Comprehensive Care Standard

Safety and quality systems support clinicians in the delivery of comprehensive care and minimising patient harm.

• How are the health service organisation’s safety and quality systems used to:
  • Support implementation of policies and procedures for the delivery of comprehensive care
  • Identify and manage risks associated with the delivery of comprehensive care
  • Identify training requirements for the delivery of comprehensive care?

• Establish and implement governance structures for comprehensive care and minimising patient harm.
• Develop and implement policies and procedures for comprehensive care and minimising patient harm.
• Use organisation-wide risk management systems to identify, monitor, manage and review risks associated with comprehensive care and minimising patient harm.
• Deliver or provide access to training on comprehensive care and minimising patient harm based on the patient population.

Quality improvement systems are used to support the delivery of comprehensive care and minimising patient harm.

• How are the strategies to improve the outcomes of comprehensive care and associated processes continuously evaluated and improved?
• How are the outcomes of improvement activities communicated to the governing body, the workforce and consumers?

• Review, measure and assess the effectiveness and performance of organisational and clinical strategies to deliver comprehensive care and minimise patient harm.
• Implement quality improvement strategies for comprehensive care and minimising patient harm 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.

Clinicians partner with patients when providing comprehensive care and minimising patient harm.

• What processes from the Partnering with Consumers Standard do clinicians use to involve patients when providing comprehensive care?
• How does the health service organisation collect feedback from patients about information provided on comprehensive care?

• Review strategies in the Partnering with Consumers Standard to inform the implementation of actions in the Comprehensive Care Standard.
• Provide information to patients about comprehensive care and minimising patient harm tailored to their specific needs and level of health literacy.

The health service organisation provides systems to enable and support the delivery of comprehensive care to patients.

• What systems and processes are in place to support clinicians to communicate, deliver and document comprehensive care in the setting that best meets patients’ needs?
• What systems and processes are in place to ensure the timely referral of patients to relevant services?
• What systems and processes are used to identify the clinician with overall responsibility for the patient? How is this communicated to the patient and the team?

• Work with clinicians and consumers to design and implement systems for developing, documenting and communicating comprehensive care plans.
• Implement systems to ensure that patients receive care in the setting that best meets their clinical needs.
• Work with internal and external services to implement timely referral processes.
• Develop processes for ensuring that the clinician with overall accountability for a patient’s care is identifiable at all times.

Clinicians are supported to work in collaborative multidisciplinary teams, and they understand their own roles and responsibilities, and those of other team members.

•  How do multidisciplinary collaboration and teamwork operate in the health service organisation?
• How are the roles and responsibilities of each clinician working in a team defined? How is this communicated to team members and the patient?

• Develop structured processes to support multidisciplinary teamwork and collaboration.

Clinicians work together to plan and deliver comprehensive care in partnership with patients, carers and families.

• How are clinicians supported to collaborate with each other, patients, carers and families in planning and delivering comprehensive care?

• Ensure that clinicians use organisational processes and collaborate with each other, and with patients, carers and families, to plan and deliver comprehensive care.

Processes are in place for integrated and timely screening, assessment and risk identification.

• How does the health service organisation ensure that screening and assessment processes used to identify the risks of harm are integrated and timely?

• Assess the risks and clinical requirements of the patients who use the health service organisation and agree on relevant screening and assessment processes.
• Ensure that the risks of harm identified in the Minimising patient harm criterion of this standard are addressed in these processes.

Patients are supported to document clear advance care plans.

What processes are in place to support patients to document an advance care plan?

Develop processes to support patients to document clear advance care plans.

Patients receive initial and, if necessary, repeated screening for cognitive, behavioural, mental and physical conditions, issues or risks of harm.

• What processes are used for screening patients at presentation, during clinical examination, at history taking and at other appropriate times?
• Do the screening processes used have the capacity to identify cognitive, behavioural, mental and physical conditions, issues and risks of harm?
• Do these screening processes have the capacity to identify social and other circumstances that may compound the risks?

• Work with clinicians to integrate screening processes into their workflow.
• Develop information about screening processes to include in orientation, education and training programs.
• Develop strategies and processes for clinicians to provide feedback about the usability and effectiveness of screening processes.

Patients receive comprehensive assessment to determine their healthcare needs and appropriate treatment options.

• What processes are in place for clinicians to ensure comprehensive assessment of patients’ conditions and risks that were identified through the screening process?
• How does the health service organisation ensure that clinicians use these processes?

• Ensure that clinicians talk to patients, carers and families about conditions and risks identified through screening processes, and work in partnership to comprehensively assess these conditions and risks.
• Involve clinicians in evaluating and improving processes for comprehensive assessment.

Findings of screening and assessment processes are documented accurately and contemporaneously.

•  What systems and processes are in place for documenting the findings of screening and assessment processes in the healthcare record?
• What processes are used to ensure that, if appropriate, information about the identified risks is shared with all members of the workforce who have contact with the patient?

• Support clinicians to use organisational and local processes to document the findings of the screening and assessment processes.
• Involve clinicians in evaluating and improving documentation processes.

Clinicians use shared decision-making processes to develop person-centred and goal-directed comprehensive care plans that meet identified patient needs.

• What processes are used for shared decision making between clinicians and the patient, carer and support people?
• How do clinicians elicit patient preferences and goals of care, including social and wellbeing goals?
• What processes are in place for developing a comprehensive and individualised plan that addresses the significance and complexity of the patient’s health issues and risk of harm, and identifies the agreed goals of care?

• Support clinicians to use shared decision-making processes in the context of planning and delivering comprehensive care.
• Provide guidance about the requirements for comprehensive care plans in the health service organisation.

The comprehensive care plan is used to direct the delivery of safe and effective care that aligns with the patient’s needs and preferences.

• What processes are in place to ensure that the care delivered is consistent with the patient’s comprehensive care plan?
• What processes are in place to ensure that the workforce monitors the effectiveness of a patient’s care plan, including reviewing and updating the plan when necessary, in collaboration with the patient, carer and family?

• Develop processes to ensure that clinicians and other members of the workforce are aware of their obligation to provide care in accordance with the comprehensive care plan, and in collaboration with patients, carers and family members
• Develop processes to ensure that the effectiveness and currency of the comprehensive care plan are routinely reviewed
• Develop guidance about indications to reassess the patient’s care needs, preferences and goals, and revise the comprehensive care plan.

Patients with end-of-life care needs are identified as soon as possible to maximise opportunities for appropriate decision making and care.

• How does the health service organisation identify patients who are at the end of their life?
• How does the health service organisation ensure that these processes are consistent with the National Consensus Statement: Essential elements for safe and high-quality end-of-life care

• Use the National Consensus Statement: Essential elements for safe and high-quality end-of-life care to develop a systematic process for identifying patients with end-of-life care needs.

Clinicians can access advice from specialist palliative care clinicians when planning and delivering end-of-life care. 

• How do clinicians gain access to specialist palliative care advice?

• Develop agreements with local palliative care providers to enable access to specialist palliative care advice.
• Develop processes for clinicians to access specialist palliative care advice.

Patients with an advance care plan receive care in line with their plan if they lack capacity to participate in decision making.

• How does the health service organisation receive advance care plans from patients?
• How does the health service organisation ensure that advance care plans are documented in the patient’s healthcare record and that care is provided in accordance with these plans?

• Develop processes to receive, document and provide access to advance care plans.

The workforce has access to support and supervision to alleviate workplace stress associated with delivering end-of-life care.

How does the health service organisation ensure that members of the workforce receive supervision and support when delivering end-of-life care?

Develop processes to ensure that all members of the workforce providing end-of-life care know how to access supervision and support.

Patients receive safe and high-quality end-of-life care.

• What data are collected about the safety and quality of end-of-life care in the health service organisation?
• How are these data reviewed to ensure that they align with planned goals of care for the patient?

 Implement processes for evaluating the safety and quality of end-of-life care.

Clinicians support consumers, carers and families to make shared decisions about end-of-life care.

•  How are clinicians supported to share decisions about end-of-life care with patients, carers and families?
• How are clinicians supported to deliver care that aligns with the National Consensus Statement: Essential elements for safe and high-quality end-of-life care?

• Provide guidance for clinicians about using processes for shared decision making in the context of end-of-life care.

Evidence-based guidelines are used for prevention and care for patients at risk of or with a pressure injury.

• How are decision-making and management processes described for preventing pressure injuries and for wound management?
• What processes are in place to ensure that evidence-based documents and tools for preventing pressure injuries and wound management are current and consistent with best-practice guidelines?

How does the health service organisation ensure that the workforce is following best-practice guidelines and tools for the prevention of pressure injuries?

• Use information from screening and assessment processes to prevent and manage pressure injuries.
• Develop or adapt a wound management system that is based on best-practice guidelines.
• Identify individuals or groups with responsibility for overseeing this system.

The risk of harm from pressure injuries is minimised by routinely conducting skin inspections.

• What assessment tools or processes are used by the workforce to complete a comprehensive skin inspection for at-risk patients?
• What processes are in place to ensure that prevention plans (including skin inspections) for patients at risk of a pressure injury are consistent with best-practice guidelines?

• Develop or adapt a process to prompt clinicians to perform and document comprehensive skin inspections as part of routine patient care.

Patients with or at risk of pressure injuries are provided with information and are involved in their pressure injury care, and devices and equipment that minimise the risk of harm are used.

• What processes are in place to ensure that equipment, devices and products are being used in line with best-practice guidelines to prevent and effectively manage pressure injuries?
• What information and support are provided to patients about the prevention and management of pressure injuries?

• Provide information for patients and carers about the prevention and management of pressure injuries.
• Facilitate access to equipment and devices for the prevention and management of pressure injuries.

Clinical practice for preventing and managing falls is evidence based, and patient risks and harm are minimised.

• How does the health service organisation ensure that falls prevention, harm minimisation and post-fall management plans are consistent with best-practice guidelines?

•  Identify all areas in the organisation that present falls risks and develop a risk management approach to implementing evidence-based improvement strategies.

Patients are provided with equipment and devices to promote safe mobility and reduce harm from falls.

• What equipment and devices are available for patients to prevent harm from falls or to manage patients who are at risk of falling?

• Identify and facilitate access to the equipment and devices required for the organisation’s patient population.
• Develop a log to register equipment and devices used in falls prevention and management, and record their maintenance.

Patients, carers and families are provided with information about falls risks and preventing falls.

What information and support are provided to patients and carers about falls risk and prevention?

• Provide information to, and have discussions with, patients, carers and families about falls risks.
• Seek feedback on information provided to patients and carers, and amend it to improve the information.
• Ensure that the discharge planning protocol prompts the workforce to consider referral to appropriate services.

Patients’ nutrition and hydration needs are identified and documented in their comprehensive care plan.

How does the health service organisation ensure that the planning, preparation and distribution of food, fluids and nutritional supplements are safe and acceptable, and meet a patient’s needs?

Put in place processes for addressing patients’ nutrition and hydration needs.

The workforce ensures that the nutrition and hydration needs of patients are met.

• How does the health service organisation collect and report data on nutrition risk screening and assessment?
• What information is reported to the executive about the nutritional care of at-risk patients?
• What support is given to patients who require nutritional support or assistance with eating and drinking?

• Monitor the nutritional care of patients.
• Provide assistance to patients to ensure that their nutrition needs are met.

A system for caring for cognitive impairment is implemented that minimises the risk of harm for people with cognitive impairment or at risk of developing delirium. The use of antipsychotics and other psychoactive medicines is in line with best practice and legislation.

• What processes are in place to manage safety and quality issues for patients with, or at risk of, developing cognitive impairment?
• How is the use of antipsychotics and other psychoactive medicines monitored, and how is feedback provided to clinicians?
• What supports are available for clinicians to use non-pharmacological approaches in response to behavioural and psychological symptoms of dementia?

• Review, revise or develop a system for providing high-quality care for patients with cognitive impairment.
• Allocate roles, responsibilities and accountabilities for establishing or maintaining the system.
• Implement a system for caring for cognitive impairment.
• Regularly monitor the use of best-practice evidence-based strategies in the care plan, provide feedback and implement improvement strategies.

Risks are minimised by undertaking strategies to recognise, prevent, treat and manage cognitive impairment. Clinicians, patients, carers and families work together to minimise anxiety or distress experienced by the person with cognitive impairment.

• How is the workforce supported to recognise, prevent, treat and manage cognitive impairment?
• How is feedback from patients with cognitive impairment, and their carers and families collected and used to inform improvement strategies?

• Review and, if necessary, revise the organisation’s education and training program to support implementation.
• Provide access to education and training about the system that supports caring for patients with cognitive impairment, and agreed tools and responsibilities.
• Work with clinicians and consumers to design and implement systems for working together and for implementing strategies to minimise anxiety and distress experienced by a person with cognitive impairment.
• Use regular feedback from patients, carers and families to improve collaboration.

The workforce has the skills and knowledge to engage collaboratively to identify and respond to patients at risk of self-harm or suicide.

• What processes are in place to ensure that the workforce can work collaboratively to identify patients at risk of self-harm or suicide?
• How does the health service organisation ensure that clinicians know how to respond safely and effectively to patients who are distressed, have thoughts of self-harm or suicide, or have self-harmed?
• How do members of the workforce gain access to specialist mental health expertise to provide care to patients who have thoughts of self-harm or suicide, or have self-harmed?

•  Implement screening for thoughts of self-harm or suicide for people who present with self-harm, mental illness or acute emotional distress.
• Set up a tiered system for response according to the level of risk.
• Ensure that the environment is safe.
• Maintain a recovery-oriented approach throughout engagement.

Adequate follow-up support is arranged and agreed by the nominated participants for when people who have self-harmed or reported suicidal thoughts leave the health service organisation.

• What procedures and processes are in place to ensure rigorous follow-up for people who have harmed themselves or reported suicidal ideation?
• What partnerships have been developed with key agencies when responsibility for follow-up is transferred between agencies?
• How does the health service organisation identify gaps in referral processes?

• Develop a collaborative post-discharge treatment plan involving the person, their carers and family, and key service providers before the person leaves the health service organisation.
• Communicate this plan verbally and in writing to all people who have a role in implementing the plan.
• Ensure that plan is implemented.

The risk of aggression and violence is minimised by reducing environmental or procedural triggers for aggression.

•  What processes are in place to ensure that the workforce can identify situations that may precipitate aggression?
• What processes are used to mitigate these situations?
• What features of the environment are used to minimise sources of potential conflict?

•  Identify factors in the environment that could trigger aggression or complicate management of aggression when it occurs.
• Identify elements of the organisation’s procedures that could contribute to stress, which may lead to aggression.
• Implement strategies to lessen stresses caused by environmental or procedural factors.

Collaborative processes are used to minimise the risk of aggression and violence, and incidents are managed safely when they occur.

• What processes are in place to ensure that the workforce can work collaboratively to identify patients at risk of becoming aggressive or violent?
• What strategies are used to support patients at risk of becoming aggressive or violent to control their behaviour?
• How does the health service organisation minimise harm to patients, carers, families and the workforce from patients who are aggressive or violent?

• Train the workforce to effectively screen for specific risks.
• Implement processes that support members of the workforce to use strategies to reduce the risk of violence.
• Implement processes to respond to aggression and violence when they occur, to minimise the risk of harm to people.

Harm relating to the use of restraint is minimised.

• What strategies does the health service organisation have in place to minimise the use of restraint?
• Are members of the workforce competent to implement restraint safely?
• How does the health service organisation ensure that the workforce is aware of safety implications of different forms of physical and mechanical restraint with different patient populations?
• What processes (for example, benchmarking, routine review) are used to review the use of restraints in the health service organisation?

• Understand where and when restraint is used in the health service organisation.
• Benchmark the use of restraint.
• Demonstrate implementation of strategies to reduce the use of restraint.
• Ensure that members of the workforce who implement restraint are trained to do so safely.
• Monitor and document appropriate observations during and subsequent to restraint.
• When restraint has occurred, offer debriefing for the people involved, including patients, carers and members of the workforce.

Harm relating to the use of seclusion is minimised.

• What strategies does the health service organisation have in place to minimise the use of seclusion?
• How does the health service organisation ensure that the workforce is competent in implementing de-escalation strategies?
• What processes (for example, benchmarking, routine review) are used to review the use of seclusion in the health service organisation?

•  Implement strategies to minimise the use of seclusion.
• Ensure that seclusion is only implemented by members of the workforce who have been trained to implement it safely.
• Monitor and document appropriate observations during and subsequent to seclusion.
• Review the use of seclusion within the health service organisation.