Advisory details
| Item | Details |
|---|---|
| Advisory number | AS18/15 |
| Version number | 6.0 |
| Trim number | D24-20998 |
| Publication date | June 2024 |
| Replaces | AS18/15 version 5.0 published on November 2022 |
| Compliance with this advisory | It is mandatory for approved accrediting agencies to implement this advisory. |
| Information in this advisory applies to |
|
| Key relationship | Comprehensive Care Standard |
| Attachment | Nil |
| Notes | Updated guidance and timeframes for compliance |
| Responsible officer | Anna Thornton, Chief Nursing Officer Phone: 1800 304 056 Email: AdviceCentre@safetyandquality.gov.au |
| To be reviewed | December 2025 |
Purpose
This advisory describes the minimum requirements for Action 5.13 for health service organisations establishing comprehensive care plans.
Issue
A single comprehensive care plan has proven to be difficult for health service organisations to achieve. Changes to requirements outlined in this Advisory are a response to feedback from the health system.
Action 5.13 states: Clinicians use processes for shared decision making to develop and document a comprehensive and individualised plan that:
- Addresses the significance and complexity of the patient’s health issues and risks of harm
- Identifies agreed goals and actions for the patient’s treatment and care
- Identifies the support people a patient wants involved in communications and decision-making about their care
- Commences discharge planning at the beginning of the episode of care
- Includes a plan for referral to follow-up services if appropriate and available
- Is consistent with best practice and evidence.
A single plan is not a requirement of Action 5.13. However, each patient should have a comprehensive plan for care developed relevant to their care needs. The plan for care should allow for core information to be easily shared, accessed and acted on by all members of the multidisciplinary team.
In day hospitals, the scope and complexity of the plan for care will reflect the episode of care and screening for only those risks relevant to the patient and the service being provided.
The plan for care can be documented on paper or in electronic form.
Revised requirements
Health service organisations
Health service organisations are to implement an approach to comprehensive care planning that:
- Supports the workforce to develop plans for care, and use pathways and tools endorsed by the organisation
- Implements multidisciplinary models of care appropriate to the patient population and clinical context
- Ensures the workforce are orientated, educated or trained in the organisation’s approach to care planning
- Monitors and evaluates the outcomes of the comprehensive care planning processes.
Accrediting agencies
Up to 1 January 2026 accrediting agencies can rate action 5.13 'met' where evidence is provided that progress is being made on the requirements above.
From 1 January 2026, accrediting agencies are to rate action 5.13 'met' if the organisation has fully implemented the requirement above.