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TitleNational Safety and Quality Health Service Standards Accreditation Workbook
LanguageEnglish
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Total Pages180
Table of Contents
                            National Safety and Quality Health Service Standards Accreditation Workbook
Quick guide
Contents
Introduction
Types of evidence included in this workbook
Clinical Governance Standard
	Criterion: Governance, leadership and culture
		Governance, leadership and culture
			Action 1.1
			Action 1.2
		Management and executive leadership
			Action 1.3
			Action 1.4
			Action 1.5
		Clinical leadership
			Action 1.6
	Criterion: Patient safety and quality systems
		Policies and procedures
			Action 1.7
		Quality improvement
			Action 1.8
			Action 1.9
		Risk management
			Action 1.10
		Incident management systems and open disclosure
			Action 1.11
			Action 1.12
		Feedback and complaints management
			Action 1.13
			Action 1.14
		Diversity and high-risk groups
			Action 1.15
		Healthcare records
			Action 1.16
			Action 1.17
			Action 1.18
	Criterion: Clinical performance and effectiveness
		Safety and quality training
			Action 1.19
			Action 1.20
			Action 1.21
		Performance management
			Action 1.22
		Credentialing and scope of clinical practice
			Action 1.23
			Action 1.24
		Safety and quality roles and responsibilities
			Action 1.25
			Action 1.26
		Evidence-based care
			Action 1.27
		Variation in clinical practice and health outcomes
			Action 1.28
	Criterion: Safe environment for the delivery of care
		Safe environment
			Action 1.29
			Action 1.30
			Action 1.31
			Action 1.32
			Action 1.33
Partnering with Consumers Standard
	Criterion: Clinical governance and quality improvement systems to support partnering with consumers
		Integrating clinical governance
			Action 2.1
		Applying quality improvement systems
			Action 2.2
	Criterion: Partnering with patients in their own care
		Healthcare rights and informed consent
			Action 2.3
			Action 2.4
			Action 2.5
		Sharing decisions and planning care
			Action 2.6
			Action 2.7
	Criterion: Health literacy
		Communication that supports effective partnerships
			Action 2.8
			Action 2.9
			Action 2.10
	Criterion: Partnering with consumers in organisational design and governance
		Partnerships in healthcare governance, planning, design, measurement and evaluation
			Action 2.11
			Action 2.12
			Action 2.13
			Action 2.14
Preventing and Controlling Healthcare-Associated Infection Standard
	Criterion: Clinical governance and quality improvement to prevent and control healthcare-associated infections, and support antimicrobial stewardship
		Integrating clinical governance
			Action 3.1
		Applying quality improvement systems
			Action 3.2
		Partnering with consumers
			Action 3.3
		Surveillance
			Action 3.4
	Criterion: Infection prevention and control systems
		Standard and transmission-based precautions
			Action 3.5
			Action 3.6
			Action 3.7
		Hand hygiene
			Action 3.8
		Aseptic technique
			Action 3.9
		Invasive medical devices
			Action 3.10
		Clean environment
			Action 3.11
			Action 3.12
		Workforce immunisation
			Action 3.13
	Criterion: Reprocessing of reusable medical devices
		Reprocessing of reusable devices
			Action 3.14
	Criterion: Antimicrobial stewardship
		Antimicrobial stewardship
			Action 3.15
			Action 3.16
Medication Safety Standard
	Criterion: Clinical governance and quality improvement to support medication management
		Integrating clinical governance
			Action 4.1
		Applying quality improvement systems
			Action 4.2
		Partnering with consumers
			Action 4.3
		Medicines scope of clinical practice
			Action 4.4
	Criterion: Documentation of patient information
		Medication reconciliation
			Action 4.5
			Action 4.6
		Adverse drug reactions
			Action 4.7
			Action 4.8
			Action 4.9
	Criterion: Continuity of medication management
		Medication review
			Action 4.10
		Information for patients
			Action 4.11
		Provision of a medication list
			Action 4.12
	Criterion: Medication management processes
		Medicines information and decision support tools
			Action 4.13
		Safe and secure storage and distribution of medicines
			Action 4.14
		High-risk medicines
			Action 4.15
Comprehensive Care Standard
	Criterion: Clinical governance and quality improvement to support comprehensive care
		Integrating clinical governance
			Action 5.1
		Applying quality improvement systems
			Action 5.2
		Partnering with consumers
			Action 5.3
		Designing systems to deliver comprehensive care
			Action 5.4
		Collaboration and teamwork
			Action 5.5
			Action 5.6
	Criterion: Developing the comprehensive care plan
		Planning for comprehensive care
			Action 5.7
			Action 5.8
			Action 5.9
		Screening of risk
			Action 5.10
		Clinical assessment
			Action 5.11
		Developing the comprehensive care plan
			Action 5.12
			Action 5.13
	Criterion: Delivering comprehensive care
		Using the comprehensive care plan
			Action 5.14
		Comprehensive care at the end of life
			Action 5.15
			Action 5.16
			Action 5.17
			Action 5.18
			Action 5.19
			Action 5.20
	Criterion: Minimising patient harm
		Preventing and managing pressure injuries
			Action 5.21
			Action 5.22
			Action 5.23
		Preventing falls and harm from falls
			Action 5.24
			Action 5.25
			Action 5.26
		Nutrition and hydration
			Action 5.27
			Action 5.28
		Preventing delirium and managing cognitive impairment
			Action 5.29
			Action 5.30
		Predicting, preventing and managing self-harm and suicide
			Action 5.31
			Action 5.32
		Predicting, preventing and managing aggression and violence
			Action 5.33
			Action 5.34
		Minimising restrictive practices: restraint
			Action 5.35
		Minimising restrictive practices: seclusion
			Action 5.36
Communicating for Safety Standard
	Criterion: Clinical governance and quality improvement to support effective communication
		Integrating clinical governance
			Action 6.1
		Applying quality improvement systems
			Action 6.2
		Partnering with consumers
			Action 6.3
		Organisational systems to support effective communication
			Action 6.4
	Criterion: Correct identification and procedure matching
		Correct identification and procedure matching
			Action 6.5
			Action 6.6
	Criterion: Communication at clinical handover
		Clinical handover
			Action 6.7
			Action 6.8
	Criterion: Communication of critical information
		Communicating critical information
			Action 6.9
			Action 6.10
	Criterion: Documentation of information
		Documentation of information
			Action 6.11
Blood Management Standard
	Criterion: Clinical governance and quality improvement to support blood management
		Integrating clinical governance
			Action 7.1
		Applying quality improvement systems
			Action 7.2
		Partnering with consumers
			Action 7.3
	Criterion: Prescribing and clinical use of blood and blood products
		Optimising and conserving patients’ own blood
			Action 7.4
		Documenting
			Action 7.5
		Prescribing and administering blood and blood products
			Action 7.6
		Reporting adverse events
			Action 7.7
			Action 7.8
	Criterion: Managing the availability and safety of blood and blood products
		Storing, distributing and tracing blood and blood products
			Action 7.9
		Availability of blood
			Action 7.10
Recognising and Responding to Acute Deterioration Standard
	Criterion: Clinical governance and quality improvement to support recognition and response systems
		Action 8.1
		Applying quality improvement systems
			Action 8.2
		Partnering with consumers
			Action 8.3
	Criterion: Detecting and recognising acute deterioration, and escalating care
		Recognising acute deterioration
			Action 8.4
			Action 8.5
		Escalating care
			Action 8.6
			Action 8.7
			Action 8.8
			Action 8.9
	Criterion: Responding to acute deterioration
		Responding to deterioration
			Action 8.10
			Action 8.11
			Action 8.12
			Action 8.13
Glossary
References
                        
Document Text Contents
Page 1




National Safety and Quality
Health Service Standards
Accreditation
Workbook



Page 2




Published by the Australian Commission on Safety and Quality in Health Care
Level ˜, ˚˜˜ Elizabeth Street, Sydney NSW ˚˛˛˛
Phone: (˛˚) ˝˙˚ˆ ˇˆ˛˛
Fax: (˛˚) ˝˙˚ˆ ˇˆ˙ˇ
Email:
[email protected]
Website:
www.safetyandquality.gov.au
ISBN: ˝˘-˙-˝˚˜ˆˆ˜-˛˝-ˇ
© Australian Commission on Safety and Quality in Health Care ˚˛˙˘
All material and work produced by the Australian Commission on Safety and Quality in Health Care is protected
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otherwise noted, all material presented in this publication is licensed under a
Creative Commons Attribution-
NonCommercial-NoDerivative.˛ International licence
.Enquiries about the licence and any use of this publication are welcome and can be sent to
comm
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.The Commission™s preference is that you attribute this publication (and any material sourced from it) using the
following citation:
Australian Commission on Safety and Quality in Health Care. National Safety and Quality Health Service
Standards accreditation workbook. Sydney: ACSQHC; ˚˛˙˘.
Disclaimer
The content of this document is published in good faith by the Australian Commission on Safety and Quality
in Health Care for information purposes. The document is not intended to provide guidance on particular
healthcare choices. You should contact your healthcare provider on particular healthcare choices.
This document includes the views or recommendations of its authors and third parties. Publication of
this document by the Commission does not necessarily rect the views of the Commission, or indicate a
commitment to a particular course of action. The Commission does not accept any legal liability for any injury,
loss or damage incurred by the use of, or reliance on, this document.
Acknowledgement
The Commission would like to thank all of our partners for their contributions to the development of the
NSQHS Standards and their continuing commitment to improving safety and quality across the Australian
healthcare system.
This document was released in November ˚˛˙˘.



Page 90




Accreditation Workbook
NSQHS Standards
Information for patients
Action ˛.ˇˇThe health service organisation has processes to support clinicians to provide patients with
information about their individual medicines needs and risks
R
How do clinicians inform patients about options for
their care, including use of medicines?
What information do clinicians provide to patients
about the benets and risks of medicine-related
treatment options?
How do clinicians gain access to medicine-related
information for patients?
Examples of evidenceSelect only examples currently in use:
Ł Policy documents that dene the roles,
responsibilities and accountabilities of the
clinical workforce in informing patients and
carers about their individual medicines needs
and risks
Ł Audit results of workforce compliance with
policies, procedures, protocols and guidelines
for informing patients and carers about their
individual medicines needs and risks
Ł Observation that information about medicines
needs and risks is available for clinicians to use
during discussions with patients and carers
Ł Examples of resources that can be provided to
support discussion about patients™ medicines
needs and risks
Ł Results from evaluation of the usefulness of
locally produced medicine-related information,
and patients™ understanding of their medicines
needs and risks
Ł Communication with the workforce that
promotes the importance of discussing medicines
needs and risks with patients.



Page 91




NSQHS Standards
Accreditation Workbook
Provision of a medication list
Action ˛.ˇ˘The health service organisation has processes to:
a.
Generate a current medicines list and the reasons for any changes
b.
Distribute the current medicines list to receiving clinicians at transitions of care
c.
Provide patients on discharge with a current medicines list and the reasons for any changes
R
What processes are used by clinicians to document
and maintain a current medicines list during a
patient™s episode of care?
How do clinicians generate a current medicines list,
including reasons for any changes, to use at clinical
handover and provide on discharge?
Examples of evidenceSelect only examples currently in use:
Ł Policy documents that outline the generation,
distribution and provision of a medicines list
(with reasons for any changes) to patients and
clinicians, including at transitions of care and on
discharge
Ł Audit results of documenting medicines lists on
admission
Ł Audit results of providing a medicines list to
patients on discharge
Ł Orientation or training documents about
generating and updating medicines lists
Ł Documented process to gain consent before
sharing a patient™s medicines list on discharge
Ł Examples where medicines lists have been
tailored to the specic needs of recipients
(patient, general practictioner, community
pharmacist).



Page 179




ˇ˙˜
NSQHS Standards
Accreditation Workbook
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Page 180




Level ˜, ˚˜˜ Elizabeth Street
Sydney NSW ˚˛˛˛
GPO Box ˜˛
Sydney NSW ˚˛˛˙
Telephone: (˛˚) ˝˙˚ˆ ˇˆ˛˛
Fax: (˛˚) ˝˙˚ˆ ˇˆ˙ˇ
[email protected]
www.safetyandquality.gov.au

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