Table 1: Applicability of NSQHS Standards to community health services Health service type Definition Standards 1 2 3 4 5 6 7 8 9 10 Aboriginal and Torres Strait Islander health services A comprehensive, integrated primary healthcare service that includes clinical care, communicable disease, environmental health, pharmaceuticals, counselling, preventive medicine, health education and promotion, rehabilitative services, antenatal and postnatal care, maternal and child care and other specific programs and support services.2 All items All items Some items may not be applicable All items All items except Action 5.3.1 All items All items only for blood products used All items Not All items Allied health care Services include a range of therapies offered by qualified clinicians such as physiotherapy, occupational therapy, dietetics and nutrition, speech pathology and optical services.3 All items All items Some items may not be applicable Some items may not be applicable All items except Action 5.3.1 All items Not Some items may not be applicable Not All items Cancer screening services Screening and diagnostic services that help to detect cancer. This includes breast, skin, bowel and cervical cancer.4 All items All items Some items may not be applicable All items All items except Action 5.3.1 All items Not Not Not Not
Health service type Definition Standards 1 2 3 4 5 6 7 8 9 10 Community mental health ‘Community mental health care’ refers to government- operated specialised mental health care provided by community mental healthcare services and hospital-based ambulatory care services, such as outpatients and day clinics.5 All items All items Some items may not be applicable All items All items except Action 5.3.1 All items All items only for blood products used All items Some items may be All items Community nursing Nursing practice that combines public health care, health promotion and primary health care delivered in partnerships with patients and their communities to prevent illness and promote health. Services may be delivered through centre-based care or via home-visiting service.6 All items All items Some items may not be applicable All items All items except Action 5.3.1 All items All items only for blood products used All items Some items may be All items Community rehabilitation programs Programs that seek to equip, empower and provide education and training to rehabilitation clients, carers, family and community members. Programs focus on client environments, networks for care and personal engagement in rehabilitation.7 All items All items Some items may not be applicable Some items may be All items except Action 5.3.1 Some items may not be applicable Not Some items may not be applicable Some items may not be applicable Some items may not be applicable Crisis or emergency Services for people in need of urgent assistance. This includes assessment, information, referral, counselling, help lines and 24- hour telephone support.8 All items All items Not except for item 3.15 Not All items except Action 5.3.1 All items Not Not Not Not
Health service type Definition Standards 1 2 3 4 5 6 7 8 9 10 Dental and oral health programs Practice providing dental care including minor surgery under local anaesthetic or sedation.9 All items All items Some items may not be applicable All items All items except Action 5.3.1 All items All items only for blood products used Not Not Not Drug and alcohol services Any service or facility established or maintained primarily for the care, treatment or rehabilitation of people with alcohol and other drug issues, whether conducted independently or in conjunction with any other service or facility.10 All items All items Some items may not be applicable All items All items except Action 5.3.1 All items All items only for blood products used All items Not All items Hearing services Includes hearing assessment and hearing rehabilitation provided by a qualified hearing service provider.11. All items All items Not Not All items except Action 5.3.1 All items Not Not Not Some items may be Maternal and child community health services Health services for children from birth to school age and their families, focusing on promotion of health and development, prevention, early detection of, and intervention for physical, emotional and social factors affecting young children and their families.12 All items All items Some items may not be applicable Some items may be All items except Action 5.3.1 All items Not Not Not Not
Health service type Definition Standards 1 2 3 4 5 6 7 8 9 10 Men’s health Management of health conditions and risks that are most common or specific to men in order to promote optimal physical, emotional and social health, which extends beyond sexual or reproductive health.13 All items All items Some items may not be applicable All items All items except Action 5.3.1 All items Not Not Not Not Offender health services The provision of primary health care services, including assessment and ongoing chronic disease management, and access to secondary and tertiary services for offenders serving custodial sentences in the care of the state.14 All items All items Some items may not be applicable All items All items except Action 5.3.1 All items All items only for blood products used Some items may be Some items may be Some items may be Palliative care Care that aims to improve the quality of life for individuals with an eventually fatal condition, and their families, by reducing their suffering through early identification, assessment and treatment of pain, physical, psychological, social, cultural and spiritual needs.15 All items All items Some items may not be applicable All items All items except Action 5.3.1 All items Not All items Some items may be All items
Health service type Definition Standards 1 2 3 4 5 6 7 8 9 10 Primary healthcare centre A primary healthcare centre brings together a wide range of community and rural health services to meet local community needs using a community nursing model, some centres may have some inpatient sub-acute beds or provide residential aged care and emergency services, if required.9 All items All items All items All items All items except Action 5.3.1 All items All items only for blood products used All items Some items may be All items Royal Flying Doctor’s Service and other aerial transport services The Royal Flying Doctor Service supports sustainable delivery of primary care services to people in rural and remote communities, including the provision of aeromedical evacuations, primary and community health clinics, medical checks and remote consultations.9 All items All items All items All items All items except Action 5.3.1 All items All items only for blood products used All items All items All items Sexual abuse services Support services offer confidential counselling, advocacy and referral to sexual abuse victims including children, men and women.16 All items All items Some items may not be applicable Some items may be All items except Action 5.3.1 All items Not Not Not Not Women’s health Management of the physical, emotional and mental health of women, their families and their relationships, with focused importance on their psychosocial and cultural environment in treatment.13 All items All items Some items may not be applicable All items All items except Action 5.3.1 All items Not Not Not Not
Standard Core actions Developmental actions Standard 4 Medication Safety 4.1.1 4.1.2 4.2.1 4.2.2 4.3.1 4.3.2 4.3.3 4.4.1 4.4.2 4.5.1 4.5.2 4.6.1 4.6.2 4.7.1 4.7.2 4.7.3 4.9.1 4.9.2 4.9.3 4.10.1 4.10.2 4.10.3 4.10.4 4.10.5 4.10.6 4.11.1 4.11.2 4.12.1 4.12.2 4.12.3 4.12.4 4.8.1 4.13.1 4.13.2 4.14.1 4.15.1 4.15.2 Subtotal 31 6 Standard 5 Patient Identification and Procedure Matching 5.1.1 5.1.2 5.2.1 5.2.2 5.3.1 5.4.1 5.5.1 5.5.2 5.5.3 Nil Subtotal 9 0 Standard 6 Clinical Handover 6.1.1 6.1.2 6.1.3 6.2.1 6.3.1 6.3.3 6.3.4 6.4.1 6.4.2 6.3.2 6.5.1 Subtotal 9 2 Standard 7 Blood and Blood Products 7.1.1 7.1.2 7.1.3 7.2.1 7.2.2 7.3.1 7.3.2 7.3.3 7.4.1 7.5.1 7.5.2 7.5.3 7.6.1 7.6.2 7.6.3 7.7.1 7.7.2 7.8.1 7.8.2 7.9.1 7.9.2 7.10.1 7.11.1 Subtotal 20 3
Standard Core actions Developmental actions Standard 8 Preventing and Managing Pressure Injuries 8.1.1 8.1.2 8.2.1 8.2.2 8.2.3 8.2.4 8.3.1 8.4.1 8.5.1 8.5.2 8.5.3 8.6.1 8.6.2 8.6.3 8.7.1 8.8.1 8.8.2 8.8.3 8.8.4 8.7.3 8.7.4 8.9.1 Subtotal 20 4 Standard 9 Recognising and Responding to Clinical Deterioration in Acute Health Care 9.1.1 9.1.2 9.2.1 9.2.2 9.2.3 9.2.4 9.3.2 9.3.3 9.4.1 9.4.2 9.4.3 9.5.1 9.5.2 9.6.1 9.6.2 9.3.1 9.7.1 9.8.1 9.8.2 9.9.1 9.9.2 9.9.3 9.9.4 Subtotal 15 8 Standard 10 Preventing Falls and Harm from Falls 10.1.1 10.1.2 10.2.1 10.2.2 10.2.3 10.2.4 10.3.1 10.4.1 10.5.1 10.5.2 10.5.3 10.6.1 10.6.2 10.6.3 10.7.1 10.7.2 10.7.3 10.8.1 10.9.1 10.10.1 Subtotal 18 2 TOTAL 208 48
Overview of what is required Suggested approach Examples of evidence 1.1 Implementing a governance system that sets out the policies, procedures and/or protocols for: establishing and maintaining a clinical governance framework identifying safety and quality risks collecting and reviewing performance data implementing prevention strategies based on data analysis analysing reported incidents implementing performance management procedures ensuring compliance with legislative requirements and relevant industry standards communicating with and informing the clinical and non-clinical workforce undertaking regular clinical audits 1.1.1 An organisation-wide management system is in place for the development, implementation and regular review of policies, procedures and/or protocols This action relates to all policies, procedures and/or protocols for the NSQHS Standards. Policies, procedures and/or protocols may be developed at different levels within your community health service, but need to be integrated into a single system to ensure their utility. Your community health service should ensure that policies, procedures and/or protocols: are based on evidence and good practice are regularly reviewed and updated incorporate any legislative requirements or industry standards that must be met. Your community health service should have: procedures in place that comply with the organisation’s policies mechanisms to monitor the use of procedures by the workforce Identify the system for developing, implementing and reviewing the policies, procedures and/or protocols used by your community health service. Responsibilities for this may sit with the overarching health service organisation. If the health service organisation has a system in place, ensure that local procedures or work instructions for your community health service are consistent with the overarching policies, procedures and/or protocols. If no system is in place, develop policies, procedures and/or protocols for your community health service that specify: the roles, responsibilities and accountabilities for each manager the position(s) with delegations for implementing, amending or endorsing policies. Policies, procedures and/or protocols that address the areas identified in . Register or list of policies, procedures and/or protocols that details implementation date, date policy documents were amended or due for review, a prioritised schedule for future reviews and persons/position or committee responsible. Results of audits of policy documents, consumer clinical records and clinical practice that have resulted in a change to policies, procedures or protocols. Relevant documentation of committee structures and roles with responsibilities for policy, procedure and protocol development. Memos, newsletters or other communication material provided to the workforce about new or revised policies, procedures or protocols. Governance and quality improvement systems
Governance and quality improvement systems Overview of what is required Suggested approach Examples of evidence 1.4.2 Annual mandatory training programs to meet the requirements of these Standards A policy should be in place that outlines the annual mandatory training requirements for the workforce. Throughout the NSQHS Standards there are actions that require the workforce to participate in education and training and be competent in areas such as aseptic technique () and consumer-centred care () to meet the requirements of the NSQHS Standards. Your community health service should ensure that training undertaken is reconciled with the skills needed. Further training for the workforce, including agency and locum workforce, should be offered by your community health service based on identified needs and risks within the organisation. Education and training may involve: tutorial sessions that may be combined with general administrative meetings dedicated time for teaching, supervision and assessment of new skills locally managed and run professional development sessions formal training provided by the workforce or external providers. Maintain a register of training provided or records of attendance and achievement at mandatory training programs by the clinical workforce. Evidence of the assessment of training needs through review of incidents, performance data, workforce feedback, workforce reviews, system audits and policy. Schedule of planned annual mandatory training that addresses the requirements of the NSQHS Standards. Education resources and records of attendance at mandatory training by the workforce. Evaluation survey or report on training programs on workforce safety and quality roles, responsibilities and accountabilities. Memos, newsletters or other communication material provided to the workforce regarding annual mandatory training requirements. 1.4.3 Locum and agency workforce have the necessary information, training and orientation to the workplace to fulfil their safety and quality roles and responsibilities All agency and locum staff should undergo orientation prior to or upon commencement of work in your community health service. Your community health service should ensure there is a process in place to orientate locum or agency staff to your organisation and that adequate supervision and support is available to fulfil their safety and quality roles and responsibilities. Document the orientation program and participation by locum and agency workforce. Assess the need for training in safety and quality and risk assessment at orientation. Provide access to training or include training requirements in contractual arrangements with locum and agency providers. Orientation manuals and education resources for locum and agency workforce. Position descriptions, duty statements and employment contracts that detail the safety and quality roles, responsibilities and accountabilities for locum and agency workforce.
Overview of what is required Suggested approach Examples of evidence 1.10.5 Supervision of the clinical workforce is provided whenever it is necessary for individuals to fulfil their designated role Clinicians who are developing their skills or are completing an assessment phase may need to be supervised. Your community health service should have documented procedures for identifying which members of the workforce are to be supervised, who can provide supervision and how long supervision is required. You should ensure that reports on the supervised workforce are prepared routinely, in line with the documented procedure. Requirements for supervision can be defined in: policies, procedures and/or protocols position descriptions professional registration requirements professional qualifications and training programs. Policies, procedures and/or protocols for the supervision of clinicians. Supervision or mentorship program. Position descriptions, duty statements or employment contracts that describe requirements for supervised staff and supervisors. Register of workforce qualifications and areas of credentialed practice. Documented review of qualifications and competencies for the clinical workforce. Supervision and observational reports of clinical practice. 1.11 Implementing a performance development system for the clinical workforce that supports performance improvement within their scope of practice 1.11.1 A valid and reliable performance review process is in place for the clinical workforce 1.11.2 The clinical workforce participates in regular performance reviews that support individual development and improvement Your community health service should implement and maintain a robust system of performance review and development for all clinicians. You should review this system regularly to ensure its design, resourcing and monitoring support safe and good quality clinical practices, clinical engagement and good consumer outcomes. If the overarching health service organisation has a performance review process, engage the workforce to put these requirements in place locally. If your community health service is required to implement a performance review process: develop a policy, procedure and/or protocol for conducting performance reviews that defines participants, timeframes and record keeping requirements Policies, procedures and/or protocols outlining the performance review system. A documented performance development system that meets professional development guidelines and credentialing requirements. Individual professional development plans that document training needs identified through individual performance reviews. Audit of use of policies, procedures and/or protocols on the performance review process for the clinical workforce. Performance and skills management
Incident and complaints management Overview of what is required Suggested approach Examples of evidence implement a monitoring and reporting system for open disclosure events provide reports to the governing body about the effectiveness of the open disclosure process review open disclosure events to determine how the program could be improved. 1.16.2 The clinical workforce are trained in open disclosure processes Your community health service should review the need to include open disclosure in its orientation, education and training program. You will need to monitor participation in training by the workforce. Incorporate open disclosure into the orientation, education and training program. Record participation in training. Orientation manuals, education resources and records of attendance at training by the workforce on open disclosure processes. Patient rights and engagement Overview of what is required Suggested approach Examples of evidence 1.17 Implementing through organisational policies and practices a patient charter of rights that is consistent with the current national charter of healthcare rights 1.17.1 The organisation has a charter of patient rights that is consistent with the current national charter of healthcare rights Your community health service should adopt the Australian Charter of Healthcare Rights66 or a charter that is consistent with the Australian Charter of Healthcare Rights.66 If the overarching health service organisation has specified the charter of healthcare rights to be used, ensure the requirements of this charter are being met locally. If your community health service is required to implement a charter of healthcare rights: identify local manager(s) with responsibility for implementing the charter Policies, procedures and/or protocols regarding the implementation and use of a charter of consumer rights. A charter of consumer rights consistent with the Australian Charter of Healthcare Rights66 is available.
Patient rights and engagement Overview of what is required Suggested approach Examples of evidence 1.18.3 Mechanisms are in place to align the information provided to patients with their capacity to understand Your community health service should have available consumer information and resources that have been developed to meet the needs of the consumer population. These resources may be provided by the overarching health service organisation or your local consumer advocacy organisation. Where resources are not available from these sources, your community health service should develop your own or adapt relevant resources (see ). If you are developing consumer information publications locally, obtain and document feedback from consumers about information publications. Suggested strategies include: discuss publications with consumers in waiting rooms hold a focus group or workshop with consumers make follow-up phone calls to consumers who have been provided with information publications conduct a survey (electronic, mail or phone) of consumers who have been provided with information publications. If you use publications that have been developed externally, try to source information that has been developed with input from consumers. Relevant documentation from committees and other meetings that demonstrate consumer involvement in developing consumer information resources. A register of interpreter and other advocacy and support services available to the workforce and consumers. Analysis of consumer feedback on resources developed and distributed by the organisation. Translated consumer information resources available (depending on the consumer profile of the service). 1.18.4 Patients and carers are supported to document clear advance care directives and/or treatment-limiting orders Your community health service should put in place mechanisms to inform and support consumers and carers with advance care directives and treatment-limiting orders. The workforce will need to be trained to understand the legal and ethical issues associated with drafting and implementing advance care directives and orders. Refer to Item 9.8 in the NSQHS Standard 9: Safety and Quality Improvement Guide.21 If the overarching health service organisation specifies processes for documenting advance care directives and treatment-limiting orders, put these requirements in place locally. If your community health service is required to implement a process, then: identify senior clinicians and/or managers with responsibility for managing the advance care directive system engage relevant clinicians and managers to develop policies, procedures and/or protocols for the advance care directive system Policies, procedures and/or protocols on advance care directives and orders that are consistent with jurisdictional guidelines and legislative requirements. Review of consumer clinical records for evidence that information on advance care directives was provided to consumers, where appropriate. Audit of consumer clinical records that contain advance care directives or treatment-limiting orders.
Patient rights and engagement Overview of what is required Suggested approach Examples of evidence 1.19.2 Systems are in place to restrict inappropriate access to and dissemination of patient clinical information Your community health service should ensure that policies, procedures and/or protocols for the clinical record system support the confidentiality and privacy of consumer information. These will need to consider the unique risks to paper-based and electronic records in use and ensure they are consistent with the law and good practice. Regular auditing of the consumer clinical record system will ensure processes are being followed and identify areas for improvement. Processes should be in place to deal with any instances of inappropriate access. Ensure policies, procedures and/or protocols are in place to protect the confidentiality of consumer information and the physical security of clinical records. Inform the workforce of their responsibilities to protect consumer privacy and confidentiality and the consequences of intentional and unintentional breaches of these obligations. Regularly undertake a review of access and dissemination of consumer clinical information and implement strategies to improve. Policies, procedures and/or protocols for sharing consumer information by telephone, electronically and other methods that are consistent with privacy legislation, jurisdictional directives and insurers’ requirements. Workforce code of conduct that includes privacy and confidentiality of consumer information. Secure archival storage system for and electronic records. Workforce confidentiality agreements. Consumer clinical records that include consent for transfer of information to other service providers or national health related registers. Templates for the issuing of log-on and password details for electronic consumer record systems.
Governance and systems for infection prevention, control and surveillance Overview of what is required Suggested approach Examples of evidence Regular monitoring of workforce use of infection prevention policies, procedures and/or protocols enables local managers to take swift action to reduce infection risk. safe sharps management () environmental cleaning () waste management, cleaning, disinfection and sterilisation activities () use of personal protective equipment ( and ) or incident data. If auditing is conducted by the overarching health service organisation, your community health service may be asked to contribute data and information or perform local audits and report results to the governing body. Reports on the review of infection risks or data for interventions to manage healthcare associated infection risks. Relevant documentation from committees and other meetings where reports on infection prevention and control activities are tabled and discussed. 3.1.3 The effectiveness of the infection prevention and control systems is regularly reviewed at the highest level of governance in the organisation Your community health service should ensure that data and information about the performance of the organisation’s infection prevention and control system is reported to the local manager(s) responsible for the system and the senior executive, in line with policy and timeframes for reporting. Identify an individual, or team, responsible for the local management or governance of infection prevention and control. This role needs to be identified locally, even if overall responsibility for infection prevention and control governance sits with the overarching health service organisation. Routinely provide the results from audits, any surveillance and incident reviews to the local governance bodies, and any relevant governance bodies within your community health service. Include infection prevention and control on meeting agendas and reports to the governing body. A schedule for the reporting of infection prevention and control activities. Reports on the performance of the infection prevention and control system presented to the organisation’s governing body. Relevant documentation from committees and other meetings where reports on the performance of the infection prevention and control system are tabled and discussed. Reports of evidence-based interventions that have been initiated for identified infection control risks. A business plan that demonstrates review of health service performance against key performance indicators.
Governance and systems for infection prevention, control and surveillance Overview of what is required Suggested approach Examples of evidence The outcome of risk assessments should be reviewed by the individual or committee responsible for managing the organisation’s infection prevention and control system and used to inform the: development and review of infection prevention and control policies, procedures and/or protocols development and implementation of improvement strategies. These improvement strategies may be the same as those implemented for . A quality improvement plan in line with that includes strategies to improve infection prevention and control. Examples of improvement activities that have been implemented and evaluated to reduce the risks of healthcare associated infection. Memos, newsletters or other communication material provided to the workforce and consumers on healthcare associated infections. 3.4 Undertaking quality improvement activities to reduce healthcare associated infections through changes to practice 3.4.1 Quality improvement activities are implemented to reduce and prevent healthcare associated infections 3.4.2 Compliance with changes in practice are monitored 3.4.3 The effectiveness of changes to practice are evaluated The intent of Item 3.4 is that infection prevention and control programs incorporate quality and safety principles to reduce infection rates. Actions 3.4.1 to 3.4.3 relate to the implementation of an overarching quality improvement approach to infection prevention and control. Appendix 1 outlines the steps for using a quality improvement approach. The activities undertaken as part of , , , , , and may also be used to demonstrate compliance with these actions. You should monitor any improvement activities undertaken to reduce infection risks to: Where relevant, undertake or participate in quality improvement activities that are conducted by the overarching health service organisation. If your community health service is responsible for implementing quality improvement activities, you should: engage clinicians and consumers to evaluate data and information on infection rates and risks conduct a review of existing infection control measures to identify areas for improvement brainstorm strategies to address the issues identified A risk register in line with that includes actions to address identified risks. A quality improvement plan in line with that shows implementation, regular review, revision and evaluation of outcomes. A log of activities conducted as part of a quality improvement model such as Data reports collected and monitored from pre- and post-quality initiatives. Outcomes and results of checklists and audits of infection control processes provided by external safety and quality organisations.
Overview of what is required Suggested approach Examples of evidence 3.11 Implementing systems for using standard precautions and transmission based precautions 3.11.1 Standard precautions and transmission-based precautions consistent with the current national guidelines are in use The intent of Item 3.11 is to minimise infection risk to both consumers and clinicians through the routine application of basic infection prevention and control strategies. ‘Standard precautions’ refers to work practices that ensure a basic level of infection prevention and control. They apply to everyone, regardless of their perceived or confirmed infection status and should be applied in all treatment settings, including consumer’s homes. Infections that are transmitted by blood-to-blood contact (e.g. HIV, hepatitis B and hepatitis C) can be effectively controlled by standard precautions. These infections do not require transmission- based precautions to be used. Transmission-based precautions are required when there is an increased risk of transmission, with consumers or members of the workforce, suspected or confirmed to be infected with agents transmitted by contact, droplet or airborne routes. Identify whether the overarching health service organisation has a policy and governance framework for standard precautions and transmission-based precautions that is consistent with the current national guidelines and ensure it is operationalised locally. If you need to create a governance framework at a local level, you should: ensure that policies, procedures and/or protocols are based on the Australian Guidelines for the Prevention and Control of Infections in Health Care 41 use standardised signage for standard and transmission-based precautions ensure the policies, procedures and/or protocols address the areas of greatest infection risks ensure the workforce are aware of circumstances when standard and transmission-based precautions should be used and the appropriate use of them. Policies, procedures and/or protocols for the use of standard and transmission-based precautions that are consistent with the Australian Guidelines for the Prevention and Control of Infections in Health Care.41 Clear signage and instructions for the workforce and consumers is displayed in treatment and waiting areas. Workforce has access to relevant personal protective equipment. Infection prevention and control strategies Overview of what is required Suggested approach Examples of evidence Orientation manuals, education resources and records of attendance at training by the workforce on aseptic technique. Managing patients with infections and colonisations
Managing patients with infections and colonisations Overview of what is required Suggested approach Examples of evidence Develop an action plan that incorporates information from audits of standard precautions and transmission-based precautions. Maintain records of attendance by the workforce at education and training on safe work practices relating to standard precautions. Update resources on standard precautions and transmission-based precautions incorporating improvements in practice. Ensure resources are available to the workforce. Examples of improvement activities that have been implemented and evaluated to improve compliance with standard precautions. Memos, newsletters or other communication material provided to the workforce and consumers on the use standard precautions. Orientation manuals, education resources and records of attendance at training by the workforce on standard precautions. Standard and transmission-based precaution signage available and accessible to the health workforce. 3.11.4 Compliance with transmission-based precautions is monitored 3.11.5 Action is taken to improve compliance with transmission-based precautions The workforce need to know when and how to apply transmission-based precautions to minimise infection risk. Your community health service should regularly review workplace practices to assess workforce compliance with national infection control guidelines. Auditing practices against the key elements of transmission-based precautions should identify gaps or risks and inform the development of strategies to minimise these risks. This information will determine the areas where improvements are needed. Once gaps and risks are identified, your community health service will need to consider appropriate improvement activities to address these. Develop, implement and monitor quality improvement plans that focus on areas where audit results have identified gaps in the application of transmission-based precautions. Maintain and monitor a risk register that includes actions to mitigate identified risks. Provide communication materials to the workforce and consumers. Maintain education and training records for the workforce. Use standard signage to provide instruction to both workforce and consumers. Audits of workforce compliance with elements of transmission-based precautions and associated safe work practices. Reports provided to relevant committee(s) and/or the governing body on workforce compliance with transmission-based precautions. Relevant documentation from committees and other meetings where reports on workforce compliance with transmission-based precautions are reviewed and discussed. A risk register in line with that includes actions to address identified risks. A quality improvement plan in line with that includes actions to address issues identified.
Managing patients with infections and colonisations Overview of what is required Suggested approach Examples of evidence Consumers who are known to have an infection or are contagious may need to be excluded from the service for a period of time. Exclusion of consumers may not always be feasible when services are provided in the home environment. Clinicians should utilise appropriate standard and transmission-based precautions when providing care in a consumer’s home (see ). Ensure protocols outline how consumers will be assessed, treated, deferred or alerted to risks when making appointments during periods when infections may be more common e.g. seasonal influenza during winter or local outbreaks of viral gastroenteritis. Where relevant, analyse reports on maintenance and air handling systems and identify actions to reduce the risks identified. Review audit results or evaluation reports of the cleaning activities undertaken by cleaning staff or cleaning contractors. Audit of risk assessment practices against guidelines and policies. Reports from surveillance activities. Audit data on the use of risk alerts. Review of maintenance and air handling system requirements. 3.13 Developing and implementing protocols relating to the admission, receipt and transfer of patients with an infection 3.13.1 Mechanisms are in use for checking for pre-existing healthcare associated infections or communicable disease on presentation for care 3.13.2 A process for communicating a patient’s infectious status is in place whenever responsibility for care is transferred between service providers or facilities The intent of these actions is to minimise exposure of the workforce and consumers to infectious agents transmissible from other consumers presenting for care or being referred for treatment. Mechanisms should be in place to enable the workforce to effectively assess infection risk or identify infectious diseases on presentation or when consumers commence services. Key times when a consumer’s infectious status should be evaluated and documented include: Ensure policies, procedures and/or protocols are in place that outline how consumers will be assessed, treated, deferred or alerted to risks: on presentation or commencement of services when making appointments during periods when infections may be more common e.g. seasonal influenza or local outbreaks of viral gastroenteritis. Planning for the management of consumers with suspected or confirmed infections may involve: Policies, procedures and/or protocols that outline the identification and management of consumers with pre-existing healthcare associated infection or communicable disease. Policies, procedures and/or protocols that address the clinical risk of handover for consumers with infections. Relevant documentation from committees and other meetings related to healthcare associated infection screening.
Governance and systems for medication safety Overview of what is required Suggested approach Examples of evidence regularly review and update the log or register of medication authorities routinely revalidate medication authorities. Ensure contracts for medication management services from an external provider specify the medication authorities in the scope of practice of the contractor. Review medication incidents in which unauthorised clinicians have prescribed, supplied or administered medicines. Review the effectiveness of the medication authorisation system and use the information to identify areas for improvement. Audit of medication authorities and prescribing practices during a clinical record or random audit. Relevant documentation from committees and other meetings where reports on medication incidents and breaches of the medication authorisation system are reviewed and discussed. A risk register in line with that includes actions to address identified risks. A quality improvement plan in line with that includes actions to address issues identified. Examples of improvement activities to increase the effectiveness of the medication authority system that have been implemented and evaluated. 4.4 Using a robust organisation-wide system of reporting, investigating and managing change to respond to medication incidents 4.4.1 Adverse medication incidents are regularly monitored, reported and investigated These actions relate to processes for recording, reporting and responding to medication incidents when they occur in community health services or where, during the course of providing consumer care, community health services identify an adverse medication incident that may have occurred externally to the service. Your community health service needs to ensure that systems are in place to ensure: adverse medication incidents are managed medication incident reporting occurs If the overarching health service organisation has an established system for reporting medication incidents, these should be implemented locally. If your community health service is responsible for implementing a system for reporting medication incidents you need to ensure: policies, procedures and/or protocols are in place to report incidents, including forms or templates that are accessible to the workforce Policies, procedures and/or protocols for reporting, investigating and managing medication incidents, adverse drug reactions and near misses. An incident register in line with that includes documentation of medication incidents, adverse drug reactions and near misses. Relevant documentation from committees and meetings that demonstrate medication incidents are routinely reviewed.
Documentation of patient information Overview of what is required Suggested approach Examples of evidence report adverse drug reactions to the TGA (see ). providing education and training for the workforce on identifying, documenting and recording medication allergies and adverse drug reactions guidance for the workforce on how to communicate with consumers/carers when adverse drug reactions occur. Include information on known medication allergies and adverse drug reactions from service contractors, such as a community pharmacist, in the consumer’s clinical record. Audit of the use of adverse drug reaction alert systems in electronic medicines management software. Orientation manuals, education resources and records of attendance at training by the workforce about recording known medication allergies and reporting adverse drug reactions. 4.7.2 Action is taken to reduce the risk of adverse reactions It is important that your community health service monitors the quality and use of documented adverse drug reactions. Use audits and quality improvement activities to monitor adverse drug reaction documentation (see ). Use the results of audits to identify actions to improve documentation, reduce risks and guide education needs, and ensure these are included in the relevant quality improvement plan (see ) and risk register (see ). Consider using an adverse drug reaction summary sheet at the front of the consumer’s clinical record, and allergy alert stickers on paper-based records. Where electronic clinical records are used, ensure that adverse drug reactions are recorded and visible when medicines are prescribed, dispensed, supplied and administered. Relevant documentation from committees and other meetings where reports on adverse drug reactions are reviewed and quality improvement strategies discussed. Register of adverse drug reactions that includes actions to address identified risks and documentation of completed actions. A quality improvement plan in line with that includes actions to address issues identified and evaluation of outcomes. Examples of improvement activities that have been implemented to reduce the risk of adverse reactions, such as changes to policies, procedures and/or protocols. Orientation manuals, education resources and records of attendance at training of workforce on: obtaining and documenting a medication allergy and adverse drug reaction history
Documentation of patient information Overview of what is required Suggested approach Examples of evidence 4.8 The clinical workforce reviewing the patient’s current medication orders against their medication history and prescriber’s medication plan, and reconciling any discrepancies 4.8.1 Current medicines are documented and reconciled at admission and transfer of care between healthcare settings Medication reconciliation improves consumer safety by mitigating the risk of a medication incident. Consumers of your community health service who are prescribed or administered medicines should have their medicines reconciled when commencing services and when services cease. For long-term clients, additional reconciliation may be required. To achieve this action your community health service should: ensure a process for a formal, structured process of medication reconciliation is implemented integrate this process into existing work flows monitor workforce compliance with this process look for opportunities to improve this process. Define and document the types of consumers who may require medication reconciliation. This may include determining which types of services/visits require medication reconciliation, and how often it should be carried out. A screening or risk assessment approach may be appropriate for identifying consumers at risk. Identify existing and suitable procedures, guidelines or similar, for a formal, structured process on reconciling medicines. Develop an implementation plan to integrate the process into existing workflow, using a multidisciplinary, quality improvement approach that involves consumers and carers in the process. The plan might include: using the MMP or equivalent (hard copy or electronic) document to support the reconciliation process giving priority to reconciling medicines for consumers with a higher risk of experiencing medication-related adverse events, and where medicines have been commenced, changed or ceased during care provided by your community health service. Policies, procedures and/or protocols that define and prioritise the types of consumers who may require medication reconciliation, and include requirements for reconciling medicines on service commencement, transition to another healthcare setting or when services cease. Implementation of a screening tool or risk assessment tool. Audit of consumer clinical record with documented medication reconciliation on service commencement, transition and when services cease. Audit of consumer clinical records with a completed medication management plan or equivalent (hard copy or electronic). Orientation manuals, education resources and records of attendance at training by the workforce on processes for reconciling medicines.
Medication management processes Overview of what is required Suggested approach Examples of evidence Identify methods to promote the use of information resources about medicines and decision support tools that are effective for your community health service. This may involve using communication strategies that have been implemented in your community health service, such as newsletters, presentations, in service education sessions, awareness campaigns and desktop icons. 4.9.2 The use of the information and decision support tools is regularly reviewed Your community health service should ensure there is a process in place to regularly review the currency and endorsement of information resources about medicines and decision support tools, particularly when there is a change to organisational policies, procedures and/or protocols or new versions of tools are released. Information about medicines should be regularly reviewed to ensure they remain relevant to the community health service policies, procedures and/or protocols, the services it provides, medication management practices and emerging clinical evidence. Audit the availability and currency of information resources about medicines and other decision support tools in your community health service. Obtain clinician feedback about the content and usefulness of resources, using methods such as targeted surveys, discussion groups, or existing communication infrastructure. This strategy should be multidisciplinary. Relevant documentation from committees and other meetings where the development and maintenance of information resources about medicines and decision support tools are discussed. Observational audit or survey on use and currency of decision support tools. Records of clinical workforce access to electronic medicines information systems (where available). Record of workforce feedback and suggestions on information about medicines, and decision support tools.
Medication management processes Overview of what is required Suggested approach Examples of evidence regular review of medicines stock lists to ensure that products and stock levels are aligned to clinical needs standardised labelling of storage areas, physical separation of products (e.g. look- alike, sound-alike products), use of National Tall Man Lettering inspection of medicine storage areas, facilities and/or equipment to ensure appropriateness of products stocked, levels of stock, expiry dates, and sustained compliance with medication safety strategies. Where medicine storage risks are identified in home settings, the workforce should provide advice to consumers on the safe and appropriate storage of medicines. A risk register in line with that demonstrates action taken to reduce identified risks. A quality improvement plan in line with that includes actions to address issues identified. Examples of improvement activities that have been implemented and evaluated to reduce the risks associated with storage and distribution of medicines. Memos, newsletters or other communication material provided to the workforce on safe and secure distribution and storage of medicines. Orientation manuals, education resources and records of attendance at training by the workforce on safe and secure distribution and storage of medicines. Information sheets for consumers on the safe and appropriate storage of medicines at home. 4.10.3 The storage of temperature-sensitive medicines is monitored This action is applicable to community health services that distribute or administer temperature- sensitive medicines. Your community health service needs to ensure the integrity of temperature-sensitive medicines is maintained by: storing medicines according to manufacturer recommendations using equipment allocated solely for pharmaceutical products If your community health service distributes or administers temperature-sensitive medicines, review the current arrangements for the storage of temperature-sensitive medicines to ensure: policies, procedures and/or protocols are in place for regular monitoring and recording of storage temperatures staff with responsibilities for the administration and storage of temperature-sensitive medicines are aware of specific requirements to protect the integrity of medicines and what action to take if there is a cold-chain breach Policies, procedures and/or protocols for the safe and effective storage of temperature- sensitive medicines in refrigerators and when being transported. Policies, procedures and/or protocols for management of cold-chain breaches. Orientation manuals, education resources and records of attendance at training by the workforce on safe and effective storage of temperature-sensitive medicines.
Governance and systems for the prevention and management of pressure injuries Overview of what is required Suggested approach Examples of evidence Audit consumer clinical records for: use of pressure injury risk screening and assessment tools completed pressure injury treatment and management plans. Provide reports on workforce compliance with the pressure injury prevention and management system to the responsible individual, relevant committee and/or the governing body. 8.2 Using a risk assessment framework and reporting systems to identify, investigate and take action to reduce the frequency and severity of pressure injuries 8.2.1 An organisation-wide system for reporting pressure injuries is in use 8.2.2 Administrative and clinical data are used to regularly monitor and investigate the frequency and severity of pressure injuries 8.2.3 Information on pressure injuries is regularly reported to the highest level of governance in the health service organisation 8.2.4 Action is taken to reduce the frequency and severity of pressure injuries Many of the actions in Standard 8 are based on a quality improvement cycle where: policies, procedures and/or protocols for pressure injury prevention and management are developed (either locally or centrally) the pressure injury prevention and management systems are implemented locally compliance with, and performance of the pressure injury prevention and management systems is monitored (centrally or locally) local action is taken to improve performance. Actions 8.2.2 and 8.2.3 relate to the monitoring stage of the quality improvement cycle. They require the following activities take place: Ensure that pressure injuries are included in the incident reporting system required under . Review the information on pressure injuries reported through the incident reporting system to ensure sufficient data is collected to identify the factors that contributed to the development of pressure injuries. Review reports on pressure injuries from the incident reporting system and results of investigations and include in the organisation- wide risk register (see ). Ensure the workforce are trained in identifying and reporting pressure injuries using the organisation’s incident reporting system. Policies, procedures and/or protocols that outline processes for reporting the incidence of pressure injuries. Standardised forms or templates for pressure injury reporting. Reports on routine performance measures for pressure injuries, including: frequency and severity usage rates of specified products or equipment. Reports on the prevalence and incidence of pressure injuries provided to the individual or committee responsible for the pressure injury prevention and management system, and/or the governing body.
Governance and systems for the prevention and management of pressure injuries Overview of what is required Suggested approach Examples of evidence Your policies, procedures and/or protocols should provide guidance on alternatives available and what to document when a person in their own home refuses to use recommended equipment or recommended equipment is not available. Relevant documentation from committees and other meetings where reports on pressure injury prevention and management equipment resource allocation and efficacy are reviewed and discussed. Preventing pressure injuries Overview of what is required Suggested approach Examples of evidence 8.5 Identifying risk factors for pressure injuries using an agreed screening tool for all presenting patients within timeframes set by best practice guidelines 8.5.1 An agreed tool to screen for pressure injury risk is used by the clinical workforce to identify patients at risk of a pressure injury 8.5.2 The use of the screening tool is monitored to identify the proportion of at-risk patients that are screened for pressure injuries on presentation 8.5.3 Action is taken to maximise the proportion of patients who are screened for pressure injury on presentation The next part of the organisation-wide pressure injury prevention and management system concerns the processes that are in place for identifying consumers who are at risk of developing pressure injuries. These actions require the inclusion of agreed risk assessment criteria for pressure injury in your community health service’s service commencement and ongoing assessment policies, procedures and/or protocols. Your community health service needs to agree on the screening process for pressure injuries including which evidence-based tools will be used. Ensure the pressure injury policy framework implemented locally includes an agreed process and criteria for screening to identify at risk consumers. Conduct local audits, or participate in audits conducted by the overarching health service organisation for compliance with the screening process. Monitoring and data collection systems should identify the proportion of consumers who are: screened at admission for their risk of pressure injury identified as at risk of pressure injury through the initial screening process Policies, procedures and/or protocols for screening consumers for pressure injury risk. Relevant documentation from committees and other meetings where pressure injury risk screening processes are discussed, agreed and monitored. Orientation manuals, education resources and records of attendance at training by the workforce on assessment processes including conducting pressure injury risk screening. Audit of consumer clinical records to demonstrate compliance with the screening process and use of agreed screening tool, where applicable.
Preventing pressure injuries Overview of what is required Suggested approach Examples of evidence When pressure injuries are reported, information should be gathered about what, if any, prevention plan was in place. This information should be reviewed to ensure the prevention strategies were implemented and that they are evidence-based and consistent with best practice guidelines. 8.7.3 Patient clinical records are monitored to determine the proportion of at-risk patients that have an implemented pressure injury prevention plan 8.7.4 Action is taken to increase the proportion of patients at risk of pressure injuries who have an implemented prevention plan Your community health service should undertake regular audits of consumer clinical records to determine the proportion of at risk consumers with a documented pressure injury prevention plan and to help identify where system improvements could be made. Conduct local audits, or participate in audits conducted by the overarching health service organisation to determine the proportion of consumers identified as at risk of pressure injuries with a completed prevention plan. Observational audits may be undertaken to determine whether at risk consumers are provided care that is consistent with their individual pressure injury prevention plan. Seek feedback from the workforce to identify any barriers to the development, implementation and documentation of pressure injury prevention plans. Use audit results and other information about pressure injury prevention plans to identify gaps in the current system and agree on quality improvement activities to address issues. Provide feedback to the workforce on compliance with processes for implementing pressure injury prevention plans and quality improvement activities undertaken to address issues. Audit of consumer clinical records to determine the proportion of at risk consumers with a current injury prevention plan. Report on consumers with documented pressure injury prevention plans compared to consumers screened as at risk. Memos, newsletters or other communication material provided to the workforce on pressure injury prevention plans and quality improvement activities. Relevant documentation from committees and other meetings where reports on implementation of pressure injury prevention plans are reviewed and discussed. A risk register in line with that includes actions to address identified risks. A quality improvement plan in line with that includes actions to address issues identified. Examples of improvement activities that have been implemented and evaluated.
Communicating with patients and carers Overview of what is required Suggested approach Examples of evidence 8.10 Developing a plan of management in partnership with patients and carers 8.10.1 Pressure injury management plans are developed in partnership with patients and carers Your community health service should inform consumers and carers about the purpose and process of developing a pressure injury management plan and invite them to be involved in its development (see ). Engage and collaborate with consumers and carers in the development of pressure injury management plans. Document the involvement of consumers and carers in pressure injury management plans. Seek feedback from consumers about their satisfaction with their involvement in the development of pressure injury management plans. Pressure injury management plans that provide space for consumer comment and signature. Results of consumer experience surveys regarding pressure injury management planning. Observation of consumers participating in making decisions about their care. Audit of consumer clinical records that demonstrates collaboration between clinicians and consumers in the development of pressure injury treatment plans.
Governance and systems for preventing falls Overview of what is required Suggested approach Examples of evidence making amendments to local policies, procedures and/or protocols or making recommendations to the overarching health service organisation for policies that sit at that level undertaking local evaluation, or participating in external evaluations of the impact of quality improvement activities. Memos, newsletters or other communication material provided to the workforce on performance of the falls management system and improvement strategies. A quality improvement plan in line with that includes actions to address identified falls issues. Examples of improvement activities that have been implemented and evaluated. 10.3 Undertaking quality improvement activities to address safety risks and ensure the effectiveness of the falls prevention system 10.3.1 Quality improvement activities are undertaken to prevent falls and minimise patient harm This action relates to the overarching quality improvement approach that is needed to prevent falls, reduce the harm from falls and improve falls management. Your community health service should use a continuous quality improvement methodology to implement falls prevention strategies (see ). Activities undertaken as part of , , and can be used to demonstrate compliance with this action. Review information from the organisation’s risk register, incident reporting system and other performance audits to identify areas of improvement for the falls management system. Where services are provided in home settings, consider the appropriateness of conducting environmental reviews and recommendations for modifications. Review the physical environment of your community health service and make modifications, where possible, to reduce the risk of falls. Participate in quality improvement activities that are conducted by the overarching health service organisation, where relevant. When conducting quality improvement activities locally, use a standardised quality improvement methodology to bring about change such as a Plan–Do–Study–Act cycle (see ). A risk register in line with that includes actions to address identified falls risks. A quality improvement plan in line with that includes actions to address issues identified. Completed environmental assessment of your community health service. Evidence of completed home environment assessments and recommendations for modifications according to falls risk. Relevant documentation from committees and other meetings where falls reduction strategies are discussed and agreed. Examples of improvement activities that have been implemented and evaluated. Reports on the impact of falls reduction strategies and quality improvement activities. Memos, newsletters or other communication materials provided to the workforce on the falls management system.
Governance and systems for preventing falls Overview of what is required Suggested approach Examples of evidence managing consumers falls risk in their own home who refuse to use recommended equipment implementing prevention plans when recommended equipment is not available accessing equipment depending on the consumers personal circumstances, for example hiring or purchasing options. Screening and assessing risk of falls and harm from falling Overview of what is required Suggested approach Examples of evidence 10.5 Using a best practice-based tool to screen patients on presentation, during admission and when clinically indicated for the risk of falls 10.5.1 A best practice screening tool is used by the clinical workforce to identify the risk of falls 10.5.2 Use of the screening tool is monitored to identify the proportion of at-risk patients that were screened for falls 10.5.3 Action is taken to increase the proportion of at-risk patients who are screened for falls upon presentation and during admission To achieve these actions, your community health service should ensure that: consumers are screened for their falls risk (either through a screening tool or through a process, such as clinical judgement) the result of the screening process is recorded in the consumers clinical record both screening and recording are monitored strategies to increase the number of consumers with a completed falls risk screening are implemented. Engage clinicians in the development, implementation and review of the falls management system including policies, procedures and/or protocols for screening of falls risk. This process should include a review of falls screening tools that are appropriate for your community health service and seek agreement on their inclusion as part of the screening process. Conduct local audits, or participate in audits of compliance conducted by the overarching health service organisation on the use of the agreed screening tool. Policies, procedures and/or protocols that outline the use of evidence-based falls screening tools (or use of clinical judgement) for screening consumers for risk of falls. Records of feedback from clinicians on the falls risk screening process including the use of screening tools. Audits of consumer clinical records for use of agreed screening tools or compliance with screening requirements. Observational audits for use of falls screening processes and tools.
Screening and assessing risk of falls and harm from falling Overview of what is required Suggested approach Examples of evidence both assessment and recording are to be monitored and strategies to increase the rate of assessment implemented, if appropriate. For community health services that do not have the capacity to conduct a comprehensive assessment, the falls management system should include a process that includes referrals for consumers to seek follow-up with another clinician, e.g. a general practitioner, community pharmacist or rehabilitation service, where available. Conduct local audits, or participate in audits of compliance conducted by the overarching health service organisation to assess the completion of comprehensive falls assessments. Seek feedback from the workforce on the barriers to conducting comprehensive falls assessments and use of agreed falls assessment tools. Provide reports on the proportion of at risk consumers receiving a comprehensive falls assessment to the individual or committee responsible for the falls management system and/or the governing body. Identify strategies to increase the rate of at risk consumers receiving a comprehensive falls assessment. Orientation manuals, education resources and records of attendance at training by the workforce on falls risk factors and assessment. Reports on the proportion of consumers at risk of falling that receive a comprehensive falls assessment are provided to the individual or committee responsible for the falls management system and/or the governing body. Reports on the number of consumers assessed and the incidence of falls. Observational audits on use of the assessment tool. Relevant documentation from committees and other meetings where reports on the use of falls assessment tools and compliance with assessment processes are reviewed and discussed. A quality improvement plan in line with that includes actions to address issues identified. Examples of improvement activities that have been implemented and evaluated.
Preventing falls and harm from falling Overview of what is required Suggested approach Examples of evidence Use the data and information collected from falls prevention and harm minimisation plans to implement strategies to improve their effectiveness in reducing incidence of falls. Communicate changes to the falls management system to the workforce and ensure they are aware of and trained in new policies, procedures and/or protocols. Examples of improvement activities that have been implemented and evaluated. Memos, newsletters or other communication material developed for workforce and consumers. 10.8 Patients at risk of falling are referred to appropriate services, where available, as part of the discharge process 10.8.1 Discharge planning includes referral to appropriate services, where available This action relates to the need to consider falls risks when services cease and care is transferred. Establish relationships with external service providers to identify services that can be accessed by consumers when services cease or care is transferred. Maintain a log of services to which your community health service can refer consumers for follow up. Implement formal referral arrangements or memoranda of understanding with external service providers to whom you regularly refer. Work with referring clinicians to develop standardised referral documents, forms or templates. Referral documentation to the general practitioner (or other provider) should detail falls risks identified and falls experienced during the episode of care and actions taken. The falls management system should include criteria for referral of consumers to other service providers. A log of external service providers to which your community health service regularly refers. Formal contractual arrangement or memorandum of understanding between external service providers and your community health service. Standardised referral documents, forms or templates. Feedback from the workforce and external service providers on the organisation’s referral and clinical handover processes. Audit of consumer clinical records shows that falls risk is identified in the service cessation plan and includes referrals to: specialist clinicians such as geriatricians, ophthalmologists continence consultants or nurses allied health professionals such as physiotherapists, occupational therapists, podiatrists, dieticians or optometrists general practitioners.
This criterion will be achieved by Actions required C/D 3.1 Developing and implementing governance systems for effective infection prevention and control to minimise the risk to patients of healthcare associated infections 3.1.1 A risk management approach is taken when implementing policies, procedures and/or protocols for: standard infection control precautions transmission-based precautions aseptic technique safe handling and disposal of sharps prevention and management of occupational exposure to blood and body substances environmental cleaning and disinfection antimicrobial prescribing outbreaks or unusual clusters of communicable infection processing of reusable medical devices single-use devices surveillance and reporting of data where relevant reporting of communicable and notifiable diseases provision of risk assessment guidelines to workforce exposure-prone procedures C 3.1.2 The use of policies, procedures and/or protocols is regularly monitored C 3.1.4 Action is taken to improve the effectiveness of infection prevention and control policies, procedures and/or protocols D 3.7 Promoting collaboration with occupational health and safety programs to decrease the risk of infection or injury to healthcare workers 3.7.1 Infection prevention and control consultation related to occupational health and safety policies, procedures and/or protocols are being implemented to address: communicable disease status occupational management and prophylaxis work restrictions personal protective equipment assessment of risk to healthcare workers for occupational allergies evaluation of new products and procedures C 3.13 Developing and implementing protocols relating to the admission, receipt and transfer of patients with an infection 3.13.1 Mechanisms are in use to check for pre-existing healthcare associated infection or communicable disease on presentation for care C
This criterion will be achieved by Actions required C/D 6.2 Establishing and maintaining structured and documented processes for clinical handover 6.2.1 The workforce has access to documented structured processes for clinical handover that include: preparing for handover, including setting the location and time whilst maintaining continuity of patient care organising relevant workforce members to participate being aware of the clinical context and patient needs participating in effective handover resulting in transfer of responsibility and accountability for care C 8.1 Developing and implementing policies, procedures and/or protocols that are based on current best practice guidelines 8.1.1 Policies, procedures and/or protocols are in use that are consistent with best practice guidelines and incorporate screening and assessment tools C 8.1.2 The use of policies, procedures and/or protocols are regularly monitored C 10.1 Developing, implementing and reviewing policies, procedures and/or protocols, including the associated tools, that are based on the current national guidelines for preventing falls and harm from falls 10.1.1 Policies, procedures and/or protocols are in use that are consistent with best practice guidelines (where available) and incorporate screening and assessment tools C