Action 8.02

Applying quality improvement systems

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Action 8.02 states

The health service organisation applies the quality improvement system from the Clinical Governance Standard when:

  1. Monitoring recognition and response systems
  2. Implementing strategies to improve recognition and response systems
  3. Reporting on effectiveness and outcomes of recognition and response systems

Intent

Quality improvement systems are used to support recognition of, and response to, acute deterioration.

Reflective questions

How are the health service organisation’s recognition and response systems continuously evaluated and improved?

How are the outcomes of improvement activities reported to the governing body, the workforce, consumers and other organisations?

Key tasks

  • Review, measure, and assess the effectiveness and performance of, recognition and response systems
  • Implement quality improvement strategies for recognition and response systems based on the outcomes of monitoring activities
  • Provide information on the outcomes of quality improvement activities to the governing body, the workforce, consumers and other organisations.

Strategies for improvement

Hospitals

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

Health service organisations should use these and other established safety and quality systems to support monitoring, reporting and implementation of quality improvement strategies for recognising and responding to acute deterioration.

Monitor effectiveness and performance

Use the organisation’s quality improvement systems to identify and set priorities for the organisational and clinical strategies for recognition and response systems.

Review these systems to ensure that they include processes to monitor the effectiveness of recognition and response systems, such as:

  • Intermittent audits of practices such as vital sign documentation
  • Data from electronic systems such as missed or delayed escalation
  • Ongoing data collection about processes such as rapid response activation, or outcomes such as cardiac arrest rates
  • Periodic surveys of workforce attitudes and patient experiences of using the recognition and response systems.

Specifications for quality measures, and other tools for evaluating systems for recognising and responding to acute physiological deterioration are available for download: Audit tools and quality measures for recognition and response systems.

When adverse events occur, investigate them to identify any issues with the performance or use of recognition and response systems. Sentinel events, such as inpatient suicides, should be reviewed to detect if deterioration in a person’s mental state was identified, and what steps were taken in response. Other data sources for review include use of restrictive practices, unplanned transfers to mental health units and involuntary treatment rates. Use this information to make improvements.

Implement quality improvement strategies

A Guide to Support Implementation of the National Consensus Statement: Essential elements for recognising and responding to clinical deterioration provides detailed information about how to develop, implement, evaluate and improve systems for recognising and responding to acute physiological deterioration.

Report outcomes

Report evaluation findings to the highest level of governance in the organisation and to the workforce. Use the data to work with consumers, the workforce, clinical leaders and managers to identify and implement improvements to recognition and response systems.

Day Procedure Services

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

Health service organisations should use these and other established safety and quality systems to support monitoring, reporting and implementation of quality improvement strategies for recognising and responding to acute deterioration.

Monitor effectiveness and performance

Use the organisation’s quality improvement systems to identify and set priorities for the organisational and clinical strategies for recognition and response systems.

Review these systems to ensure that they include processes to monitor the effectiveness of recognition and response systems, such as:

  • Intermittent audits of practices such as vital sign documentation
  • Ongoing data collection about escalation processes, or outcomes such as unplanned patient transfer to another healthcare service
  • Periodic surveys of workforce attitudes and patient experiences of using the recognition and response systems.

Specifications for quality measures, and other tools for evaluating systems for recognising and responding to acute physiological deterioration are available for download: Audit tools and quality measures for recognition and response systems.

When adverse events occur, investigate them to identify any issues with the performance or use of recognition and response systems. Data sources for review include use of restrictive practices and unplanned transfers to mental health units. Use this information to make improvements.

Implement quality improvement strategies

A Guide to Support Implementation of the National Consensus Statement: Essential elements for recognising and responding to clinical deterioration provides detailed information about how to develop, implement, evaluate and improve systems for recognising and responding to acute physiological deterioration.

Report on outcomes

Report evaluation findings to the highest level of governance in the organisation and to the workforce. Use the data to work with consumers, the workforce, clinical leaders and managers to identify and implement improvements to recognition and response systems.

Examples of evidence

Select only examples currently in use:

  • Documented data collection processes for the recognition and response systems
  • Workforce survey results and patient experience data relating to recognising and responding to acute deterioration
  • Quality measures and tools for evaluating the recognition and response systems
  • Reports to the highest level of governance and the workforce on evaluation findings
  • Improvements made to the recognition and response systems
  • Evidence of local quality improvement projects based on investigation of reported incidents and evaluation data, and from the recognition and response systems
  • Evidence of risk assessment and evaluation processes undertaken when implementing new tools and processes as part of the recognition and response systems (for example, electronic systems for monitoring vital signs and escalating care).

MPS & Small Hospitals

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

Health service organisations should use these and other established safety and quality systems to support monitoring, reporting and implementation of quality improvement strategies for recognising and responding to acute deterioration.

Monitor effectiveness and performance

Use the organisation’s quality improvement systems to identify and set priorities for the organisational and clinical strategies for recognition and response systems.

Review these systems to ensure that they include processes to monitor the effectiveness of recognition and response systems, such as:

  • Intermittent audits of practices such as vital sign documentation
  • Data from electronic systems such as missed or delayed escalation
  • Ongoing data collection about processes such as rapid response activation, or outcomes such as cardiac arrest rates
  • Periodic surveys of workforce attitudes and patient experiences of using the recognition and response systems.

Specifications for quality measures, and other tools for evaluating systems for recognising and responding to acute physiological deterioration are available for download: Audit tools and quality measures for recognition and response systems.

When adverse events occur, investigate them to identify any issues with the performance or use of recognition and response systems. Sentinel events, such as inpatient suicides, should be reviewed to detect if deterioration in a person’s mental state was identified, and what steps were taken in response. Other data sources for review include use of restrictive practices, unplanned transfers to mental health units and involuntary treatment rates. Use this information to make improvements.

Implement quality improvement strategies

A Guide to Support Implementation of the National Consensus Statement: Essential elements for recognising and responding to clinical deterioration provides detailed information about how to develop, implement, evaluate and improve systems for recognising and responding to acute physiological deterioration.

Report outcomes

Report evaluation findings to the highest level of governance in the organisation and to the workforce. Use the data to work with consumers, the workforce, clinical leaders and managers to identify and implement improvements to recognition and response systems.

Hospitals

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

Health service organisations should use these and other established safety and quality systems to support monitoring, reporting and implementation of quality improvement strategies for recognising and responding to acute deterioration.

Monitor effectiveness and performance

Use the organisation’s quality improvement systems to identify and set priorities for the organisational and clinical strategies for recognition and response systems.

Review these systems to ensure that they include processes to monitor the effectiveness of recognition and response systems, such as:

  • Intermittent audits of practices such as vital sign documentation
  • Data from electronic systems such as missed or delayed escalation
  • Ongoing data collection about processes such as rapid response activation, or outcomes such as cardiac arrest rates
  • Periodic surveys of workforce attitudes and patient experiences of using the recognition and response systems.

Specifications for quality measures, and other tools for evaluating systems for recognising and responding to acute physiological deterioration are available for download: Audit tools and quality measures for recognition and response systems.

When adverse events occur, investigate them to identify any issues with the performance or use of recognition and response systems. Sentinel events, such as inpatient suicides, should be reviewed to detect if deterioration in a person’s mental state was identified, and what steps were taken in response. Other data sources for review include use of restrictive practices, unplanned transfers to mental health units and involuntary treatment rates. Use this information to make improvements.

Implement quality improvement strategies

A Guide to Support Implementation of the National Consensus Statement: Essential elements for recognising and responding to clinical deterioration provides detailed information about how to develop, implement, evaluate and improve systems for recognising and responding to acute physiological deterioration.

Report outcomes

Report evaluation findings to the highest level of governance in the organisation and to the workforce. Use the data to work with consumers, the workforce, clinical leaders and managers to identify and implement improvements to recognition and response systems.

Day Procedure Services

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

Health service organisations should use these and other established safety and quality systems to support monitoring, reporting and implementation of quality improvement strategies for recognising and responding to acute deterioration.

Monitor effectiveness and performance

Use the organisation’s quality improvement systems to identify and set priorities for the organisational and clinical strategies for recognition and response systems.

Review these systems to ensure that they include processes to monitor the effectiveness of recognition and response systems, such as:

  • Intermittent audits of practices such as vital sign documentation
  • Ongoing data collection about escalation processes, or outcomes such as unplanned patient transfer to another healthcare service
  • Periodic surveys of workforce attitudes and patient experiences of using the recognition and response systems.

Specifications for quality measures, and other tools for evaluating systems for recognising and responding to acute physiological deterioration are available for download: Audit tools and quality measures for recognition and response systems.

When adverse events occur, investigate them to identify any issues with the performance or use of recognition and response systems. Data sources for review include use of restrictive practices and unplanned transfers to mental health units. Use this information to make improvements.

Implement quality improvement strategies

A Guide to Support Implementation of the National Consensus Statement: Essential elements for recognising and responding to clinical deterioration provides detailed information about how to develop, implement, evaluate and improve systems for recognising and responding to acute physiological deterioration.

Report on outcomes

Report evaluation findings to the highest level of governance in the organisation and to the workforce. Use the data to work with consumers, the workforce, clinical leaders and managers to identify and implement improvements to recognition and response systems.

Examples of evidence

Select only examples currently in use:

  • Documented data collection processes for the recognition and response systems
  • Workforce survey results and patient experience data relating to recognising and responding to acute deterioration
  • Quality measures and tools for evaluating the recognition and response systems
  • Reports to the highest level of governance and the workforce on evaluation findings
  • Improvements made to the recognition and response systems
  • Evidence of local quality improvement projects based on investigation of reported incidents and evaluation data, and from the recognition and response systems
  • Evidence of risk assessment and evaluation processes undertaken when implementing new tools and processes as part of the recognition and response systems (for example, electronic systems for monitoring vital signs and escalating care).

MPS & Small Hospitals

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

Health service organisations should use these and other established safety and quality systems to support monitoring, reporting and implementation of quality improvement strategies for recognising and responding to acute deterioration.

Monitor effectiveness and performance

Use the organisation’s quality improvement systems to identify and set priorities for the organisational and clinical strategies for recognition and response systems.

Review these systems to ensure that they include processes to monitor the effectiveness of recognition and response systems, such as:

  • Intermittent audits of practices such as vital sign documentation
  • Data from electronic systems such as missed or delayed escalation
  • Ongoing data collection about processes such as rapid response activation, or outcomes such as cardiac arrest rates
  • Periodic surveys of workforce attitudes and patient experiences of using the recognition and response systems.

Specifications for quality measures, and other tools for evaluating systems for recognising and responding to acute physiological deterioration are available for download: Audit tools and quality measures for recognition and response systems.

When adverse events occur, investigate them to identify any issues with the performance or use of recognition and response systems. Sentinel events, such as inpatient suicides, should be reviewed to detect if deterioration in a person’s mental state was identified, and what steps were taken in response. Other data sources for review include use of restrictive practices, unplanned transfers to mental health units and involuntary treatment rates. Use this information to make improvements.

Implement quality improvement strategies

A Guide to Support Implementation of the National Consensus Statement: Essential elements for recognising and responding to clinical deterioration provides detailed information about how to develop, implement, evaluate and improve systems for recognising and responding to acute physiological deterioration.

Report outcomes

Report evaluation findings to the highest level of governance in the organisation and to the workforce. Use the data to work with consumers, the workforce, clinical leaders and managers to identify and implement improvements to recognition and response systems.

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