Patient safety and quality systems

Policies, procedures and protocols are important tools to describe a healthcare service’s agreed ways of working. They form an integral part of its clinical governance framework. They should:

• Address how safety and quality risks are identified, prioritised, minimised or eliminated.
• Support compliance to safety and quality legislation, regulation and jurisdictional requirements.

• Be based on evidence and best practice.
• Be implemented consistently throughout the healthcare service, with implementation monitored.
• Be regularly reviewed to identify whether there are areas for improvements. 
• Be updated when improvements are identified, and improvements implemented. 

Policies, procedures and protocols relating to safety and quality may also be relevant to your healthcare service’s legal, jurisdictional and business obligations. For certain healthcare services, integrating these systems may be appropriate. At all times, your healthcare service must adhere to regulatory requirements as prescribed in relevant Commonwealth, state and territory legislation, such as work health and safety obligations.

• 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

• 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?

Examples of evidence

• 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

Australian Commission on Safety and Quality in Health Care: National Model Clinical Governance Framework. Provides guidance on policies, procedures and protocols, based on the National Safety and Quality Health Service (NSQHS) Standards. The principles and strategies outlined are broadly applicable.

Data to support safety and quality improvement

Measurement and feedback are key to quality improvement. Data is fundamental to measurement and can be used to identify areas where a healthcare service is doing well and areas where improvement is required. At a healthcare service level, data that can be used to inform measurement for quality improvement may include:

• Data relating to types of services provided
• Patient information, such as the number of appointments over a period of time, reasons for seeking advice/treatment, improvements in health outcomes over time
• Feedback from patients including experiences, compliments and complaints
• Information collected from the workforce about their experiences
• Incidents, near misses and adverse events
• Attendance and appointment data, patient enquiries or community demographics, or other data that is relevant to the healthcare service. Some healthcare services may be required to collect data as part of a contract or agreement which may also be used to identify safety and quality improvement priorities.

Relevant data will differ between healthcare services and will depend on the safety and quality priorities identified. No single measure should be used in isolation to assess the safety and quality of a healthcare service. Instead, a comprehensive measurement and improvement system should be adopted.

Validated indicators, measurement and reporting tools

The Commission undertakes a range of projects to support the meaningful use of data to improve patient care, and will be working to develop tools and resources that would support healthcare services to use data for quality improvement.

National Primary Healthcare Data

The Australian Institute for Health and Welfare (AIHW) is leading the development of a Primary Health Care Information System, including the development of a National Primary Health Care Data Asset, to gain a better understanding of a patient’s journey and experiences within the primary healthcare system.^3,4 This work will help fill existing aggregate primary healthcare data gaps at regional and national levels, to enable identification of trends and priorities for safety and quality improvement.

In addition, data provided to Primary Health Networks can be used to inform service and system planning at local and regional levels.

• 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

• 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 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?

• 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

Australian Commission on Safety and Quality in Health Care: Clinical Care Standards. Recommended indicators and data sets within relevant Clinical Care Standards, which aim to support implementation of quality standards for specific clinical conditions.

Institute for Healthcare Improvement: Plan, Do, Study, Action (PDSA) Worksheet. A useful tool for documenting a test of change.

South Eastern Melbourne Primary Health Network: Quality Improvement.

BMJ Journals, quality and care: How safe is primary care? A systematic review. The review investigated how often patient safety incidents occur in primary care and how often these were associated with patient harm.

Australian Institute of Health and Welfare:  Primary health care data development. Information about the AIHW’s project that will encompass the governance, standards, infrastructure, collection, analysis and reporting of primary health care data within Australia. 

Pride in Health + Wellbeing: Getting Better Audit tool. A free tool to measure your healthcare service’s LGBTQ-Inclusion.

World Health Organization. Primary health care measurement framework and indicators: monitoring health systems through a primary health care lens. A conceptual framework for measuring primary health care performance at a health system level, including a menu of indicators to track and monitor progress, and identify gaps and areas for improvement.

Risk management

Risk management helps healthcare services make decisions to avoid or mitigate adverse events and outcomes. It involves implementing a continuous process to identify, mitigate and manage safety and quality risks.

Risks will differ between services and are dependent on the complexity associated with the services it delivers, as well as the size of the service itself. Examples of risks include cold-chain failures in the storage of temperature-sensitive medicines; lack of privacy controls to protect patient healthcare records; loss of key utilities such as electricity; and access to technology such as electronic medical records, all of which can increase risks to patient harm.

In using a risk management approach, healthcare services will identify, analyse, evaluate and treat risks to safety and quality in the service. In determining the best course of action to mitigate and manage safety and quality risks, healthcare services can use a general risk analysis matrix, such as the one in Table 1: Healthcare service risk analysis matrix.

Table 1: Healthcare service risk analysis matrix

Planning for emergencies and disasters

A risk management approach should be applied when planning for emergencies and disasters, for example floods, fires and pandemics. Consider possible scenarios where disruption to service provision may occur and determine how these will be managed to ensure continuity of care for patients.

• 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 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 in order to meet safety and quality requirements, and legal and business obligations.

• 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 a on emergency or disaster?

• 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

Australian Commission on Safety and Quality in Health Care: Risk Management Approach. Provides a framework to assess and address risks identified in the organisation.

ISO Standards: 31000:2018 Risk management – Guidelines. For use by people who create and protect value in organisations by managing risks, making decisions, setting and achieving objectives and improving performance.

Australian Government Business: Assess and manage risk. Learn how to develop a risk management plan to prepare and protect your business.

NEJM Catalyst: What Is Risk Management in Healthcare? (nejm.org). Looks at the systems and processes employed to uncover, mitigate, and prevent risks in healthcare institutions.

Your local Primary Health Network may have guidelines, tools and resources to support your healthcare service prepare for emergencies and disasters, specific to your local area.

An incident management system is the way a healthcare service records and learns from safety and quality incidents, near misses and adverse events. It relies on a culture of reporting and review, so individuals and services can learn from previous adverse events and change their processes and systems to reduce the risk of them happening again.

The incident management system should include:

• A paper-based or electronic register where incidents can be recorded and tracked
• Training and support for the workforce to recognise, respond to, and report incidents
• Support for patients, carers and families to communicate concerns or report incidents
• A process for responding to and reviewing incidents that involves relevant members of the workforce and provides timely feedback to the workforce, patients, carers and families who have communicated concerns or incidents
• A process for regular analysis of incidents recoded to inform safety and quality improvement priorities and risks, and used to monitor and measure the healthcare service’s performance
• A process to regularly review and improve the incident management system.

An incident register collects data that includes:

• Date of the incident
• A description of the incident, including timelines, where relevant
• Information on who was involved in the incident (including all workforce, patients, carers, family or visitors to the service - such as contractors)
• A description of the harm, if any, the person experienced as a result of the incident, if known
• Action taken immediately following the incident to ensure the safety of staff, patients and the community (for example, an ambulance was called or urgent repairs to premises occurred)
• Details of open disclosure that occurred at the time of the incident, where applicable
• A statement about to whom the incident was reported, where applicable
• Name (and contact details, if needed) of the person who reported the incident This may be a member of the workforce, patients, carers, family or visitors
• Name (and contact details, if needed) of the person who documented the incident.

When reviewing incidents, for safety and quality improvements, healthcare services should consider what changes or additional actions could be introduced to prevent the incident occurring again.

Links to Action 1.04 Risk management and 1.02 Policies and procedures. 

• 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.

• 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?

• 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 take to address identified risks
• Information and resources, including incident reporting forms and tools, that are accessible to the workforce and patients

Australian Commission on Safety and Quality in Health Care: Incident management guide. Provides a concise overview of the incident management process and its underlying principles.

Allied Health Professions Australia: Incident Management (Allied Health National Insurance Disability Scheme [NDIS] Support). Provides resources to support healthcare providers establish incident management systems under the National Disability Insurance Scheme. Can be used as example policies and forms. 

Healthcare service providers should use the Australian Open Disclosure Framework whenever patients are harmed during the delivery of health care. ‘Open disclosure’ describes the process of the healthcare provider having an open discussion with the patient, carers and the patient’s family about adverse events that resulted in harm to the patient while receiving health care. Further information on open disclosure, including applicability for sole practitioners and small practices is available on the Commission’s website.

Elements of open disclosure in the Framework are:

• An apology or expression of regret, which should include the words ‘I am sorry’ or ‘we are sorry’
• A factual explanation of what happened
• An opportunity for the patient who has experienced harm or an unexpected event, and/or their carers and family to relate their experience
• A discussion of the potential consequences of the adverse event
• An explanation of the steps being taken to manage the adverse event and prevent recurrence.

In using the Australian Open Disclosure Framework, healthcare services should:

• Foster a culture that supports and prioritises open disclosure processes as part of good clinical care
• Determine how open disclosure processes are implemented in the healthcare service, taking into consideration the principles and elements of the Framework
• Support and provide open disclosure training, peer support and mentorship, including communications skills training that supports empathetic and respectful communication
• Ensure access to appropriate support for the workforce, people who have experienced harm and their support people
• Conduct continuous evaluation of open disclosure processes and feedback of results to the workforce, patients who have experienced harm and their support people for quality improvement
• Try to communicate lessons learned throughout the broader health system through existing mechanisms and relevant authorities, such as conferences or professional networks.

Links to Action 1.05 Incident management

• 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

• 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

• 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?

• 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

Australian Commission on Safety and Quality in Health Care: Australian Open Disclosure Framework – Better communication, a better way to care. A framework designed to enable healthcare services and healthcare providers to communicate openly when health care does not go to plan.

Australian Commission on Safety and Quality in Health Care: Implementing the Australian Open Disclosure Framework in Small Practices. Resource to assist sole healthcare providers and those working in small practices implement and practice open disclosure in accordance with the Australian Open Disclosure Framework.

Australian Commission for Safety and Quality in Health Care Fact Sheet: Preparing and participating in open disclosure discussions. Information for consumers and carers.

Australian Commission for Safety and Quality in Health Care Fact Sheet: Open disclosure – what to expect if you experience harm during health care? Information for consumers and carers.

Regular collection of patient feedback to inform safety and quality priorities is an important element of measuring the quality of care. This can be done using feedback forms, informal conversations with patients or follow-up telephone calls. Patient feedback can often be referred to as ‘Patient-reported experience measures’ (PREMs). These are derived from patients’ responses to survey or interview questions about their recent experiences of services received at a healthcare service.

Similarly, feedback from the workforce about their understanding and use of safety and quality systems indicates a healthcare service’s safety and quality culture and can be used to identify opportunities for improvement. Feedback may be sought through informal conversations, meetings or emails, surveys, performance discussions and information used to identify safety and quality training and development needs. 

Links to Action 1.03 Measurement and quality improvement

• 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.

• How and when does your healthcare service seek feedback from patients on their care?
• How and when does your healthcare service seek feedback from the workforce on their understanding and use of safety and quality systems?
• How has the feedback been used to improve care?

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

Australian Commission for Safety and Quality in Health Care: Australian Hospital Patient Experience Question Set. This is available in 20 languages, easy English, large print and braille. While originally designed for the hospital setting, the types of questions that could be used to collect patient feedback are broadly applicable.

Australian Institute for Health and Welfare: Patient experiences in Australia by PHN

Your profession-specific representative organisation may implement surveys for healthcare services to use in collecting feedback from patients.

Complaints from patients provide a unique opportunity to discuss with patients the care they have received, address any gaps in service delivery, and make improvements. 

A well-designed complaints management system includes:

• A clear description of how patients can report complaints
• Opportunities for patients to submit complaints
• A process on complaints reporting, investigation, and actions taken
• Description of the roles, responsibilities and accountabilities of the workforce in complaints management
• Processes for compliance with relevant state and territory mandatory reporting requirements
• Information on how information on complaints and complaints resolution are communicated to patients
• A process to analyse complaints in a timely way and improve safety and quality of care
• Mechanisms that link complaints management with other organisational processes and systems, including measurement and quality improvement, incident management system, open disclosure, risk management and policy development.

Links to actions 1.02 Policies and procedures; 1.03 Measurement and quality improvement; 1.04 Risk management; 1.05 and 1.06 Incident management and open disclosure; and 2.07g Accessing healthcare service information.

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.

• 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?

• Information on how patients may make complaints (links to Action 2.07g Accessing healthcare service information)
• 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

Australian Commission on Safety and Quality in Health Care: Australian Charter of Healthcare Rights (second edition). Describes the rights that people can expect when receiving health care. A range of resources are available to support the use of the Charter healthcare services.

Australian Commission on Safety and Quality in Health Care: Your healthcare rights – Key contacts. Lists a number of organisations who may be able to advise or support you if you have a question about healthcare rights.

Australian Health Practitioners Regulation Agency: Concerns about practitioners.

Understanding your patient population, inequities and the challenges these can cause is an important step in providing safe, high-quality health care that is appropriate for your local community.

‘Health inequities’ are systematic differences in the health status or in the distribution of health resources between different population groups, arising from social conditions in which people are born, grow, live, work and age, which can lead to further differences in health outcomes.[i]^,[ii] Examples of population groups that experience inequities include:

• Peoples of Aboriginal and Torres Strait Islander origin
• People with disability
• People with diverse backgrounds - that is, people’s social, economic and geographic circumstances as well as their cultural backgrounds, religions, beliefs and practices, languages spoken, sexual orientation, gender identity and gender expression, and sex characteristics.

People can belong to multiple population groups, and there are intersections and tensions that must be considered.

Identifying these population groups can then be used to inform the planning and delivery of health care for patients in a way that maximises access and seeks to overcome these challenges and in turn, reduce the risk of avoidable differences in health outcomes.

 Links to actions 1.10 Patient populations and social determinants of health; and 1.24 and 1.25 Safe environment.

• Identify patients in your healthcare service 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.

• 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?

• 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

Australian Government Department of Health: Your local Primary Health Network. Information about the population profile and location of your local Primary Health Network (PHN), plus links to tools.

Australian Bureau of Statistics Census data: QuickStats and Community Profiles. Search Census data.

Pride in Health + Wellbeing: Statistics. Provides the latest LGBTQ health statistics from research in the previous 12 months.

Health inequities are systematic differences in the health status or in the distribution of health resources between different population groups, arising from social conditions in which people are born, grow, live, work and age, which can lead to further differences in health outcomes.^7,8

Healthcare services have an important role to play in ensuring that healthcare providers consider information on population groups, and tailor care to achieve better health outcomes. Figure 1 describes the impact of equality, equity and justice. In a healthcare setting, information on your patient populations and the inequities that exist can inform planning and delivery of health care to achieve better outcomes.

Figure 1: Demonstration of the differences between equality, equity and justice

• Source: Assessing the Aboriginal and Torres Strait Islander actions in national safety and quality standards: Learner’s Guide (ACSQHC, 2022, unpublished)

Care should be planned and delivered that is tailored to meet patients’ needs and preferences and ensure the principles of the Australian Charter of Healthcare Rights (second edition)⁹ are applied.

• 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.

Links to actions 1.09 Patient populations and social determinants of health; 1.24 Safe environment; 2.02 Healthcare rights and informed consent; and 2.06 Communication that supports effective partnerships.

• How does your healthcare service tailor its care to meet the different needs of its patient population groups?

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 interpreter
• 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 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.

Australian Commission on Safety and Quality in Health Care: NSQHS Standards User Guide for Health Service Organisations Providing Care for Patients from Migrant and Refugee Backgrounds. Provides practical support for healthcare services where specific efforts or additional attention is required to meet the health needs of this patient population, based on the National Safety and Quality Health Service (NSQHS) Standards. The principles and strategies outlined in this resource are broadly applicable.  

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 NSQHS Standards. The principles and strategies outlined in this resource are broadly applicable.

Australian Commission on Safety and Quality in Health Care: NSQHS Standards User Guide for health service organisations providing care for patients with cognitive impairment or at risk of delirium. Provides practical support for healthcare services where specific efforts or additional attention is required to meet the health needs of this patient population, based on the National Safety and Quality Health Service (NSQHS) Standards. The principles and strategies outlined in this resource are broadly applicable.

Australian Commission on Safety and Quality in Health Care: NSQHS Standards User Guide for health services providing care for people with mental health issues. Provides practical support for healthcare services where specific efforts or additional attention is required to meet the health needs of this patient population, based on the National Safety and Quality Health Service (NSQHS) Standards. The principles and strategies outlined in this resource are broadly applicable.

Australian Commission on Safety and Quality in Health Care: NSQHS Standards User Guide for acute and community health service organisations that provide care for children. Provides practical support for healthcare services where specific efforts or additional attention is required to meet the health needs of this patient population, based on the National Safety and Quality Health Service (NSQHS) Standards. The principles and strategies outlined in this resource are broadly applicable.

Council for Intellectual Disability: Resources for health practitioners. Resources for healthcare providers to support better appointments when working with people with intellectual disability.

Pride in Health + Wellbeing. A national membership program that supports organisations within the Health, Wellbeing and Humans services sector to improve their LGBTQ inclusive care, remove systematic barriers to accessing care and thereby reduce health disparities faced by LGBTQ communities.

Dementia Australia: Dementia Friendly communities. Ensure that people living with dementia are welcome, included and valued.

Down Syndrome Australia: Health Resources. Provides access to information to make informed health decisions.

Developmental Disability WA: Resources. Provides current resources, including online courses.

Queensland Centre for Intellectual and Developmental Disability: Resources. QCIDD provides current resources.

NSW Government Agency for Clinical Innovation: Intellectual Disability Network Resources. These resources relate to the care and health of people with intellectual disability across all ages, including acquired brain injuries by enhancing the capacity of primary and secondary health services.

NSW Government Agency for Clinical Innovation: Brain Injury Rehabilitation Network Resources. These resources relate to rehabilitation outcomes for adults, young people and children following traumatic brain injury.

Australian Government Department of Health: National Roadmap for Improving the Health of People with Intellectual Disability. Aims to address serious health inequities faced by people with intellectual disability. It outlines how we can create a health system where people with intellectual disability are valued, respected and have access to high quality, timely and comprehensive health care.

Healthcare records provide one of the most important information sources available to healthcare providers. Undocumented or poorly documented information relies on individual healthcare providers’ memory and is less likely to be communicated and retained. This can lead to a loss of information, which can result in misdiagnosis, and inadequate or inappropriate treatment and harm.

Healthcare records can be paper-based, electronic, or a mix of both. Irrespective of the form, an effective healthcare record system must be applied consistently. This includes:

• When creating, maintaining and using patient healthcare records
• Recording patient notes and relevant communications between healthcare providers
• Complying with relevant privacy and security regulations

The records should be designed so they can be audited for clinical review and improvement. Healthcare services should have a process for patients to access to their healthcare records.

For detailed information about what should be included in a patient’s healthcare record, refer to Explanatory notes in Action 3.26.

Links to actions 1.12, 1.13 and 1.14 Healthcare records and 3.26 Processes for effective communication.

• 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

• 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?

• 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
• Observation of safe and secure storage systems for healthcare records, including evidence of fire protection and pest control strategies

The Privacy Act 1988 (the Privacy Act) outlines the privacy responsibilities that most healthcare providers have to comply with in managing health and personal information. The key requirements are contained in the Australian Privacy Principles (APPs).

Office of the Australian Information Commissioner OAIC: Privacy in your state. Looks at what privacy laws apply in each state and territory and what privacy laws apply to private sector health service providers.

Office of the Australian Information Commissioner OAIC: Privacy for health service providers. Provides additional information about healthcare provider obligations.

Open Notes website: Information about an international movement advocating for improving how medical information is shared patients and their care partners.

Reports from other healthcare providers, such as patient referrals, medication reviews, pathology or diagnostic imaging results can be a critical component in determining the course of action in a patient’s health care.  

Ensuring a healthcare service has established processes to receive, review, act on and document reports on patients will minimise the risk of loss of information, which can result in misdiagnosis and harm. This should include processes for receiving and actioning urgent reports when a patient’s healthcare provider is unavailable, or reports are received out of hours.

Links to actions 1.11, 1.13 and 1.14 Healthcare records and 3.26 Processes for effective communication.

• 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

• 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?

• Policies, procedures and protocols that describe how patient reports are received, reviewed, actioned and documented in a timely way
• Example of patient reports that have been received, reviewed, actioned and documented in a patient’s healthcare record

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

Note: This action is only applicable if your healthcare service uses My Health Record.

My Health Record is a secure online summary of a patient’s key health information, and is available to all Australians.¹⁰ Healthcare providers registered with My Health Record can upload and view patient information, which may encompass information uploaded by your patient’s other healthcare providers, and use this information in the planning and delivery of health care. Information available through My Health Record can include a patient’s health summary, medication prescribing and dispensing history, pathology reports, diagnostic imaging reports and discharge summaries.¹¹

‘Healthcare identifiers’ are unique numbers assigned and used in health-related information to clearly identify the patient, the treating professional and the organisation where healthcare is provided. They reduce the potential for errors with healthcare related information and communication. In Australia, the Healthcare Identifiers (HI) Service is a national system for uniquely identifying, healthcare providers, healthcare organisations and individuals receiving healthcare. These include:

• Individual Healthcare Identifier (IHI) – identifies a patient (individual) receiving healthcare. An IHI uniquely identifies individuals who receive healthcare, including Australian citizens, permanent residents and visitors to Australia
• Healthcare Provider Identifier – Individual (HPI-I) – identifies an individual healthcare provider who provides healthcare, such as general practitioners, allied health professionals, specialists, nurses, dentists and pharmacists, amongst others
• Healthcare Provider Identifier – Organisation (HPI-O) – identifies the healthcare provider organisation where healthcare is provided, such as hospitals, medical practices, pathology or radiology laboratories and pharmacies. Healthcare providers must be registered with the HI Service and assigned healthcare identifiers to access a patient’s My Health Record.

'Standard national terminologies’ are a structured vocabulary used in clinical practice to accurately describe the care and treatment of patients. Healthcare providers around the world use specialised vocabulary to describe diseases, operations, clinical procedures, findings, treatments and medicines. In Australia, terminologies include SNOMED CT-AU and Australian Medicines Terminology.

Healthcare services that use My Health Record system must have processes to:

• Use national healthcare identifiers for patients and healthcare providers
• Use standard national terminologies when uploading patient reports and information
• Support healthcare providers to use My Health Record to optimise safe, high-quality health care.

1.11, 1.12 and 1.14 Healthcare records and 3.26 Processes for effective communication.

• 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 the Australian Medicines Terminology (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

• 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?

• Evidence of registration with and contributions to My Health Record
• Documented process 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)

Australian Digital Health Agency: My Health Record. Provides a suite of training, resources and guides.

Office of the Australian Information Commissioner: Healthcare identifiers. The OAIC is the independent regulator of the privacy aspects of the Healthcare Identifiers Act 2010 (HI Act) and the Healthcare Identifiers Regulations 2010  (HI Regulations).

National Clinical Terminologies Service: What is clinical terminology? Operated by the Australian Digital Health Agency, is responsible for managing, developing and distributing national clinical terminologies and related tools and services.

Note: This action is only applicable if your healthcare service uses My Health Record.

My Health Record is a secure online summary of a patient’s key health information, and is available to all Australians.¹² Healthcare providers registered with My Health Record can upload and view patient information, including information uploaded by other healthcare providers. This information can be used in the planning and delivery of health care. Information available through My Health Record can include a patient’s health summary, medication prescribing and dispensing history, pathology reports, diagnostic imaging reports and discharge summaries.¹³

Healthcare services providing clinical information to My Health Record are required to comply with a range of legislative requirements, including:

• My Health Records Act 2012
• My Health Records Rule
• My Health Records Regulation, and where a healthcare service is undertaking Assisted Registration
• My Health Records (Assisted Registration) Rule.¹⁴

More detailed information about these obligations are available on the My Health Record website.

As part of these obligations, your healthcare service must ensure clinical information uploaded is accurate and complete. Undocumented or poorly documented records can lead to a loss of information, which can result in misdiagnosis and harm.

1.11, 1.12 and 1.13 Healthcare records and 3.26 Processes for effective communication.

• 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

• 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?

• 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 to the My Health Record system
• Example of clinical information uploaded by the healthcare service in My Health Record

Australian Digital Health Agency: My Health Record website. Provides a suite of information and resources regarding viewing and uploading clinical information.