Action 6.04

Some states and territories may have mandated tools and approaches for patient identification, procedure matching, clinical handover and communication of critical information. Comply with relevant state and territory policies.

Identify situations when safe communication is required

Consider all the situations and times in the organisation when identification, procedure matching and information about a patient’s care need to be communicated or transferred to ensure that the patient receives the right care. This includes communication with the patient, carer and family (if appropriate), and between clinicians and multidisciplinary teams. Situations can include:

• When care, treatment or medicine is provided to a patient
• When a patient is undergoing a procedure
• When there is a change of clinician (for example, at shift change); for high-risk patients, this could include when a clinician goes on a break or has to leave the patient unattended (for example, in an intensive care unit)
• When a person is moved between different levels of care in the same location (for example, surgery to ward)
• When part of person’s care is transferred for diagnostic purposes
• When there is follow-up of patient referrals and communication of test results (for example, from pathology or radiology)
• When a person is transferred to a different service (for example, hospital to aged care home or other non-government organisation)
• When a person is admitted to a hospital, or leaves a hospital and returns to their carer or primary clinician (for example, general practitioner).

Clinical communication policies should describe what is expected and required of the workforce in key high-risk situations. These should be tailored to the service context.

Review policies and processes

Actions to identify the health service organisation’s clinical communication needs may include:

• Reviewing or mapping the organisation’s current clinical communication processes
• Analysing patient flow patterns and work processes that require information to be shared (inside and outside the organisation)
• Collecting baseline data about the clinical communication issues or needs of the organisation by interviewing, surveying or observing the workforce and consumers
• Performing a risk assessment to determine clinical communication gaps, areas for improvement or good practice.

Engage management, clinicians (senior and junior) and consumers to ensure that there is a comprehensive understanding of the gaps and issues, whether the workforce is aware of existing communication processes, and whether they are using them.

Where gaps are identified, revise or develop policies and processes to reduce these gaps. Do this in collaboration with clinicians, consumers and other members of the workforce to ensure that they are user centred and meet the needs of the people involved. This may include consultations, small pilots to test a process, collaborative design workshops or small working groups.

Provide resources and tools to aid effective communication processes

Provide information about the policies, processes, resources and tools for communicating at key high-risk situations to all members of the workforce.

Educate, train and support the workforce about the use of these tools and their responsibilities to effectively communicate in key high-risk situations.

Support teamwork and effective communication

Consider how teams work and communicate with each other within and outside the organisation (across disciplines). Patient identification, procedure matching, clinical handover and communication of critical information in acute care services will often involve multiple clinicians or teams. Given the complexity of health care, these clinicians and teams may change regularly or over time, depending on the needs of the patient.^1,2 To deliver comprehensive care that is safe and continuous, teamwork and effective communication are critical. The links between this standard and the Comprehensive Care Standard are important to ensure that safe, comprehensive care is delivered.

Communicate with transport services

When a patient is transferred into or out of the organisation, consider what processes are in place to communicate with the transport services that are moving the patient (for example, ambulance, the Royal Flying Doctor Service). These services may have their own communication protocols and processes. Collaborate with them to ensure that there is a shared understanding of roles, responsibilities, how communication should occur and the documentation of clinical information.

Consider the role of non-clinicians

Consider the role that non-clinicians play in communicating with patients about their care or transfers. Non-clinicians (such as members of the wards, reception and administration workforces) communicate regularly with patients about appointments, tests, referrals and transfers. They therefore have a role in patient care.

Implement policies, directives or memorandums that outline the expectations and requirements for non-clinicians when they are communicating with patients (including maintaining patient confidentiality). An example could include setting the expectation that members of the workforce who are transferring patients communicate with the patient to let them know where they are going, why they are being moved, if they are going over bumps, and so on. This is to ensure that the patient feels safe, secure and cared for at all times.

Some states and territories may have mandated tools and approaches for patient identification, procedure matching, clinical handover and communication of critical information. Comply with relevant state and territory policies. Governance arrangements, such as associated by-laws, rules or regulations, may also outline required processes, approaches or tools.

Identify situations when safe communication is required

Consider all the situations and times in the organisation when identification, procedure matching and information about a patient’s care need to be communicated or transferred to ensure that the patient receives the right care. This includes communication with the patient, carer and family (if appropriate). Situations can include:

• During pre-admission screening
• When care, treatment or medicine is provided to a patient
• When a patient is undergoing a procedure (consider the perioperative and postoperative pathways)
• When there is a change of clinician (for example, between operating workforce and recovery workforce)
• When a patient is moved between different levels of care in the same location
• When follow-up on patient referrals and communication of test results to the admitting clinician are required
• When a patient is transferred to an acute hospital because of acute deterioration
• When a patient is discharged from the day procedure service.

Clinical communication policies should describe what is expected and required of the workforce at key high-risk situations. These should be tailored to the service context.

Review policies and processes

Actions to identify the health service organisation’s clinical communication needs may include:

• Reviewing or mapping the organisation’s current clinical communication processes
• Analysing patient flow patterns and work processes that require information to be shared (inside and outside the organisation)
• Collecting baseline data about the clinical communication issues or needs of the organisation by interviewing, surveying or observing the workforce and consumers
• Performing a risk assessment to determine clinical communication gaps, areas for improvement and good practice.

Engage management, clinicians and consumers to ensure that there is a comprehensive understanding of the gaps and issues, that the workforce is aware of existing communication processes, and that they are using them.

Where gaps are identified, revise or develop policies and processes to address these gaps. Do this in collaboration with clinicians, consumers and other members of the workforce to ensure that policies and processes are user centred and meet the needs of the people involved. This may include consultations, small pilots to test a process or small working groups.

Provide resources and tools to facilitate effective communication processes

Provide information about the policies, processes, resources and tools for communicating during key high-risk situations to all members of the workforce.

Educate, train and support the workforce about the use of these tools and their responsibilities to effectively communicate during key high-risk situations.

Consider the role of non-clinicians

Consider the role that non-clinicians play in communicating with patients about their care or transfers. Non-clinicians (such as ward, reception and administration workforce) communicate regularly with patients about appointments, tests, referrals and transfers. They therefore have a role in patient care. Implement policies, directives or memorandums that outline the expectations and requirements for non-clinicians when they are communicating with patients (including maintaining patient confidentiality).

Examples of evidence

Select only examples currently in use:

• Review of organisational process mapping that identifies the situations when patient identification, procedure matching, clinical handover, and communication of emerging or changing critical information are required
• Policy documents that describe the processes for the internal transfer of patients, including temporary or time-limited transfers
• Policy documents that describe the processes for the external transfer or discharge of patients, including prioritisation and eligibility criteria, referral processes and required documentation
• Audit results of healthcare records for completed patient journey risk assessments
• Risk register that includes identified risks for
  • patient identification
  • procedure matching
  • transfer and handover of patient care
  • receipt and distribution of critical information to responsible clinicians and the multidisciplinary care team
• Activities to manage identified risks with patient identification, transfer and handover of patientcare, and receipt and distribution of critical information
• Reports, investigations and feedback from the incident management and investigation system that identifies adverse events, incidents and near misses relating to patient identification, transfer and handover of patient care, or receipt and distribution of critical information
• Documentation about structured processes for communicating critical information to the responsible clinicians when all or part of care is transferred
• Documented processes for communicating critical information when there is an unexpected change in a patient’s status or when new critical information becomes available
• Standardised and structured templates to support clinical communication, such as referral forms, ‘timeout’ procedures, procedure matching checklists and discharge summaries, that are updated in line with identified risks, consumer feedback and committee recommendations
• Evidence of a paging system or other communication method for alerting clinicians who can make decisions about care when there is a change in a patient’s condition or new critical information is received
• Audit results of healthcare records for completed standardised discharge or referral forms.

MPSs or small hospitals that are part of a local health network or private hospital group should adopt or adapt and use the established clinical communication processes. This may include mandated tools and approaches for patient identification, procedure matching, clinical handover and communication of critical information.

Small hospitals that are not part of a local health network or private hospital group should:

• Identify the situations in which identification, procedure matching, structured clinical handover and communication of critical information are required, such as
  • when care, treatment or medicine is provided to a patient
  • when a patient is undergoing a procedure
  • when there is a change of clinician (for example, at shift change); for high-risk patients, this could include when a clinician goes on a break or has to leave the patient unattended (for example, in an intensive care unit)
  • when a person is moved between different levels of care in the same location (for example, from acute care to subacute care, to aged care)
  • when part of person’s care is transferred for diagnostic purposes within the organisation or to another service
  • when there is follow-up of patient referrals and communication of test results (for example, from pathology or radiology)
  • when a person is transferred to a different organisation or referral service (for example, to a base hospital)
  • when a person is admitted to a hospital, or leaves a hospital and returns to their carer or primary care clinician (for example, general practitioner)
• Review the organisation’s policies and processes to determine whether they support and enable effective communication in these situations, including by
  • reviewing or mapping the organisation’s current clinical communication processes
  • analysing patient flow patterns and work processes that require information to be shared (inside and outside the organisation)
  • collecting baseline data about the clinical communication issues or needs of the organisation by interviewing, surveying or observing the workforce and consumers
  • performing a risk assessment to determine clinical communication gaps, areas for improvement or good practice
• If there are gaps, or improvements can be made, revise or develop policies and processes to close these gaps
• In clinical communication policies, describe what is expected and required of the workforce in these situations, and tailor these to the service context
• Provide resources and tools to encourage effective communication processes in these situations
• Communicate about the policies, processes and tools for communicating in these situations, and make this information available to all members of the workforce
• Educate, train and support the workforce about the use of tools and their responsibilities to effectively communicate in these situations.

Communicate with transport services

When a patient is transferred into or out of the organisation, consider what processes are in place to communicate with the transport services that are moving the patient (for example, ambulance, the Royal Flying Doctor Service). These services may have their own communication protocols and processes. Collaborate with them to ensure that there is a shared understanding of roles, responsibilities, how communication should occur and the documentation of clinical information. This is especially important for small hospitals and MPSs because of the possible long distances and travel times to other organisations.

Consider the role of non-clinicians

Consider the role that non-clinicians play in communicating with patients about their care or transfers. Non-clinicians (such as members of the wards, reception and administration workforces) communicate regularly with patients about appointments, tests, referrals and transfers. They therefore have a role in patient care.

Implement policies, directives or memorandums that outline the expectations and requirements for non-clinicians when they are communicating with patients (including maintaining patient confidentiality). An example could include setting the expectation that members of the workforce who are transferring patients will communicate with the patient to let them know where they are going, why they are being moved, if they are going over bumps, and so on. This is to ensure that the patient feels safe, secure and cared for at all times.