Safety and Quality in Health Care | My Assignment Tutor

National Safety andQuality Health ServiceStandardsSecond editionPublished by the Australian Commission on Safety and Quality in Health CareLevel 5, 255 Elizabeth Street, Sydney NSW 2000Phone: (02) 9126 3600Fax: (02) 9126 3613Email: mail@safetyandquality.gov.auWebsite: www.safetyandquality.gov.auISBN: 978-1-925665-17-8© Australian Commission on Safety and Quality in Health Care 2017All material and work produced by the Australian Commission on Safety and Quality in Health Care is protectedby copyright. The Commission reserves the right to set out the terms and conditions for the use of such material.As far as practicable, material for which the copyright is owned by a third party will be clearly labelled. TheCommission has made all reasonable efforts to ensure that this material has been reproduced in this publicationwith the full consent of the copyright owners.With the exception of any material protected by a trademark, any content provided by third parties, and whereotherwise noted, all material presented in this publication is licensed under a Creative Commons AttributionNonCommercial-NoDerivatives 4.0 International licence.Enquiries about the licence and any use of this publication are welcome and can be sent tocommunications@safetyandquality.gov.au.The Commission’s preference is that you attribute this publication (and any material sourced from it) using thefollowing citation:Australian Commission on Safety and Quality in Health Care. National Safety and Quality Health ServiceStandards. 2nd ed. Sydney: ACSQHC; 2017.DisclaimerThe content of this document is published in good faith by the Australian Commission on Safety and Qualityin Health Care for information purposes. The document is not intended to provide guidance on particularhealthcare 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 ofthis document by the Commission does not necessarily reflect the views of the Commission, or indicate acommitment 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.AcknowledgementThe Commission would like to thank all of our partners for their contributions to the development of the NSQHSStandards and their continuing commitment to improving safety and quality across the Australian healthcaresystem.This document was released in November 2017.ContentsIntroduction 1Clinical Governance Standard 3Partnering with Consumers Standard 13Preventing and Controlling Healthcare-Associated Infection Standard 21Medication Safety Standard 29Comprehensive Care Standard 37Communicating for Safety Standard 47Blood Management Standard 55Recognising and Responding to Acute Deterioration Standard 61Glossary 67References 77 NSQHS Standards 1IntroductionThe National Safety and Quality Health Service(NSQHS) Standards were developed by theAustralian Commission on Safety and Quality inHealth Care (the Commission) in collaboration withthe Australian Government, states and territories,the private sector, clinical experts, patients andcarers. The primary aims of the NSQHS Standardsare to protect the public from harm and to improvethe quality of health service provision. They providea quality assurance mechanism that tests whetherrelevant systems are in place to ensure that expectedstandards of safety and quality are met.There are eight NSQHS Standards, which coverhigh-prevalence adverse events, healthcareassociated infections, medication safety,comprehensive care, clinical communication, theprevention and management of pressure injuries,the prevention of falls, and responding to clinicaldeterioration. Importantly, these NSQHS Standardshave provided a nationally consistent statementabout the standard of care consumers can expectfrom their health service organisations.The eight NSQHS Standards are:Clinical Governance, which describes theclinical governance, and safety and qualitysystems that are required to maintain andimprove the reliability, safety and quality ofhealth care, and improve health outcomesfor patients.Partnering with Consumers, whichdescribes the systems and strategies tocreate a person-centred health system byincluding patients in shared decisionmaking, to ensure that patients are partnersin their own care, and that consumers areinvolved in the development and design ofquality health care.Preventing and Controlling HealthcareAssociated Infection, which describes thesystems and strategies to prevent infection,to manage infections effectively when theyoccur, and to limit the development ofantimicrobial resistance through prudentuse of antimicrobials, as part of effectiveantimicrobial stewardship.Medication Safety, which describes thesystems and strategies to ensure thatclinicians safely prescribe, dispense andadminister appropriate medicines toinformed patients, and monitor use of themedicines.Comprehensive Care, which describes theintegrated screening, assessment and riskidentification processes for developing anindividualised care plan, to prevent andminimise the risks of harm in identifiedareas.Communicating for Safety, whichdescribes the systems and strategies foreffective communication between patients,carers and families, multidisciplinary teamsand clinicians, and across the health serviceorganisation.Blood Management, which describes thesystems and strategies for the safe,appropriate, efficient and effective care ofpatients’ own blood, as well as othersupplies of blood and blood products.Recognising and Responding to AcuteDeterioration, which describes the systemsand processes to respond effectively topatients when their physical, mental orcognitive condition deteriorates.Each standard contains:• A description of the standard• A statement of intent• A list of criteria that describe the key areascovered by the standard• Explanatory notes on the content of the standard• Item headings for groups of actions in eachcriterion• Actions that describe what is required to meetthe standard.2 NSQHS StandardsThe NSQHS Standards require theimplementation of organisation-wide systemsfor clinical governance, partnering withconsumers, healthcare-associated infections,medication safety, comprehensive care, effectivecommunication, blood management, andrecognising and responding to acute deterioration.The Clinical Governance Standard and thePartnering with Consumers Standard set theoverarching system requirements for the effectiveimplementation of the remaining six standards,which consider specific high-risk clinical areasof patient care. The NSQHS Standards describethe patient care journey and are designed tobe implemented in an integrated way. Similarimplementation strategies apply to multiple actionsacross the NSQHS Standards. It is important toidentify the links between actions across each ofthe eight NSQHS Standards. This will help healthservice organisations to ensure that their safetyand quality systems are integrated, and reduce theduplication of effort in implementing the eightstandards separately.Important improvements in the safety and qualityof patient care have been documented followingimplementation of the first edition of the NSQHSStandards from 2011, including:• A decline in the Staphylococcus aureusbacteraemia rate per 10,000 patient days undersurveillance between 2010 and 2014, from 1.1 to0.87 cases• A drop in the yearly number of methicillinresistant S. aureus bacteraemia cases between2010 and 2014, from 505 to 389• A decline of almost one-half in the national rateof central line-associated bloodstream infectionsbetween 2012–13 and 2013–14, from 1.02 to 0.6per 1,000 line days.• Greater prioritisation of antimicrobialstewardship activities in health serviceorganisations• Better documentation of adverse drug reactionsand medication history• Reduction in yearly red blood cell issues by theNational Blood Authority between mid-2010 andmid-2015, from approximately 800,000 units to667,000 units• Declining rates of in-hospital cardiac arrest andintensive care unit admissions following cardiacarrests.The Commission has worked closely with partnersto review the NSQHS Standards and develop thesecond edition, embedding person-centred careand addressing the needs of people who may beat greater risk of harm. The NSQHS Standards(second edition) set requirements for providingcomprehensive care for all patients, and includeactions related to health literacy, end-of-life care,care for Aboriginal and Torres Strait Islander people,and care for people with lived experience of mentalillness or cognitive impairment.More informationA range of other supporting resources to assisthealth service organisations to implementthe NSQHS Standards are available on theCommission’s website.The Advice Centre provides support for healthservice organisations, surveyors and accreditingagencies on NSQHS Standards implementation.Email: accreditation@safetyandquality.gov.auPhone: 1800 304 0561Clinical GovernanceStandard4 Clinical Governance Standard • NSQHS StandardsClinical Governance StandardLeaders of a health service organisation have a responsibility to thecommunity for continuous improvement of the safety and qualityof their services, and ensuring that they are person centred, safe andeffective.Intention of this standardTo implement a clinical governance framework that ensures that patients andconsumers receive safe and high-quality health care.CriteriaGovernance, leadership and cultureLeaders at all levels in the organisation set up and use clinical governance systems toimprove the safety and quality of health care for patients.Patient safety and quality systemsSafety and quality systems are integrated with governance processes to enableorganisations to actively manage and improve the safety and quality of health carefor patients.Clinical performance and effectivenessThe workforce has the right qualifications, skills and supervision to provide safe, highquality health care to patients.Safe environment for the delivery of careThe environment promotes safe and high-quality health care for patients.NSQHS Standards • Clinical Governance Standard 5Explanatory notesThorough research has identified the elements ofan effective clinical governance system and theeffect of good clinical governance on health serviceperformance.1 Research in Australia2 and overseas3notes the importance of leaders in influencing thequality of care by supporting the workforce, shapingculture, setting direction, and monitoring progressin safety and quality performance. Engagingmanagers and clinicians in governance and qualityimprovement activities is important for aligningclinical and managerial priorities.4Clinical governance is the set of relationships andresponsibilities established by a health serviceorganisation between its department of health(for the public sector), governing body, executive,clinicians, patients, consumers and otherstakeholders to ensure good clinical outcomes.5It ensures that the community and health serviceorganisations can be confident that systems are inplace to deliver safe and high-quality health careand continuously improve services.Clinical governance is an integrated componentof corporate governance of health serviceorganisations. It ensures that everyone – fromfrontline clinicians to managers and members ofgoverning bodies, such as boards – is accountableto patients and the community for assuring thedelivery of health services that are safe, effective,integrated, high quality and continuouslyimproving.Each health service organisation needs to put inplace strategies for clinical governance that considerits local circumstances.This standard includes actions related to the role ofleaders and others in safety and quality, Aboriginaland Torres Strait Islander health and e-health.To support the delivery of safe and high-qualitycare for patients and consumers, the AustralianCommission on Safety and Quality in Health Care(the Commission) has developed the NationalModel Clinical Governance Framework.5 Healthservice organisations should refer to the frameworkfor more details on clinical governance, and theassociated roles and responsibilities.6 Clinical Governance Standard • NSQHS StandardsGovernance, leadership and cultureLeaders at all levels in the organisation set up and use clinical governance systems to improve the safety andquality of health care for patients. ItemActionGovernance,leadership andculture1.1 The governing body:a. Provides leadership to develop a culture of safety and qualityimprovement, and satisfies itself that this culture exists within theorganisationb. Provides leadership to ensure partnering with patients, carers andconsumersc. Sets priorities and strategic directions for safe and high-quality clinicalcare, and ensures that these are communicated effectively to theworkforce and the communityd. Endorses the organisation’s clinical governance frameworke. Ensures that roles and responsibilities are clearly defined for thegoverning body, management, clinicians and the workforcef. Monitors the action taken as a result of analyses of clinical incidentsg. Reviews reports and monitors the organisation’s progress on safetyand quality performance1.2 The governing body ensures that the organisation’s safety and qualitypriorities address the specific health needs of Aboriginal and Torres StraitIslander peopleOrganisationalleadership1.3 The health service organisation establishes and maintains a clinicalgovernance framework, and uses the processes within the framework todrive improvements in safety and quality1.4 The health service organisation implements and monitors strategies tomeet the organisation’s safety and quality priorities for Aboriginal andTorres Strait Islander people1.5 The health service organisation considers the safety and quality of healthcare for patients in its business decision-makingClinical leadership1.6 Clinical leaders support clinicians to:a. Understand and perform their delegated safety and quality roles andresponsibilitiesb. Operate within the clinical governance framework to improve thesafety and quality of health care for patients NSQHS Standards • Clinical Governance Standard 7Patient safety and quality systemsSafety and quality systems are integrated with governance processes to enable organisations to activelymanage and improve the safety and quality of health care for patients. ItemActionPolicies andprocedures1.7 The health service organisation uses a risk management approach to:a. Set out, review, and maintain the currency and effectiveness of,policies, procedures and protocolsb. Monitor and take action to improve adherence to policies, proceduresand protocolsc. Review compliance with legislation, regulation and jurisdictionalrequirementsMeasurementand qualityimprovement1.8 The health service organisation uses organisation-wide qualityimprovement systems that:a. Identify safety and quality measures, and monitor and reportperformance and outcomesb. Identify areas for improvement in safety and qualityc. Implement and monitor safety and quality improvement strategiesd. Involve consumers and the workforce in the review of safety andquality performance and systems1.9 The health service organisation ensures that timely reports on safety andquality systems and performance are provided to:a. The governing bodyb. The workforcec. Consumers and the local communityd. Other relevant health service organisationsRisk management1.10 The health service organisation:a. Identifies and documents organisational risksb. Uses clinical and other data collections to support risk assessmentsc. Acts to reduce risksd. Regularly reviews and acts to improve the effectiveness of the riskmanagement systeme. Reports on risks to the workforce and consumersf. Plans for, and manages, internal and external emergencies anddisasters 8 Clinical Governance Standard • NSQHS Standards ItemActionIncidentmanagementsystems and opendisclosure1.11 The health service organisation has organisation-wide incidentmanagement and investigation systems, and:a. Supports the workforce to recognise and report incidentsb. Supports patients, carers and families to communicate concerns orincidentsc. Involves the workforce and consumers in the review of incidentsd. Provides timely feedback on the analysis of incidents to the governingbody, the workforce and consumerse. Uses the information from the analysis of incidents to improve safetyand qualityf. Incorporates risks identified in the analysis of incidents into the riskmanagement systemg. Regularly reviews and acts to improve the effectiveness of the incidentmanagement and investigation systems1.12 The health service organisation:a. Uses an open disclosure program that is consistent with the AustralianOpen Disclosure Framework6b. Monitors and acts to improve the effectiveness of open disclosureprocessesFeedback andcomplaintsmanagement1.13 The health service organisation:a. Has processes to seek regular feedback from patients, carers andfamilies about their experiences and outcomes of careb. Has processes to regularly seek feedback from the workforce on theirunderstanding and use of the safety and quality systemsc. Uses this information to improve safety and quality systems1.14 The health service organisation has an organisation-wide complaintsmanagement system, and:a. Encourages and supports patients, carers and families, and theworkforce to report complaintsb. Involves the workforce and consumers in the review of complaintsc. Resolves complaints in a timely wayd. Provides timely feedback to the governing body, the workforce andconsumers on the analysis of complaints and actions takene. Uses information from the analysis of complaints to informimprovements in safety and quality systemsf. Records the risks identified from the analysis of complaints in the riskmanagement systemg. Regularly reviews and acts to improve the effectiveness of thecomplaints management system NSQHS Standards • Clinical Governance Standard 9 ItemActionDiversity andhigh-risk groups1.15 The health service organisation:a. Identifies the diversity of the consumers using its servicesb. Identifies groups of patients using its services who are at higher risk ofharmc. Incorporates information on the diversity of its consumers and higherrisk groups into the planning and delivery of careHealthcarerecords1.16 The health service organisation has healthcare record systems that:a. Make the healthcare record available to clinicians at the point of careb. Support the workforce to maintain accurate and complete healthcarerecordsc. Comply with security and privacy regulationsd. Support systematic audit of clinical informatione. Integrate multiple information systems, where they are used1.17 The health service organisation works towards implementing systems thatcan provide clinical information into the My Health Record system that:a. Are designed to optimise the safety and quality of health care forpatientsb. Use national patient and provider identifiersc. Use standard national terminologies1.18 The health service organisation providing clinical information into the MyHealth Record system has processes that:a. Describe access to the system by the workforce, to comply withlegislative requirementsb. Maintain the accuracy and completeness of the clinical informationthe organisation uploads into the system 10 Clinical Governance Standard • NSQHS StandardsClinical performance and effectivenessThe workforce has the right qualifications, skills and supervision to provide safe, high-quality health careto patients. ItemActionSafety and qualitytraining1.19 The health service organisation provides orientation to the organisationthat describes roles and responsibilities for safety and quality for:a. Members of the governing bodyb. Clinicians, and any other employed, contracted, locum, agency,student or volunteer members of the organisation1.20 The health service organisation uses its training systems to:a. Assess the competency and training needs of its workforceb. Implement a mandatory training program to meet its requirementsarising from these standardsc. Provide access to training to meet its safety and quality training needsd. Monitor the workforce’s participation in training1.21 The health service organisation has strategies to improve the culturalawareness and cultural competency of the workforce to meet the needsof its Aboriginal and Torres Strait Islander patientsPerformancemanagement1.22 The health service organisation has valid and reliable performance reviewprocesses that:a. Require members of the workforce to regularly take part in a review oftheir performanceb. Identify needs for training and development in safety and qualityc. Incorporate information on training requirements into theorganisation’s training systemCredentialing andscope of clinicalpractice1.23 The health service organisation has processes to:a. Define the scope of clinical practice for clinicians, considering theclinical service capacity of the organisation and clinical services planb. Monitor clinicians’ practices to ensure that they are operating withintheir designated scope of clinical practicec. Review the scope of clinical practice of clinicians periodicallyand whenever a new clinical service, procedure or technology isintroduced or substantially altered1.24 The health service organisation:a. Conducts processes to ensure that clinicians are credentialed, whererelevantb. Monitors and improves the effectiveness of the credentialing process NSQHS Standards • Clinical Governance Standard 11 ItemActionSafety andquality roles andresponsibilities1.25 The health service organisation has processes to:a. Support the workforce to understand and perform their roles andresponsibilities for safety and qualityb. Assign safety and quality roles and responsibilities to the workforce,including locums and agency staff1.26 The health service organisation provides supervision for clinicians toensure that they can safely fulfil their designated roles, including access toafter-hours advice, where appropriateEvidence-basedcare1.27 The health service organisation has processes that:a. Provide clinicians with ready access to best-practice guidelines,integrated care pathways, clinical pathways and decision support toolsrelevant to their clinical practiceb. Support clinicians to use the best available evidence, including relevantclinical care standards developed by the Australian Commission onSafety and Quality in Health CareVariation inclinical practiceand healthoutcomes1.28 The health service organisation has systems to:a. Monitor variation in practice against expected health outcomesb. Provide feedback to clinicians on variation in practice and healthoutcomesc. Review performance against external measuresd. Support clinicians to take part in clinical review of their practicee. Use information on unwarranted clinical variation to informimprovements in safety and quality systemsf. Record the risks identified from unwarranted clinical variation in therisk management system 12 Clinical Governance Standard • NSQHS StandardsSafe environment for the delivery of careThe environment promotes safe and high-quality health care for patients. ItemActionSafe environment1.29 The health service organisation maximises safety and quality of care:a. Through the design of the environmentb. By maintaining buildings, plant, equipment, utilities, devices and otherinfrastructure that are fit for purpose1.30 The health service organisation:a. Identifies service areas that have a high risk of unpredictablebehaviours and develops strategies to minimise the risks of harm forpatients, carers, families, consumers and the workforceb. Provides access to a calm and quiet environment when it is clinicallyrequired1.31 The health service organisation facilitates access to services and facilitiesby using signage and directions that are clear and fit for purpose1.32 The health service organisation admitting patients overnight has processesthat allow flexible visiting arrangements to meet patients’ needs, when it issafe to do so1.33 The health service organisation demonstrates a welcoming environmentthat recognises the importance of the cultural beliefs and practices ofAboriginal and Torres Strait Islander people 2Partnering withConsumers Standard14 Partnering with Consumers Standard • NSQHS StandardsPartnering with ConsumersStandardLeaders of a health service organisation develop, implement andmaintain systems to partner with consumers. These partnershipsrelate to the planning, design, delivery, measurement and evaluation ofcare. The workforce uses these systems to partner with consumers.Intention of this standardTo create an organisation in which there are mutually valuable outcomes by having:• Consumers as partners in planning, design, delivery, measurement and evaluation ofsystems and services• Patients as partners in their own care, to the extent that they choose.CriteriaClinical governance and quality improvement systems tosupport partnering with consumersSystems are designed and used to support patients, carers, families and consumers to bepartners in healthcare planning, design, measurement and evaluation.Partnering with patients in their own careSystems that are based on partnering with patients in their own care are used to supportthe delivery of care. Patients are partners in their own care to the extent that they choose.Health literacyHealth service organisations communicate with patients in a way that supports effectivepartnerships.Partnering with consumers in organisational design andgovernanceConsumers are partners in the design and governance of the organisation.NSQHS Standards • Partnering with Consumers Standard 15Explanatory notesEffective partnerships exist when people are treatedwith dignity and respect, information is sharedwith them, and participation and collaboration inhealthcare processes are encouraged and supportedto the extent that people choose.7Different types of partnerships with patients andconsumers exist within the healthcare system.These partnerships are not mutually exclusive,and are needed at all levels to ensure that a healthservice organisation achieves the best possibleoutcome for all parties.8 Partnerships withpatients and consumers comprise many different,interwoven practices that reflect the three key levelsat which partnerships are needed9:1. At the level of the individualPartnerships relate to the interaction betweenclinicians and patients when care is provided.At this level, a partnership involves providingcare that is respectful; sharing information inan ongoing way; working with patients, carersand families to make decisions and plan care;and supporting and encouraging patients intheir own care.2. At the level of a service, department or programof carePartnerships relate to the organisation anddelivery of care within specific areas. At thislevel, a partnership involves the participationof patients, carers, families and consumers inthe overall design of the service, departmentor program. This could be as full members ofquality improvement and redesign teams, andparticipating in planning, implementing andevaluating change.3. At the level of the health servicePartnerships relate to the involvement ofconsumers in overall governance, policy andplanning. This level overlaps with the previouslevel, since a health service is made up of variousservices, departments and programs. At thislevel, partnerships relate to the involvement ofconsumers and consumer representatives asfull members of key organisational governancecommittees in areas such as patient safety,facility design, quality improvement, patientor family education, ethics and research. Thislevel can also involve partnerships with localcommunity organisations and members of localcommunities.Delivering care that is based on partnershipsprovides many benefits for patients, consumers,clinicians, health service organisations and thehealth system. Effective partnerships, a positiveexperience for patients, and high-quality health careand improved safety are linked.9-11 The involvementof patients and consumers in planning, delivery,monitoring and evaluation can also have a positiveeffect on service planning and development,information development and dissemination, andthe attitudes of healthcare providers.9,12,13 Deliveringhealth care that is based on partnerships can resultin reduced hospital costs, lower cost per case andreduced length of stay.14,1516 Partnering with Consumers Standard • NSQHS StandardsClinical governance and quality improvement systems tosupport partnering with consumersSystems are designed and used to support patients, carers, families and consumers to be partners inhealthcare planning, design, measurement and evaluation. ItemActionIntegrating clinicalgovernance2.1 Clinicians use the safety and quality systems from the Clinical GovernanceStandard when:a. Implementing policies and procedures for partnering with consumersb. Managing risks associated with partnering with consumersc. Identifying training requirements for partnering with consumersApplying qualityimprovementsystems2.2 The health service organisation applies the quality improvement systemfrom the Clinical Governance Standard when:a. Monitoring processes for partnering with consumersb. Implementing strategies to improve processes for partnering withconsumersc. Reporting on partnering with consumers NSQHS Standards • Partnering with Consumers Standard 17Partnering with patients in their own careSystems that are based on partnering with patients in their own care are used to support the delivery of care.Patients are partners in their own care to the extent that they choose. ItemActionHealthcare rightsand informedconsent2.3 The health service organisation uses a charter of rights that is:a. Consistent with the Australian Charter of Healthcare Rights16b. Easily accessible for patients, carers, families and consumers2.4 The health service organisation ensures that its informed consentprocesses comply with legislation and best practice2.5 The health service organisation has processes to identify:a. The capacity of a patient to make decisions about their own careb. A substitute decision-maker if a patient does not have the capacity tomake decisions for themselvesSharing decisionsand planning care2.6 The health service organisation has processes for clinicians to partner withpatients and/or their substitute decision-maker to plan, communicate, setgoals, and make decisions about their current and future care2.7 The health service organisation supports the workforce to formpartnerships with patients and carers so that patients can be activelyinvolved in their own care 18 Partnering with Consumers Standard • NSQHS StandardsHealth literacyHealth service organisations communicate with consumers in a way that supports effective partnerships. ItemActionCommunicationthat supportseffectivepartnerships2.8 The health service organisation uses communication mechanisms that aretailored to the diversity of the consumers who use its services and, whererelevant, the diversity of the local community2.9 Where information for patients, carers, families and consumers abouthealth and health services is developed internally, the organisationinvolves consumers in its development and review2.10 The health service organisation supports clinicians to communicate withpatients, carers, families and consumers about health and health care sothat:a. Information is provided in a way that meets the needs of patients,carers, families and consumersb. Information provided is easy to understand and usec. The clinical needs of patients are addressed while they are in thehealth service organisationd. Information needs for ongoing care are provided on discharge NSQHS Standards • Partnering with Consumers Standard 19Partnering with consumers in organisational designand governanceConsumers are partners in the design and governance of the organisation. ItemActionPartnershipsin healthcaregovernanceplanning, design,measurementand evaluation2.11 The health service organisation:a. Involves consumers in partnerships in the governance of, and todesign, measure and evaluate, health careb. Has processes so that the consumers involved in these partnershipsreflect the diversity of consumers who use the service or, whererelevant, the diversity of the local community2.12 The health service organisation provides orientation, support andeducation to consumers who are partnering in the governance, design,measurement and evaluation of the organisation2.13 The health service organisation works in partnership with Aboriginal andTorres Strait Islander communities to meet their healthcare needs2.14 The health service organisation works in partnership with consumers toincorporate their views and experiences into training and education forthe workforce 3Preventing and ControllingHealthcare-AssociatedInfection Standard22 Preventing and Controlling Healthcare-Associated Infection Standard • NSQHS StandardsPreventing and ControllingHealthcare-AssociatedInfection StandardLeaders of a health service organisation describe, implement andmonitor systems to prevent, manage or control healthcare-associatedinfections and antimicrobial resistance, to reduce harm and achievegood health outcomes for patients. The workforce uses these systems.Intention of this standardTo reduce the risk of patients acquiring preventable healthcare-associated infections,effectively manage infections if they occur, and limit the development of antimicrobialresistance through prudent use of antimicrobials as part of antimicrobial stewardship.CriteriaClinical governance and quality improvement to preventand control healthcare-associated infections, and supportantimicrobial stewardshipSystems are in place to support and promote prevention and control of healthcareassociated infections, and improve antimicrobial stewardship.Infection prevention and control systemsEvidence-based systems are used to prevent and control healthcare-associatedinfections. Patients presenting with, or with risk factors for, infection or colonisationwith an organism of local, national or global significance are identified promptly, andreceive the necessary management and treatment. The health service organisation isclean and hygienic.Reprocessing of reusable medical devicesReprocessing of reusable equipment, instruments and devices is consistent with relevantcurrent national standards, and meets current best practice.Antimicrobial stewardshipThe health service organisation implements systems for the safe and appropriateprescribing and use of antimicrobials as part of an antimicrobial stewardship program.NSQHS Standards • Preventing and Controlling Healthcare-Associated Infection Standard 23Explanatory notesIn Australian healthcare settings, patients areoften treated in close proximity to each other. Theyundergo invasive procedures, have medical devicesinserted, and receive broad-spectrum antibiotics andimmunosuppression therapies. These conditionscreate ideal opportunities for the adaptation andspread of pathogenic infectious agents.Each year, many infections are associated with theprovision of health care and affect a large numberof patients.17 Healthcare-associated infections areone of the most common complications affectingpatients. Some of these infections require strongerand more expensive medicines (with increasedrisk of complications), and may result in lifelongdisability or death. Such infections:• Cause considerable harm• Increase patient use of health services – forexample, extended length of stay, and increaseduse of health resources such as inpatient beds,treatment options and investigations• Place greater demands on the clinical workforce.Infectious microorganisms evolve over time, andcontinue to present new challenges for infectionprevention and control. Currently, the mainconcerns are the emergence and transmission ofantibiotic-resistant bacteria such as carbapenemaseproducing Enterobacteriaceae, transmission ofexisting organisms such as multidrug-resistantStaphylococcus aureus and vancomycin-resistantEnterococcus, and the increase in Clostridiumdifficile infections being identified in healthservice organisations.Infection prevention and control aims to reduce thedevelopment of resistant organisms and minimisethe risk of transmission through the isolation ofthe infectious agent or the patient. This is done, inpart, by applying standard and transmission-basedprecautions as safe work practices in the healthcaresetting. However, just as there is no single causeof infection, there is no single solution to theproblems posed by healthcare-associated infections.Successful infection prevention and control requiresa collaborative approach and several strategiesacross all levels of the healthcare system. Thesestrategies include:• Governance• Risk identification and management• Surveillance activities to identify areas for actionand quality improvement activities (hand hygieneassessment, awareness and practice of aseptictechnique)• Safe and appropriate prescribing and use ofantimicrobial agents through antimicrobialstewardship and consumer engagement.Although all infection prevention and controlprograms have essential elements that must beconsidered, programs will need to be tailored toreflect local context and risk.Systems and governance for infection preventionand surveillance must be consistent with relevantnational resources, including the AustralianGuidelines for the Prevention and Control of Infectionin Healthcare.1824 Preventing and Controlling Healthcare-Associated Infection Standard • NSQHS StandardsClinical governance and quality improvement to preventand control healthcare-associated infections, andsupport antimicrobial stewardshipSystems are in place to support and promote prevention and control of healthcare-associated infections, andimprove antimicrobial stewardship. ItemActionIntegrating clinicalgovernance3.1 The workforce uses the safety and quality systems from the ClinicalGovernance Standard when:a. Implementing policies and procedures for healthcare-associatedinfections and antimicrobial stewardshipb. Managing risks associated with healthcare-associated infections andantimicrobial stewardshipc. Identifying training requirements for preventing and controllinghealthcare-associated infections, and antimicrobial stewardshipApplying qualityimprovementsystems3.2 The health service organisation applies the quality improvement systemfrom the Clinical Governance Standard when:a. Monitoring the performance of systems for prevention and controlof healthcare-associated infections, and the effectiveness of theantimicrobial stewardship programb. Implementing strategies to improve outcomes and associatedprocesses of systems for prevention and control of healthcareassociated infections, and antimicrobial stewardshipc. Reporting on the outcomes of prevention and control of healthcareassociated infections, and the antimicrobial stewardship programPartnering withconsumers3.3 Clinicians use organisational processes from the Partnering withConsumers Standard when preventing and managing healthcareassociated infections, and implementing the antimicrobial stewardshipprogram to:a. Actively involve patients in their own careb. Meet the patient’s information needsc. Share decision-makingSurveillance3.4 The health service organisation has a surveillance strategy for healthcareassociated infections and antimicrobial use that:a. Collects data on healthcare-associated infections and antimicrobialuse relevant to the size and scope of the organisationb. Monitors, assesses and uses surveillance data to reduce the risksassociated with healthcare-associated infections and supportappropriate antimicrobial prescribingc. Reports surveillance data on healthcare-associated infections andantimicrobial use to the workforce, the governing body, consumersand other relevant groups NSQHS Standards • Preventing and Controlling Healthcare-Associated Infection Standard 25Infection prevention and control systemsEvidence-based systems are used to prevent and control healthcare-associated infections. Patients presentingwith, or with risk factors for, infection or colonisation with an organism of local, national or globalsignificance are identified promptly, and receive the necessary management and treatment. The healthservice organisation is clean and hygienic. ItemActionStandard andtransmissionbased precautions3.5 The health service organisation has processes to apply standard andtransmission-based precautions that are consistent with the currentedition of the Australian Guidelines for the Prevention and Control ofInfection in Healthcare18, and jurisdictional requirements3.6 Clinicians assess infection risks and use transmission-based precautionsbased on the risk of transmission of infectious agents, and consider:a. Patients’ risks, which are evaluated at referral, on admission or onpresentation for care, and re-evaluated when clinically required duringcareb. Whether a patient has a communicable disease, or an existing ora pre-existing colonisation or infection with organisms of local ornational significancec. Accommodation needs to manage infection risksd. The need to control the environmente. Precautions required when the patient is moved within the facility orto external servicesf. The need for additional environmental cleaning or disinfectiong. Equipment requirements3.7 The health service organisation has processes for communicating relevantdetails of a patient’s infectious status whenever responsibility for care istransferred between clinicians or health service organisationsHand hygiene3.8 The health service organisation has a hand hygiene program that:a. Is consistent with the current National Hand Hygiene Initiative, andjurisdictional requirementsb. Addresses noncompliance or inconsistency with the current NationalHand Hygiene InitiativeAseptic technique3.9 The health service organisation has processes for aseptic technique that:a. Identify the procedures where aseptic technique appliesb. Assess the competence of the workforce in performing aseptictechniquec. Provide training to address gaps in competencyd. Monitor compliance with the organisation’s policies on aseptictechnique 26 Preventing and Controlling Healthcare-Associated Infection Standard • NSQHS Standards ItemActionInvasive medicaldevices3.10 The health service organisation has processes for the appropriate useand management of invasive medical devices that are consistent with thecurrent edition of the Australian Guidelines for the Prevention and Controlof Infection in Healthcare18Cleanenvironment3.11 The health service organisation has processes to maintain a clean andhygienic environment – in line with the current edition of the AustralianGuidelines for the Prevention and Control of Infection in Healthcare18, andjurisdictional requirements – that:a. Respond to environmental risksb. Require cleaning and disinfection in line with recommended cleaningfrequenciesc. Include training in the appropriate use of specialised personalprotective equipment for the workforce3.12 The health service organisation has processes to evaluate and respond toinfection risks for:a. New and existing equipment, devices and products used in theorganisationb. Maintaining, repairing and upgrading buildings, equipment, furnishingsand fittingsc. Handling, transporting and storing linenWorkforceimmunisation3.13 The health service organisation has a risk-based workforce immunisationprogram that:a. Is consistent with the current edition of the Australian ImmunisationHandbook19b. Is consistent with jurisdictional requirements for vaccine-preventablediseasesc. Addresses specific risks to the workforce and patients NSQHS Standards • Preventing and Controlling Healthcare-Associated Infection Standard 27Reprocessing of reusable medical devicesReprocessing of reusable equipment, instruments and devices is consistent with relevant current nationalstandards, and meets current best practice. ItemActionReprocessing ofreusable devices3.14 Where reusable equipment, instruments and devices are used, the healthservice organisation has:a. Processes for reprocessing that are consistent with relevant nationaland international standards, in conjunction with manufacturers’guidelinesb. A traceability process for critical and semi-critical equipment,instruments and devices that is capable of identifying• the patient• the procedure• the reusable equipment, instruments and devices that were usedfor the procedure 28 Preventing and Controlling Healthcare-Associated Infection Standard • NSQHS StandardsAntimicrobial stewardshipThe health service organisation implements systems for the safe and appropriate prescribing and use ofantimicrobials as part of an antimicrobial stewardship program. ItemActionAntimicrobialstewardship3.15 The health service organisation has an antimicrobial stewardship programthat:a. Includes an antimicrobial stewardship policyb. Provides access to, and promotes the use of, current evidence-basedAustralian therapeutic guidelines and resources on antimicrobialprescribingc. Has an antimicrobial formulary that includes restriction rules andapproval processesd. Incorporates core elements, recommendations and principles fromthe current Antimicrobial Stewardship Clinical Care Standard203.16 The antimicrobial stewardship program will:a. Review antimicrobial prescribing and useb. Use surveillance data on antimicrobial resistance and use to supportappropriate prescribingc. Evaluate performance of the program, identify areas for improvement,and take action to improve the appropriateness of antimicrobialprescribing and used. Report to clinicians and the governing body regarding• compliance with the antimicrobial stewardship policy• antimicrobial use and resistance• appropriateness of prescribing and compliance with currentevidence-based Australian therapeutic guidelines or resources onantimicrobial prescribing 4Medication Safety Standard30 Medication Safety Standard • NSQHS StandardsMedication Safety StandardLeaders of a health service organisation describe, implement andmonitor systems to reduce the occurrence of medication incidents, andimprove the safety and quality of medication use. The workforce usesthese systems.Intention of this standardTo ensure clinicians are competent to safely prescribe, dispense and administerappropriate medicines and to monitor medicine use. To ensure consumers are informedabout medicines and understand their individual medicine needs and risks.CriteriaClinical governance and quality improvement to supportmedication managementOrganisation-wide systems are used to support and promote safety for procuring,supplying, storing, compounding, manufacturing, prescribing, dispensing,administering and monitoring the effects of medicines.Documentation of patient informationA patient’s best possible medication history is recorded when commencing an episodeof care. The best possible medication history, and information relating to medicineallergies and adverse drug reactions are available to clinicians.Continuity of medication managementA patient’s medicines are reviewed, and information is provided to them about theirmedicine needs and risks. A medicines list is provided to the patient and the receivingclinician when handing over care.Medication management processesHealth service organisations procure medicines for safety. Clinicians are supported tosupply, store, compound, manufacture, prescribe, dispense, administer, monitor andsafely dispose of medicines.NSQHS Standards • Medication Safety Standard 31Explanatory notesMedicines are the most common treatment used inhealth care. Although appropriate use of medicinescontributes to significant improvements in health,medicines can also be associated with harm.21Because they are so commonly used, medicines areassociated with a higher incidence of errors andadverse events than other healthcare interventions.Some of these adverse events are costly, and up to50% are potentially avoidable.22The proportion of medicine-related hospitaladmissions has been estimated at approximately2–3%.23 This proportion remains consistent,and, based on 2011–12 Australian hospital dataof 9.3 million separations, suggests a medicinerelated hospital admission rate of 230,000 annually.Some subpopulations have higher estimates – forexample, 12% of medical admissions and 20–30%of admissions for those aged 65 years and over.21Studies have also revealed an average of threemedicine-related problems per resident in aged carefacilities24, and 40–50% of residents being prescribedpotentially inappropriate medicines.25,26In general practice, 8.5–12% of patients are reportedto have experienced an adverse medicine eventwithin the previous six months27-29, consistentwith previous estimates of 10% of patients.30Errors affect both health outcomes for consumersand healthcare costs. The cost of such adverseevents to individual patients and the healthcaresystem is significant. A study published in2009 reported that medication-related hospitaladmissions in Australia were estimated to cost$660 million.21 Estimates, with an average cost perseparation of $5,204 in 2011–12, place this figurecloser to $1.2 billion.21 The effects on patients’quality of life are more difficult to quantify.Standardising and systemising processes canimprove medication safety by preventing medicationincidents. Other recognised solutions for reducingcommon causes of medication incidents include:• Improving governance and quality measuresrelating to medication safety• Improving clinician–workforce communicationand clinical handover• Improving clinician–patient communication andpartnership• Using technology to support informationrecording and transfer• Providing better access to patient informationand clinical decision support.32 Medication Safety Standard • NSQHS StandardsClinical governance and quality improvement to supportmedication managementOrganisation-wide systems are used to support and promote safety for procuring, supplying, storing,compounding, manufacturing, prescribing, dispensing, administering and monitoring the effects of medicines. ItemActionIntegrating clinicalgovernance4.1 Clinicians use the safety and quality systems from the Clinical GovernanceStandard when:a. Implementing policies and procedures for medication managementb. Managing risks associated with medication managementc. Identifying training requirements for medication managementApplying qualityimprovementsystems4.2 The health service organisation applies the quality improvement systemfrom the Clinical Governance Standard when:a. Monitoring the effectiveness and performance of medicationmanagementb. Implementing strategies to improve medication managementoutcomes and associated processesc. Reporting on outcomes for medication managementPartnering withconsumers4.3 Clinicians use organisational processes from the Partnering withConsumers Standard in medication management to:a. Actively involve patients in their own careb. Meet the patient’s information needsc. Share decision-makingMedicines scopeof clinical practice4.4 The health service organisation has processes to define and verify thescope of clinical practice for prescribing, dispensing and administeringmedicines for relevant clinicians NSQHS Standards • Medication Safety Standard 33Documentation of patient informationA patient’s best possible medication history is recorded when commencing an episode of care. The bestpossible medication history, and information relating to medicine allergies and adverse drug reactions areavailable to clinicians. ItemActionMedicationreconciliation4.5 Clinicians take a best possible medication history, which is documentedin the healthcare record on presentation or as early as possible in theepisode of care4.6 Clinicians review a patient’s current medication orders against their bestpossible medication history and the documented treatment plan, andreconcile any discrepancies on presentation and at transitions of careAdverse drugreactions4.7 The health service organisation has processes for documenting a patient’shistory of medicine allergies and adverse drug reactions in the healthcarerecord on presentation4.8 The health service organisation has processes for documenting adversedrug reactions experienced by patients during an episode of care in thehealthcare record and in the organisation-wide incident reporting system4.9 The health service organisation has processes for reporting adversedrug reactions experienced by patients to the Therapeutic GoodsAdministration, in accordance with its requirements 34 Medication Safety Standard • NSQHS StandardsContinuity of medication managementA patient’s medicines are reviewed, and information is provided to them about their medicines needs andrisks. A medicines list is provided to the patient and the receiving clinician when handing over care. ItemActionMedication review4.10 The health service organisation has processes:a. To perform medication reviews for patients, in line with evidence andbest practiceb. To prioritise medication reviews, based on a patient’s clinical needsand minimising the risk of medication-related problemsc. That specify the requirements for documentation of medicationreviews, including actions taken as a resultInformation forpatients4.11 The health service organisation has processes to support clinicians toprovide patients with information about their individual medicines needsand risksProvision of amedicines list4.12 The health service organisation has processes to:a. Generate a current medicines list and the reasons for any changesb. Distribute the current medicines list to receiving clinicians attransitions of carec. Provide patients on discharge with a current medicines list and thereasons for any changes NSQHS Standards • Medication Safety Standard 35Medication management processesHealth service organisations procure medicines for safety. Clinicians are supported to supply, store,compound, manufacture, prescribe, dispense, administer, monitor and safely dispose of medicines. ItemActionInformationand decisionsupport tools formedicines4.13 The health service organisation ensures that information and decisionsupport tools for medicines are available to cliniciansSafe and securestorage anddistribution ofmedicines4.14 The health service organisation complies with manufacturers’ directions,legislation, and jurisdictional requirements for the:a. Safe and secure storage and distribution of medicinesb. Storage of temperature-sensitive medicines and cold chainmanagementc. Disposal of unused, unwanted or expired medicinesHigh-riskmedicines4.15 The health service organisation:a. Identifies high-risk medicines used within the organisationb. Has a system to store, prescribe, dispense and administer high-riskmedicines safely 5Comprehensive Care Standard38 Comprehensive Care Standard • NSQHS StandardsComprehensive Care StandardLeaders of a health service organisation set up and maintain systemsand processes to support clinicians to deliver comprehensive care. Theyalso set up and maintain systems to prevent and manage specific risksof harm to patients during the delivery of health care. The workforceuses the systems to deliver comprehensive care and manage risk.Intention of this standardTo ensure that patients receive comprehensive care – that is, coordinated deliveryof the total health care required or requested by a patient. This care is aligned withthe patient’s expressed goals of care and healthcare needs, considers the effect of thepatient’s health issues on their life and wellbeing, and is clinically appropriate.To ensure that risks of harm for patients during health care are prevented and managed.Clinicians identify patients at risk of specific harm during health care by applying thescreening and assessment processes required in this standard.CriteriaClinical governance and quality improvement to supportcomprehensive careSystems are in place to support clinicians to deliver comprehensive care.Developing the comprehensive care planIntegrated screening and assessment processes are used in collaboration with patients,carers and families to develop a goal-directed comprehensive care plan.Delivering comprehensive careSafe care is delivered based on the comprehensive care plan, and in partnership withpatients, carers and family. Comprehensive care is delivered to patients at the end of life.Minimising patient harmPatients at risk of specific harm are identified, and clinicians deliver targeted strategiesto prevent and manage harm.NSQHS Standards • Comprehensive Care Standard 39Explanatory notesComprehensive careSafety and quality gaps are often reported as failuresto provide adequate care for specific conditions,or in specific situations or settings, or to achieveexpected outcomes in certain populations. Thepurpose of the Comprehensive Care Standard is toaddress the cross-cutting issues underlying manyadverse events. These issues often include failures to:• Provide continuous and collaborative care• Work in partnership with patients, carers andfamilies to adequately identify, assess andmanage patients’ clinical risks, and find out theirpreferences for care• Communicate and work as a team (that is,between members of the healthcare team).Processes for delivering comprehensive care willvary, even within a health service organisation. Takea flexible approach to standardisation so that safetyand quality systems support local implementationand innovation. Target screening, assessment,comprehensive care planning and delivery processesto improve the safety and quality of care delivered tothe population that the organisation serves.Although this standard refers to actions neededwithin a single episode of patient care, it isfundamental that each single episode or period ofcare is considered as part of the continuum of carefor a patient. Meaningful implementation of thisstandard requires attention to the processes forpartnering with patients in their own care, and forsafely managing transitions between episodes ofcare. This requires that the systems and processesnecessary to meet the requirements of this standardalso meet the requirements of the Partnering withConsumers Standard and the Communicating forSafety Standard.Minimising patient harmImplement targeted, best-practice strategies toprevent and minimise the risk of specific harmsidentified in this standard.Pressure injuriesPressure injuries can occur to patients of anyage who have one or more of the following riskfactors: immobility, older age, lack of sensoryperception, poor nutrition or hydration, excessmoisture or dryness, poor skin integrity, reducedblood flow, limited alertness or muscle spasms.Evidence-based strategies to prevent pressureinjuries exist and should be applied if screeningidentifies that a patient is at risk.FallsFalls also occur in all age groups. However, therisk of falls and the harm from falls vary betweenindividuals as a result of differences in factorssuch as eyesight, balance, cognitive impairment,muscle strength, bone density and medicineuse. The Australian Commission on Safety andQuality in Health Care has developed evidencebased guidelines for older people.31-33 Policies andprocedures for other age groups need to be basedon available evidence and best practice.Poor nutrition and malnutritionPatients with poor nutrition, includingmalnutrition, are at greater risk of pressure injuriesand their pressure injuries are more severe.8,34 Theyare also at greater risk of healthcare-associatedinfections and mortality in hospital, and for up tothree years following discharge.35-39 Malnutritionsignificantly increases length of hospital stay andunplanned readmissions.37,38,40 Ensure that patientsat risk of poor nutrition are identified and thatstrategies are put in place to reduce these risks.40 Comprehensive Care Standard • NSQHS StandardsCognitive impairmentPeople with cognitive impairment who areadmitted to hospital are at a significantlyincreased risk of preventable complications suchas falls, pressure injuries, delirium and failure toreturn to premorbid function, as well as adverseoutcomes such as unexpected death, or early andunplanned entry into residential care.41 Peoplewith cognitive impairment may also experiencedistress in unfamiliar and busy environments.Although cognitive impairment is a commoncondition experienced by people in healthservice organisations, it is often not detected, oris dismissed or misdiagnosed. Delirium can beprevented with the right care42, and harm canbe minimised if systems are in place to identifycognitive impairment and the risk of delirium,so that strategies can be incorporated in thecomprehensive care plan and implemented.Unpredictable behavioursPeople in healthcare settings can exhibitunpredictable behaviours that may lead to harm.Health service organisations need systems toidentify situations where there is higher riskof harm, and strategies to mitigate or preventthese risks. They also need systems to managesituations in which harm relating to unpredictablebehaviour occurs. For the purpose of this standard,unpredictable behaviours include self-harm, suicide,aggression and violence. It is important that systemsdesigned to respond to the risks of unpredictablebehaviour minimise further trauma to patients andothers. This relates to both the material practicesand the attitude with which care is delivered.Processes to manage people who have thoughtsof harming themselves, with or without suicidalintent, or who have actually harmed themselves areneeded. These processes need to provide physicalsafety, and support to deal with psychological andother issues contributing to self-harm. The healthservice organisation is responsible for ensuring thatfollow-up services are arranged before the personleaves the health service, because of the known risksof self-harm after discharge.43Some people are at higher risk of aggressivebehaviour as a result of impaired coping skillsrelating to intoxication, acute physical deteriorationor mental illness. Healthcare-related situations,such as waiting times, crowded or high-stimulusenvironments, and conflicts regarding treatmentdecisions, can precipitate aggression. Membersof the workforce need skills to identify the riskof aggression, and strategies to safely manageaggression and violence when they do occur.Restrictive practicesMinimising and, where possible, eliminating theuse of restrictive practices (including restraint andseclusion) are key parts of national mental healthpolicy.44,45 Minimising the use of restraint in otherhealthcare settings besides mental health has alsobeen identified as a clinical priority. Identifyingrisks relating to unpredictable behaviour early andusing tailored response strategies can reduce the useof restrictive practices. Restrictive practices mustonly be implemented by members of the workforcewho have been trained in their safe use. The healthservice organisation needs processes to benchmarkand review the use of restrictive practices.Key links with other standardsTo implement systems that meet the requirementsof the Comprehensive Care Standard, identifywhere there are synergies with the other NSQHSStandards. This will help ensure that theorganisation’s safety and quality systems, policiesand processes are integrated, and will reduce therisk of duplication of effort arising from attemptsto implement the eight standards separately.NSQHS Standards • Comprehensive Care Standard 41Clinical governance and quality improvement to supportcomprehensive careSystems are in place to support clinicians to deliver comprehensive care. ItemActionIntegrating clinicalgovernance5.1 Clinicians use the safety and quality systems from the Clinical GovernanceStandard when:a. Implementing policies and procedures for comprehensive careb. Managing risks associated with comprehensive carec. Identifying training requirements to deliver comprehensive careApplying qualityimprovementsystems5.2 The health service organisation applies the quality improvement systemfrom the Clinical Governance Standard when:a. Monitoring the delivery of comprehensive careb. Implementing strategies to improve the outcomes fromcomprehensive care and associated processesc. Reporting on delivery of comprehensive carePartnering withconsumers5.3 Clinicians use organisational processes from the Partnering withConsumers Standard when providing comprehensive care to:a. Actively involve patients in their own careb. Meet the patient’s information needsc. Share decision-makingDesigningsystems to delivercomprehensivecare5.4 The health service organisation has systems for comprehensive care that:a. Support clinicians to develop, document and communicatecomprehensive plans for patients’ care and treatmentb. Provide care to patients in the setting that best meets their clinicalneedsc. Ensure timely referral of patients with specialist healthcare needs torelevant servicesd. Identify, at all times, the clinician with overall accountability for apatient’s careCollaboration andteamwork5.5 The health service organisation has processes to:a. Support multidisciplinary collaboration and teamworkb. Define the roles and responsibilities of each clinician working in a team5.6 Clinicians work collaboratively to plan and deliver comprehensive care 42 Comprehensive Care Standard • NSQHS StandardsDeveloping the comprehensive care planIntegrated screening and assessment processes are used in collaboration with patients, carers and families todevelop a goal-directed comprehensive care plan. ItemActionPlanning forcomprehensivecare5.7 The health service organisation has processes relevant to the patientsusing the service and the services provided:a. For integrated and timely screening and assessmentb. That identify the risks of harm in the ‘Minimising patient harm’ criterion5.8 The health service organisation has processes to routinely ask patientsif they identify as being of Aboriginal and/or Torres Strait Islander origin,and to record this information in administrative and clinical informationsystems5.9 Patients are supported to document clear advance care plansScreening of risk5.10 Clinicians use relevant screening processes:a. On presentation, during clinical examination and history taking, andwhen required during careb. To identify cognitive, behavioural, mental and physical conditions,issues, and risks of harmc. To identify social and other circumstances that may compound theserisksClinicalassessment5.11 Clinicians comprehensively assess the conditions and risks identifiedthrough the screening processDeveloping thecomprehensivecare plan5.12 Clinicians document the findings of the screening and clinical assessmentprocesses, including any relevant alerts, in the healthcare record5.13 Clinicians use processes for shared decision making to develop anddocument a comprehensive and individualised plan that:a. Addresses the significance and complexity of the patient’s healthissues and risks of harmb. Identifies agreed goals and actions for the patient’s treatment and carec. Identifies the support people a patient wants involved incommunications and decision-making about their cared. Commences discharge planning at the beginning of the episode ofcaree. Includes a plan for referral to follow-up services, if appropriate andavailablef. Is consistent with best practice and evidence NSQHS Standards • Comprehensive Care Standard 43Delivering comprehensive careSafe care is delivered based on the comprehensive care plan, and in partnership with patients, carers andfamilies. Comprehensive care is delivered to patients at the end of life. ItemActionUsing thecomprehensivecare plan5.14 The workforce, patients, carers and families work in partnership to:a. Use the comprehensive care plan to deliver careb. Monitor the effectiveness of the comprehensive care plan in meetingthe goals of carec. Review and update the comprehensive care plan if it is not effectived. Reassess the patient’s needs if changes in diagnosis, behaviour,cognition, or mental or physical condition occurComprehensivecare at the endof life5.15 The health service organisation has processes to identify patients whoare at the end of life that are consistent with the National ConsensusStatement: Essential elements for safe and high-quality end-of-life care465.16 The health service organisation providing end-of-life care has processesto provide clinicians with access to specialist palliative care advice5.17 The health service organisation has processes to ensure that currentadvance care plans:a. Can be received from patientsb. Are documented in the patient’s healthcare record5.18 The health service organisation provides access to supervision andsupport for the workforce providing end-of-life care5.19 The health service organisation has processes for routinely reviewing thesafety and quality of end-of-life care that is provided against the plannedgoals of care5.20 Clinicians support patients, carers and families to make shared decisionsabout end-of-life care in accordance with the National ConsensusStatement: Essential elements for safe and high-quality end-of-life care46 44 Comprehensive Care Standard • NSQHS StandardsMinimising patient harmPatients at risk of specific harm are identified, and clinicians deliver targeted strategies to prevent andmanage harm. ItemActionPreventingand managingpressure injuries5.21 The health service organisation providing services to patients at risk ofpressure injuries has systems for pressure injury prevention and woundmanagement that are consistent with best-practice guidelines5.22 Clinicians providing care to patients at risk of developing, or with, apressure injury conduct comprehensive skin inspections in accordancewith best-practice time frames and frequency5.23 The health service organisation providing services to patients at risk ofpressure injuries ensures that:a. Patients, carers and families are provided with information aboutpreventing pressure injuriesb. Equipment, devices and products are used in line with best-practiceguidelines to prevent and effectively manage pressure injuriesPreventing fallsand harm fromfalls5.24 The health service organisation providing services to patients at risk of fallshas systems that are consistent with best-practice guidelines for:a. Falls preventionb. Minimising harm from fallsc. Post-fall management5.25 The health service organisation providing services to patients at risk of fallsensures that equipment, devices and tools are available to promote safemobility and manage the risks of falls5.26 Clinicians providing care to patients at risk of falls provide patients,carers and families with information about reducing falls risks and fallsprevention strategiesNutrition andhydration5.27 The health service organisation that admits patients overnight has systemsfor the preparation and distribution of food and fluids that includenutrition care plans based on current evidence and best practice5.28 The workforce uses the systems for preparation and distribution of foodand fluids to:a. Meet patients’ nutritional needs and requirementsb. Monitor the nutritional care of patients at riskc. Identify, and provide access to, nutritional support for patients whocannot meet their nutritional requirements with food aloned. Support patients who require assistance with eating and drinking NSQHS Standards • Comprehensive Care Standard 45 ItemActionPreventingdelirium andmanagingcognitiveimpairment5.29 The health service organisation providing services to patients who havecognitive impairment or are at risk of developing delirium has a system forcaring for patients with cognitive impairment to:a. Incorporate best-practice strategies for early recognition, prevention,treatment and management of cognitive impairment in the care plan,including the Delirium Clinical Care Standard47, where relevantb. Manage the use of antipsychotics and other psychoactive medicines,in accordance with best practice and legislation5.30 Clinicians providing care to patients who have cognitive impairment or areat risk of developing delirium use the system for caring for patients withcognitive impairment to:a. Recognise, prevent, treat and manage cognitive impairmentb. Collaborate with patients, carers and families to understand the patientand implement individualised strategies that minimise any anxiety ordistress while they are receiving carePredicting,preventing andmanaging selfharm and suicide5.31 The health service organisation has systems to support collaboration withpatients, carers and families to:a. Identify when a patient is at risk of self-harmb. Identify when a patient is at risk of suicidec. Safely and effectively respond to patients who are distressed, havethoughts of self-harm or suicide, or have self-harmed5.32 The health service organisation ensures that follow-up arrangementsare developed, communicated and implemented for people who haveharmed themselves or reported suicidal thoughtsPredicting,preventingand managingaggression andviolence5.33 The health service organisation has processes to identify and mitigatesituations that may precipitate aggression5.34 The health service organisation has processes to support collaborationwith patients, carers and families to:a. Identify patients at risk of becoming aggressive or violentb. Implement de-escalation strategiesc. Safely manage aggression, and minimise harm to patients, carers,families and the workforce 46 Comprehensive Care Standard • NSQHS Standards ItemActionMinimisingrestrictivepractices: restraint5.35 Where restraint is clinically necessary to prevent harm, the health serviceorganisation has systems that:a. Minimise and, where possible, eliminate the use of restraintb. Govern the use of restraint in accordance with legislationc. Report use of restraint to the governing bodyMinimisingrestrictivepractices:seclusion5.36 Where seclusion is clinically necessary to prevent harm and is permittedunder legislation, the health service organisation has systems that:a. Minimise and, where possible, eliminate the use of seclusionb. Govern the use of seclusion in accordance with legislationc. Report use of seclusion to the governing body 6Communicating forSafety Standard48 Communicating for Safety Standard • NSQHS StandardsCommunicating for SafetyStandardLeaders of a health service organisation set up and maintain systemsand processes to support effective communication with patients, carersand families; between multidisciplinary teams and clinicians; andacross health service organisations. The workforce uses these systemsto effectively communicate to ensure safety.Intention of this standardTo ensure timely, purpose-driven and effective communication and documentation thatsupport continuous, coordinated and safe care for patients.CriteriaClinical governance and quality improvement to supporteffective communicationSystems are in place for effective and coordinated communication that supports thedelivery of continuous and safe care for patients.Correct identification and procedure matchingSystems to maintain the identity of the patient are used to ensure that the patientreceives the care intended for them.Communication at clinical handoverProcesses for structured clinical handover are used to effectively communicate about thehealth care of patients.Communication of critical informationSystems to effectively communicate critical information and risks when they emerge orchange are used to ensure safe patient care.Documentation of informationEssential information is documented in the healthcare record to ensure patient safety.NSQHS Standards • Communicating for Safety Standard 49Explanatory notesCommunication is a key safety and quality issue.This standard recognises the importance ofeffective communication and its role in supportingcontinuous, coordinated and safe patient care.Actions in this standard outline the high-risksituations in which effective communicationand documentation are required. They includetransitions of care (clinical handover), when criticalinformation about a patient’s care emerges orchanges, and when it is important to ensure that apatient is correctly identified and matched to theirintended care.To meet this standard, health service organisationsare required to have systems and processesin place to support effective communicationand documentation at these high-risk times.Recognising that communication is a variableprocess, organisations will need to develop, describeand adapt these systems to their service context toensure that communication processes are flexible,and appropriate for the nature of the organisationand the consumers who use their service.Communication is inherent to patient care, andinformal communications will occur throughoutcare delivery. It is not intended that this standardwill apply to all communications within anorganisation. Rather, the intention is to ensure thatsystems and processes are in place at key times wheneffective communication and documentation arecritical to patient safety.Communication is relevant across all of theNSQHS Standards, and many of the actions inthis standard rely on, and are linked to, actions inthe other NSQHS Standards. In particular, thisstandard should be applied in conjunction with theClinical Governance, Partnering with Consumers,Medication Safety, Comprehensive Care, andRecognising and Responding to Acute Deteriorationstandards.The review of the NSQHS Standards found thatStandard 6: Clinical Handover was often interpretednarrowly as only referring to shift-to-shift handover.However, because effective communication iscritical at other key times throughout the deliveryof health care, changes have been made to thisstandard to deal with clinical communicationsmore broadly.50 Communicating for Safety Standard • NSQHS StandardsClinical governance and quality improvement to supporteffective communicationSystems are in place for effective and coordinated communication that supports the delivery of continuousand safe care for patients. ItemActionIntegrating clinicalgovernance6.1 Clinicians use the safety and quality systems from the Clinical GovernanceStandard when:a. Implementing policies and procedures to support effective clinicalcommunicationb. Managing risks associated with clinical communicationc. Identifying training requirements for effective and coordinated clinicalcommunicationApplying qualityimprovementsystems6.2 The health service organisation applies the quality improvement systemfrom the Clinical Governance Standard when:a. Monitoring the effectiveness of clinical communication and associatedprocessesb. Implementing strategies to improve clinical communication andassociated processesc. Reporting on the effectiveness and outcomes of clinicalcommunication processesPartnering withconsumers6.3 Clinicians use organisational processes from the Partnering withConsumers Standard to effectively communicate with patients, carers andfamilies during high-risk situations to:a. Actively involve patients in their own careb. Meet the patient’s information needsc. Share decision-makingOrganisationalprocesses tosupport effectivecommunication6.4 The health service organisation has clinical communications processes tosupport effective communication when:a. Identification and procedure matching should occurb. All or part of a patient’s care is transferred within the organisation,between multidisciplinary teams, between clinicians or betweenorganisations; and on dischargec. Critical information about a patient’s care, including information onrisks, emerges or changes NSQHS Standards • Communicating for Safety Standard 51Correct identification and procedure matchingSystems to maintain the identity of the patient are used to ensure that the patient receives the care intendedfor them. ItemActionCorrectidentificationand procedurematching6.5 The health service organisation:a. Defines approved identifiers for patients according to best-practiceguidelinesb. Requires at least three approved identifiers on registration andadmission; when care, medication, therapy and other servicesare provided; and when clinical handover, transfer or dischargedocumentation is generated6.6 The health service organisation specifies the:a. Processes to correctly match patients to their careb. Information that should be documented about the process ofcorrectly matching patients to their intended care 52 Communicating for Safety Standard • NSQHS StandardsCommunication at clinical handoverProcesses for structured clinical handover are used to effectively communicate about the health care ofpatients. ItemActionClinical handover6.7 The health service organisation, in collaboration with clinicians, definesthe:a. Minimum information content to be communicated at clinicalhandover, based on best-practice guidelinesb. Risks relevant to the service context and the particular needs ofpatients, carers and familiesc. Clinicians who are involved in the clinical handover6.8 Clinicians use structured clinical handover processes that include:a. Preparing and scheduling clinical handoverb. Having the relevant information at clinical handoverc. Organising relevant clinicians and others to participate in clinicalhandoverd. Being aware of the patient’s goals and preferencese. Supporting patients, carers and families to be involved in clinicalhandover, in accordance with the wishes of the patientf. Ensuring that clinical handover results in the transfer of responsibilityand accountability for care NSQHS Standards • Communicating for Safety Standard 53Communication of critical informationSystems to effectively communicate critical information and risks when they emerge or change are used toensure safe patient care. ItemActionCommunicatingcriticalinformation6.9 Clinicians and multidisciplinary teams use clinical communicationprocesses to effectively communicate critical information, alerts and risks,in a timely way, when they emerge or change to:a. Clinicians who can make decisions about careb. Patients, carers and families, in accordance with the wishes of thepatient6.10 The health service organisation ensures that there are communicationprocesses for patients, carers and families to directly communicate criticalinformation and risks about care to clinicians 54 Communicating for Safety Standard • NSQHS StandardsDocumentation of informationEssential information is documented in the healthcare record to ensure patient safety. ItemActionDocumentationof information6.11 The health service organisation has processes to contemporaneouslydocument information in the healthcare record, including:a. Critical information, alerts and risksb. Reassessment processes and outcomesc. Changes to the care plan 7Blood Management Standard56 Blood Management Standard • NSQHS StandardsBlood Management StandardLeaders of a health service organisation describe, implement andmonitor systems to ensure the safe, appropriate, efficient and effectivecare of patients’ own blood, as well as other blood and blood products.The workforce uses the blood product safety systems.Intention of this standardTo identify risks, and put in place strategies, to ensure that a patient’s own blood isoptimised and conserved, and that any blood and blood products the patient receives areappropriate and safe.CriteriaClinical governance and quality improvement to support bloodmanagementOrganisation-wide governance and quality improvement systems are used to ensuresafe and high-quality care of patients’ own blood, and to ensure that blood productrequirements are met.Prescribing and clinical use of blood and blood productsThe clinical use of blood and blood products is appropriate, and strategies are used toreduce the risks associated with transfusion.Managing the availability and safety of blood and bloodproductsStrategies are used to effectively manage the availability and safety of blood and bloodproducts.NSQHS Standards • Blood Management Standard 57Explanatory notesThis standard is a revision of Standard 7: Blood andBlood Products in the NSQHS Standards (1st ed.).The actions in this standard have been refined to:• Focus on the patient receiving blood and bloodproducts, rather than only on the blood andblood products• Focus on effectively optimising and conservinga patient’s own blood, reducing the unnecessaryrisk of exposure to blood products and associatedadverse events• More explicitly consider identified gaps inpractice• Remove duplications in the standard• More specifically reflect national policyagreements about blood and blood products.Treatment with blood and blood products can belifesaving. However, using biological materials,blood and blood products has some inherent risks.Actions to minimise these risks include screeningand testing donors and donated blood; and ensuringthat all treatment options, and their risks andbenefits, are considered before deciding to transfuse.The scope of this standard covers all elements of theclinical process, including:• Making clinical decisions• Obtaining recipient samples and assessingcompatibility with donated products• Safely administering the products to theintended recipient• Storing and disposing of blood and bloodproducts• Reporting and investigating any adversereactions or incidents.This standard also aims to ensure that safe,appropriate, effective and efficient bloodmanagement systems are in place.The standard supports the principles of good patientblood management that provide for clinicallyappropriate and safe management of patients whileavoiding transfusion of blood and blood products,and its associated risks.Research and practice show that the dual approachof implementing governance structures andevidence-based clinical guidelines is the mosteffective way to ensure the appropriate and safeuse of blood and blood products.58 Blood Management Standard • NSQHS StandardsClinical governance and quality improvement to supportblood managementOrganisation-wide governance and quality improvement systems are used to ensure safe and high-qualitycare of patients’ own blood, and to ensure that blood product requirements are met. ItemActionIntegrating clinicalgovernance7.1 Clinicians use the safety and quality systems from the Clinical GovernanceStandard when:a. Implementing policies and procedures for blood managementb. Managing risks associated with blood managementc. Identifying training requirements for blood managementApplying qualityimprovementsystems7.2 The health service organisation applies the quality improvement systemfrom the Clinical Governance Standard when:a. Monitoring the performance of the blood management systemb. Implementing strategies to improve blood management andassociated processesc. Reporting on the outcomes of blood managementPartnering withconsumers7.3 Clinicians use organisational processes from the Partnering withConsumers Standard when providing safe blood management to:a. Actively involve patients in their own careb. Meet the patient’s information needsc. Share decision-making NSQHS Standards • Blood Management Standard 59Prescribing and clinical use of blood and blood productsThe clinical use of blood and blood products is appropriate, and strategies are used to reduce the risksassociated with transfusion. ItemActionOptimising andconservingpatients’ ownblood7.4 Clinicians use the blood and blood products processes to managethe need for, and minimise the inappropriate use of, blood and bloodproducts by:a. Optimising patients’ own red cell mass, haemoglobin and iron storesb. Identifying and managing patients with, or at risk of, bleedingc. Determining the clinical need for blood and blood products, andrelated risksDocumenting7.5 Clinicians document decisions relating to blood management, transfusionhistory and transfusion details in the healthcare recordPrescribing andadministeringblood and bloodproducts7.6 The health service organisation supports clinicians to prescribe andadminister blood and blood products appropriately, in accordance withnational guidelines and national criteriaReporting adverseevents7.7 The health service organisation uses processes for reporting transfusionrelated adverse events, in accordance with national guidelines and criteria7.8 The health service organisation participates in haemovigilance activities, inaccordance with the national framework 60 Blood Management Standard • NSQHS StandardsManaging the availability and safety of blood and bloodproductsStrategies are used to effectively manage the availability and safety of blood and blood products. ItemActionStoring,distributing andtracing blood andblood products7.9 The health service organisation has processes:a. That comply with manufacturers’ directions, legislation, and relevantjurisdictional requirements to store, distribute and handle blood andblood products safely and securelyb. To trace blood and blood products from entry into the organisation totransfusion, discard or transferAvailability ofblood7.10 The health service organisation has processes to:a. Manage the availability of blood and blood products to meet clinicalneedb. Eliminate avoidable wastagec. Respond in times of shortage 8Recognising and Responding toAcute Deterioration Standard62 Recognising and Responding to Acute Deterioration Standard • NSQHS StandardsRecognising and Responding toAcute Deterioration StandardLeaders of a health service organisation set up and maintain systemsfor recognising and responding to acute deterioration. The workforceuses the recognition and response systems.Intention of this standardTo ensure that a person’s acute deterioration is recognised promptly and appropriateaction is taken. Acute deterioration includes physiological changes, as well as acutechanges in cognition and mental state.CriteriaClinical governance and quality improvement to supportrecognition and response systemsOrganisation-wide systems are used to support and promote detection and recognitionof acute deterioration, and the response to patients whose condition acutelydeteriorates. These systems are consistent with the National Consensus Statement:Essential elements for recognising and responding to acute physiological deterioration48,the National Consensus Statement: Essential elements for safe and high-quality end-of-lifecare46, National Consensus Statement: Essential elements for recognising and responding todeterioration in a person’s mental state, and the Delirium Clinical Care Standard.47Detecting and recognising acute deterioration, and escalating careAcute deterioration is detected and recognised, and action is taken to escalate care.Responding to acute deteriorationAppropriate and timely care is provided to patients whose condition is acutelydeteriorating.NSQHS Standards • Recognising and Responding to Acute Deterioration Standard 63Explanatory notesSerious adverse events such as unexpected deathand cardiac arrest are often preceded by observablephysiological and clinical abnormalities.49 Otherserious events such as suicide or aggression are alsooften preceded by observed or reported changes ina person’s behaviour or mood that can indicate adeterioration in their mental state.Early identification of deterioration may improveoutcomes and lessen the intervention required tostabilise patients whose condition deteriorates inhospital.50There is evidence that the warning signs of clinicaldeterioration are not always identified or acted onappropriately.51 The organisation and workforcefactors that contribute to a failure to recognise andrespond to a deteriorating patient are complex andoverlapping. They include52-54:• Not monitoring physiological observationsconsistently or not understanding observedchanges in physiological observations• Lack of knowledge of signs and symptoms thatcould signal deterioration• Lack of awareness of the potential for a person’smental state to deteriorate• Lack of awareness of delirium, and the benefits ofearly recognition and treatment55• Lack of formal systems for responding todeterioration• Lack of skills to manage patients who aredeteriorating• Failure to communicate clinical concerns,including during clinical handover• Attributing physical or mental symptoms to anexisting condition, such as dementia or a mentalhealth condition.56,57Systems to recognise deterioration early andrespond to it appropriately need to deal with allof these factors, and need to be applied acrossa healthcare facility. The National ConsensusStatement: Essential elements for recognising andresponding to acute physiological deterioration48,which was developed by the Australian Commissionon Safety and Quality in Health Care (theCommission), has been endorsed by Australianhealth ministers as the national approach forrecognising and responding to clinical deteriorationin acute care facilities in Australia. It providesa consistent national model to support clinical,organisational and strategic efforts to improverecognition and response systems. This standardbuilds on the national consensus statement to driveimplementation in acute care facilities.The Commission’s National Consensus Statement:Essential elements for recognising and respondingto deterioration in a person’s mental state outlinesthe principles that underpin safe and effectiveresponses to deterioration in a person’s mental state,and provides information about the interrelatedcomponents that a health service organisation canimplement to provide this care.This standard applies to all patients – adults,adolescents, children and babies – in acutehealthcare facilities, and to all types of patients,including medical, surgical, maternity and mentalhealth patients. Acute healthcare facilities rangefrom large tertiary referral centres to small districtand community hospitals.The Commission’s Delirium Clinical CareStandard47 highlights the importance of being alertto, and assessing, delirium with any reported orobserved changes in a person’s mental state.64 Recognising and Responding to Acute Deterioration Standard • NSQHS StandardsClinical governance and quality improvement to supportrecognition and response systemsOrganisation-wide systems are used to support and promote detection and recognition of acutedeterioration, and the response to patients whose condition acutely deteriorates. These systems areconsistent with the National Consensus Statement: Essential elements for recognising and responding to acutephysiological deterioration48, the National Consensus Statement: Essential elements for safe and high-quality endof-life care46, the National Consensus Statement: Essential elements for recognising and responding to deteriorationin a person’s mental state, and the Delirium Clinical Care Standard.47 ItemActionIntegratingclinicalgovernance8.1 Clinicians use the safety and quality systems from the Clinical GovernanceStandard when:a. Implementing policies and procedures for recognising and respondingto acute deteriorationb. Managing risks associated with recognising and responding to acutedeteriorationc. Identifying training requirements for recognising and responding toacute deteriorationApplying qualityimprovementsystems8.2 The health service organisation applies the quality improvement systemfrom the Clinical Governance Standard when:a. Monitoring recognition and response systemsb. Implementing strategies to improve recognition and response systemsc. Reporting on effectiveness and outcomes of recognition and responsesystemsPartnering withconsumers8.3 Clinicians use organisational processes from the Partnering withConsumers Standard when recognising and responding to acutedeterioration to:a. Actively involve patients in their own careb. Meet the patient’s information needsc. Share decision-making NSQHS Standards • Recognising and Responding to Acute Deterioration Standard 65Detecting and recognising acute deterioration, andescalating careAcute deterioration is detected and recognised, and action is taken to escalate care. ItemActionRecognisingacutedeterioration8.4 The health service organisation has processes for clinicians to detectacute physiological deterioration that require clinicians to:a. Document individualised vital sign monitoring plansb. Monitor patients as required by their individualised monitoring planc. Graphically document and track changes in agreed observations todetect acute deterioration over time, as appropriate for the patient8.5 The health service organisation has processes for clinicians to recogniseacute deterioration in mental state that require clinicians to:a. Monitor patients at risk of acute deterioration in mental state, includingpatients at risk of developing deliriumb. Include the person’s known early warning signs of deterioration inmental state in their individualised monitoring planc. Assess possible causes of acute deterioration in mental state, includingdelirium, when changes in behaviour, cognitive function, perception,physical function or emotional state are observed or reportedd. Determine the required level of observatione. Document and communicate observed or reported changes inmental stateEscalating care8.6 The health service organisation has protocols that specify criteria forescalating care, including:a. Agreed vital sign parameters and other indicators of physiologicaldeteriorationb. Agreed indicators of deterioration in mental statec. Agreed parameters and other indicators for calling emergencyassistanced. Patient pain or distress that is not able to be managed using availabletreatmente. Worry or concern in members of the workforce, patients, carers andfamilies about acute deterioration8.7 The health service organisation has processes for patients, carers orfamilies to directly escalate care8.8 The health service organisation provides the workforce with mechanismsto escalate care and call for emergency assistance8.9 The workforce uses the recognition and response systems to escalatecare 66 Recognising and Responding to Acute Deterioration Standard • NSQHS StandardsResponding to acute deteriorationAppropriate and timely care is provided to patients whose condition is acutely deteriorating. ItemActionResponding todeterioration8.10 The health service organisation has processes that support timelyresponse by clinicians with the skills required to manage episodes of acutedeterioration8.11 The health service organisation has processes to ensure rapid access at alltimes to at least one clinician, either on site or in close proximity, who candeliver advanced life support8.12 The health service organisation has processes to ensure rapid referral tomental health services to meet the needs of patients whose mental statehas acutely deteriorated8.13 The health service organisation has processes for rapid referral to servicesthat can provide definitive management of acute physical deterioration NSQHS Standards • Glossary 67GlossaryIf appropriate, glossary definitions from externalsources have been adapted to fit the context of theNSQHS Standards.acute deterioration: physiological, psychologicalor cognitive changes that may indicate a worseningof the patient’s health status; this may occur acrosshours or days.advance care plan: a plan that states preferencesabout health and personal care, and preferred healthoutcomes. An advance care planning discussion willoften result in an advance care plan. Plans should bemade on the person’s behalf and prepared from theperson’s perspective to guide decisions about care.58advanced life support: the preservation orrestoration of life by the establishment and/ormaintenance of airway, breathing and circulationusing invasive techniques such as defibrillation,advanced airway management, intravenous accessand drug therapy.48adverse drug reaction: a response to a medicinethat is noxious and unintended, and occurs atdoses normally used or tested in humans for theprophylaxis, diagnosis or therapy of disease, or forthe modification of physiological function.59 Anallergy is a type of adverse drug reaction.adverse event: an incident that results, or could haveresulted, in harm to a patient or consumer. A nearmiss is a type of adverse event. See also near missalert: warning of a potential risk to a patient.allergy: occurs when a person’s immune systemreacts to allergens in the environment that areharmless for most people. Typical allergens includesome medicines, foods and latex.60 An allergenmay be encountered through inhalation, ingestion,injection or skin contact.61 A medicine allergy is onetype of adverse drug reaction.antimicrobial: a chemical substance that inhibits ordestroys bacteria, viruses or fungi, and can be safelyadministered to humans and animals.62antimicrobial resistance: failure of an antimicrobialto inhibit a microorganism at the antimicrobialconcentrations usually achieved over time withstandard dosing regimens.62antimicrobial stewardship: an ongoing effort bya health service organisation to reduce the risksassociated with increasing antimicrobial resistanceand to extend the effectiveness of antimicrobialtreatments. It may incorporate several strategies,including monitoring and review of antimicrobialuse.62approved identifiers: items of information acceptedfor use in identification, including family and givennames, date of birth, sex, address, healthcare recordnumber and Individual Healthcare Identifier. Healthservice organisations and clinicians are responsiblefor specifying the approved items for identificationand procedure matching. Identifiers such as room orbed number should not be used.aseptic technique: a technique that aims to preventmicroorganisms on hands, surfaces and equipmentfrom being introduced to susceptible sites. Unlikesterile techniques, aseptic techniques can beachieved in typical ward and home settings.63assessment: a clinician’s evaluation of a diseaseor condition based on the patient’s subjectivereport of the symptoms and course of the illnessor condition, and the clinician’s objective findings.These findings include data obtained throughlaboratory tests, physical examination and medicalhistory; and information reported by carers, familymembers and other members of the healthcareteam. The assessment is an essential element of acomprehensive care plan.41audit (clinical): a systematic review of clinical careagainst a predetermined set of criteria.64Australian Charter of Healthcare Rights: specifiesthe key rights of patients when seeking or receivinghealthcare services. It was endorsed by healthministers in 2008.16Australian Open Disclosure Framework: endorsedby health ministers in 2013, it provides a frameworkfor health service organisations and clinicians tocommunicate openly with patients when healthcare does not go to plan.668 Glossary • NSQHS Standardsbest possible medication history: a list of all themedicines a patient is using at presentation. The listincludes the name, dose, route and frequency of themedicine, and is documented on a specific form orin a specific place. All prescribed, over-the-counterand complementary medicines should be included.This history is obtained by a trained clinicianinterviewing the patient (and/or their carer) andis confirmed, where appropriate, by using othersources of medicines information.65best practice: when the diagnosis, treatment or careprovided is based on the best available evidence,which is used to achieve the best possible outcomesfor patients.best-practice guidelines: a set of recommendedactions that are developed using the best availableevidence. They provide clinicians with evidenceinformed recommendations that support clinicalpractice, and guide clinician and patient decisionsabout appropriate health care in specific clinicalpractice settings and circumstances.66blood management: a process that improvesoutcomes for patients by improving their medicaland surgical management in ways that boost andconserve their own blood, and ensure that any bloodand blood products patients receive are appropriateand safe.blood products: the products derived from freshblood – red blood cells and platelets, fresh frozenplasma, cryoprecipitate and cryodepleted plasma,plasma-derived blood products, and recombinantblood products.business decision-making: decision-makingregarding service planning and management for ahealth service organisation. It covers the purchaseof building finishes, equipment and plant; programmaintenance; workforce training for safe handlingof equipment and plant; and all issues for whichbusiness decisions are taken that might affect thesafety and wellbeing of patients, visitors and theworkforce.care pathway: a complex intervention that supportsmutual decision-making and organisation of careprocesses for a well-defined group of patients duringa well-defined period.67carer: a person who provides personal care, supportand assistance to another individual who needs itbecause they have a disability, medical condition(including a terminal or chronic illness) or mentalillness, or they are frail or aged. An individual is nota carer merely because they are a spouse, de factopartner, parent, child, other relative or guardianof an individual, or live with an individual whorequires care. A person is not considered a carer ifthey are paid, a volunteer for an organisation, orcaring as part of a training or education program.68clinical care standards: nationally relevantstandards developed by the Australian Commissionon Safety and Quality in Health Care, and agreedby health ministers, that identify and define thecare people should expect to be offered or receivefor specific conditions.clinical communication: the exchange ofinformation about a person’s care that occursbetween treating clinicians, patients, carers andfamilies, and other members of a multidisciplinaryteam. Communication can be through severaldifferent channels, including face-to-face meetings,telephone, written notes or other documentation,and electronic means. See also effective clinicalcommunication, clinical communication processclinical communication process: the method ofexchanging information about a person’s care.It involves several components, and includes thesender (the person who is communicating theinformation), the receiver (the person receiving theinformation), the message (the information that iscommunicated) and the channel of communication.Various channels of communication can be used,including verbal (face to face, over the phone,through Skype), written and electronic.69 Sendingand receipt of the information can occur at the sametime, such as verbal communication between twoclinicians, or at different times, such as non-verbalcommunication during which a clinician documentsa patient’s goals, assessments and comprehensivecare plan in the healthcare record, which is laterread by another clinician.NSQHS Standards • Glossary 69clinical governance: an integrated componentof corporate governance of health serviceorganisations. It ensures that everyone – fromfrontline clinicians to managers and members ofgoverning bodies, such as boards – is accountableto patients and the community for assuring thedelivery of safe, effective and high-quality services.Clinical governance systems provide confidence tothe community and the healthcare organisationthat systems are in place to deliver safe and highquality health care.clinical handover: the transfer of professionalresponsibility and accountability for some or allaspects of care for a patient, or group of patients,to another person or professional group on atemporary or permanent basis.70clinical information system: a computerisedhealthcare record and management system that isused by clinicians in healthcare settings. Clinicalinformation systems are typically organisationwide, have high levels of security and access, andhave roles and rights (for example, prescribingmedicines, reviewing laboratory results,administering intravenous fluids) specified foreach clinical and administrative user. Clinicalinformation systems enable electronic data entryand data retrieval by clinicians.71clinical leaders: clinicians with management orleadership roles in a health service organisationwho can use their position or influence to changebehaviour, practice or performance. Examples aredirectors of clinical services, heads of units andclinical supervisors.clinician: a healthcare provider, trained as ahealth professional, including registered and nonregistered practitioners. Clinicians may provide carewithin a health service organisation as an employee,a contractor or a credentialed healthcare provider,or under other working arrangements. Theyinclude nurses, midwives, medical practitioners,allied health practitioners, technicians, scientistsand other clinicians who provide health care, andstudents who provide health care under supervision.cognitive impairment: deficits in one or more ofthe areas of memory, communication, attention,thinking and judgement. This can be temporary orpermanent. It can affect a person’s understanding,their ability to carry out tasks or follow instructions,their recognition of people or objects, how theyrelate to others and how they interpret theenvironment. Dementia and delirium are commonforms of cognitive impairment seen in hospitalisedolder patients.41 Cognitive impairment can also be aresult of several other conditions, such as acquiredbrain injury, a stroke, intellectual disability, licit orillicit drug use, or medicines.cold chain management: the system of transportingand storing temperature-sensitive medicines andother therapies, such as blood and blood products,within their defined temperature range at all times,from point of origin (manufacture) to point ofadministration, to ensure that the integrity of theproduct is maintained.communicable: an infection that can be transferredfrom one person or host to another.comprehensive care: health care that is based onidentified goals for the episode of care. These goalsare aligned with the patient’s expressed preferencesand healthcare needs, consider the impact of thepatient’s health issues on their life and wellbeing,and are clinically appropriate.comprehensive care plan: a document describingagreed goals of care, and outlining planned medical,nursing and allied health activities for a patient.Comprehensive care plans reflect shared decisionsmade with patients, carers and families about thetests, interventions, treatments and other activitiesneeded to achieve the goals of care. The contentof comprehensive care plans will depend on thesetting and the service that is being provided, andmay be called different things in different healthservice organisations. For example, a care orclinical pathway for a specific intervention may beconsidered a comprehensive care plan.consumer: a person who has used, or maypotentially use, health services, or is a carer for apatient using health services. A healthcare consumermay also act as a consumer representative to providea consumer perspective, contribute consumerexperiences, advocate for the interests of currentand potential health service users, and take part indecision-making processes.72contemporaneously (documenting information):recording information in the healthcare recordas soon as possible after the event that is beingdocumented.7370 Glossary • NSQHS Standardscredentialing: the formal process used by a healthservice organisation to verify the qualifications,experience, professional standing, competenciesand other relevant professional attributes ofclinicians, so that the organisation can form a viewabout the clinician’s competence, performance andprofessional suitability to provide safe, high-qualityhealthcare services within specific organisationalenvironments.74critical equipment: items that confer a high riskfor infection if they are contaminated with anymicroorganism, and must be sterile at the timeof use. They include any objects that enter steriletissue or the vascular system, because any microbialcontamination could transmit disease.18critical information: information that hasa considerable impact on a patient’s health,wellbeing or ongoing care (physical or psychological).The availability of critical information mayrequire a clinician to reassess or change apatient’s comprehensive care plan.current medicines list: See medicines listdecision support tools: tools that can helpclinicians and consumers to draw on availableevidence when making clinical decisions. Thetools have a number of formats. Some are explicitlydesigned to enable shared decision making (forexample, decision aids). Others provide some of theinformation needed for some components of theshared decision-making process (for example, riskcalculators, evidence summaries), or provide waysof initiating and structuring conversations abouthealth decisions (for example, communicationframeworks, question prompt lists).75 See also shareddecision makingde-escalation strategies: psychosocial techniquesthat aim to reduce violent or disruptive behaviour.They are intended to reduce or eliminate the risk ofviolence during the escalation phase, using verbaland non-verbal communication skills. De-escalationis about establishing rapport to gain the patient’strust, minimising restriction to protect their selfesteem, appearing externally calm and self-awarein the face of aggressive behaviour, and intuitivelyidentifying creative and flexible interventions thatwill reduce the need for aggression.76definitive management: the treatment plan for adisease or disorder that has been chosen as the bestone for the patient after all other choices have beenconsidered.77delirium: an acute disturbance of consciousness,attention, cognition and perception that tends tofluctuate during the day.78 It is a serious conditionthat can be prevented in 30–40% of cases, andshould be treated promptly and appropriately.Hospitalised older people with existing dementiaare at the greatest risk of developing delirium.Delirium can be hyperactive (the person hasheightened arousal; or can be restless, agitated andaggressive) or hypoactive (the person is withdrawn,quiet and sleepy).79deterioration in mental state: a negative change ina person’s mood or thinking, marked by a changein behaviour, cognitive function, perception oremotional state. Changes can be gradual or acute;they can be observed by members of the workforce,or reported by the person themselves, or theirfamily or carers. Deterioration in a person’s mentalstate can be related to several predisposing orprecipitating factors, including mental illness,psychological or existential stress, physiologicalchanges, cognitive impairment (including delirium),intoxication, withdrawal from substances, andresponses to social context and environment.diversity: the varying social, economic andgeographic circumstances of consumers whouse, or may use, the services of a health serviceorganisation, as well as their cultural backgrounds,religions, beliefs, practices, languages spoken andsexualities (diversity in sexualities is currentlyreferred to as lesbian, gay, bisexual, transgender andintersex, or LGBTI).effective clinical communication: two-way,coordinated and continuous communication thatresults in the timely, accurate and appropriatetransfer of information. Effective communicationis critical to, and supports, the delivery of safepatient care.emergency assistance: clinical advice or assistanceprovided when a patient’s condition has deterioratedseverely. This assistance is provided as part of therapid response system, and is additional to the careprovided by the attending clinician or team.48end of life: the period when a patient is livingwith, and impaired by, a fatal condition, even if theNSQHS Standards • Glossary 71trajectory is ambiguous or unknown. This periodmay be years in the case of patients with chronicor malignant disease, or very brief in the case ofpatients who suffer acute and unexpected illnessesor events, such as sepsis, stroke or trauma.80environment: the physical surroundings in whichhealth care is delivered, including the building,fixtures, fittings, and services such as air and watersupply. Environment can also include other patients,consumers, visitors and the workforce.episode of care: a phase of treatment. There maybe more than one episode of care within the onehospital stay. An episode of care ends when theprincipal clinical intent changes or when the patientis formally separated from the facility.81escalation protocol: the protocol that sets out theorganisational response required for different levelsof abnormal physiological measurements or otherobserved deterioration. The protocol applies to thecare of all patients at all times.48fall: an event that results in a person coming to restinadvertently on the ground or floor, or anotherlower level.82goals of care: clinical and other goals for a patient’sepisode of care that are determined in the context ofa shared decision-making process.governance: the set of relationships andresponsibilities established by a health serviceorganisation between its executive, workforce andstakeholders (including patients and consumers).Governance incorporates the processes, customs,policy directives, laws and conventions affecting theway an organisation is directed, administered orcontrolled. Governance arrangements provide thestructure for setting the corporate objectives (social,fiscal, legal, human resources) of the organisationand the means to achieve the objectives. Theyalso specify the mechanisms for monitoringperformance. Effective governance provides a clearstatement of individual accountabilities within theorganisation to help align the roles, interests andactions of different participants in the organisationto achieve the organisation’s objectives. In theNSQHS Standards, governance includes bothcorporate and clinical governance.governing body: a board, chief executive officer,organisation owner, partnership or other highestlevel of governance (individual or group ofindividuals) that has ultimate responsibility forstrategic and operational decisions affecting safetyand quality in a health service organisation.guidelines: clinical practice guidelines aresystematically developed statements to assistclinician and consumer decisions about appropriatehealth care for specific circumstances.83haemovigilance: a set of surveillance procedurescovering the entire blood transfusion chain, fromthe donation and processing of blood and itscomponents, to their provision and transfusion topatients, to their follow-up. It includes monitoring,reporting, investigating and analysing adverseevents related to the donation, processing andtransfusion of blood, as well as development andimplementation of recommendations to prevent theoccurrence or recurrence of adverse events.84hand hygiene: a general term referring to any actionof hand cleansing.health care: the prevention, treatment andmanagement of illness and injury, and thepreservation of mental and physical wellbeingthrough the services offered by clinicians, such asmedical, nursing and allied health professionals.6healthcare-associated infections: infections thatare acquired in healthcare facilities (nosocomialinfections) or that occur as a result of healthcareinterventions (iatrogenic infections). Healthcareassociated infections may manifest after peopleleave the healthcare facility.18healthcare record: includes a record of the patient’smedical history, treatment notes, observations,correspondence, investigations, test results,photographs, prescription records and medicationcharts for an episode of care.health literacy: the Australian Commission onSafety and Quality in Health Care separates healthliteracy into two components – individual healthliteracy and the health literacy environment.Individual health literacy is the skills, knowledge,motivation and capacity of a consumer to access,understand, appraise and apply information tomake effective decisions about health and healthcare, and take appropriate action.The health literacy environment is theinfrastructure, policies, processes, materials, peopleand relationships that make up the healthcaresystem, which affect the ways in which consumers72 Glossary • NSQHS Standardsaccess, understand, appraise and apply healthrelated information and services.85health service organisation: a separatelyconstituted health service that is responsible forimplementing clinical governance, administrationand financial management of a service unit orservice units providing health care at the directionof the governing body. A service unit involvesa group of clinicians and others working in asystematic way to deliver health care to patients.It can be in any location or setting, includingpharmacies, clinics, outpatient facilities, hospitals,patients’ homes, community settings, practices andclinicians’ rooms.higher risk (patients at higher risk of harm):a patient with multiple factors or a few specificfactors that result in their being more vulnerableto harm from health care or the healthcare system.Risk factors may include having chronic clinicalconditions; having language barriers; being ofAboriginal or Torres Strait Islander background;having low health literacy; being homeless; or beingof diverse gender identities and experiences, bodies,relationships and sexualities (currently referred to aslesbian, gay, bisexual, transgender and intersex, orLGBTI).high-risk medicines: medicines that have anincreased risk of causing significant patient harmor death if they are misused or used in error. Highrisk medicines may vary between hospitals andother healthcare settings, depending on the typesof medicines used and patients treated. Errors withthese medicines are not necessarily more commonthan with other medicines. Because they have a lowmargin of safety, the consequences of errors withhigh-risk medicines can be more devastating.86,87At a minimum, the following classes of high-riskmedicines should be considered:• Medicines with a narrow therapeutic index• Medicines that present a high risk when othersystem errors occur, such as administration viathe wrong route.hygienic environment: an environment in whichpractical prevention and control measures are usedto reduce the risk of infection from contaminationby microbes.incident (clinical): an event or circumstance thatresulted, or could have resulted, in unintended orunnecessary harm to a patient or consumer; or acomplaint, loss or damage. An incident may also bea near miss. See also near missinfection: the invasion and reproduction ofpathogenic (disease-causing) organisms inside thebody. This may cause tissue injury and disease.88informed consent: a process of communicationbetween a patient and clinician about options fortreatment, care processes or potential outcomes.This communication results in the patient’sauthorisation or agreement to undergo a specificintervention or participate in planned care.89 Thecommunication should ensure that the patient hasan understanding of the care they will receive, allthe available options and the expected outcomes,including success rates and side effects for eachoption.90injury: damage to tissues caused by an agent orcircumstance.91invasive medical devices: devices inserted throughskin, mucosal barrier or internal cavity, includingcentral lines, peripheral lines, urinary catheters,chest drains, peripherally inserted central cathetersand endotracheal tubes.jurisdictional requirements: systematicallydeveloped statements from state and territorygovernments about appropriate healthcare orservice delivery for specific circumstances.83Jurisdictional requirements encompass a numberof types of documents from state and territorygovernments, including legislation, regulations,guidelines, policies, directives and circulars.Terms used for each document may vary bystate and territory.leadership: having a vision of what can be achieved,and then communicating this to others and evolvingstrategies for realising the vision. Leaders motivatepeople, and can negotiate for resources and othersupport to achieve goals.92local community: the people living in a definedgeographic region or from a specific group whoreceive services from a health service organisation.mandatory: required by law or mandate inregulation, policy or other directive; compulsory.93NSQHS Standards • Glossary 73medication management: practices used to managethe provision of medicines. Medication managementhas also been described as a cycle, pathway or system,which is complex and involves a number of differentclinicians. The patient is the central focus. The systemincludes manufacturing, compounding, procuring,dispensing, prescribing, storing, administering,supplying and monitoring the effects of medicines.It also includes decision-making, and rules,guidelines, support tools, policies and procedures thatare in place to direct the use of medicines.94medication reconciliation: a formal process ofobtaining and verifying a complete and accuratelist of each patient’s current medicines, andmatching the medicines the patient should beprescribed to those they are actually prescribed.Any discrepancies are discussed with the prescriber,and reasons for changes to therapy are documentedand communicated when care is transferred.Medication review may form part of the medicationreconciliation process.medication review: a systematic assessmentof medication management for an individualpatient that aims to optimise the patient’smedicines and outcomes of therapy by providing arecommendation or making a change.95 Medicationreview may be part of medication reconciliation.medicine: a chemical substance given with theintention of preventing, diagnosing, curing,controlling or alleviating disease, or otherwiseimproving the physical or mental wellbeingof people. These include prescription, nonprescription, investigational, clinical trial andcomplementary medicines, irrespective of howthey are administered.96medicine-related problem: any event involvingtreatment with a medicine that has a negativeeffect on a patient’s health or prevents a positiveoutcome. Consideration should be given to diseasespecific, laboratory test–specific and patient-specificinformation. Medicine-related problems includeissues with medicines such as:• Underuse• Overuse• Use of inappropriate medicines (includingtherapeutic duplication)• Adverse drug reactions, including interactions(medicine–medicine, medicine–disease,medicine–nutrient, medicine–laboratory test)• Noncompliance.97,98medicines list: prepared by a clinician, a medicineslist contains, at a minimum:• All medicines a patient is taking, includingover-the-counter, complementary, prescriptionand non-prescription medicines; for eachmedicine, the medicine name, form, strength anddirections for use must be included94• Any medicines that should not be taken by thepatient, including those causing allergies andadverse drug reactions; for each allergy or adversedrug reaction, the medicine name, the reactiontype and the date on which the reaction wasexperienced should be included.Ideally, a medicines list also includes the intendeduse (indication) for each medicine.It is expected that the medicines list is updated andcorrect at the time of transfer (including clinicalhandover) or when services cease, and that it istailored to the audience for whom it is intended(that is, patient or clinician).99mental state: See deterioration in mental stateminimum information content: the content ofinformation that must be contained and transferredin a particular type of clinical handover. Whatis included as part of the minimum informationcontent will depend on the context and reason forthe handover or communication.100multidisciplinary team: a team including cliniciansfrom multiple disciplines who work together to delivercomprehensive care that deals with as many of thepatient’s health and other needs as possible. The teammay operate under one organisational umbrella ormay be from several organisations brought togetheras a unique team. As a patient’s condition changes,the composition of the team may change to reflectthe changing clinical and psychosocial needs ofthe patient.101 Multidisciplinary care includesinterdisciplinary care. (A discipline is a branch ofknowledge within the health system.102)My Health Record (formerly known as a personallycontrolled electronic device): the secure onlinesummary of a consumer’s health information,managed by the System Operator of the national MyHealth Record system (the Australian Digital HealthAgency). Clinicians are able to share health clinicaldocuments to a consumer’s My Health Record,according to the consumer’s access controls. Thesemay include information on medical history andtreatments, diagnoses, medicines and allergies.10374 Glossary • NSQHS Standardsnational patient identifier: a unique 16-digitnumber that is used to identify individuals whoreceive or may receive health care in the Australianhealthcare system. Also known as an IndividualHealthcare Identifier (IHI).103national provider identifier: a unique 16-digitnumber that is used to identify individual cliniciansor organisations that deliver health care in theAustralian healthcare setting. For individuals, itis also known as a Healthcare Provider Identifier– Individual (HPI-I); for organisations, it is alsoknown as a Healthcare Provider Identifier –Organisation (HPI-O).103near miss: an incident or potential incident thatwas averted and did not cause harm, but had thepotential to do so.104nutrition care plan: a plan to meet the nutritionand hydration needs of a patient. The nutrition careplan is developed for the patient after their nutritionand hydration needs have been assessed.open disclosure: an open discussion with a patientand carer about an incident that resulted in harm tothe patient while receiving health care. The criteriaof open disclosure are an expression of regret, and afactual explanation of what happened, the potentialconsequences, and the steps taken to manage theevent and prevent recurrence.105organisation-wide: intended for use throughout thehealth service organisation.orientation: a formal process of informing andtraining a worker starting in a new position orbeginning work for an organisation, which coversthe policies, processes and procedures applicable tothe organisation.outcome: the status of an individual, group ofpeople or population that is wholly or partiallyattributable to an action, agent or circumstance.91partnership: a situation that develops whenpatients and consumers are treated with dignityand respect, when information is shared withthem, and when participation and collaborationin healthcare processes are encouraged andsupported to the extent that patients and consumerschoose. Partnerships can exist in different waysin a health service organisation, including at thelevel of individual interactions; at the level of aservice, department or program; and at the levelof the organisation. They can also exist withconsumers and groups in the community. Generally,partnerships at all levels are necessary to ensurethat the health service organisation is responsive topatient and consumer input and needs, although thenature of the activities for these different types ofpartnership will depend on the context of the healthservice organisation.patient: a person who is receiving care in a healthservice organisation.person-centred care: an approach to the planning,delivery and evaluation of health care that isfounded on mutually beneficial partnerships amongclinicians and patients.106 Person-centred care isrespectful of, and responsive to, the preferences,needs and values of patients and consumers. Keydimensions of person-centred care include respect,emotional support, physical comfort, informationand communication, continuity and transition, carecoordination, involvement of carers and family, andaccess to care.9 Also known as patient-centred careor consumer-centred care.point of care: the time and location of aninteraction between a patient and a clinician for thepurpose of delivering care.policy: a set of principles that reflect theorganisation’s mission and direction. All proceduresand protocols are linked to a policy statement.pressure injuries: injuries of the skin and/orunderlying tissue, usually over a bony prominence,caused by unrelieved pressure, friction or shearing.They occur most commonly on the sacrum and heel,but can develop anywhere on the body. Pressureinjury is a synonymous term for pressure ulcer.procedure: the set of instructions to make policiesand protocols operational, which are specific to anorganisation.procedure matching: the processes of correctlymatching patients to their intended care.process: a series of actions or steps taken to achievea particular goal.107program: an initiative, or series of initiatives,designed to deal with a particular issue, withresources, a time frame, objectives and deliverablesallocated to it.protocol: an established set of rules used tocomplete tasks or a set of tasks.NSQHS Standards • Glossary 75purpose-driven communication: communication inwhich all the parties involved in the communicationprocess have a shared understanding of why thecommunication is taking place (for example, togather, share, receive or check information), whataction needs to be taken and who is responsible fortaking that action.quality improvement: the combined efforts ofthe workforce and others – including consumers,patients and their families, researchers, plannersand educators – to make changes that will leadto better patient outcomes (health), better systemperformance (care) and better professionaldevelopment.108 Quality improvement activitiesmay be undertaken in sequence, intermittentlyor continually.regularly: occurring at recurring intervals. Thespecific interval for regular review, evaluation, auditor monitoring needs to be determined for each case.In the NSQHS Standards (2nd ed.), the intervalshould be consistent with best practice, risk based,and determined by the subject and nature of theactivity.responsibility and accountability for care:accountability includes the obligation to report andbe answerable for consequences. Responsibilityis the acknowledgement that a person has to takeaction that is appropriate to a patient’s care needsand the health service organisation.109restraint: the restriction of an individual’s freedomof movement by physical or mechanical means.110reusable device: a medical device that is designatedby its manufacturer as suitable for reprocessing andreuse.111risk: the chance of something happening that willhave a negative impact. Risk is measured by theconsequences of an event and its likelihood.risk assessment: assessment, analysis andmanagement of risks. It involves recognisingwhich events may lead to harm in the future, andminimising their likelihood and consequences.112risk management: the design and implementationof a program to identify and avoid or minimise risksto patients, employees, volunteers, visitors and theorganisation.safety culture: a commitment to safety thatpermeates all levels of an organisation, from theclinical workforce to executive management.Features commonly include acknowledgementof the high-risk, error-prone nature of anorganisation’s activities; a blame-free environmentin which individuals are able to report errors or nearmisses without fear of reprimand or punishment;an expectation of collaboration across all areasand levels of an organisation to seek solutions tovulnerabilities; and a willingness of the organisationto direct resources to deal with safety concerns.113scope of clinical practice: the extent of anindividual clinician’s approved clinical practicewithin a particular organisation, based on theclinician’s skills, knowledge, performance andprofessional suitability, and the needs and servicecapability of the organisation.74screening: a process of identifying patients who areat risk, or already have a disease or injury. Screeningrequires enough knowledge to make a clinicaljudgement.114seclusion: the confinement of a patient, at any timeof the day or night, alone in a room or area fromwhich free exit is prevented.110self-harm: includes self-poisoning, overdoses andminor injury, as well as potentially dangerous andlife-threatening forms of injury. Self-harm is abehaviour and not an illness. People self-harm tocope with distress or to communicate that they aredistressed.115semi-critical equipment: items that come intocontact with mucous membranes or non-intact skin,and should be single use or sterilised after each use.If this is not possible, high-level disinfection is theminimum level of reprocessing that is acceptable.18service context: the particular context in which careis delivered. Health service delivery occurs in manydifferent ways, and the service context will dependon the organisation’s function, size and organisationof care regarding service delivery mode, location andworkforce.116shared decision making: a consultation process inwhich a clinician and a patient jointly participatein making a health decision, having discussed theoptions, and their benefits and harms, and havingconsidered the patient’s values, preferences andcircumstances.75standard: agreed attributes and processes designedto ensure that a product, service or method willperform consistently at a designated level.9176 Glossary • NSQHS Standardsstandard national terminologies: a structuredvocabulary used in clinical practice to accuratelydescribe the care and treatment of patients.Healthcare providers around the world usespecialised vocabulary to describe diseases,operations, clinical procedures, findings, treatmentsand medicines. In Australia, terminologies includeSNOMED CT-AU and Australian MedicinesTerminology.117 Standard national terminologies arealso referred to as clinical terminologies.standard precautions: work practices that providea first-line approach to infection prevention andcontrol, and are used for the care and treatment ofall patients.111structured clinical handover: a structuredformat used to deliver information (the minimuminformation content), enabling all participantsto know the purpose of the handover, and theinformation that they are required to know andcommunicate.64substitute decision-maker: a person appointedor identified by law to make health, medical,residential and other personal (but not financialor legal) decisions on behalf of a patient whosedecision-making capacity is impaired. A substitutedecision-maker may be appointed by the patient,appointed for (on behalf of) the person, or identifiedas the default decision-maker by legislation, whichvaries by state and territory.41surveillance: an epidemiological practice thatinvolves monitoring the spread of disease toestablish progression patterns. The main roles ofsurveillance are to predict and observe spread; toprovide a measure for strategies that may minimisethe harm caused by outbreak, epidemic andpandemic situations; and to increase knowledgeof the factors that might contribute to suchcircumstances.88system: the resources, policies, processes andprocedures that are organised, integrated,regulated and administered to accomplish astated goal. A system:• Brings together risk management, governance,and operational processes and procedures,including education, training and orientation• Deploys an active implementation plan; feedbackmechanisms include agreed protocols andguidelines, decision support tools and otherresource materials• Uses several incentives and sanctions to influencebehaviour and encourage compliance with policy,protocol, regulation and procedures.The workforce is both a resource in the system andinvolved in all elements of systems development,implementation, monitoring, improvement andevaluation.timely (communication): communication ofinformation within a reasonable time frame.This will depend on how important or time criticalthe information is to a patient’s ongoing careor wellbeing, the context in which the service isprovided and the clinical acuity of the patient.traceability: the ability to trace the history,application or location of reusable medical devices.Some professional groups may refer to traceabilityas tracking.111training: the development of knowledge and skills.transfusion history: a list of transfusions a patienthas had before presentation, including details ofany adverse reactions to the transfusion and anyspecial transfusion requirements. The completenessof the history will depend on the availability ofinformation. It is expected that information willbe obtained by reviewing any available referralinformation and interviewing the patient ortheir carer.transitions of care: situations when all or part ofa patient’s care is transferred between healthcarelocations, providers, or levels of care within thesame location, as the patient’s conditions and careneeds change.118transmission-based precautions: extra workpractices used in situations when standardprecautions alone may not be enough to preventtransmission of infection. Transmission-basedprecautions are used in conjunction with standardprecautions.18workforce: all people working in a health serviceorganisation, including clinicians and any otheremployed or contracted, locum, agency, student,volunteer or peer workers. 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