National Safety and Quality Health Service Standards Guide for Multi-Purpose Services and Small ...

290 Pages·2017·6.25 MB·English

National Safety and Quality
Health Service Standards
Guide for Multi-Purpose
Services and Small
Hospitals
Published by the Australian Commission on Safety and Quality in Health Care
Level 5, 255 Elizabeth Street, Sydney NSW 2000
Phone: [phone]
Fax: [phone]
Email:
Quick guide
Clinical Governance Standard 5
Partnering with Consumers Standard 41
Preventing and Controlling Healthcare-Associated Infection Standard 67
Medication Safety Standard 95
Comprehensive Care Standard 127
Communicating for Safety Standard 177
Blood Management Standard 211
Recognising and Responding to Acute Deterioration Standard 229
Contents
Quick guide iii
Introduction 1
Clinical Governance Standard 5
Criterion: Governance, leadership and culture 8
Governance, leadership and culture 9
Action 1.1 9
Action 1.2 10
Organisational leadership 11
Action 1.3 11
Action 1.4 12
Action 1.5 13
Clinical leadership 14
Action 1.6 14
Criterion: Patient safety and quality systems 15
Policies and procedures 15
Action 1.7 15
Measurement and quality improvement 16
Action 1.8 16
Action 1.9 17
Risk management 18
Action 1.10 18
Incident management systems and open disclosure 19
Action 1.11 19
Action 1.12 20
Feedback and complaints management 21
Action 1.13 21
Action 1.14 22
Diversity and high-risk groups 23
Action 1.15 23
iv Guide for Multi-Purpose Services and Small Hospitals • NSQHS Standards
Healthcare records 24
Action 1.16 24
Action 1.17 25
Action 1.18 26
Criterion: Clinical performance and efectiveness 27
Safety and quality training 27
Action 1.19 27
Action 1.20 28
Action 1.21 29
Performance management 30
Action 1.22 30
Credentialing and scope of clinical practice 31
Action 1.23 31
Action 1.24 32
Safety and quality roles and responsibilities 33
Action 1.25 33
Action 1.26 34
Evidence-based care 34
Action 1.27 34
Variation in clinical practice and health outcomes 36
Action 1.28 36
Criterion: Safe environment for the delivery of care 37
Safe environment 37
Action 1.29 37
Action 1.30 38
Action 1.31 39
Action 1.32 39
Action 1.33 40
Partnering with Consumers Standard 41
Criterion: Clinical governance and quality improvement systems to
support partnering with consumers 45
Integrating clinical governance 45
Action 2.1 45
Applying quality improvement systems 47
Action 2.2 47
NSQHS Standards • Guide for Multi-Purpose Services and Small Hospitals v
Criterion: Partnering with patients in their own care 49
Healthcare rights and informed consent 50
Action 2.3 50
Action 2.4 51
Action 2.5 52
Sharing decisions and planning care 53
Action 2.6 53
Action 2.7 55
Criterion: Health literacy 56
Communication that supports efective partnerships 57
Action 2.8 57
Action 2.9 58
Action 2.10 59
Criterion: Partnering with consumers in organisational design
and governance 60
Partnerships in healthcare governance planning, design,
measurement and evaluation 60
Action 2.11 60
Action 2.12 62
Action 2.13 62
Action 2.14 63
Resources 64
Preventing and Controlling Healthcare-Associated Infection Standard 67
Criterion: Clinical governance and quality improvement to
prevent and control healthcare-associated infections, and support
antimicrobial stewardship 70
Integrating clinical governance 71
Action 3.1 71
Applying quality improvement systems 73
Action 3.2 73
Partnering with consumers 74
Action 3.3 74
Surveillance 75
Action 3.4 75
vi Guide for Multi-Purpose Services and Small Hospitals • NSQHS Standards
Criterion: Infection prevention and control systems 77
Standard and transmission-based precautions 78
Action 3.5 78
Action 3.6 79
Action 3.7 80
Hand hygiene 81
Action 3.8 81
Aseptic technique 82
Action 3.9 82
Invasive medical devices 83
Action 3.10 83
Clean environment 84
Action 3.11 84
Action 3.12 85
Workforce immunisation 86
Action 3.13 86
Criterion: Reprocessing of reusable medical devices 87
Reprocessing of reusable devices 87
Action 3.14 87
Criterion: Antimicrobial stewardship 89
Antimicrobial stewardship 90
Action 3.15 90
Action 3.16 92
Resources 94
Medication Safety Standard 95
Criterion: Clinical governance and quality improvement to support
medication management 99
Integrating clinical governance 100
Action 4.1 100
Applying quality improvement systems 102
Action 4.2 102
Partnering with consumers 104
Action 4.3 104
Medicines scope of clinical practice 105
Action 4.4 105
NSQHS Standards • Guide for Multi-Purpose Services and Small Hospitals vii
Criterion: Documentation of patient information 107
Medication reconciliation 108
Action 4.5 108
Action 4.6 109
Adverse drug reactions 109
Action 4.7 109
Action 4.8 110
Action 4.9 111
Criterion: Continuity of medication management 112
Medication review 113
Action 4.10 113
Information for patients 115
Action 4.11 115
Provision of a medicines list 116
Action 4.12 116
Criterion: Medication management processes 118
Information and decision support tools for medicines 119
Action 4.13 119
Safe and secure storage and distribution of medicines 120
Action 4.14 120
High-risk medicines 121
Action 4.15 121
Resources 123
Comprehensive Care Standard 127
Criterion: Clinical governance and quality improvement to support
comprehensive care 131
Integrating clinical governance 131
Action 5.1 131
Applying quality improvement systems 133
Action 5.2 133
Partnering with consumers 134
Action 5.3 134
Designing systems to deliver comprehensive care 135
Action 5.4 135
viii Guide for Multi-Purpose Services and Small Hospitals • NSQHS Standards
Collaboration and teamwork 138
Action 5.5 138
Action 5.6 139
Criterion: Developing the comprehensive care plan 141
Planning for comprehensive care 141
Action 5.7 141
Action 5.8 142
Action 5.9 143
Screening of risk 144
Action 5.10 144
Clinical assessment 145
Action 5.11 145
Developing the comprehensive care plan 146
Action 5.12 146
Action 5.13 147
Criterion: Delivering comprehensive care 150
Using the comprehensive care plan 150
Action 5.14 150
Comprehensive care at the end of life 152
Action 5.15 152
Action 5.16 152
Action 5.17 153
Action 5.18 154
Action 5.19 155
Action 5.20 156
Criterion: Minimising patient harm 157
Preventing and managing pressure injuries 157
Action 5.21 157
Action 5.22 158
Action 5.23 158
Preventing falls and harm from falls 159
Action 5.24 159
Action 5.25 160
Action 5.26 160
Nutrition and hydration 161
Action 5.27 161
Action 5.28 162
NSQHS Standards • Guide for Multi-Purpose Services and Small Hospitals ix
Preventing delirium and managing cognitive impairment 163
Action 5.29 163
Action 5.30 165
Predicting, preventing and managing self-harm and suicide 166
Action 5.31 166
Action 5.32 168
Predicting, preventing and managing aggression and violence 169
Action 5.33 169
Action 5.34 170
Minimising restrictive practices: restraint 171
Action 5.35 171
Minimising restrictive practices: seclusion 173
Action 5.36 173
Resources 174
Communicating for Safety Standard 177
Criterion: Clinical governance and quality improvement to support
efective communication 182
Integrating clinical governance 182
Action 6.1 182
Applying quality improvement systems 185
Action 6.2 185
Partnering with consumers 187
Action 6.3 187
Organisational processes to support efective communication 188
Action 6.4 188
Criterion: Correct identifcation and procedure matching 190
Correct identifcation and procedure matching 191
Action 6.5 191
Action 6.6 193
Criterion: Communication at clinical handover 194
Clinical handover 198
Action 6.7 198
Action 6.8 199
x Guide for Multi-Purpose Services and Small Hospitals • NSQHS Standards