Action 8.01

The Clinical Governance Standard has specific actions relating to health service organisations’ safety and quality systems.

• Action 1.07 – policies and procedures
• Action 1.10 – risk management systems
• Actions 1.19, 1.20 and 1.21 – education and training

Health service organisations should:

• Use these and other established safety and quality systems to support policies and procedures, risk management and training for recognising and responding to acute deterioration
• Ensure that current versions of all relevant policies and procedures are readily available and accessible to clinicians.

Policies may be developed or adapted at different levels within the organisation. However, all policy documents should be incorporated into a single, coherent set to maximise the effectiveness of the policy development process.

Implement policies and procedures

Ensure that policies and procedures provide guidance about aspects of recognising and responding to acute deterioration, such as:

• Screening, assessment and comprehensive care planning processes that are required as part of the Comprehensive Care Standard to identify patients at risk of acute deterioration, and develop appropriate monitoring and escalation plans
• Escalation and emergency assistance processes
• Patient and family escalation processes
• Requirements for communicating and documenting the outcome of rapid response calls
• Roles, responsibilities and accountabilities of multidisciplinary team members in recognising and responding to acute deterioration
• Processes for referral to services required to definitively manage episodes of acute deterioration in physical or mental state.

Manage risks

Use established risk management systems (see Action 1.10) to identify, monitor, manage and review risks associated with recognising and responding to acute deterioration that align with the requirements of the Clinical Governance Standard.

Develop processes to manage clinical risks for different populations served by the organisation, clinical and workplace risks for the workforce, and organisational risks.

Use information from measurement and quality improvement systems, adverse events, clinical outcomes and patient experiences to inform and update risk assessments and the risk management system. Consider the training the workforce may need to effectively use the incident management and investigation system to inform risk management, and to plan and implement quality improvement processes to mitigate the risks.

Assess training and competency needs

Assess the competency and training needs of the workforce in line with the requirements of Actions 1.19, 1.20 and 1.21. Perform a risk assessment to inform the training schedule and to set priorities for the members of the workforce who need training. Develop, or provide access to, training and education resources to meet the needs of the workforce regarding recognising and responding to clinical deterioration.

The Clinical Governance Standard has specific actions relating to health service organisations’ safety and quality systems.

• Action 1.07 – policies and procedures
• Action 1.10 – risk management systems
• Actions 1.19, 1.20 and 1.21 – education and training

Health service organisations should:

• Use these and other established safety and quality systems to support policies and procedures, risk management and training for recognising and responding to acute deterioration
• Ensure that current versions of all relevant policies and procedures are readily available and accessible to clinicians.

Policies may be developed or adapted at different levels within the organisation. However, all policy documents should be incorporated into a single, coherent set to maximise the effectiveness of the policy development process.

Implement policies and procedures

Ensure that policies and procedures provide guidance about aspects of recognising and responding to acute deterioration, such as:

• Screening, assessment and comprehensive care planning processes that are required as part of the Comprehensive Care Standard to identify patients at risk of acute deterioration, and develop appropriate monitoring and escalation plans
• Escalation and emergency assistance processes
• Patient and family escalation processes
• Requirements for communicating and documenting the outcomes of episodes of acute deterioration
• Roles, responsibilities and accountabilities of multidisciplinary team members in recognising and responding to acute deterioration
• Processes for referral to services required to definitively manage episodes of acute deterioration in physical or mental state.

Manage risks

Use established risk management systems (see Action 1.10) to identify, monitor, manage and review risks associated with recognising and responding to acute deterioration that align with the requirements of the Clinical Governance Standard.

Develop processes to manage clinical risks for the population served by the organisation, clinical and workplace risks for the workforce, and organisational risks.

Use information from measurement and quality improvement systems, adverse events, clinical outcomes and patient experiences to inform and update risk assessments and the risk management system. Consider the training the workforce may need to effectively use the incident management and investigation system to inform risk management, and to plan and implement quality improvement processes to mitigate the risks.

Assess training and competency needs 

Assess the competency and training needs of the workforce in line with the requirements of Actions 1.19, 1.20 and 1.21. Perform a risk assessment to inform the training schedule and to set priorities for the members of the workforce who need training. Develop, or provide access to, training and education resources to meet the needs of the workforce regarding recognising and responding to acute deterioration.

Examples of evidence

Select only examples currently in use:

• Policy documents about recognising and responding to acute deterioration
• Observation of clinicians’ practice that shows use of the health service organisation’s processesfor recognising and responding to acute deterioration
• Records of interviews with clinicians that show that they understand the health serviceorganisation’s processes for recognising and responding to acute deterioration
• Risk management system that includes actions to manage risks identified in recognising andresponding to acute deterioration
• Documentation of requirements for reporting failures to recognise, escalate or respond to acutedeterioration
• Reports from the incident management and investigation system about incidents relating to recognising and responding to acute deterioration
• Education plan for recognising and responding to acute deterioration.

The Clinical Governance Standard has specific actions relating to health service organisations’ safety and quality systems.

• Action 1.07 – policies and procedures
• Action 1.10 – risk management systems
• Actions 1.19, 1.20 and 1.21 – education and training

Health service organisations should:

• Use these and other established safety and quality systems to support policies and procedures, risk management and training for recognising and responding to acute deterioration
• Ensure that current versions of all relevant policies and procedures are readily available and accessible to clinicians.

Policies may be developed or adapted at different levels within the organisation. However, all policy documents should be incorporated into a single, coherent set to maximise the effectiveness of the policy development process.

Implement policies and procedures

Ensure that policies and procedures provide guidance about aspects of recognising and responding to acute deterioration, such as:

• Screening, assessment and comprehensive care planning processes that are required as part of the Comprehensive Care Standard to identify patients at risk of acute deterioration, and developing appropriate monitoring and escalation plans
• Escalation and emergency assistance processes
• Patient and family escalation processes
• Requirements for communicating and documenting the outcome of rapid response calls
• Roles, responsibilities and accountabilities of multidisciplinary team members in recognising and responding to acute deterioration
• Processes for referral to services required to definitively manage episodes of acute deterioration in physical or mental state.

Manage risks

Use established risk management systems (see Action 1.10) to identify, monitor, manage and review risks associated with recognising and responding to acute deterioration that align with the requirements of the Clinical Governance Standard.

Develop processes to manage clinical risks for different populations served by the organisation, clinical and workplace risks for the workforce, and organisational risks.

Use information from measurement and quality improvement systems, adverse events, clinical outcomes and patient experiences to inform and update risk assessments and the risk management system. Consider the training the workforce may need to effectively use the incident management and investigation system to inform risk management, and to plan and implement quality improvement processes to mitigate the risks.

Assess training and competency needs 

Assess the competency and training needs of the workforce in line with the requirements of Actions 1.19, 1.20 and 1.21. Perform a risk assessment to inform the training schedule and to set priorities for the members of the workforce who need training. Develop, or provide access to, training and education resources to meet the needs of the workforce regarding recognising and responding to acute deterioration.