudes and patient experiences of using the system for comprehensive care
• Regular, informal quality checks of patient, carer and family experiences and perspectives (for example, conducting five-minute interviews at the bedside or in the waiting room).

Implement quality improvement strategies

Use the results of monitoring activities to show improvements, or areas in which improvement is required. If appropriate, use quality improvement activities that are consistent and measurable across the corporate group.

Use the results of organisational risk assessments to identify gaps, plan, and set priorities for areas for investigation or action.

When adverse events occur, specifically investigate to identify any issues in the performance or use of the system for comprehensive care. Use this information to make improvements.

Report outcomes

Report evaluation findings to the governing body and the workforce. Use the data to work with consumers, the workforce, clinical leaders and managers to identify and implement improvements to the system for comprehensive care.

Strategies for monitoring, preventing and minimising specific risks of harm can be found in the Minimising patient harm criterion of this standard.

Examples of evidence

Select only examples currently in use:

• Record of quality improvement activities relating to comprehensive care
• Administrative and clinical data that are used to determine risk, priorities for improvement and effectiveness of improvement interventions for provision of comprehensive care
• Audit results of healthcare records for documentation of screening, assessment and shared decision-making processes, and comprehensive care plans
• Schedules for planned audits of issues associated with delivery of comprehensive care
• Committee and meeting records in which quality performance and improvement strategies for delivery of comprehensive care were discussed
• Results of data analysis on outcomes such as discharge delays, the alignment of documented patient preferences with actual care and the prevalence of adverse events associated with identified risks
• Actions taken to manage identified risks associated with delivery of comprehensive care
• Reports to the highest level of governance, consumers and the workforce on delivery of comprehensive care, or other documented information on trends relating to identified risks
• Communication with the workforce and patients about improvement activities and outcomes
• Documentation from incident monitoring that captures data relating to delivery of comprehensive care
• Examples of improvement activities that have been implemented and evaluated to improve teamwork, screening assessment or shared decision making
• Feedback provided to the workforce about the results of audits relating to delivery of comprehensive care and actions to deal with issues identified
• Results of consumer and carer experience surveys, and actions taken to deal with issues identified
• Results of workforce surveys for attitudes regarding delivery of care that is based on a patient’s identified goals for the episode of care
• Adverse events register that includes actions taken to improve performance in relation to adverse events associated with delivery of care that is based on a patient’s identified goals for the episode of care.

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

• Action 1.08 – quality improvement systems
• Action 1.09 – reporting
• Action 1.11 – incident management and investigation systems

Health service organisations should use these and other established safety and quality systems to support  monitoring, reporting and implementation of quality improvement strategies for comprehensive care.

Monitor effectiveness and performance

Use the organisation’s quality improvement systems to identify and set priorities for the organisational and clinical strategies to deliver comprehensive care and minimise patient harm.

Review these systems to ensure that they include requirements for:

• Intermittent audits of documentation on screening and assessment processes, patient preferences and goals, and shared decision making
• Ongoing data collection about processes such as patient admission and discharge, hourly rounding, multidisciplinary team rounds and meetings, clinical handover, and discharge planning
• Ongoing data collection about outcomes such as length of stay, the alignment of documented patient preferences with actual care, patient experiences, and the prevalence of adverse events associated with this standard (for example, falls, pressure injuries, delirium, restraint)
• Periodic surveys of workforce attitudes and patient experiences of using the system for comprehensive care
• Regular, informal quality checks of patient, carer and family experiences and perspectives (for example, conducting five-minute interviews at the bedside or in the waiting room).

Implement quality improvement strategies

Use the results of monitoring activities to show improvements or areas in which improvement is required. If appropriate, use quality improvement activities that are consistent and measurable across the corporate group, network or health service.

Use the results of organisational risk assessments to identify gaps, plan, and set priorities for areas for investigation or action.

When adverse events occur, specifically investigate to identify any issues in the performance or use of the system for comprehensive care. Use this information to make improvements.

Report outcomes

Report evaluation findings to the governing body and the workforce. Use the data to work with consumers, the workforce, clinical leaders and managers to identify and implement improvements to the system for comprehensive care.

Strategies for monitoring, preventing and minimising specific risks of harm can be found in the Minimising patient harm criterion of this standard.