Primary and Community Healthcare Clinical Governance Standard

• How are continuous improvement opportunities identified, prioritised, reported and actioned?
• How do you involve the workforce in your healthcare service’s safety and quality improvement processes?

• By understanding the safety and quality risks and performance of your healthcare service, identify the priority areas for safety and quality and the time required for the change to occur. Communicate these priorities to others in your healthcare service.
• Establish mechanisms for incorporating safety and quality of health care into the healthcare service’s business decision-making.
• For the people in your healthcare service, describe their safety and quality roles and responsibilities. 

Note: the way responsibilities are assigned depends on the size of your healthcare service, whether your healthcare service is in a rural or remote area and the safety and quality risks involved. 

The type and comprehensiveness of evidence used is dependent on each healthcare service context. The content and complexity of the policies and processes will likely depend on the size of the healthcare service, but could include:

• Description of safety and quality roles and responsibilities of members of the workforce in your healthcare service
• Summary of safety and quality improvement priorities
• Communications with your workforce about safety and quality priorities, such as emails, entries in a staff communications book, pin-board notice
• Position descriptions describing the safety and quality roles and responsibilities for each member of the workforce
• Policies, protocols or documented process that detail how healthcare providers work together in a patient’s care, within or between another service
• Minutes of meetings, notes on business decisions that consider where patient safety and quality can be improved
• Documented clinical governance framework
• Demonstration of shared leadership and collaborative teamwork in multidisciplinary healthcare teams in rural and remote settings
• Annual declaration confirming compliance to the Primary and Community Healthcare Standards. 

• What policies, procedures and protocols are available in your healthcare service? What safety and quality risks do they seek to reduce or eliminate?
• How does the workforce access and use policies, procedures and protocols?
• How is the implementation of policies, procedures and protocols monitored and reviewed to identify areas of improvement?

• Develop safety and quality policies, procedures and protocols relevant to reducing or eliminating safety and quality risks in the healthcare service.
• Support the workforce to implement policies, procedures and protocols, including making them easily accessible.
• Implement a schedule to monitor, review and update policies and procedures using a risk management approach.

• The type and comprehensiveness of evidence used is dependent on each healthcare service context. The content and complexity of the policies and processes will likely depend on the size of the healthcare service, but could include:
• Policies, procedures and protocols that aim to reduce or eliminate safety and quality risks
• Observation that demonstrates policies and procedures are easily accessible by the workforce and used in everyday practice
• Documented changes to policies, procedures and protocols implemented following the monitoring and review of implementation and identification of improvements.

• What data does your healthcare service use to identify areas for improvement?
• What changes have been made in your healthcare service as a result of the review of data?
• What impact, if any, have changes that have been implemented made? How was this impact measured?
• How is information about your service’s safety and quality performance communicated to patients, carers and families and the workforce? 

• Identify and collect data within your healthcare service that can be used to inform the safety and quality improvement priorities for the service.
• Routinely review data collected to identify areas for improvement and take action to make continuous improvements.
• Measure changes in safety and quality outcomes as a result of improvements implemented.
• Communicate information of the service’s safety and quality to patients, carers and families and the workforce.

• The type and comprehensiveness of evidence used is dependent on each healthcare service context, but could include:
• Data collected and reviewed to identify safety and quality improvements
• Examples of changes made within the healthcare service as a result of the review of data and improvements made
• Examples of how information about your service’s safety and quality is communicated to patients, carers and families and the workforce, for example
  • certificates of safety and quality performance displayed in common service areas
  • information on notice board in workforce areas
  • communication books or meeting records.

• How do you identify the safety and quality risks in your healthcare service?
• How are these risks mitigated or managed, and documented?
• How do you prioritise risks?
• How will continuity of care for patients be managed in the event of an emergency or disaster? 

• Develop and implement a risk-management process to identify, manage and mitigate safety and quality risks.
• Identify risks to the service and document them in a central location accessible to the workforce.
• Support the workforce to understand, document and participate in managing risks using the service’s orientation system, education, or other existing strategies.
• Maintain a risk register and regularly monitor risks and the strategies or activities that have been put in place to mitigate them.
• Clearly articulate the roles and responsibilities for identifying and managing risks and ensure those with responsibilities for taking action on risks have the training, knowledge and resources required to fulfil their responsibilities.
• Identify and plan for emergency or disasters scenarios and the risks that may be associated with these situations to ensure safety and high-quality care.

For certain healthcare services, it may be appropriate to integrate risk-management systems with other systems to meet safety and quality requirements, and legal and business obligations. 

The type and comprehensiveness of evidence used is dependent on each healthcare service context. The content and complexity of policies and processes will likely depend on the size of the healthcare service, but could include:

• Documented processes that describe how safety and quality risks are identified, managed, documented and monitored
• Risk register implemented and utilised by the workforce
• Training documents (for example, syllabus, attendance records, competency assessments) relating to risk management
• Emergency and disaster plans
• Business continuity plans.

• How does your healthcare service identify, report, document and manage incidents?
• How are patients, carers and families supported to communicate concerns or report incidents?
• How could the incident management system be improved?

• Implement an incident management system.
• Train the workforce to use the incident management system, including types of incidents, risks and near misses that must be reported.
• Inform patients about how they can report risks, incidents or concerns.
• Regularly review incident data, and identify learnings from incidents that could be implemented to drive improvements in safety and quality.
• Periodically review the incident management system to identify areas of improvement.

For certain healthcare services, it may be appropriate to integrate incident management systems with other systems to meet safety and quality requirements, and legal and business obligations. 

• The type and comprehensiveness of evidence used is dependent on each healthcare service context, but could include:
• Description of how your service identifies, reports, documents and investigates incidents, near misses and adverse events
• Examples of reports on incidents, near misses and adverse events identified in the service, and the actions taken to manage identified risks
• Training documents (for example, syllabus, attendance records and competency assessments) relating to recognising, reporting, investigating, recording and analysing incidents, near misses and adverse events
• Meetings or communication records where discussion occurred about incidents and the strategies and actions taken to address identified risks
• Information and resources, including incident reporting forms and tools, that are accessible to the workforce and patients
• Records of improvements made from incidents
• Records of risks identified from the analysis of incidents
• Evidence of incident management reviews.

• Who is responsible for taking action when a patient is harmed during care in your service?
• How are the workforce trained and supported to implement open disclosure?

• Adopt and implement the Australian Open Disclosure Framework when a patient is harmed in the delivery of care.
• Ensure that members of the workforce who will be involved in open disclosure are appropriately trained.
• Regularly review incidents, recorded in the incident management system against the healthcare service’s processes and consistency with the Australian Open Disclosure Framework.

• The type and comprehensiveness of evidence used is dependent on each healthcare service context. The content and complexity of the policies and processes will likely depend on the size of the healthcare service, but could include:
• Policy documents that are consistent with the principles and processes outlined in the Australian Open Disclosure Framework, and which have been adopted and implemented in a way that reflects the context of service provision
• Meeting, communication records or records of an open disclosure
• Training documents (for example, syllabus, attendance records, competency assessments or role-play scenarios where open disclosure is required) relating to the open disclosure program.

• How and when is feedback sought from patients about their care?
• How and when is feedback sought from the workforce about their understanding and use of safety and quality systems?
• How has the feedback been used to improve care? 

• Regularly seek feedback from patients and the workforce and use this feedback to identify areas for safety and quality improvements.
• Implement changes to address improvement opportunities.

For certain healthcare services, it may be appropriate to integrate systems to seek and record feedback with other systems to meet safety and quality requirements, legal and business obligations. 

The type and comprehensiveness of evidence used is dependent on each healthcare service context, but could include: 

• Records of feedback, for example, survey responses and reports, notes from discussions with patients or the workforce, meeting or communication records, training and development plans
• Examples of safety and quality improvements made as a result of patient and/or workforce feedback.

• How can patients, carers and families make a complaint in your service?
• How are complaints resolved in a timely manner?
• How are relevant members of the workforce, patients, carers and families involved in the review of complaints?
• How has your service learnt from the analysis of and action following complaints?

• Implement a process for
  • patients to report complaints
  • your healthcare service to resolve complaints in a timely way
  • your healthcare service to analyse complaints to identify opportunities for improvement.

For certain healthcare services, it may be appropriate to integrate systems to report and manage complaints with other systems to meet safety and quality requirements, legal and business obligations. 

The type and comprehensiveness of evidence used is dependent on each healthcare service context. The content and complexity of the policies and processes will likely depend on the size of the healthcare service, but could include:

• Information on how patients may make complaints
• Complaints register that includes detail on the issues identified, people involved and actions taken to resolve complaints
• Policy documents that describe the processes for reporting, investigating and analysing complaints
• Examples of improvement activities that have been implemented in response to complaints.

• What are the local patient populations that access your healthcare service?
• What potential challenges do these population groups face that could have an impact on their health outcomes?

• Identify patients in your healthcare service that are at risk of avoidable differences in health outcomes. This can be done via review of healthcare records and observation within the healthcare service, or by supporting patients to self-identify.

The type and comprehensiveness of evidence used is dependent on each healthcare service context, but could include: 

• A list of patient populations where health inequities exist and the potential challenges these population groups face that could have an impact on their health outcomes.

• Use information on patient groups to identify challenges and barriers to health care and inform the planning and delivery of health.
• Provide access to training and or support for the workforce to improve awareness and understanding of patient population groups using your healthcare service.

Examples of evidence will be dependent on patient populations identified in your healthcare service’s locality, but could include: 

• Amended processes or protocols
• Accessing resources or information packs in different languages
• Using an appropriately trained and credentialed interpreter. Interpreters may be required in Auslan, First Nations sign languages or spoken languages other than English
• Examples of referring a patient on to other service providers if health issues are identified that impact on the care your healthcare service is providing
• Hiring a workforce that speaks languages other than English to support communication with local community members
• Participation in programs to support services improve their inclusive care
• Adjustments to premises to support disability access including appropriate adaptations and remedial action to existing infrastructure.

• How do healthcare providers access healthcare records at the point of patient care?
• How are healthcare providers supported to record patient notes, file relevant communications with other healthcare providers and ensure healthcare records are complete, current and up to date?
• How are healthcare records stored securely?
• What processes are in place for auditing healthcare records?
• How can patients access their healthcare records?

• Implement a process to create, maintain and use healthcare records that
  • makes healthcare records available to healthcare providers at the point of care
  • supports healthcare providers to maintain accurate and complete healthcare records
  • complies with privacy and security regulations.
• Conduct regular audits of healthcare records to identify areas for safety and quality improvement.
• Implement a process to facilitate a patient’s access to their healthcare record when required or requested.
• Provide training to healthcare providers about the healthcare record system during orientation and refresher training as required.

The type and comprehensiveness of evidence used is dependent on each healthcare service context. The content and complexity of the policies and processes will likely depend on the size of the healthcare service, but could include:

• Policy documents on healthcare record management, including access, storage, security, consent and sharing patient information
• Audit templates or reports on results of healthcare records for compliance with policies or procedures
• Demonstration or observation of how healthcare records are accessible at the point of patient care
• Training (for example, syllabus, attendance records, competency assessments) relating to the healthcare records system
• Documented information system management, data security and data breach protocols
• Observation of safe and secure storage systems for healthcare records, including evidence of fire protection and pest control strategies.

• How are patient reports received, reviewed, actioned and documented in your healthcare service?
• What processes are in place to recall patients when needed to discuss patient reports, identified risks and subsequent health care options? 

• Implement a process to consistently
  • receive reports on patients and have reports reviewed by relevant healthcare providers and take action on reports in a timely manner
  • recall patients when required to discuss reports and subsequent health care options and risks
  • document reports in a patient’s healthcare record.
• During orientation and/or when needed, explain to healthcare providers about processes to receive, action and record patients’ reports.

The type and comprehensiveness of evidence used is dependent on each healthcare service context. The content and complexity of the policies and processes will likely depend on the size of the healthcare service, but could include:

• Policies, procedures and protocols that describe
  • how patient reports are received, reviewed, actioned and documented in a timely manner
  • how patient recalls are managed
  • processes to communicate about patient reports and health care options
• Example of patient reports that have been received, reviewed, actioned and documented in a patient’s healthcare record.

• How does using My Health Record in your healthcare service benefit patients?
• How is your service using national healthcare identifiers and standard national terminologies?
• How is the workforce supported to use My Health Record?

• Develop and implement a process for the use of My Health Record that includes using unique national identifiers for patients, healthcare providers and healthcare service organisations in local information systems and in clinical documents loaded into the My Health Record system.
• Implement standard national terminologies such as AMT in healthcare records and clinical documents loaded to My Health Record.
• Support the workforce to use standard national terminologies when uploading to My Health Record by facilitating access, providing training and making resources available.

The type and comprehensiveness of evidence used is dependent on each healthcare service context, but could include: 

• Evidence of registration with and contributions to My Health Record
• Documented processes for accessing and contributing to My Health Record using national healthcare identifiers and standard national terminologies
• Example of an entry by the healthcare service in My Health Record
• Training records relating to My Health Record (for example, syllabus, attendance records, competency assessments).

• How is information uploaded to My Health Record in your healthcare service?
• How is clinical information reviewed for accuracy and completeness before uploading to My Health Record?

• Implement a process that can be used to upload relevant clinical information to My Health Record using compliant clinical software, ensuring information uploaded is accurate and complete.
• Provide training to healthcare providers on how to upload information to My Health Record.

The type and comprehensiveness of evidence used is dependent on each healthcare service context. The content and complexity of the policies and processes will likely depend on the size of the healthcare service, but could include:

• Process for uploading clinical information to My Health Record, including steps to ensure accuracy and completeness of information uploaded
• Training documents (for example, syllabus, attendance records and competency assessments) on how to access and contribute to patient information in the My Health Record system
• Examples of clinical information uploaded by the healthcare service in My Health Record.

• What orientation and training do new members of your service’s workforce undertake?
• How are ongoing training needs identified?
• How does your workforce ensure relevant training is completed? 

• Implement and document the minimum orientation and training your workforce must complete on commencement at your healthcare service.
• Provide ongoing education and training on relevant aspects of safety and quality for all members of the workforce, when change occurs in the service or when new services are introduced.
• Ensure that staff who have additional safety and quality responsibilities are provided with additional training to meet the requirements of their role.
• Maintain training records and a training schedule for staff to ensure that safety and quality training is provided in a timely manner, as required.

The type and comprehensiveness of evidence used is dependent on each healthcare service context, but could include:

• Orientation and training documents that detail content and participation by the workforce
• Training plans and records for members of the workforce that include the requirements of the Standards
• Description of how training needs of the workforce are identified.

• What cultural safety training has your workforce undertaken?
• How does your healthcare service support the workforce to provide culturally safe services? 

• Facilitating ongoing access to cultural safety training for all members of your workforce, that is tailored to your Aboriginal and Torres Strait Islander patients
• Participating in and celebrating events of significance to Aboriginal and Torres Strait Islander communities, for example, National Sorry Day, National Reconciliation Week, NAIDOC week
• Recruiting more Aboriginal and Torres Strait Islander peoples to be part of your healthcare service’s workforce where possible
• Considering the establishment of a Reconciliation Action Plan for your healthcare service
• Developing an understanding and appreciation of your specific community context, particularly in rural and remote settings.

The type and comprehensiveness of evidence used is dependent on each healthcare service context, but could include: 

• Training documents that are specific to Aboriginal and Torres Strait Islander cultural safety and are tailored to the needs of the service’s patient population
• Evidence of participation in events of significance to Aboriginal and Torres Strait Islander communities, for example, National Sorry Day, National Reconciliation Week
• Evidence of recruitment of Aboriginal and/or Torres Strait Islander peoples to the workforce
• A Reconciliation Action Plan
• Evidence of cultural orientation to a community.

• Ensure that safety and quality roles and responsibilities are clearly defined and described in your healthcare service’s clinical governance framework.
• Support the workforce to understand and fulfil their assigned safety and quality roles and responsibilities through position descriptions, orientation and training, ongoing communications, performance review processes (if applicable).

The type and comprehensiveness of evidence used is dependent on each healthcare service context. The content and complexity of the policies and processes will likely depend on the size of the healthcare service, but could include:

• Policy documents or position descriptions that outline or describe the safety and quality roles and responsibilities of the workforce
• Training and orientation documents about the safety and quality roles and responsibilities of the workforce
• In larger healthcare services, an organisational chart and delegation policy that demonstrates clinical governance reporting lines and relationships, where applicable.

• How does the performance review process ensure that safety and quality training and development needs are identified?
• How is the safety and quality performance of non-clinical members of the workforce evaluated? 

• Establish processes to review and evaluate the safety and quality performance of the workforce and identify their training and development needs.
• Identify the training needs that support the implementation of these standards.
   

The type and comprehensiveness of the evidence used is dependent on each healthcare service context, but could include:

• Professional development plans or portfolios for healthcare providers registered with a national board under the National Registration and Accreditation Scheme, or that are self-regulated
• Documentation of discussions about workforce performance and identified training needs
• Schedule of training and workforce participation.
   

• Where is a healthcare provider’s scope of clinical practice described?
• What processes are in place to ensure a healthcare provider works within their scope of clinical practice in your healthcare service?
• How is a healthcare provider’s scope of clinical practice reviewed when a clinical service, procedure or technology is introduced or substantially altered? 

• Record the scope of clinical practice for healthcare providers within your healthcare service, either in a stand-alone document, position description or contract for services.
• Incorporate a periodic review of a healthcare provider’s scope of clinical practice when a clinical service, procedure or technology is introduced or substantially altered.

The type and comprehensiveness of evidence used is dependent on each healthcare service context, but could include:

• Documented scope of clinical practice described in position descriptions, contract for services or standalone document
• Review of services provided against the described scope of clinical practice, or records of performance reviews or communication that demonstrate monitoring
• Planning documents to introduce new services (including workforce, equipment, procedures and the scope of clinical practice amendments required)
• Evidence of a regular review of the described scope of clinical practice, position descriptions or contract for services and any changes made.

• Which best-practice guidelines, clinical care standards developed by the Commission and decision support tools are available to healthcare providers in your service?
• How are your healthcare providers supported to use best-practice guidelines, clinical care standards and decision support tools in the delivery of health care?

• Provide healthcare providers with access to best-practice guidelines and available evidence, clinical care standards developed by the Commission and decision support tools relevant to their clinical practice.
• Support healthcare providers to use relevant best-practice guidelines, available evidence and clinical care standards developed by the Commission.
• Support healthcare providers to use decision support tools relevant to their clinical practice in their delivery of health care to patients.
• Support healthcare providers to participate in continuing professional development activities, and facilitate a culture of peer sharing and learning from patient case studies within the healthcare service (where possible).

The type and comprehensiveness of evidence used is dependent on each healthcare service context, but could include:

• Evidence of the best-practice guidelines, clinical care standards developed by the Commission and decision support tools that are available to healthcare providers
• Description of how healthcare providers access and use best-practice guidelines, pathways, decision support tools and clinical care standards that reflect best available evidence
• Training documents (for example, continuing professional development records) relating to clinical updates.

• What areas of clinical practice has your healthcare service reviewed for variations in health care?
• What reasons, if any, were identified for variation?
• Was the variation warranted or unwarranted?
• What improvements were identified and how were these improvements implemented?
• What checks and balances are in place to ensure that patients are receiving the right care, and the right amount of care according to their needs and preferences, at the right time?

• Identify the areas of clinical practice to review the care delivered against relevant best practice. This may be based on the population served, the common services provided or high-risk services.
• Discuss or review how services are delivered against best-practice care. This could be done via continuing professional development and documented self-reflection, peer evaluation or group evaluation within a large healthcare service.
• Where clinical variation is identified, explore the reasons for variation, determine if the variation is warranted or unwarranted and identify areas for improvement.
• Act to improve the appropriateness of care
  • specify the desired goal for improvement
  • explore the reasons for current practice
  • identify the barriers or enablers for any desired change in practice
  • make changes to healthcare processes
  • monitor progress and make further changes as necessary.
• Maintain records of reviews and actions taken as a result of examining the variation and the appropriateness of care.

• The type and comprehensiveness of evidence used is dependent on each healthcare service context, but could include:
• Records of continuing professional development and self-reflection
• Records of clinical practice audits where service delivery was compared against best-practice guidelines and opportunities for improvement identified
• Reports that compare clinical practice using external sources such as the Australian Atlas of Healthcare Variation, or data provided by or shared with external organisations such as Primary Health Networks or professional organisations
• Examples of improvement activities that have been implemented and reviewed to reduce unwarranted variation, including relevant clinical care standards.

• How often is your healthcare service’s environment reviewed? What improvements have been made to ensure it is fit for purpose, well maintained and privacy is provided to patients?
• What equipment does your service use to deliver health care? How often are maintenance checks conducted on equipment?
• What are key considerations for healthcare providers visiting a patient’s home when determining the most appropriate space to deliver health care?

• Implement a schedule and process to regularly review the spaces where healthcare services are delivered. Action any required improvements to ensure spaces are fit for purpose and well maintained, and that there is space for the patient’s privacy when health care is provided.
• Implement a schedule and process to conduct maintenance checks on equipment used by the healthcare service. Action any required repairs or replacement equipment to ensure they are fit for purpose, safe and in good working order at all times.
• For healthcare services providing home-based care, implement a process for a risk management approach to determining the most appropriate space in a patient’s home for the provision of health care.

The type and comprehensiveness of evidence used is dependent on the context of each healthcare service, but could include: 

• Maintenance schedule for healthcare service premises, mobile vehicles and equipment
• Completed risk assessments for care provided in patient’s homes or other locations, and any actions taken to address the risks
• Register of equipment that includes details of their maintenance schedule and completed repairs or replacements
• Observation of design and use of the environment that supports safe, high-quality care, including supporting patient privacy
• Checklists of actions to be completed or equipment required to safely deliver care outside the healthcare service’s environment.

• Which spaces in your healthcare service have a higher risk of causing people to feel stressed?
• How are people who are behaving unpredictably supported in a way that minimises risks of harm to others in your healthcare service?
• How do healthcare providers delivering home-based care identify areas where a patient may behave unpredictably? How do they use this information to determine the most appropriate space in a patient’s home for the provision of health care, and circumstances where home-based care is not appropriate?

• Identify any spaces in the healthcare service that have a high risk of potentially causing stress leading to people behaving unpredictably.
• Develop and implement strategies that can be used in instances where unpredictable behaviour occurs to minimise the risk of harm to others in the healthcare service.
• For healthcare services providing home-based care, incorporate the identification of areas that have a high risk of unpredictable behaviours into the process for a risk management approach. This helps to determine the most appropriate space in a patient’s home for the provision of health care, and circumstances where home-based care is not appropriate. 

The type and comprehensiveness of evidence used is dependent on each healthcare service context. The content and complexity of the policies and processes will likely depend on the size of the healthcare service, but could include:

• Observation of flexible use of spaces to minimise the risk of harm to others when there is a high risk of unpredictable behaviours
• Examples of risk management approaches used during home visits
• Training and orientation documents about safe work practices and emergency situations
• Evidence of policies, processes and training used to support workforce to implement strategies
• Entries into risk register documenting responses to unpredictable behaviour. 

• How is patient population information used to plan service delivery and manage the inherent barriers that exist to care for patients?
• What adjustments have been made to decrease the barriers to allow equal access for patients?

• Implement strategies to support patients to access your healthcare service, with particular consideration for barriers to health care faced by patients from diverse communities and patients with disability, including barriers compounded by a person’s combination of needs and experiences.
• Ensure the telehealth and/or virtual care infrastructure is available for patients.
• Foster multidisciplinary healthcare teams to meet consumer healthcare needs.

The type and comprehensiveness of evidence used is dependent on each healthcare service context. The content and complexity of the policies and processes will likely depend on the size of the healthcare service, but could include:

• Examples of how demographic data and characteristics of the local community or patient population have been used to plan for or improve access to services
• Processes that enable access to the service for people with a disability, such as providing outreach or flexible appointment times
• Observation of the written health information about accessing the healthcare service in a range of formats tailored to the local community and patient populations
• Observation of the healthcare service’s physical environment and the equipment that supports access for patients with low mobility
• Observation of non-verbal demonstrations of inclusion in environment, for example, non-gendered bathrooms, display of rainbow flag
• Observation of infrastructure that supports telehealth and/or virtual care practices
• Evidence of culturally informed comprehensive care planning
• Examples of resources or partner organisations that the healthcare service uses to enable people from diverse backgrounds to access the healthcare service
• Records of training or professional development undertaken by the workforce to meet the needs of people from diverse populations. 

• How does your healthcare service provide a culturally safe environment for Aboriginal and Torres Strait Islander peoples?
• How does your healthcare service recognise cultural beliefs and practices of Aboriginal and Torres Strait Islander peoples? 

The type and comprehensiveness of evidence used is dependent on the context of each healthcare service, but could include:

• Physical space that reflects the cultural identity of Aboriginal and Torres Strait Islander peoples
• Implementation of culturally appropriate programs (for example, incorporating traditional healing practices)
• Evidence of cultural competency training
• Resources tailored to the needs of Aboriginal and Torres Strait patients such as use of visual aids or posters with culturally relevant information
• Evidence of working in partnership with Aboriginal and Torres Strait Islander patients and local Aboriginal Community Controlled services where there is a significant Aboriginal or Torres Strait Islander patient cohort when carrying out a review of the design, use and layout healthcare service.