Safe environment

Your healthcare service’s environment can support the delivery of safe, high-quality health care for patients. Good design can also reduce the potential for adverse events and incidents, reduce infections associated with heath care, ensure privacy is maintained and improve patient and workforce satisfaction.

Regardless of the location or mechanism used to deliver service, the equipment and devices used should be fit for purpose and well maintained. 

Where healthcare services are delivered from a fixed location or mobile outreach service, the spaces used in the delivery of health care should be clean, designed to minimise harm and well maintained. Where telehealth or virtual care forms part of service delivery, the information and communications technologies (ICT) should be included in the equipment used, and devices should use programs that are accessible to patients. 

Healthcare services providing home-based care must take a risk management approach in determining the most appropriate space to use when attending to a patient in their home and in circumstances where home-based care is not appropriate.

• How often is your healthcare service’s environment reviewed? What improvements have been made to ensure it is fit for purpose, well maintained and privacy is provided to patients?
• What equipment does your service use to deliver health care? How often are maintenance checks conducted on equipment?
• What are key considerations for healthcare providers visiting a patient’s home when determining the most appropriate space to deliver health care?

• Implement a schedule and process to regularly review the spaces where healthcare services are delivered. Action any required improvements to ensure spaces are fit for purpose and well maintained, and that there is space for the patient’s privacy when health care is provided.
• Implement a schedule and process to conduct maintenance checks on equipment used by the healthcare service. Action any required repairs or replacement equipment to ensure they are fit for purpose, safe and in good working order at all times.
• For healthcare services providing home-based care, implement a process for a risk management approach to determining the most appropriate space in a patient’s home for the provision of health care.

The type and comprehensiveness of evidence used is dependent on the context of each healthcare service, but could include: 

• Maintenance schedule for healthcare service premises, mobile vehicles and equipment 
• Completed risk assessments for care provided in patient’s homes or other locations, and any actions taken to address the risks
• Register of equipment that includes details of their maintenance schedule and completed repairs or replacements 
• Observation of design and use of the environment that supports safe, high-quality care, including supporting patient privacy 
• Checklists of actions to be completed or equipment required to safely deliver care outside the healthcare service’s environment.

Resources

• Office of Industrial Relations Workplace Health and Safety Queensland: A guide to working safely in people’s homes – is an easy-to-read guide providing practical advice about how to manage work health and safety for community workers working in people’s homes. 
• World Health Organization: Medical equipment maintenance programme overview – describes the key elements of a maintenance strategy for medical equipment.

Within any health setting, there are spaces where there is a higher potential for stress and conflict. These include busy, high-traffic areas, and the stress they may cause can be exacerbated when people are uncertain about what care will be provided and whether there are actual or perceived delays in accessing treatment. 

People respond to stress in different ways and have different needs in terms of environmental response. A calm and quiet environment is clinically appropriate for a person experiencing agitation and aggressive feelings, and this minimises risks of them harming themselves and others.^[i]

Children can experience fear when exposed to new surroundings. In some instances, providing a separate safe space that is age-appropriate, with access to play equipment, books or toys in good working order, where the child can be supervised by their accompanying adult may support their unique needs and minimise risks of disruption and/or harm.^[ii]

Supporting health providers by providing training or orientation about managing unexpected behaviour in the healthcare service’s environment will also help minimise risks. 

Healthcare services providing home-based care must identify areas that have a high risk of unpredictable behaviours. This forms part of their risk management approach in determining the most appropriate space when attending to a patient in their home, and circumstances where home-based care is not appropriate.

Links to Actions 1.04 Risk management and 3.32 Planning for safety

• Which spaces in your healthcare service have a higher risk of causing people to feel stressed? 
• How are people who are behaving unpredictably supported in a way that minimises risks of harm to others in your healthcare service?
• How do healthcare providers delivering home-based care identify areas where a patient may behave unpredictably? How do they use this information to determine the most appropriate space in a patient’s home for the provision of health care, and circumstances where home-based care is not appropriate?

• Identify any spaces in the healthcare service that have a high risk of potentially causing stress leading to people behaving unpredictably. 
• Develop and implement strategies that can be used in instances where unpredictable behaviour occurs to minimise the risk of harm to others in the healthcare service.
• For healthcare services providing home-based care, incorporate the identification of areas that have a high risk of unpredictable behaviours into the process for a risk management approach. This helps to determine the most appropriate space in a patient’s home for the provision of health care, and circumstances where home-based care is not appropriate. 

The type and comprehensiveness of evidence used is dependent on each healthcare service context. The content and complexity of the policies and processes will likely depend on the size of the healthcare service, but could include:

• Observation of flexible use of spaces to minimise the risk of harm to others when there is a high risk of unpredictable behaviours 
• Examples of risk management approaches used during home visits 
• Training and orientation documents about safe work practices and emergency situations 
• Evidence of policies, processes and training used to support workforce to implement strategies 
• Entries into risk register documenting responses to unpredictable behaviour. 

Resource

• National Institute for Health and Care Excellence: Violence and aggression: short-term management in mental health, health and community settings – aims to safeguard both staff and people who use services by helping to prevent violent situations and providing guidance to manage them safely when they occur.

Supporting patients to access your healthcare service is fundamental to the delivery of safe, high-quality health care. Support should consider relevant feedback from patients as well as consideration for patient populations that have historically faced barriers to accessing health care. 

People with diverse backgrounds 

Diverse backgrounds are the varying social, economic and geographical circumstances of consumers who access, or may access, the services of a healthcare service.^[i] The intersectional needs and experiences of people may be due to a variety of factors. They also encompass the cultural backgrounds, disability status, religions, beliefs and practices, languages spoken, sexual orientation, gender identity and gender expression, and sex characteristics.19 While barriers faced may vary, they can include the communication, cultural experience or attitude of healthcare providers. 

People with disability 

There is a complex relationship between disability and health; disability can contribute to health issues and long-term health conditions can cause disability.^[ii] Some people with disability experience barriers to accessing health care, such as unacceptable or lengthy waiting times, cost, inaccessibility of buildings and discrimination by health professionals, as well as issues caused by lack of communication between the different health professionals who treat them.20 These barriers are often compounded by the intersectional needs and experiences of the person with disability.

Supporting access to health care

Your healthcare service can support patients to access health care by understanding the barriers and challenges faced by patient populations and making changes to mitigate the barriers identified. The specific circumstances of population groups should be considered in determining how access for patients may be supported. They may include but not limited to: 

• Being aware of and understanding the health needs and sensitivities of patient populations
• Providing relevant information in a language which is accessible to the local population
• Adjusting the physical environment to support wheelchair access 
• Including artwork and signage that demonstrates a welcoming environment to patient populations 
• Ensuring that spaces for children are age-appropriate, and provide enough space for accompanying adults
• Having a mix of experience, skill sets, genders and cultures in the workforce to cater to patient populations 
• Providing inclusivity and culturally responsive training for the workforce to increase their confidence, knowledge and skills when working with diverse communities 
• Provide access to services such as the Translating and Interpreting Service (TIS National) which provides access to phone and on-site interpreting services in over 150 languages 
• Supporting patients to communicate with the assistance of the National Relay Service
• Providing telehealth or virtual care options for patients to access health services, particularly in rural and remote locations.

Where access to appropriate health care cannot be provided, your healthcare service should facilitate the referral of patients to alternative, accessible services. 

Links to Actions 1.09 and 1.10 Patient populations and social determinants of health; 2.06 Communication that supports effective partnerships and 2.07 Accessing healthcare service information

• How is patient population information used to plan service delivery and manage the inherent barriers that exist to care for patients? 
• What adjustments have been made to decrease the barriers to allow equal access for patients?

The type and comprehensiveness of evidence used is dependent on each healthcare service context. The content and complexity of the policies and processes will likely depend on the size of the healthcare service, but could include:

• Examples of how demographic data and characteristics of the local community or patient population have been used to plan for or improve access to services 
• Processes that enable access to the service for people with a disability, such as providing outreach or flexible appointment times
• Observation of the written health information about accessing the healthcare service in a range of formats tailored to the local community and patient populations
• Observation of the healthcare service’s physical environment and the equipment that supports access for patients with low mobility 
• Observation of non-verbal demonstrations of inclusion in environment, for example, non-gendered bathrooms, display of rainbow flag
• Observation of infrastructure that supports telehealth and/or virtual care practices
• Evidence of culturally informed comprehensive care planning
• Examples of resources or partner organisations that the healthcare service uses to enable people from diverse backgrounds to access the healthcare service
• Records of training or professional development undertaken by the workforce to meet the needs of people from diverse populations. 

Commission resources

• Cognitive impairment fact sheet: Clinicians can take action to reduce the risk of harm – a fact sheet listing the steps and details a quality and safety pathway.
• Cognitive impairment resources – to help improve the safety and quality of health care for people with cognitive impairment or at risk of delirium. 
• NSQHS Standards User Guide for health service organisations providing care for patients with cognitive impairment or at risk of delirium – provides practical support for healthcare services where specific efforts or additional attention is required to meet the health needs of this patient population, based on the NSQHS Standards. The principles and strategies outlined in this resource are broadly applicable. 
• NSQHS Standards User Guide for health services providing care for people with mental health issues – provides practical support for healthcare services where specific efforts or additional attention is required to meet the health needs of this patient population, based on the NSQHS Standards. The principles and strategies outlined in this resource are broadly applicable. 

Other resources

• Australian Human Rights Commission: Access for all: Improving accessibility for consumers with disability – provides practical tips for businesses on improving access to goods, services, facilities, premises and information for consumers with disability.
• Australian Human Rights Commission: Disability Rights – promoting the rights of people with disabilities and building a more accessible, more inclusive community.
• Australian Government: Translating and Interpreting Service (TIS) – a free interpreting service which aims to provide equitable access to key services for people with limited or no English language proficiency.
• Australian Government: National Relay Service – for people who are deaf and/or find it hard hearing or speaking with people who use a phone.
• Council for Intellectual Disability: Resources for health practitioners – resources for healthcare providers to support better appointments when working with people with intellectual disability. 
• Diversity Council of Australia: Leading Diversity and Inclusion in the Workplace – the website includes comprehensive directory of diversity and inclusion service providers in Australia. 
• People with Disability Australia: Language Guide – best-practice advice to assist developing policies and information that has inclusive and respectful language around disability.
• Pride in Health + Wellbeing: About The HWEI Benchmarking Index – the annual Health + Wellbeing Equality Index (HWEI) has been designed as a free tool to assess and benchmark LGBTQI+ service provision among health, wellbeing and human service providers.

Some Aboriginal and Torres Strait Islander peoples do not access primary healthcare services due to barriers such as cost, long wait times, lack of service availability, dislike of the service, embarrassment or feeling afraid or uninformed, experiences of discrimination and racism, and poor communication with healthcare providers.[i],[ii] In 2018–19, about one in eight Aboriginal and Torres Strait Islander people reported they did not go to the doctor when they needed to, and about one in five did not go to the dentist when they needed to.²²

Providing a culturally safe environment is an important element of providing culturally safe care. Culturally safe services improve Aboriginal and Torres Strait Islander peoples’ experiences of, and access to, health care.

The Commission defines ‘cultural safety’ in accordance with the Cultural Respect Framework 2016–2026 for Aboriginal and Torres Strait Islander Health.¹¹ Cultural safety identifies that health consumers are safest when health professionals have considered power relations, cultural differences and patients’ rights. Part of this process requires health professionals to examine their own realities, beliefs and attitudes.

The essential features of cultural safety are: 

• Understanding one’s culture 
• Acknowledging difference, so that caregivers are actively mindful and respectful of difference(s) 
• Being informed by the theory of power relations; any attempt to depoliticise cultural safety is to miss the point 
• Appreciating the historical context of colonisation, the practices of racism at individual and institutional levels and their impact on Aboriginal and Torres Strait Islander peoples living and wellbeing, both in the present and past 
• Its presence or absence is determined by the experience of the recipient of care and not defined by the caregiver.¹²

Providing a culturally safe environment in your healthcare service is about creating a place where Aboriginal and Torres Strait Islander peoples feel safe, comfortable, accepted and confident that they will be respected, will be listened to and will receive high-quality care. Healthcare services should recognise the importance of cultural beliefs and practices of Aboriginal and Torres Strait Islander peoples. Cultural determinants of health are anchored in Aboriginal and Torres Strait Islander ways of knowing, being and doing that encompass a holistic understanding of health and wellbeing. 

The physical, emotional and relational aspects of spaces are all critical components of creating culturally safe environments:

• Physical – design, layout and appearance
• Emotional – the feeling of being supported and cared for within the healthcare service 
• Relational – the quality of relationships developed with the workforce and other consumers.

Ways that your healthcare service can create culturally safe environments are interrelated with improving cultural safety. They may include:

• Where there is a significant Aboriginal or Torres Strait Islander patient cohort, consult with your Aboriginal and Torres Strait Islander patients and local Aboriginal Community Controlled services to review the design, use and layout of the healthcare service, and to maximise privacy and minimise distress in clinical spaces
• Providing access to training and scope for reflective practice, to enable healthcare providers deliver culturally safe care.

Links to Actions 1.09 and 1.10 Patient populations and social determinants of health and 1.16 Safety and quality training

Commission resource

NSQHS Standards User guide for Aboriginal and Torres Strait Islander health – provides practical support for the implementation of the Aboriginal and Torres Strait Islander-specific actions in the NSQHS Standards. The principles and strategies outlined in this resource are broadly applicable.