Communicating for Safety Standard

Safety and quality systems support effective clinical communication.

• How are the health service organisation’s safety and quality systems used to:
  • support implementation of policies and procedures for effective clinical communication
  • identify and manage risks associated with clinical communication
  • identify training requirements for the delivery of effective clinical communication?

• Establish and implement governance structures for clinical communication
• Develop and implement policies and procedures for clinical communication
• Use organisation-wide risk management systems to identify, monitor, manage and review risks associated with clinical communication
• Deliver or provide access to training on clinical communication based on the specific needs of the clinical workforce.

Quality improvement systems are used to support the effectiveness of clinical communications.

• How is the effectiveness of clinical communication and associated processes continuously evaluated and improved?

How are the outcomes of improvement activities reported to the governing body, the workforce, consumers and other organisations?

• Review, measure, and assess the effectiveness and performance of, organisational and clinical strategies for clinical communications
• Implement quality improvement strategies for clinical communications based on the outcomes of monitoring activities
• Provide information on the outcomes of quality improvement activities to the governing body, the workforce, consumers and other organisations.

Principles of person-centred care, shared decision making and health literacy inform the way clinicians communicate with patients, carers and families during the key high-risk situations described in the Communicating for Safety Standard.

• What processes from the Partnering with Consumers Standard do clinicians use to effectively communicate with patients, carers and families during high-risk situations, to involve patients in planning and making decisions about their own care?
• How does the health service organisation collect feedback from patients about information provided about clinical communication?

• Review strategies in the Partnering with Consumers Standard to inform the implementation of actions in the Communicating for Safety Standard
• Provide information to patients about clinical communications tailored to their specific needs and level of health literacy.

Processes to support effective clinical communication are in place for key high-risk situations, where effective communication with patients, carers and families, and between clinicians and multidisciplinary teams is critical to ensure safe patient care.

• What processes are in place for patient identification, procedure matching, clinical handover and communication of critical information or risks?
• How is the workforce supported to use these processes?
• What are the high-risk situations in which patient identification, procedure matching, and the communication or sharing of information are critical to ensuring safe, continuous patient care?

• Identify the situations within the organisation in which identification, procedure matching, structured clinical handover and communication of critical information are required
• Review the organisation’s policies and processes to determine whether they support and enable effective communication at these times
• If there are gaps, or improvements can be made, revise or develop policies and processes to reduce these gaps
• Provide resources and tools to encourage effective communication processes at these times.

A comprehensive, organisation-wide system is in place for the reliable and correct identification of patients when care, medicine, therapy and other services are provided or transferred.

• What processes are used to ensure consistent and correct identification at any point in a patient’s admission, care, treatment or transfer?
• How are the requirements to use at least three approved patient identifiers described and monitored?

• Define the approved patient identifiers for use in the organisation, according to best-practice guidelines
• Develop or confirm an organisation-wide system for patient identification
• Implement policies and processes that require at least three approved identifiers to be used at registration and on admission; when care, medicine, therapy or other services are provided; and whenever clinical handover or transfer occurs, or discharge documentation is generated.

Explicit processes are in place to correctly match patients with their intended care, to ensure that the right patient receives the right care.

• How are the processes for matching a patient to their intended care described?
• How does the health service organisation ensure that the workforce is using these processes?

• Develop explicit, documented protocols that outline the process of matching a patient to their intended treatment, tailored to the procedure and organisation
• Check that these processes align with nationally agreed policies, if they exist
• Ensure that policies specify which information should be documented about the process of identification and procedure matching.

Accurate and relevant information about a patient’s care is communicated and transferred at every clinical handover to ensure safe, high-quality patient care.

• How does the health service organisation describe the minimum information content to be communicated at each clinical handover?
• What processes are used to ensure that the health service organisation collaborates with the clinicians who are involved in clinical handover when determining the minimum information content for different handovers?

• Collaborate with clinicians to define the minimum information content to be communicated for each type of clinical handover identified within the organisation (see Action 6.04).

Clinicians use structured clinical handover processes that are consistent with the key principles of clinical handover, to effectively communicate relevant, accurate and up-to-date information about a patient’s care to ensure patient safety.

• How does the health service organisation describe the different situations in which structured clinical handover should take place, the method of communication, who should be involved and the structured communication tools to assist with handover?
• How are the patient’s goals and preferences communicated to those involved in clinical handover?
• How does the health service organisation ensure that discharge summaries are provided to the relevant people involved in a patient’s ongoing care?

• Document the structured clinical handover processes required in the organisation, ensuring that they are consistent with the key principles for clinical handover
• Clearly communicate the clinical handover policies and processes to the workforce, including expectations for using clinical handover processes
• Provide access to structured clinical handover tools
• Support the workforce, patients and carers to use structured clinical handover processes and tools.

Emerging or new critical information, alerts and risks are communicated in a timely manner to clinicians who can make decisions about care, and to the patient, family and carer, to ensure safe patient care.

• What processes are used to identify the clinician(s) who can make decisions about care and take action if needed?
• How do clinicians communicate critical information to other clinicians who can make decisions about care, and patients and carers, in a timely way?

• Define what ‘critical information’ and ‘risks to patient’s care’ mean for the service context.
• Implement processes to identify the clinicians who are responsible for a patient’s care and can make decisions about care at any given time.
• Identify when and to whom communication of critical information, alerts or risks should occur, including communication with patients, carers or families.
• Develop and implement standardised processes that describe how communication of critical information, alerts or risks should occur.

Patients and carers can communicate critical information and risks about their care to clinicians.

• What processes are in place to support patients and carers to communicate critical information about their care to clinicians?
• What feedback processes are in place to let patients and carers know that they have been heard and action has been taken, if necessary?

• Develop and implement processes for patients and carers to communicate critical information and risks about their care
• Support patients and carers to understand and use these processes.

Relevant, accurate, complete and timely information about a patient’s care is documented in the healthcare record to support safe patient care.

• How does the health service organisation describe the roles, responsibilities and expectations of the workforce regarding documenting information?
• What processes are in place to ensure that complete, accurate and up-to-date information is recorded in the healthcare record and is accessible to clinicians?

• Develop and implement systems to support the contemporaneous documentation of critical information in the healthcare record.
• Record the organisation’s documentation policies and make them available to the workforce.
• Communicate to the workforce their roles and responsibilities for documentation.