A better way to care
Introduction to National Safety and Quality Health Service Standards 1
The Victorian Department of Health is making this document freely available on the internet for health services to use and adapt to meet the National Safety and Quality Health Service Standards of the Australian Commission on Safety and Quality in Health Care. Each health service is responsible for all decisions on how to use this document at its health service and for any changes to the document. Health services need to review this document with respect to the local regulatory framework, processes and training requirements.
The author disclaims any warranties, whether expressed or implied, including any warranty as to the quality, accuracy, or suitability of this information for any particular purpose. The author and reviewers cannot be held responsible for the continued currency of the information, for any errors or omissions, and for any consequences arising there from.
Published by Sector Performance, Quality and Rural Health, Victorian Government, Department of Health
June 2014
Introduction to National Safety and Quality Health Service Standards 1
Acknowledgements
The Department of Health Victoria acknowledges the contribution of medical and health specialists, Victorian health services, and members of the National Safety and Quality Health Service Standards: Educational Resources Project project team, Steering Group and Advisory Committee.
For the Partnering with Consumers module and Person and Family Centred Care modulethe Consumer Partnerships and Quality Standards Unit, Department of Health Victoria; and, the Health Issues Centre,provided specialist advice
For the Preventing and Controlling Healthcare Associated Infections module the Victorian Rural Infection Control Practice Group (RICPRAC) provided specialist advice.
For the Blood and Blood Products module the Blood Matters Program, Department of Health, Victoria/ Australian Red Cross Blood Service, provided specialist advice.
For the Preventing and Managing Pressure Injuries module, Regional Wounds Victoria provided specialist advice.
For the Preventing Falls and Harm from Falls module Professor Keith Hill, Head of School, School of Physiotherapy and Exercise Science, Faculty of Health Sciences, Curtin University provided specialist advice.
The Educational Resources Project Steering Group members comprised:
Associate Professor Leanne Boyd, Steering Group Chair; Director of Education, Cabrini Education and Research Precinct, Cabrini Health
Ms Madeleine Cosgrave, Project Manager
Ms Susan Biggar, Senior Manager, Consumer Partnerships, Health Issues Centre
Mr. David Brown, Consumer representative
Dr Jason Goh, Medical Administration Registrar - Cabrini Health
Mr Matthew Johnson, Simulation Manager, Cabrini Education and Research Precinct, Cabrini Health
Ms Tanya Warren, Educator, Cabrini Education and Research Precinct, Cabrini Health
Ms Marg Way, Director, Clinical Governance, Alfred Health
Mr Ben Witham, Senior Policy Officer, Quality and Safety, Department of Health Victoria
The Educational Resources Project Advisory Committee members comprised:
Associate Professor Leanne Boyd, Advisory Committee Chair; Director of Education, Cabrini Education and Research Precinct, Cabrini Health
Ms Madeleine Cosgrave, Project Manager
Ms Margaret Banks, Senior Program Director, Australian Commission on Safety and Quality in Health Care
Ms Marrianne Beaty, Oral Health National Standards Advisor, Dental Health Services Victoria)
Ms Susan Biggar, Senior Manager, Consumer Partnerships, Health Issues Centre
Mr David Brown, Consumer representative
Dr Jason Goh, Medical Administration Registrar, Cabrini Health
Ms Catherine Harmer, Manager, Consumer Partnerships and Quality Standards, Department of Health, Victoria
Ms Cindy Hawkins, Director, Monash Innovation and Quality, Monash Health
Ms Karen James, Quality and Safety Manager, Hepburn Health Service
Mr Matthew Johnson, Simulation Manager, Cabrini Health
Ms Annette Penney, Director ,Quality and Risk, Goulburn Valley Health
Ms Gayle Stone, Project Officer, Quality Programs,Commission for Hospital Improvement, Department of Health Victoria
Ms Deb Sudano, Senior Policy Officer, Quality and Safety, Department of Health Victoria
Ms Tanya Warren, Educator, Cabrini Health
Ms Marg Way, Director, Clinical Governance, Alfred Health
Mr Ben Witham, Senior Policy Officer, Quality and Safety, Department of Health Victoria
Contents
Introduction to National Safety and Quality Health Service Standards
Introduction
Learning outcomes
Aim of NSQHS Standards
Background
Standard 1: Governance for Safety and Quality in Health Service Organisations
Standard 2: Partnering with Consumers
Standard 3: Preventing and Controlling Healthcare Associated Infections
Standard 4: Medication Safety
Standard 5: Patient Identification and Procedure Matching
Standard 6: Clinical Handover
Standard 7: Blood and Blood Products
Standard 8: Preventing and Managing Pressure Injuries
Standard 9: Recognising and Responding to Clinical Deterioration in Acute Health Care
Standard 10: Preventing Falls and Harm from Falls
Accreditation
Accreditation
Accreditation process
Summary
References
Introduction to National Safety and Quality Health Service Standards 1
Introduction to National Safety and Quality Health Service Standards
Introduction
This module relates to the National Safety and Quality Health Service (NSQHS) Standards.
Learning outcomes
On completion of this module, clinicians will be able to:
- Describe the safety and quality areas covered by the NSQHS Standards.
- Describe the intention of the NSQHS Standards.
- Differentiate between core and developmental actions.
- Understand the link between standards and accreditation.
Aim of NSQHS Standards
The Australian Commission on Safety and Quality in Health Care (the Commission) developed the 10 NSQHS Standards to reduce the risk of patient harm and improve the quality of health service provision in Australia.
The Standards focus on governance, consumer involvement and clinically related areas and provide a nationally consistent statement of the level of care consumers should be able to expect from health services.
Background
The NSQHS Standards from the Commission have been implemented nationally from 2013 and are compulsory for the majority of public and private health care organisations.
The principles inStandard 1: Governance for Safety and Quality in Health Service Organisations and Standard 2: Partnering with Consumersare fundamental to all Standards andprovide a framework for their implementation.
Standard 1: Governance for Safety and Quality in Health Service Organisations
Good governance is vital to improving safety and quality of health care services. Health service organisation leaders implement governance systems to set, monitor and improve the performance of the organisation as well as communicate the importance of the patient experience and quality management to all members of the workforce. Clinicians and other members of the workforce use the governance systems.
This standard requires that:
- There is an integrated system of governance that actively manages patient safety and quality risks.
- The governance system sets out safety and quality policy, procedures and/or protocols, as well as assigns roles, responsibilities and accountabilities for patient safety and quality.
- The clinical workforce is guided by current best practice and uses clinical guidelines that are supported by the best available evidence.
- Managers and the clinical workforce have the right qualifications, skills and approach to provide safe, high‐quality health care.
- Patient feedback is actively encouraged. Patient safety and quality incidents and complaints are recognised, reported and analysed. This information is used to improve safety systems.
- Patient rights are respected and their engagement in their care is supported.
- Organisational policies reflect the Australian Charter of Health Care Rights and processes are in place to enable patients to be partners in decisions about their care.
ACSQHC, 2012
Manager Responsibilities
To ensure that:
- systems are in place including escalation protocols,to assess and maximise patient safety and minimise risks to patients
- systems and practice models encourage collaboration between patients, carers and the health care team regarding care planning and treatment decisions
- policies and procedures are current, evidence based and comprehensive and are easily accessible to staff
- data from audits, complaints and incidents is used to improve systems and practices
- staff have the skills, training and resources to support safe and effective care
- staff are aware of safety and quality systems and are encouraged and supported to adhere to these systems
- feedback is providedto staff on performance evaluation from incidents, complaints, audits, surveys and other data collections
Staff Responsibilities
- access and comply with evidence based policies and procedures
- conform with scope of practice requirements and keep up to date with training and skill development
- report ALL adverse events and near misses in the local risk or incident managementsystem and be aware of quality improvements to systems and practices
- participate in relevant education, training, audit and quality improvement activities
ACSQHC, 2012
Standard 2: Partnering with Consumers
There is growing evidence about the improvement in health outcomes from real partnerships between health service organisations, health professionals, patients and carers.
Leaders of health service organisations are responsible for implementing systems to support partnering with patients and carersto improve the quality of care. These systems will assist in developing partnerships between patients, carers, clinicians and health services.
Patient centred care is an approach to health care that is respectful of, and responsive to, the preferences, needs and values of patients and consumers. An integral component of patient centred care is collaboration – partnering with consumers.
This standard requires that:
- Governance structures are in place to form partnerships with consumers and carers.
- Consumers and carers are supported by the health care organisation to actively participate in the improvement of the patient/client experience and their health outcomes.
- Consumers and carers receive information on the health service organisation’s performance and contribute to the ongoing monitoring, measurement and evaluation of performance for continuous quality improvement.
Manager responsibilities
To ensure that:
- consumer engagement policies and processes exist within the organisation and strategies are implemented to support meaningful engagement
- governance structures exist to facilitate partnerships with consumers
- staff are aware of, understand and are supported to apply, concepts of patient centred care
- patient information pamphlets have been reviewed by consumers for appropriateness of content, language and format
- patients and carers provide feedback within the organisation and are involved in quality improvement initiatives
- education and training is provided to staff in relation to patient centred care
Staff responsibilities
- treat patients and their families with dignity and respect
- understand, document and communicate patients’ and carers’ needs and preferences and assist them to be met
- encourage patients and carers to be involved in decision making about their care and participate in care planning and treatment decisions
- provide accurate and timely information to patients and their carers ensuring that this information is understood
- participate in relevant education and training
- assist patients and carers to provide feedback within your organisation
ACSQHC, 2012
Standard 3: Preventing and Controlling Healthcare Associated Infections
Health care associated infections are the most common complications affecting patients in hospitals. Each year, around 200,000 health care associated infections are contracted by patients in Australia. At least half of health care associated infections are preventable.
NHMRC, 2010
Clinical leaders and senior managers of a health service organisation implement systems to prevent and manage health care associated infections and communicate these to the workforce to improve patient outcomes. Clinicians and other members of the workforce use the health care associated infection prevention and control systems.
This standard requires that:
- Effective governance and management systems for health care associated infections are implemented and maintained.
- Strategies for the prevention and control of healthcare associated infections are developed and implemented.
- Patients presenting with, or acquiring, an infection or colonisation during their care are identified promptly and receive the necessary treatment and management.
- Safe and appropriate antimicrobial prescribing is a strategic goal of the clinical governance system.
- Health care facilities and the associated environment are clean and hygienic.
- Reprocessing of reusable equipment and instrumentation meets current best practice guidelines.
- Information on health care associated infection is provided to patients, carers, consumers and service providers.
Manager responsibilities
To ensure that
- staff are aware of, and comply with, infection prevention and control practices, hand hygiene procedures and aseptic technique
- systems are in place to assess patients for communicable diseases on presentation and communicate status at all clinical handovers
- antimicrobial stewardship guidelines are promoted and implemented
- staff immunisation requirements are monitored
- staff are provided with timely information on data collection and surveillance activities
Staff responsibilities
- follow the 5 moments for hand hygiene, and infection prevention and control precautions
- practice the principles of aseptic technique and antimicrobial stewardship
- ensure safe handling of sharps and prevent occupational exposure to blood and body fluids
- assess patients for communicable diseases and communicate status as part of all clinical handovers
- involve patients and their families in reducing the risk of infections
- comply with workforce immunisation requirements against vaccine preventable diseases
ACSQHC, 2012
Standard 4: Medication Safety
Medicines are the most common treatment in health care. Because they are so commonly used, medicines are associated with a higher incidence of errors and adverse events than other health care interventions.
Clinical leaders and senior managers of health service organisations implement systems to reduce the occurrence of medication incidents and improve the safety and quality of medicine use. Clinicians and other members of the workforce use the systems to safely manage medicines.
This standard requires that:
- Health service organisations have mechanisms for the safe prescribing, dispensing, supplying, administering, storing, manufacturing, compounding and monitoring of the effects of medicines.
- The clinical workforce accurately records a patient’s/client’s medication history and this history is available throughout the episode of care.
- The clinical workforce is supported for the prescribing, dispensing, administering, storing, manufacturing, compounding and monitoring of medicines.
- The clinical workforce provides a complete list of patient’s medicines to the receiving clinician and patient when handing over care or changing medicines.
- The clinical workforce informs patients about their options, risks and responsibilities for an agreed medication management plan.
Manager responsibilities
To ensure that:
- legislation, scope of practice requirements and health service policies and protocols are followed when medicines are prescribed, stored, dispensed and administered
- medicines are included within patient identification and clinical handover protocols
- systems are in place and staff are supported to collaborate with patients and carers in the development of their medication plan
- education and training requirements for medication safety are met
- current and accurate medicines information and decision support tools are available to staff when medicines are prescribed, dispensed and administered
- regular assessment and audits are completed to identify areas of weakness in the medication use system and guide and monitor improvement
Staff responsibilities
- be awareof, and comply with, legislation, scope of practice and health service policies and protocols in relation to prescribing, storing, dispensing and administering medicinesincluding high risk medicines
- ensure that patient identification and clinical handover protocols are followed in relation to medicines. This includes a current comprehensive list of medicines, including reasons for any changes, provided to the receiving clinician and patient at discharge
- obtain and record an accurate medication history when patients are admitted that includes allergies and adverse drug reactions
- understand responsibility for reconciling medicines when care is transferred
- participate in medication safety education and training, practice review and improvement programs
- provide the patient and carer, if appropriate, with patient specific medicine information which includes treatment, options, benefits and associated risks
- ensure information provided to patients is presented in a format which meets their needs and is understood
- report all medication related incidents and near misses in the risk or incident management system
ACSQHC, 2012
Standard 5: Patient Identification and Procedure Matching
Ensuring the right care is provided to the right patient is an essential part of providing and receiving safe care. The failure to correctly identify patients/clients and match that information to an intended treatment or intervention continues to result in procedures being performed on the wrong person, wrong side or wrong site, medication errors, blood transfusion errors and errors in diagnostic testing.
Clinical leaders and senior managers of a health service organisation implement systems to ensure the correct identification of patients/clients and correct matching of patients with their intended treatment. Clinicians and other members of the workforce use the patient identification and procedure matching systems.