Published: May 2022
Action 1.07
The health service organisation uses a risk management approach to:
- Set out, review, and maintain the currency and effectiveness of policies, procedures and protocols
- Monitor and take action to improve adherence to policies, procedures and protocols
- Review compliance with legislation, regulation and jurisdictional requirements
Guidance developed by the Commission on the key tasks for meeting this action include:
- Set up a comprehensive suite of policies, procedures and protocols that, where appropriate, emphasise safety and quality et up mechanisms to maintain currency of policies, procedures and protocols, and to communicate changes in them to the workforce
- Review the use and effectiveness of organisational policies, procedures and protocols, this may include through clinical audits or performance reviews
- Periodically review policies, procedures and protocols to align them to state or territory requirements, and ensure that they reflect best practice and current evidence
- Develop or adapt a legislative compliance system that incorporates a compliance register to ensure that policies, procedures and protocols are regularly and reliably updated, and respond to relevant regulatory changes, compliance issues and case law.
Issue
The Commission has received queries following assessments to the NSQHS Standards regarding the compliance with this action.
Guidance
It is the responsibility of the governing body to ensure that policies and procedures are being developed, implemented, maintained, reviewed, and evaluated throughout the health service organisation. These documents should cover, among other things clinical safety and quality risks and be consistent with the organisation’s regulatory obligations. Determining the outcome for this action may need to be further considered alongside other actions, the organisational context, or risks.
When assessing this action, there is no specify ‘percentage’ deemed either acceptable or unacceptable for the number of policies and procedures that are overdue. Instead, assessors take into consideration a range of variables when determining if the system for developing and maintaining policies is effective.
Like implementation, assessments of policy documents should take a risk-based approach, by considering:
- The number of policies which are due for review that are considered ‘high-risk’ and/or ‘high impact’, including:
- those that are due, and actions taken to review and update the policy
- proportion that are overdue by 3-years or more
- the proportion of policies developed or reviewed in recent months
- a prioritised schedule for review
- Whether the organisation has a documented process for developing, authorising, implementing, monitoring, evaluating, and reviewing the health service organisation’s policy documents, which is being followed
- If a current and accurate register of policy documents which identifies where the document is up to in its review cycle, including the date of effect, dates that policy documents were amended
- Examples of policy documents that have been reviewed in response to identified risks, or changes in legislation, regulation, or changes in practice
- Ongoing monitoring of compliance and the circumstances that would trigger review before the due date which may occur due to internal or external factors such as (but not limited to):
- non-compliance
- audit results indicating poor outcomes (clinical variation)
- increasing incidents
- complaints or feedback from consumers or the workforce
- updated evidence
- new and emerging technologies
- Whether there is a committee and meeting records that describe the governance structure, delegations, roles, and responsibilities for overseeing the development of policy documents
- Whether the workforce has readily available access to current policy and procedures
- If there are audit results of clinical practice and healthcare records for compliance with policy documents
- Evidence of workforce training for new or amended policy documents, or use of policy documents
- Results from workforce surveys and feedback on policy documents
- Data or feedback from the risk management, incident management and complaints management systems that are used to update policy documents
- Communication with the workforce on new or updated policy documents
- Relevant schedule and timelines for statutory reporting
Further Information
Further information regarding this action, including strategies for improvement and examples of evidence can be found on the Commission’s website under Action 1.07 or in the NSQHS Standards Accreditation Workbook.
Published: May 2022
Action 1.16
The health service organisation has healthcare record systems that:
- Make the healthcare record available to clinicians at the point of care
- Support the workforce to maintain accurate and complete healthcare records
- Comply with security and privacy regulations
- Support systematic audit of clinical information e. Integrate multiple information systems, where they are used
Guidance developed by the Commission on the key tasks for meeting this action include:
- Review the availability of healthcare records at the point of care
- Review the processes for maintaining confidentiality and privacy of patient information, including infrastructure, policies and workforce training for paper-based and digital healthcare records, and ensure that they are consistent with the law and good practice
- Review the design of the healthcare record to ensure that it facilitates documentation of the relevant clinical elements and clinical audit
- Ensure that systems are in place for data entry to clinical registries, if required
- Periodically audit the performance of the healthcare records systems, and improve them as necessary
- If multiple information systems are used to capture patient clinical information, periodically review the data systems to ensure that the processes for information capture are well designed, well-resourced and working effectively
- Identify the individuals or committees responsible for the development, review and document control of forms, documents and files that make up the paper or digital healthcare record.
Issue
The Commission has received queries in relation to the practical meaning of point of care in relation to the placement of healthcare records.
Guidance
Storing a patient’s health care record at or near the point of care means information can be recorded contemporaneously, avoiding clinicians relying on recall and the risk of further care or changes in care by another clinician before documentation has occurred.
Point of care is both directly along-side a patient or in near proximity to the patient. This may be at the bedside or a workstation located in the clinical area or ward. The factors to be considered when assessing compliance with the requirements for point of care include:
Issues of security and privacy of information in the healthcare record that is personal and sensitive
- Storage capacity along-side a patient
- The ability of the health service organisation to maintain the integrity and completeness of the record in the proposed location
- The context of the health service organisation and any risks associated with making records available at the point of care
- State and territory legislation on the storage of healthcare records
Further Information
Action 1.16 links closely with Action 6.11 Documentation of information. These actions are supported by actions in the Clinical Governance Standard that require organisations to make the healthcare record available to clinicians at the point of care, support the workforce to maintain accurate and complete records.
Definitions in the NSQHS Standards include:
- Healthcare records consist of but is not limited to, a record of the patient’s medical history, treatment notes, observations, correspondence, investigations, test results, photographs, prescription records and medication charts for an episode of care.
- Point of care: The time and location where an interaction between a patient and clinician occurs for the purpose of delivering care. With regards to paper and electronic documents this means that they should be available to clinicians who need them, when they need them, and are in language that the intended readership can easily understand.
Published: May 2022
Action 8.04
The health service organisation has processes for clinicians to detect acute physiological deterioration that require clinicians to:
- Document individualised vital sign monitoring plans
- Monitor patients as required by their individualised monitoring plan
- Graphically document and track changes in agreed observations to detect acute deterioration over time, as appropriate for the patient
Guidance developed by the Commission on the key tasks for meeting this action include:
- Implement a system for documenting vital sign monitoring plans
- Ensure that clinicians have the necessary skills and equipment to monitor patients as required by their individualised monitoring plans
- Implement an observation chart or other mechanism for graphically documenting vital sign observations and tracking changes over time.
Issue
Users have queried the requirements for compliance with Action 8.04. Specifically, are documented policies or procedures required for this action to be met.
Requirement
Some NSQHS Standards actions state a policy or procedure is required. Where this occurs, a policy document is required that specifies the organisational requirements on this matter.
Where an action states a process is required, this may be documented in a checklist, as one part of a policy, in operational instructions, a template form or other organisational document. The form used will depend on the context of the service and the mechanism most suited to the model of care and work setting. It is not intended that separate policy documents be developed for the purpose of assessment against this action.
Published: October 2021
The 2021 Preventing and Controlling Infections Standard was developed to further support health service organisations to prevent, control and respond to infections that cause outbreaks, epidemics or pandemics, including novel and emerging infections.
The key driver for revision of the 2017 standard was gaps and uncertainties that arose during the response to COVID-19. Issues identified by clinicians and health service
organisations included better support to respond to airborne transmission of COVID-19, particularly the concerns of healthcare workers; the importance of a precautionary
approach to infection prevention and control, based on risk assessment and management; and guidance regarding management of infections in healthcare workers, and outbreak response and planning.
The intention of 2021 Preventing and Controlling Infections Standard is to:
- Reduce the risk of patients acquiring preventable infections in healthcare settings
- Effectively manage infections if they occur; and
- Limit the development of antimicrobial resistance through the appropriate use of antimicrobials, as part of antimicrobial stewardship.
The Commission anticipates that most health service organisations will find they are already meeting the requirements of the 2021 Preventing and Controlling Infections Standard.
A mapping factsheet and other resources and guides are available. Accreditation assessment against the revised standard will commence in January 2022.