Applying quality improvement systems

By implementing the Clinical Governance Standard and the Partnering with Consumers Standard, your healthcare service will establish an individualised clinical governance framework. The systems and processes that make up the clinical governance framework can be used to implement the Clinical Safety Standard, which addresses commonly encountered risks to safety and quality. These include preventing and controlling infections, medication safety, comprehensive care, communicating for safety and recognising and responding to serious deterioration and harm. 

This action requires healthcare services to use quality improvement systems for each criterion described in the Clinical Safety Standard to:

• Identify and collect data available within your healthcare service to monitor clinical safety risks
• Act on areas identified for improvement 
• Document the clinical safety risks and the action taken.

Links to Actions 1.03 Measurement and quality improvement and 1.07 Feedback and complaints management to actions in the Clinical Safety Standard

• What data does your healthcare service review to identify clinical safety improvements?
• What clinical safety changes have been made as a result of the data review?
• How is information about your healthcare service’s clinical safety performance documented and reported?

• Identify and collect data within your healthcare service that can be used to inform improvements to clinical safety.
• Take action to address the areas of clinical safety identified for improvement. 
• Document clinical safety risks using established processes from Actions 1.03 and 1.05 and action taken.

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

• Clinical safety data, for example, from incidents, collected and reviewed to identify safety and quality improvements 
• Example of clinical safety changes made within the healthcare service as a result of the review of data and implementations made
• Meetings or communication records where discussion about clinical safety incidents occurred, and the strategies and actions taken to address identified risks 
• Reports on clinical safety.

Resource

• Institute for Healthcare Improvement: Plan, Do, Study, Action (PDSA) Worksheet – a useful tool for documenting a test of change.