Action 6.01

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 the policies and procedures, risk management and training for clinical communications.
• Ensure that current versions of all relevant policies and procedures are readily available and accessible to clinicians.

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.

Implement policies and procedures

Policies and procedures should outline how organisation-wide systems support effective clinical communication.

Organisations vary significantly, depending on the size of the service, settings and circumstances. This highlights the need for a flexible approach to implementation.¹ Implementation of policies and procedures to improve clinical communications therefore requires consideration of the existing organisational structure and governance framework, and how the policies and procedures fit within the organisation’s context. Development of separate policies or procedures is not necessarily required – it may be more efficient and effective to have an overarching policy framework, supported by a flexible standardisation approach that is fit for purpose and accommodates specific localised environments (for example, communication in a general ward compared with an emergency department).

Policies and processes could include:

• An organisation-wide strategy that outlines clinical communication processes, and the flow of information to patients, carers, families and clinicians responsible for providing care
• Situations when identification, procedure matching, structured clinical handover, communication of critical information and documentation are required (linked to Actions 6.04 and 6.11)
• Agreed processes for communicating in these situations, including the structure and method of communication, and relevant information to be communicated – for example
  • points of care at which communication is required
  • appropriate communication methods
  • roles and responsibilities of the workforce
• Guidance on how to engage with, and support, patients (and carers) to communicate about their care.

Ensure that policies and procedures describe patients as key participants in clinical communication, and how patients, carers and families can be involved in clinical communication strategies and associated processes.

Document the policies, processes, resources and tools for clinical communication. Make these available to the workforce to ensure that a consistent approach is taken across the organisation and members of the workforce understand what is required of them when using the organisation’s clinical communication processes. This can be done through the organisation’s website, at meetings, through newsletters or noticeboards, or by displaying communication techniques and processes in the ward or on patient charts.

Set up governance and reporting structures to support effective clinical communication across the organisation, and effective collaboration with patients and clinicians. This could involve setting up committees with governance oversight for improving or monitoring clinical communication.

Ensure that membership of committees reflects the different disciplines that work in the organisation and are involved in delivering patient care. In particular, ensure that consumer advisors on committees or the composition of a consumer/community advisory committee reflect the organisation’s day-to-day patient community (see Action 2.11). A network of consumer advisors (groups and individuals) who can provide advice about the development of effective clinical communication processes and collaboration initiatives may be helpful.

Manage risks

Use established risk management systems (see Action 1.10) to identify, monitor, manage and review risks associated with communicating for safety. 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, and adverse events, clinical outcomes and patient experience data to inform and update risk assessments and the risk management system.

Consider the types of risks that may be associated with clinical communications, such as²:

• Contextual risks (for example, noise, interruptions, inadequate space and time, absent participants)
• Informational risks (for example, information that is unstructured, incomplete, irrelevant, inaccessible, inaccurate or not up to date)
• Interactional risks (for example, failure to design communication processes that are accessible, legible and intelligible to recipients and to which recipients can actively contribute).

Ensure that the organisation-wide risk management system can identify, assess, manage and document organisational risks associated with poor clinical communication or communication errors (see Action 1.10). This could include:

• Failure to correctly identify patients or match procedures
• Failure to communicate critical tests or diagnostic results
• Communication errors that result in misdiagnosis
• Miscommunication of clinical information at clinical handover
• Risks associated with poor documentation.

Consider potential clinical risks associated with electronic health systems (hardware and software) that are intended to aid or facilitate communication processes. For example, electronic health systems and new technology have the potential to enable faster, more effective communication; however, information systems and technology can also present challenges for privacy, and risks to clinical safety and quality if they are poorly implemented or integrated.

Consider the interaction between non-technical dimensions of healthcare (workflow, policies and personnel) and technical dimensions (software, hardware, content and user interface).³ Patient safety issues can occur when one or more technical dimensions interact unexpectedly with non-technical dimensions. For example, a change in the way that one system presents information to a clinician may lead to incorrect interpretation if the clinician is unaware of that change. Ensure that the organisation considers, monitors and manages these risks.

Carefully consider the planning and implementation of electronic handover solutions, such as electronic discharge summary systems. Use the Electronic Discharge Summary Systems Self-Evaluation Toolkit and National Guidelines for On-Screen Presentation of Discharge Summaries.

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 need training. Develop, or provide access to, training and education resources to meet the needs of the workforce in relation to clinical communication.

Provide ongoing education and training to new and existing members of the workforce about the organisation’s clinical communication policies, processes and tools. This should include information about what is required, roles and responsibilities (including how and when to escalate care, and who to), and the structure or standardised format to be used for communicating when identification, procedure matching, clinical handover and communication of critical information are required.

Provide information through orientation, training, regular updates at workforce and management meetings, mentorship programs, and feedback or debriefing sessions with members of the project workforce or clinicians.

Ensure that performance management processes established in Action 1.22 give priority to continuous development of the workforce’s communication skills. Identify any communication skills that need to be improved or refined, and incorporate these into the organisation’s training system.

Given the complexity of care and the number of people that can be involved in clinical communications, consider ongoing support for multidisciplinary education and training initiatives to encourage and sustain the implementation of any strategies.⁴ This will enable different members of the workforce to have a shared understanding of the processes and requirements for effective clinical communication.

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 the policies and procedures, risk management and training for clinical communications.
• Ensure that current versions of all relevant policies and procedures are readily available and accessible to clinicians.

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.

Implement policies and procedures

Policies and procedures should outline how organisation-wide systems support effective clinical communication.

Organisations vary significantly, depending on the size of the service, settings and circumstances. This highlights the need for a flexible approach to implementation.¹ Implementation of policies and procedures to improve clinical communications therefore requires consideration of the existing organisational structure and governance framework, and how the policies and procedures fit within the organisation’s context. Development of separate policies or procedures is not necessarily required – it may be more efficient and effective to have an overarching policy framework, supported by a flexible standardisation approach that is fit for purpose and accommodates specific localised environments (for example, communication in a general ward compared with an emergency department).

Policies and processes could include:

• An organisation-wide strategy that outlines clinical communication processes, and the flow of information to patients, carers, families and clinicians responsible for providing care
• Situations when identification, procedure matching, structured clinical handover and communication of critical information are required (linked to Actions 6.04 and 6.11)
• Agreed processes for communicating in these situations, including the structure and method of communication, and relevant information to be communicated – for example
  • points of care at which communication is required
  • appropriate communication methods
  • roles and responsibilities of the workforce
• Guidance on how to engage with, and support, patients (and carers) to communicate about their care.

Ensure that policies and procedures describe patients as key participants in clinical communication, and how patients, carers and families can be involved in clinical communication strategies and associated processes.

Document the policies, processes, resources and tools for clinical communications. Make these available to the workforce to ensure that a consistent approach is taken across the organisation and members of the workforce understand what is required of them when using the organisation’s clinical communication processes. This can be done through the organisation’s website, at meetings, through newsletters or noticeboards, or by displaying communication techniques and processes in the service on charts or tools.

Set up governance and reporting structures to support effective clinical communication across the organisation, and effective collaboration between patients and clinicians. This could involve setting up committees with governance oversight for improving or monitoring clinical communication.

Ensure that membership of committees reflects the different disciplines that work in the organisation and are involved in delivering patient care. In particular, ensure that consumer advisors reflect the organisation’s day-to-day patient community (see Action 2.11).

Manage risks

Consider the types of risks that may be associated with clinical communications, such as²:

• Contextual risks (for example, noise, interruptions, inadequate space and time, absent participants)
• Informational risks (for example, information that is not integrated, unavailable, inaccessible, unstructured, incomplete, irrelevant, inaccessible, inaccurate or not up to date)
• Interactional risks (for example, failure to design communication processes that are accessible, legible and intelligible to recipients; and to which recipients can actively contribute).

Ensure that the organisation-wide risk management system can identify, assess, manage and document organisational risks associated with poor clinical communication or communication errors (see Action 1.10). These risks could include:

• Failure to correctly identify patients or match procedures
• Miscommunication or loss of clinical information at transitions of care, such as failure to communicate information gathered at pre-admission to the treating clinician
• Failure to communicate critical results that arise during a procedure to the admitting clinician or the patient’s general practitioner
• Risks associated with poor documentation.

Consider potential clinical risks associated with electronic health systems (hardware and software) that are intended to aid or enable communication processes. For example, electronic health systems and new technology have the potential to enable faster, more effective communication; however, information systems and technology can also present challenges for privacy, and risks to clinical safety and quality if they are poorly implemented or integrated.

Consider the interaction between non-technical dimensions of healthcare (workflow, policies and personnel) and technical dimensions (software, hardware, content and user interface).³ Patient safety issues can occur when one or more technical dimensions interact unexpectedly with non-technical dimensions. For example, a change in the way that one system presents information to a clinician may lead to incorrect interpretation if the clinician is unaware of that change. Ensure that the organisation considers, monitors and manages these risks.

Carefully consider the planning and implementation of electronic handover solutions, such as electronic discharge summary systems. Use the Electronic Discharge Summary Systems Self-Evaluation Toolkit and National Guidelines for On-Screen Presentation of Discharge Summaries.

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 need training. Develop, or provide access to, training and education resources to meet the needs of the workforce in relation to clinical communication.

Provide ongoing education and training to new and existing members of the workforce about the organisation’s clinical communication policies, processes and tools. This should include information about what is required, roles and responsibilities, and the structure or standardised format to be used for communicating when identification, procedure matching, clinical handover and communication of critical information are required.

Provide information through orientation, training, regular updates at workforce and management meetings, mentorship programs, and feedback or debriefing sessions with members of the project workforce or clinicians.

Ensure that performance management processes established in Action 1.22 give priority to continuous development of the workforce’s communication skills. Identify any communication skills that need to be improved or refined, and incorporate these into the organisation’s training system.

Examples of evidence

Select only examples currently in use:

• Organisation-wide strategy that outlines clinical communication processes
• Policy documents for clinical communication that deal with identified risks relevant to the health service organisation, including
  • points of care when communication is required
  • appropriate communication methods
  • roles and responsibilities of the workforce
  • engagement of patients, carers and families
• Observation of clinicians’ practice that shows use of the health service organisation’s clinical communication processes
• Records of interviews with clinicians that show that they understand the health service organisation’s clinical communication processes
• Training documents about clinical communication systems and processes
• Terms of reference and membership of committees responsible for developing and implementing the organisation-wide clinical communication strategy and associated processes, and monitoring their effectiveness
• Committee and meeting records in which clinical communication issues and actions were discussed
• Organisation-wide risk register that identifies clinical communication risks, and describes mitigation strategies and risk monitoring
• Reports, investigations and feedback from the organisation-wide incident management and investigation system that identifies adverse events, incidents and near misses relating to clinical communication and associated processes
• Schedule of routine review of the organisation-wide clinical communication strategy and relevant policy documents, and updates in line with changes in best practice, emerging evidence, and reports of audits and investigations.

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 the policies and procedures, risk management and training for clinical communications.
• Ensure that current versions of all relevant policies and procedures are readily available and accessible to clinicians.

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.

Implement policies and procedures

Policies and procedures should outline how organisation-wide systems support effective clinical communication.

Implementation of policies and procedures to improve clinical communications requires organisations to consider their structure and governance, and how these policies and procedures may fit within the organisation’s context. This does not necessarily require the development of separate policies or procedures, as it may be more efficient and effective to have an overarching policy, supported by local application of policies that are fit for purpose for the specific localised environment (for example, communication in a general ward compared with an emergency department).

MPSs or small hospitals that are part of a local health network or private hospital group should adopt or adapt and use the established governance structures and communications policies and processes.

Small hospitals that are not part of a local health network or private hospital group should consider including in policies and processes:

• An organisation-wide strategy that outlines clinical communication processes and the flow of information to patients, carers, families and clinicians responsible for providing care
• Situations when identification, procedure matching, structured clinical handover, communication of critical information and documentation are required (linked to Actions 6.04 and 6.11)
• Agreed processes for communicating in these situations, including the structure and method of communication, and relevant information to be communicated – for example
  • points of care at which communication is required
  • appropriate communication methods
  • roles and responsibilities of the workforce
• Guidance on how to engage with, and support, patients (and carers) to communicate about their care.

Ensure that policies and procedures describe patients as key participants in clinical communication, and how patients, carers and families can be involved in clinical communication strategies and associated processes.

Document the policies, processes, resources and tools for clinical communication. Make these available to the workforce to ensure that a consistent approach is taken across the organisation and members of the workforce understand what is required of them when using the organisation’s clinical communication processes. This can be done through the organisation’s website, at meetings, through newsletters or noticeboards, or by displaying communication techniques and processes in the ward or on patient charts.

Set up governance and reporting structures to support effective clinical communication across the organisation, and effective collaboration with patients and clinicians. This could involve identifying an individual or group with governance oversight for improving or monitoring clinical communication.

A network of consumer advisors (groups and individuals) who can provide advice about the development of effective clinical communication processes and collaboration initiatives may be helpful.

Manage risks

Consider the types of risks that may be associated with clinical communications, such as²:

• Contextual risks (for example, noise, interruptions, inadequate space and time, absent participants)
• Informational risks (for example, information that is not integrated, unavailable, inaccessible, unstructured, incomplete, irrelevant, inaccessible, inaccurate or not up to date)
• Interactional risks (for example, failure to design communication processes that are accessible, legible and intelligible to recipients, and to which recipients can actively contribute).

Ensure that the organisation-wide risk management system can identify, assess, manage and document organisational risks associated with poor clinical communication or communication errors (see Action 1.10). These risks could include:

• Failure to correctly identify patients or match procedures
• Failure to communicate critical tests or diagnostic results
• Communication errors that result in misdiagnosis
• Miscommunication of clinical information at clinical handover
• Risks associated with poor documentation.

Consider potential clinical risks associated with electronic health systems (hardware and software) that are intended to aid or enable communication processes. For example, electronic health systems and new technology have the potential to enable faster, more effective communication; however, information systems and technology can also present challenges for privacy, and risks to clinical safety and quality if they are poorly implemented or integrated.

Consider the interaction between non-technical dimensions of health care (workflow, policies and personnel) and technical dimensions (software, hardware, content and user interface).³ Patient safety issues can occur when one or more technical dimensions interact unexpectedly with non-technical dimensions. For example, a change in the way that one system presents information to a clinician may lead to incorrect interpretation if the clinician is unaware of that change. Ensure that the organisation considers, monitors and manages these risks.

Carefully consider the planning and implementing of electronic handover solutions, such as electronic discharge summary systems. Use the Electronic Discharge Summary Systems Self-Evaluation Toolkit and National Guidelines for On-Screen Presentation of Discharge Summaries.

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 need training. Develop, or provide access to, training and education resources to meet the needs of the workforce in relation to clinical communication.

Provide ongoing education and training to new and existing members of the workforce about the organisation’s clinical communication policies, processes and tools. This should include information about what is required, roles and responsibilities (including how and when to escalate care, and who to), and the structure or standardised format to be used for communicating when identification, procedure matching, clinical handover and communication of critical information are required.

Provide information through orientation, training, regular updates at workforce and management meetings, mentorship programs, and feedback or debriefing sessions with members of the project workforce or clinicians.

Ensure that the performance management processes established in Action 1.22 give priority to continuous development of the workforce’s communication skills. Identify any communication skills that need to be improved or refined, and incorporate these into the organisation’s training system.

Given the complexity of care and the number of people that can be involved in clinical communications, consider ongoing support for multidisciplinary education and training initiatives to enable and sustain the implementation of any strategies.⁴ This will enable different members of the workforce to have a shared understanding of the processes and requirements for effective clinical communication.