Patient safety and quality systems

Safety and quality systems are integrated with governance processes to enable the healthcare service to actively manage and improve the safety and quality of health care for patients.

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Intention of this standard

Safety and quality systems are integrated with governance processes to enable the healthcare service to actively manage and improve the safety and quality of health care for patients.

Policies and procedures

1.02—The healthcare service uses a risk management approach to:

  1. Establish and maintain policies, procedures and protocols
  2. Make policies, procedures and protocols easily available to the workforce
  3. Monitor and take action to improve adherence to policies, procedures and protocols
  4. Ensure compliance with relevant safety and quality legislation, regulation and jurisdictional requirements

Measurement and quality improvement

1.03—The healthcare service uses a range of data to:

  1. Identify priorities for safety and quality improvement
  2. Implement and monitor safety and quality improvement activities
  3. Measure changes in safety and quality outcomes
  4. Provide timely information on safety and quality performance to patients, carers and families and the workforce

Risk management

1.04—The healthcare service:

  1. Supports the workforce to identify, mitigate and manage safety and quality risks
  2. Documents and routinely monitors safety and quality risks
  3. Plans for, and manages, ongoing service provision during internal and external emergencies and disasters

Incident management and open disclosure

1.05—The healthcare service has an incident management system that:

  1. Supports the workforce to recognise and report incidents
  2. Supports patients, carers and families to communicate concerns or report incidents
  3. Involves the workforce in the review of incidents
  4. Provides timely feedback on the analysis of incidents to the workforce and patients, carers and families who have communicated concerns or incidents
  5. Uses the information from the analysis of incidents to improve safety and quality
  6. Incorporates risks identified in the analysis of incidents into the risk management system
  7. Regularly reviews and acts to improve the effectiveness of the incident management and investigation systems

1.06—The healthcare service uses the Australian Open Disclosure Framework when a patient is harmed through the delivery of health care

Feedback and complaints management

1.07—The healthcare service:

  1. Seeks feedback from patients, carers and families about their experiences and outcomes of health care
  2. Has processes to regularly seek feedback from the workforce on their understanding and use of the safety and quality system
  3. Uses feedback to improve safety and quality

1.08—The healthcare service:

  1. Provides opportunities for its patients to report complaints
  2. Has processes to address complaints in a timely way
  3. Uses information from the analysis of complaints to improve safety and quality

Patient populations and social determinants of health

1.09—The healthcare service identifies patient populations using its service at greater risk of avoidable differences in health outcomes, including:

  1. People of Aboriginal and Torres Strait Islander origin
  2. People with disability
  3. People with diverse backgrounds

1.10—The healthcare service uses information on its patient populations to inform planning and delivery of health care for patients

Healthcare records

1.11—The healthcare service has a healthcare record system that:

  1. Makes the healthcare record available to healthcare providers at the point of care
  2. Supports healthcare providers to maintain accurate and complete healthcare records
  3. Complies with privacy and security regulations
  4. Supports audits of healthcare records
  5. Facilitates a patient’s access to their healthcare record

1.12—The healthcare service has processes to:

  1. Receive and review reports on patients
  2. Recall patients and communicate about reports and health care options
  3. Take action on reports in a timely manner
  4. Document reports in a patient’s healthcare record

1.13—The healthcare service using My Health Record has processes to:

  1. Use national healthcare identifiers for patients and healthcare providers
  2. Use standard national terminologies
  3. Support healthcare providers to use My Health Record to optimise the safety and quality of health care for patients

1.14—The healthcare service providing clinical information to the My Health Record system has processes to:

  1. Comply with legislative requirements
  2. Ensure the accuracy and completeness of information uploaded