Standard 1: Governance for safety and quality in
heath service organisations
Advice Centre Network Meeting
Margaret Banks
Senior Program Director
February 2013
Standard 1
• Overarching standard, setting the
framework to implement the clinical
standards 3 to 10
• Assessed at every accreditation event
• Not achievable without engagement at all
levels of the organisation
Standard 1 - Governance for Safety and Quality
Focus is on systems
• Setting up policies and processes
• Clarifying accountability and responsibility
• Providing a structure for good clinical practice
• Determining reporting and monitoring
• Specifying workforce requirements
• Setting the framework for ensuring patients rights
Risk Assessment
Standard 1.5 requires an organisation-wide risk management system
Risk management approach
Risk management is the design and implement of activities to identify
and avoid or minimise risks to patients, employees, visitors and the
institution.
To manage their safety and quality risks, health services will need to
– demonstrate they have undertaken a comprehensive risk analysis
– collect data that provide information about the risks and trends over
time
– prioritise risks across an the health service
– implement strategies that focus on areas of greatest risk
– consider wards/facilities specific risk and put in place strategies that
are appropriate
Workforce Training
1.4.4 requires Competency-based training is provided
to the clinical workforce to improve safety and quality
Not intended that health services apply resources to
training competent staff
Health services need to be able to:
• Articulate the competencies required
• Identify the areas posing the greatest risk to patients when the
workforce is not appropriately skilled
• Determine how competencies will be assessed
• Assess the workforce and identify those that require training
• Schedule training only for members of the workforce that require
additional or higher levels of competencies
Data and Monitoring
1.6 requires organisation monitoring and reporting, that is the basis for
monitoring and reporting throughout the rest of the Standards: eg
3.2
Surveillance of healthcare associated infections
4.10.3 Monitoring of temperature-sensitive medicines
7.8.1 Monitoring blood wastage
This information is key to:
•
Measuring and managing risks
•
Change management
•
Information for decision making
•
Identify areas for improvement
•
Driving and evaluating continuous quality improvement
•
Providing evidence for accreditation
Questions
• Is it a requirement to have the Standards as part of staff and
performance appraisals?
The Standards shouldn’t be part of the conversation, safety
and quality should be. This may include their understanding
of their role, issues they have identified, training
requirements, involvement in safety and quality activities.
• We use a Framework for Quality and Patient Care that
covers Action 1.1, do we need to badge this as a policy?
No, the name is immaterial, so long as it is clear to staff this
is the basis for setting rules and expectations and directing
bahaviour
Questions
• Is 1.3 just about WHS?
1.3 is about clarifying what each person is responsible for and how
they are held accountable for this for safety and quality generally in
the organisation and specifically for them. It is broader than
workplace health and safety and should address each of the issues
covered by these Standards and any other safety risks identified for
their organisation.
• Does my board, with extensive skill and experience in governance
need further training to meet the requirements of these Standards?
No, they may not, but they will need to be informed about the intent
of the Standards, they may advice on reading, interpreting and
knowing what safety and quality information to ask for to make
informed decisions on behalf of the organisation.
Questions
• Does 1.10 requires peer review processes be put in place for
nurses?
Peer review is one mechanism to determine if a clinician is working
within their scope of practice. For nursing, you could position
descriptions, orientation to the service unit whenever a clinician
takes up a new role, supervision, procedures that specify the level
or type of clinician to perform a task/function.
• How do we put in place 1.10.1 for VMOs?
Defining the scope of practices for VMOs is done through a
credentialling process, which considers the VMOs skills, the
requirements and capabilities of the organisation and the service to
be provided. Once defined the VMO should be informed/trained to
perform this role and any restrictions on the role. Processes need
to be in place so the VMO practices only within the agreed scope of
practice.
Questions
• The Standards require routine / regular review, how often is that?
How often a item is monitored, audited or reviewed is dependent on the
risk of harm and the service context. The simpler the service the less
frequent the review.
Where there a greater risk of patient harm, reviews will occur more often.
Harm can result because something is inherently risky, or because it
occurs frequently so the chance of harm occurring is greater, or is an
infrequent events that cause catastrophic so requires frequent review so
harm can be avoided.
• What training is mandatory and how do we provide competency based
training?
The Standards mandate training of Aseptic Technique and Basic Live
Support, and this is only provided where there are skills gaps identified
following an assessment. Other training provided in safety and quality
should be determined by the organisations safety and quality needs.
What does this mean for Accreditation?
No longer possible to achieve accreditation if:
• The organisations relies on ‘events management’
• The Quality Manager is responsible for the organisation
achieving accreditation
The new requirements mean that:
• Standards are no longer assessed ‘on balance’ and
• Health services must provide evidence that each action is
met
Again – it is not possible to meet accreditation requirements
without the participation of the whole organisation
Providing evidence for accreditation
• Quality improvement processes generate
documentation
• Evidence for accreditation should come from the
normal business of providing care and driving
improvement
• Accreditation should not be a ‘Paper War’
• Accreditation Workbooks provide a checklist only