Table Of Content

National Safety and Quality Health Service Standards Guide for Day Procedure Services Published by the Australian Commission on Safety and Quality in Health Care Level 5, 255 Elizabeth Street, Sydney NSW 2000 Phone: (02) 9126 3600 Fax: (02) 9126 3613 Email: Quick guide Clinical Governance Standard 5 Partnering with Consumers Standard 63 Preventing and Controlling Healthcare-Associated Infection Standard 97 Medication Safety Standard 137 Comprehensive Care Standard 177 Communicating for Safety Standard 215 Blood Management Standard 255 Recognising and Responding to Acute Deterioration Standard 259 Contents Quick guide iii Introduction 1 Types of evidence included in this guide 4 Clinical Governance Standard 5 Criterion: Governance, leadership and culture 8 Governance, leadership and culture 8 Action 1.1 8 Action 1.2 12 Organisational leadership 12 Action 1.3 12 Action 1.4 13 Action 1.5 14 Clinical leadership 15 Action 1.6 15 Criterion: Patient safety and quality systems 17 Policies and procedures 17 Action 1.7 17 Measurement and quality improvement 19 Action 1.8 19 Action 1.9 21 Risk management 22 Action 1.10 22 Incident management systems and open disclosure 25 Action 1.11 25 Action 1.12 27 Feedback and complaints management 29 Action 1.13 29 Action 1.14 30 Diversity and high-risk groups 33 Action 1.15 33 iv Guide for Day Procedure Services • NSQHS Standards Healthcare records 34 Action 1.16 34 Action 1.17 37 Action 1.18 38 Criterion: Clinical performance and efectiveness 40 Safety and quality training 41 Action 1.19 41 Action 1.20 42 Action 1.21 43 Performance management 45 Action 1.22 45 Credentialing and scope of clinical practice 47 Action 1.23 47 Action 1.24 49 Safety and quality roles and responsibilities 50 Action 1.25 50 Action 1.26 52 Evidence-based care 53 Action 1.27 53 Variation in clinical practice and health outcomes 55 Action 1.28 55 Criterion: Safe environment for the delivery of care 58 Safe environment 58 Action 1.29 58 Action 1.30 60 Action 1.31 61 Action 1.32 61 Action 1.33 62 NSQHS Standards • Guide for Day Procedure Services v Partnering with Consumers Standard 63 Criterion: Clinical governance and quality improvement systems to support partnering with consumers 67 Integrating clinical governance 67 Action 2.1 67 Applying quality improvement systems 69 Action 2.2 69 Criterion: Partnering with patients in their own care 71 Healthcare rights and informed consent 72 Action 2.3 72 Action 2.4 74 Action 2.5 76 Sharing decisions and planning care 78 Action 2.6 78 Action 2.7 80 Criterion: Health literacy 82 Communication that supports efective partnerships 83 Action 2.8 83 Action 2.9 85 Action 2.10 87 Criterion: Partnering with consumers in organisational design and governance 89 Partnerships in healthcare governance planning, design, measurement and evaluation 90 Action 2.11 90 Action 2.12 92 Action 2.13 93 Action 2.14 93 Resources 94 vi Guide for Day Procedure Services • NSQHS Standards Preventing and Controlling Healthcare-Associated Infection Standard 97 Criterion: Clinical governance and quality improvement to prevent and control healthcare-associated infections, and support antimicrobial stewardship 100 Integrating clinical governance 101 Action 3.1 101 Applying quality improvement systems 103 Action 3.2 103 Partnering with consumers 105 Action 3.3 105 Surveillance 107 Action 3.4 107 Criterion: Infection prevention and control systems 109 Standard and transmission-based precautions 110 Action 3.5 110 Action 3.6 112 Action 3.7 114 Hand hygiene 115 Action 3.8 115 Aseptic technique 117 Action 3.9 117 Invasive medical devices 118 Action 3.10 118 Clean environment 120 Action 3.11 120 Action 3.12 121 Workforce immunisation 123 Action 3.13 123 Criterion: Reprocessing of reusable medical devices 125 Reprocessing of reusable devices 125 Action 3.14 125 Criterion: Antimicrobial stewardship 128 Antimicrobial stewardship 128 Action 3.15 128 Action 3.16 132 Resources 135 NSQHS Standards • Guide for Day Procedure Services vii Medication Safety Standard 137 Criterion: Clinical governance and quality improvement to support medication management 140 Integrating clinical governance 141 Action 4.1 141 Applying quality improvement systems 145 Action 4.2 145 Partnering with consumers 147 Action 4.3 147 Medicines scope of clinical practice 149 Action 4.4 149 Criterion: Documentation of patient information 151 Medication reconciliation 152 Action 4.5 152 Action 4.6 153 Adverse drug reactions 154 Action 4.7 154 Action 4.8 155 Action 4.9 157 Criterion: Continuity of medication management 159 Medication review 160 Action 4.10 160 Information for patients 163 Action 4.11 163 Provision of a medicines list 165 Action 4.12 165 Criterion: Medication management processes 167 Information and decision support tools for medicines 167 Action 4.13 167 Safe and secure storage and distribution of medicines 169 Action 4.14 169 High-risk medicines 172 Action 4.15 172 Resources 173 viii Guide for Day Procedure Services • NSQHS Standards Comprehensive Care Standard 177 Criterion: Clinical governance and quality improvement to support comprehensive care 180 Integrating clinical governance 180 Action 5.1 180 Applying quality improvement systems 182 Action 5.2 182 Partnering with consumers 184 Action 5.3 184 Designing systems to deliver comprehensive care 185 Action 5.4 185 Collaboration and teamwork 187 Action 5.5 187 Action 5.6 188 Criterion: Developing the comprehensive care plan 191 Planning for comprehensive care 191 Action 5.7 191 Action 5.8 193 Action 5.9 194 Screening of risk 194 Action 5.10 194 Clinical assessment 196 Action 5.11 196 Developing the comprehensive care plan 197 Action 5.12 197 Action 5.13 198 Criterion: Delivering comprehensive care 200 Using the comprehensive care plan 200 Action 5.14 200 Comprehensive care at the end of life 202 Action 5.15 202 Action 5.16 202 Action 5.17 203 Action 5.18 204 Action 5.19 204 Action 5.20 204 NSQHS Standards • Guide for Day Procedure Services ix Criterion: Minimising patient harm 205 Preventing and managing pressure injuries 205 Action 5.21 205 Action 5.22 206 Action 5.23 207 Preventing falls and harm from falls 208 Action 5.24 208 Action 5.25 209 Action 5.26 210 Nutrition and hydration 211 Action 5.27 211 Action 5.28 211 Preventing delirium and managing cognitive impairment 212 Action 5.29 212 Action 5.30 213 Predicting, preventing and managing self-harm and suicide 214 Action 5.31 214 Action 5.32 215 Predicting, preventing and managing aggression and violence 216 Action 5.33 216 Action 5.34 217 Minimising restrictive practices: restraint 218 Action 5.35 218 Minimising restrictive practices: seclusion 218 Action 5.36 218 Resources 219 Communicating for Safety Standard 221 Criterion: Clinical governance and quality improvement to support efective communication 224 Integrating clinical governance 224 Action 6.1 224 Applying quality improvement systems 227 Action 6.2 227 Partnering with consumers 229 Action 6.3 229 x Guide for Day Procedure Services • NSQHS Standards

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National Safety and Quality Health Service Standards Guide for Day Procedure Services Published by the Australian Commission on Safety and Quality in Health Care Level 5, 255 Elizabeth Street, Sydney NSW 2000 Phone: (02) 9126 3600 Fax: (02) 9126 3613 Email: Quick guide Clinical Governance Standard 5 Partnering with Consumers Standard 63 Preventing and Controlling Healthcare-Associated Infection Standard 97 Medication Safety Standard 137 Comprehensive Care Standard 177 Communicating for Safety Standard 215 Blood Management Standard 255 Recognising and Responding to Acute Deterioration Standard 259 Contents Quick guide iii Introduction 1 Types of evidence included in this guide 4 Clinical Governance Standard 5 Criterion: Governance, leadership and culture 8 Governance, leadership and culture 8 Action 1.1 8 Action 1.2 12 Organisational leadership 12 Action 1.3 12 Action 1.4 13 Action 1.5 14 Clinical leadership 15 Action 1.6 15 Criterion: Patient safety and quality systems 17 Policies and procedures 17 Action 1.7 17 Measurement and quality improvement 19 Action 1.8 19 Action 1.9 21 Risk management 22 Action 1.10 22 Incident management systems and open disclosure 25 Action 1.11 25 Action 1.12 27 Feedback and complaints management 29 Action 1.13 29 Action 1.14 30 Diversity and high-risk groups 33 Action 1.15 33 iv Guide for Day Procedure Services • NSQHS Standards Healthcare records 34 Action 1.16 34 Action 1.17 37 Action 1.18 38 Criterion: Clinical performance and efectiveness 40 Safety and quality training 41 Action 1.19 41 Action 1.20 42 Action 1.21 43 Performance management 45 Action 1.22 45 Credentialing and scope of clinical practice 47 Action 1.23 47 Action 1.24 49 Safety and quality roles and responsibilities 50 Action 1.25 50 Action 1.26 52 Evidence-based care 53 Action 1.27 53 Variation in clinical practice and health outcomes 55 Action 1.28 55 Criterion: Safe environment for the delivery of care 58 Safe environment 58 Action 1.29 58 Action 1.30 60 Action 1.31 61 Action 1.32 61 Action 1.33 62 NSQHS Standards • Guide for Day Procedure Services v Partnering with Consumers Standard 63 Criterion: Clinical governance and quality improvement systems to support partnering with consumers 67 Integrating clinical governance 67 Action 2.1 67 Applying quality improvement systems 69 Action 2.2 69 Criterion: Partnering with patients in their own care 71 Healthcare rights and informed consent 72 Action 2.3 72 Action 2.4 74 Action 2.5 76 Sharing decisions and planning care 78 Action 2.6 78 Action 2.7 80 Criterion: Health literacy 82 Communication that supports efective partnerships 83 Action 2.8 83 Action 2.9 85 Action 2.10 87 Criterion: Partnering with consumers in organisational design and governance 89 Partnerships in healthcare governance planning, design, measurement and evaluation 90 Action 2.11 90 Action 2.12 92 Action 2.13 93 Action 2.14 93 Resources 94 vi Guide for Day Procedure Services • NSQHS Standards Preventing and Controlling Healthcare-Associated Infection Standard 97 Criterion: Clinical governance and quality improvement to prevent and control healthcare-associated infections, and support antimicrobial stewardship 100 Integrating clinical governance 101 Action 3.1 101 Applying quality improvement systems 103 Action 3.2 103 Partnering with consumers 105 Action 3.3 105 Surveillance 107 Action 3.4 107 Criterion: Infection prevention and control systems 109 Standard and transmission-based precautions 110 Action 3.5 110 Action 3.6 112 Action 3.7 114 Hand hygiene 115 Action 3.8 115 Aseptic technique 117 Action 3.9 117 Invasive medical devices 118 Action 3.10 118 Clean environment 120 Action 3.11 120 Action 3.12 121 Workforce immunisation 123 Action 3.13 123 Criterion: Reprocessing of reusable medical devices 125 Reprocessing of reusable devices 125 Action 3.14 125 Criterion: Antimicrobial stewardship 128 Antimicrobial stewardship 128 Action 3.15 128 Action 3.16 132 Resources 135 NSQHS Standards • Guide for Day Procedure Services vii Medication Safety Standard 137 Criterion: Clinical governance and quality improvement to support medication management 140 Integrating clinical governance 141 Action 4.1 141 Applying quality improvement systems 145 Action 4.2 145 Partnering with consumers 147 Action 4.3 147 Medicines scope of clinical practice 149 Action 4.4 149 Criterion: Documentation of patient information 151 Medication reconciliation 152 Action 4.5 152 Action 4.6 153 Adverse drug reactions 154 Action 4.7 154 Action 4.8 155 Action 4.9 157 Criterion: Continuity of medication management 159 Medication review 160 Action 4.10 160 Information for patients 163 Action 4.11 163 Provision of a medicines list 165 Action 4.12 165 Criterion: Medication management processes 167 Information and decision support tools for medicines 167 Action 4.13 167 Safe and secure storage and distribution of medicines 169 Action 4.14 169 High-risk medicines 172 Action 4.15 172 Resources 173 viii Guide for Day Procedure Services • NSQHS Standards Comprehensive Care Standard 177 Criterion: Clinical governance and quality improvement to support comprehensive care 180 Integrating clinical governance 180 Action 5.1 180 Applying quality improvement systems 182 Action 5.2 182 Partnering with consumers 184 Action 5.3 184 Designing systems to deliver comprehensive care 185 Action 5.4 185 Collaboration and teamwork 187 Action 5.5 187 Action 5.6 188 Criterion: Developing the comprehensive care plan 191 Planning for comprehensive care 191 Action 5.7 191 Action 5.8 193 Action 5.9 194 Screening of risk 194 Action 5.10 194 Clinical assessment 196 Action 5.11 196 Developing the comprehensive care plan 197 Action 5.12 197 Action 5.13 198 Criterion: Delivering comprehensive care 200 Using the comprehensive care plan 200 Action 5.14 200 Comprehensive care at the end of life 202 Action 5.15 202 Action 5.16 202 Action 5.17 203 Action 5.18 204 Action 5.19 204 Action 5.20 204 NSQHS Standards • Guide for Day Procedure Services ix Criterion: Minimising patient harm 205 Preventing and managing pressure injuries 205 Action 5.21 205 Action 5.22 206 Action 5.23 207 Preventing falls and harm from falls 208 Action 5.24 208 Action 5.25 209 Action 5.26 210 Nutrition and hydration 211 Action 5.27 211 Action 5.28 211 Preventing delirium and managing cognitive impairment 212 Action 5.29 212 Action 5.30 213 Predicting, preventing and managing self-harm and suicide 214 Action 5.31 214 Action 5.32 215 Predicting, preventing and managing aggression and violence 216 Action 5.33 216 Action 5.34 217 Minimising restrictive practices: restraint 218 Action 5.35 218 Minimising restrictive practices: seclusion 218 Action 5.36 218 Resources 219 Communicating for Safety Standard 221 Criterion: Clinical governance and quality improvement to support efective communication 224 Integrating clinical governance 224 Action 6.1 224 Applying quality improvement systems 227 Action 6.2 227 Partnering with consumers 229 Action 6.3 229 x Guide for Day Procedure Services • NSQHS Standards

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