Clinical performance and effectiveness

Ensuring your workforce have (and keep updated) the right qualifications, knowledge and skills is core to the delivery of safe, high-quality health care. For all healthcare providers, formal education requirements and maintenance of profession-specific registration requirements will make up the majority of safety and quality training.

Although the safety and quality of health care provided to each patient is highly dependent on the skills and performance of individual healthcare providers, it is also a healthcare service’s responsibility.¹⁵

The safety and quality roles within your healthcare service must be defined and relevant roles and responsibilities allocated.

Links to Action 1.17 Safety and quality roles and responsibilities.

All people who form part of your healthcare service’s workforce must understand their safety and quality roles in the context of your healthcare service. Orientation and access to training should occur on commencement to the service, whenever responsibilities change and when new services are introduced.

The safety and quality training needs for your workforce need to be regularly reviewed in light of the services provided, the health outcome achieved and the risks facing patients in the service.

Records of content and participation in orientation and training should be maintained to support review and future identification of training needs.

• 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

• 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?

• Orientation and training documents that detail content and participation by the workforce
• Training plans and records for members of the workforce that includes the requirements of the Standards

Resources relating to this Action may be added as they become available. 

Culturally safe services improve Aboriginal and Torres Strait Islander people’s experiences of, and access to, health care. Embedding cultural safety in our health system will improve health outcomes and address widening gaps in health and wellbeing between Aboriginal and Torres Strait Islander peoples and non-Indigenous Australians.

The Commission defines ‘cultural safety’ in accordance with the Cultural Respect Framework 2016–2026 for Aboriginal and Torres Strait Islander Health¹⁶ as:

• ‘Recognition, protection and continued advancement of the inherent rights, cultures and traditions of Aboriginal and Torres Strait Islander peoples.’

The essential features of cultural safety are:

• Understanding your own culture and cultural bias
• Acknowledging difference, requiring that caregivers are actively mindful and respectful of difference(s)
• Being informed by the theory of power relations; any attempt to depoliticise cultural safety is to miss the point
• Appreciating the historical context of colonisation, the practices of racism at individual and institutional levels and their impact on First Nations peoples’ living and wellbeing, both in the present and past
• Its presence or absence is determined by the experience of the recipient of care and not defined by the caregiver.¹⁷

When providing care to Aboriginal and Torres Strait Islander patients, the workforce should acknowledge and be respectful of the cultural factors and complex kinship relationships that exist in the local community. Currently, the Australian health system does not always meet the needs of Aboriginal and Torres Strait Islander peoples. Aboriginal and Torres Strait Islander peoples may experience:

• Language barriers in understanding health messages and difficulty in informing members of the workforce of their needs
• Financial difficulties in gaining access to treatments and funding the costs of treatment
• Perception of inferior treatment.

Embedding cultural safety is an ongoing process, and something that the workforce must be supported in doing, in partnership with Aboriginal and Torres Strait Islander peoples. Table 2 compares actions and practices that can improve the likelihood of an individual experiencing culturally safe care, versus actions and practices that lack cultural safety.

Links to actions 1.09 and 1.10 Patient populations and social determinants of health and 1.25 Safe environment.

Table 2: Practices and actions that improve the delivery of culturally safe care compared to those that lack cultural safety

Source: Adapted from Assessing the Aboriginal and Torres Strait Islander actions in national safety and quality standards: Pre-reading workshop readings and activity (ACSQHC, 2022, unpublished).

Embedding cultural safety is an ongoing process and requires multiple strategies. Key tasks may include:

• 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

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

• Training documents specific to Aboriginal and Torres Strait Islander cultural safety which is 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 (RAP)

Australian Commission on Safety and Quality in Health Care: NSQHS Standards User Guide for Aboriginal and Torres Strait Islander Health. Provides practical support for the implementation of the Aboriginal and Torres Strait Islander specific actions in the National Safety and Quality Health Service Standards. The principles and strategies outlined in these resources are broadly applicable.

Department of Health, Western Australia: Journey of health and wellbeing. This is a short video intended to raise awareness of Aboriginal people’s journey of health and wellbeing. Developed by Tim Muirhead and Danny Ford.

Australian Indigenous HealthInfoNet website, including Cultural Safety for Health Professionals. Access to resources, courses, information and literature on Aboriginal and Torres Strait Islander Health and cultural safety training

The National Registration and Accreditation Scheme: Aboriginal and Torres Strait Islander Health and Cultural Safety Strategy 2020-2025 and other work led by the Aboriginal and Torres Strait Health Strategy Group 

Aboriginal and Torres Strait Health Strategy Group, established by Australian Health Practitioner Regulation Agency (Ahpra) and the National Health Practitioner Boards.

Australian Health Ministers’ Advisory Council: Cultural Respect Framework 2016–2026 for Aboriginal and Torres Strait Islander Health . Use to develop, implement and evaluate cultural awareness and cultural competency strategies.

NATSIHWA: Cultural Safety Framework. The Framework is a companion document to both the Aboriginal and Torres Strait Islander Health Worker Professional Practice

Framework (2012) and the Growing Our Futures report by Health Workforce Australia.

Department of Health and Human Services Victoria: Improving Care for Aboriginal and Torres Strait Islander Patients Resource Kit. For people who are working together to realise the goals established by the Improving Care for Aboriginal and Torres Strait Islander Patients (ICAP) reform.

Reconciliation Australia: Reconciliation action plans. Assist businesses to embed the principles and purpose of reconciliation.

Pharmaceutical Society of Australia: Guidelines for pharmacists supporting Aboriginal and Torres Strait Islander peoples with Medicines Management. Supports you to reflect on your personal and professional connections with Aboriginal and Torres Strait Islander peoples, culture and practices.

Indigenous Allied Health Australia: Cultural responsiveness training. Delivers cultural safety training using our evidence-based Cultural Responsiveness Framework.

Reconciliation Australia: Share our Pride. Provides a glimpse of how life looks from an Aboriginal and Torres Strait Islander perspective.

Safety and quality are everybody’s responsibility. Having a culture of safety and quality improvement requires a clear understanding of who is accountable for what. Figure 2 outlines the key safety and quality roles and responsibilities and how these might be assigned, depending on the size of the healthcare service.

Figure 2: Roles and responsibilities for clinical governance in different service sizes

Source: National Safety and Quality Primary and Community Healthcare Standards (ACSQHC, 2021).

Supporting your workforce to understand and fulfil their assigned safety and quality responsibilities can be carried out in a variety of ways, and may be dependent on the size and complexity of your healthcare service. In some circumstances, a shared understanding of different people’s safety and quality roles may help contextualise an individual’s understanding of and ability to carry out assigned responsibilities. 

Links to actions 1.01 Governance, leadership and culture, and 1.15 Safety and quality training.

• Ensure 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 via position descriptions, orientation and training, ongoing communications, performance review processes (if applicable)

• How is your workforce supported to understand and fulfil their safety and quality roles and responsibilities?

• 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.

Australian Commission on Safety and Quality in Health Care: National Model Clinical Governance Framework. Provides practical guidance on clinical governance roles and responsibilities, based on the National Safety and Quality Health Service Standards. The principles of clinical governance and roles and responsibilities outlined are broadly applicable.

Regular evaluation of performance is an important tool to identify gaps in skills and understanding and training and development needs. The ways your service evaluates performance will depend on its structure and size, as well as the roles and responsibilities of people working in the healthcare service.

For healthcare providers, evaluation of performance may include continuing professional development activities, self-reflection and peer evaluation linked to maintenance of professional registration requirements. Other mechanisms include regular discussions about performance, or form part of prescribed professional development processes. However they are conducted, outcomes of performance evaluations provide opportunities to set goals and plan for skills and knowledge development, and should be linked to the overall goals of the healthcare service, including delivering safe and high-quality care.

Links to actions 1.15 Safety and quality training, 1.17 Safety and quality roles and responsibilities.

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

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

• 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 participation by the workforce

Australian Commission on Safety and Quality in Health Care: National Model Clinical Governance Framework. Provides practical guidance on clinical governance roles and responsibilities, based on the National Safety and Quality Health Service (NSQHS) Standards. The principles of clinical governance and roles and responsibilities outlined are broadly applicable and can be considered when evaluating performance. 

Australian Health Practitioner Regulation Agency: Continuing Professional Development (CPD). Links to CPD requirements, codes and guidelines for each National Board.

Australian Commission on Safety and Quality in Health Care: Review by peers: A guide for professional, clinical and administrative processes A tool to support healthcare services implementing processes for the review of professional practice.

All healthcare providers in your healthcare service must practise within a designated scope of clinical practice. Describing a scope of clinical practice for healthcare providers, monitoring healthcare providers practices and reviewing healthcare providers’ scope of clinical practice when there are substantial changes will all support the delivery of safe, high-quality health care.

The scope of clinical practice is specific to a role and describes the extent a healthcare provider’s clinical skills, knowledge, professional registration (where applicable), performance and professional suitability, are used in a healthcare service.

This is distinct from a healthcare provider’s scope of practice. The National Boards, under the National Registration and Accreditation Scheme for health practitioners, expect all registered healthcare providers to practise within their individual scope of practice and the relevant National Boards standards, codes and guidelines of their respective profession, reinforced through profession specific documents such as Codes of Conduct or equivalent.[i]

For example, a healthcare provider practising within their individual scope of practice may be qualified to provide services A, B and C. However, the healthcare service they are working within does not have the appropriate equipment or community demand for service C. While the healthcare provider is working in that particular healthcare service, their scope of clinical practice would only encompass the provision of services A and B.

Description of a healthcare provider’s scope of clinical practice could be a as stand-alone document, or included in a position description or contract of services. It should include:

• Types of services the healthcare provider is expected to deliver within the healthcare service
• Minimum requirements for professional registration, or self-regulation 
• Minimum requirements for working with specific population groups, for example Working With Children Checks when providing care to children
• Additional training or qualifications required if applicable
• Any supervision or continuing professional development requirements.

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

• 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? 

• Documented scope of clinical practice described in position descriptions, contract for services, or standalone document
• Review of services provided against 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 scope of clinical practice amendments required)
• Evidence of regular review of described scope of clinical practice, position descriptions or contract for services and any changes made

Resources relating to this Action may be added as they become available. 

The delivery of safe, high-quality health care must be underpinned by up-to-date evidence-based practice, taking into consideration clinical judgement and patient’s needs and preferences for health care.[i]

Your healthcare service has an important role in facilitating the use of evidence-based care in practice. This means giving healthcare providers ready access to, and supporting their use of, best practice guidelines, available evidence, relevant clinical care standards developed by the Australian Commission on Safety and Quality in Health Care and decision support tools[ii] relevant to their clinical practice. These resources may be profession specific, or multidisciplinary, for example, integrated clinical pathways. They may be national or international best practice guidelines, or locally adapted guidelines. 

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

• What 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?

• Evidence of best practice guidelines, clinical care standards developed by the Commission and decision support tools 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.

Australian Commission on Safety and Quality in Health Care: Clinical care standards. A small number of quality statements that describe the care patients should be offered by healthcare providers and healthcare services for a specific clinical condition or defined clinical pathway in line with current best evidence.

Primary Health Network. HealthPathways. Most Primary Health Networks (PHNs) provide access to HealthPathways, an online health information portal for healthcare providers to be used at the point of care. It provides localised information on how to assess and manage medical conditions and how to refer patients to local specialists and services in the most timely way.[i]

Therapeutic guidelines: A leading source of independent, evidence-based, practical treatment advice to assist practitioners with decision making at the point-of-care.

‘Appropriate care’ means that patients are receiving the right care, and the right amount of care according to their needs and preferences, at the right time, from the right healthcare provider. The care offered should also be informed by the best available evidence. However, healthcare interventions and outcomes of care vary between populations and across geographic areas, services and healthcare providers. Understanding this variation is critical to improving the quality and appropriateness of health care. Some variation is desirable and warranted, as it reflects differences in people’s healthcare needs and preferences. If variation is unwarranted, it signals that people are not getting appropriate care and presents an opportunity for changes and improvements. Figure 3 describes this concept in more detail.

Figure 3: Understanding healthcare variation

Healthcare providers have a professional responsibility to review the care they provide and to participate in efforts to address unwarranted clinical variation to improve the quality of care.

• Identify areas of clinical practice to review the care delivered against relevant best practice. This may be based on the population served, 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 reasons for variation, determine if 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 health care processes
  • monitor progress and make further changes as necessary
• Maintain records of reviews and actions taken as a result of examining variation and appropriateness of care

• 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 does your service have in place to ensure patients are receiving the right care, and the right amount of care according to their needs and preferences, at the right time?

• 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

Australian Commission on Safety and Quality in Health Care: User Guide for the Review of Clinical Variation in Health Care. Provides practical guidance, including clinical case studies, on how health services can review clinical practice and address unwarranted variation, based on the National Safety and Quality Health Service (NSQHS) Standards. The principles and strategies are broadly applicable.

Australian Commission on Safety and Quality in Health Care: Better Care Everywhere program series. Explores why healthcare variation happen and what we can do about it?

Australian Commission on Safety and Quality in Health Care: Australian Atlas of Healthcare Variation series. Maps of variation in care, derived from information routinely gathered by the health system, show how healthcare use differs across the country.

NPS MedicineWise: Clinical case studies. Reflective learning to inform clinical decision making.