How an effective call bell system can improve service provision 

An effective call bell system is a key part of safe and quality care delivery in facilities providing services to care recipients. It can play an important role in risk mitigation, staff management and ongoing continuous improvement processes, and also helps demonstrate to your care recipients your organisation’s commitment to safe and high quality services.  

Promptly responding to call bell requests from care recipients can aid in risk management and the prevention of issues such as falls or pressure injuries. Long or delayed response times for call bells can be a sign of policy or procedure issues relating to the staff model or communication. Monitoring call bell response times and the reasons for the calls can contribute to identifying opportunities to improve service delivery.

It’s therefore vital for organisations to have processes and procedures in place to provide this assistance for their care recipients.  

1. Staff management

One of the most important aspects of a call bell system is the provider’s ability to respond to requests in a timely way. To achieve this, facilities must manage their staffing and rostering to support their staff’s ability to respond to call bells. Failure to roster enough staff, overburdening staff with too many responsibilities, and a lack of communication around expected responsibilities, priorities and processes are all common explanations for high call bell response times. 

2. Standards compliance

While you won’t find call bells specifically mentioned in standards requirements, there’s a lot of indicators that can be supported by good call bell response practices. For example, in a number of Provider Performance Reports, the Aged Care Quality and Safety Commission has referred to call bell response times and reporting as relevant to its assessment of compliance by providers with: 

  • Standard 3(3)(b)Effective management of high-impact or high-prevalence risks associated with the care of each consumer; 
  • Standard 7(3)(a)The workforce is planned to enable, and the number and mix of members of the workforce deployed enables, the delivery and management of safe and quality care and services; and 
  • Standard 8(3)(d) – Effective risk management systems and practices 

As another example, for care facilities following NSQHS, call bell system management and reporting is relevant in relation to the Clinical Governance Standard and the Comprehensive Care Standard 

3. Quality improvement

Reviewing call bell response records can form an important part of an organisation’s continuous quality improvement processes. Accurate records of the reasons for each call bell use, as well as response times, are useful for verifying care recipient and staff feedback and/or complaints and highlighting where improvements can be made in service procedures. Commonly listed reasons for response times outside the target window indicate opportunities for organisations to review current processes and how they impact safe and quality service delivery. 

How SPP can help

We’ve developed a new policy template for providers with call bell systems to optimise their call bell procedures. The template will help providers set response time KPIs, clarify staff responsibilities, and put in place regular reporting and analysis.  

In addition, our SPP self-assessment platform allows providers to link their call bell records as evidence against relevant Standards. 

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Need help with your call bell procedures? Ask us about a free trial of SPP.

NSQHS Accreditation Assessments for HSOs: What’s Changing? 

From July 2023, the National Safety and Quality Health Service (NSQHS) Standards assessment procedure for accreditation of hospitals or day procedure services (Health Service Organisations, or HSOs) will be changing, with mandatory short notice accreditation assessments replacing the existing announced and voluntary assessments.  

Why the change?

The move to short notice assessments is intended by the Australian Commission on Safety and Quality in Health Care (the Commission) to support the continuous implementation of the NSQHS Standards and reduce the administrative burden of preparing for accreditation assessment”.

The new process is designed to move the focus of assessments from preparation for assessment, to assessment of day-to-day practice. It is intended to support and emphasise continuous self-assessment by HSOs of their compliance with the NSQHS Standards, as well as their implementation of continuous quality improvement strategies.

The Commission requires that HSOs have systems and processes in place to keep their self-assessment documentation up to date, and conduct reviews of their self-assessment and their compliance status at least every three months.  

When will we be assessed?

Short notice accreditation assessments will occur: 

  • at least once within each three-year accreditation cycle;  
  • at least 4 months before the HSO’s accreditation expires;   
  • no sooner than 6 months after the previous assessment; and 
  • within 4 years of the previous assessment. 

HSOs therefore need to be ready for an accreditation assessment at any time. HSOs may request up to 20 business days per accreditation cycle to be excluded from assessment. These are days where a short notice assessment would either directly impact the provision of the service to consumers or the consumers of the service would be unavailable.

When will we be given notice of an upcoming assessment?

The notice period for an upcoming assessment will differ depending on the HSO’s location and/or the specific services provided. 

  • If you are an HSO in a metropolitan, rural or regional area with public transport options, you will be given 24 hours’ notice of assessment. 
  • If you are an HSO in a rural or remote area with either no or restricted public transport options, you will be given 48 hours’ notice of assessment.  

For some HSOs where special permissions must be sought to conduct assessment, such as services in some Aboriginal communities, fly-in fly-out services or services operating in prisons, your assessment notice may be up to 4 weeks to accommodate these requirements. 

For more information, see the Commission’s fact sheet, or feel free to contact us if you have any questions about the new assessment changes.

The importance of active, continuous self-assessment

Regular self-assessment of your compliance with the NSQHS Standards will maintain a focus on identifying opportunities to improve your service delivery. It forms an important step in the cycle of active, continuous quality improvement. As well as tracking compliance with each standard, your self-assessment process should also incorporate improvement opportunities that you identify through consumers’ feedback and complaints, and also from any incidents or near misses that occur. 

Ideally, your streamlined self-assessment system should include: 

  • A chronological record of all the compliance gaps and improvement opportunities you identify, and when you’ve addressed them; 
  • The ability to collaborate on and track improvements, including by assigning responsibility for certain tasks to team members;  
  • A compliance status report that you can generate at any point in time; and 
  • The ability to store and link documentary evidence of your compliance with each standard (for example, relevant policies and procedures that are implemented across your organisation).

How SPP can help

Our NSQHS self-assessment modules allow providers to understand the requirements of the Standards in detail, collate all identified improvement opportunities through an individually curated action plan, and review and report on their compliance status at any time.   

They also provide a helpful way to link relevant evidence against each standard, streamlining the self-assessment process and ensuring that your evidence of compliance is kept up to date. 

SPP also has self-assessments for other standards within the National Safety and Quality family, including for: 

  • Digital Mental Health,  
  • Mental Health for Community Managed Organisations, and  
  • Primary and Community Healthcare. 

In addition, SPP provides a deep pool of resources in our Reading Room (such as policy templates and info sheets) covering all aspects of organisational good governance to help HSOs work towards best practice.  

You can find our NSQHS Standards self-assessments in SPP by searching for ‘NSQHS’ in the Standards tab or under the ‘Australian National Standards’ subheading in that same tab. 

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The new Digital Mental Health Standards

Accreditation to the National Safety and Quality Digital Mental Health Standards (NSQDMHS) became available for all organisations on November 1 2022. Digital mental health services provide valuable support to clients, as they can be easier to access for most clients, and they can also offer clients the opportunity to discuss issues anonymously.

Launched in November of 2020, the Standards are not mandatory, however they do provide an opportunity for providers to give greater confidence to users of their services.

Who are the NSQDMHS for?

The Digital Mental Health Standards are available to a variety of mental health support providers. These include providers of:

  • Peer to peer support;
  • Services that provide information about accessing mental health services;
  • Digital counselling; and
  • Treatment services (assessment, triage and referral).

Digital mental health services may be provided via telephone, video conference, online (including web chat), SMS, and mobile applications.

What is in the standards?

There are three standards, and a total of 59 actions within the Digital Mental Health Standards. The three standards are:

  • Clinical and Technical Governance Standard;
  • Partnering with Consumers Standard; and
  • Model of Care Standard.

The standards map directly to the National Safety and Quality Healthcare Standards (NSQHS), however they contain fewer requirements than the NSQHS.

For more information about the content within the National Safety and Quality Digital Mental Health Standards, see our previous blog post on the topic.

Should we consider accreditation to the NSQDMHS?

Accreditation to the Digital Mental Health Standards provides clients with the assurance that their service provider is meeting the expected standards for safety and quality. The standards will also help to refine a provider’s processes, and provide better outcomes for users.

Feedback from organisations who participated in the pilot program for the Digital Mental Health Standards was that the standards helped them to document the processes they already had in place, and helped them to identify if they had any issues or areas for improvement in their processes. Organisations highlighted the data collection and management requirements within the Standards, saying that these assisted in mapping patient care journeys and change management processes.

What is the accreditation process?

Accreditation is provided by independent accrediting agencies who have been approved by the AHSSQA Scheme. The Australian Commission on Safety and Quality in Health Care (the Commission) has a list of accreditors on their website.

The process for accreditation to the National Safety and Quality Digital Mental Health Standards is as follows:

Application and engagement

  • Application – apply to an approved accrediting agency
  • Preparation – implement the NSQDMH Standards and clarify arrangements for an assessment
  • Application for not applicable actions – not all of the actions within the NSQDMH Standards are applicable to all providers, here you will specify which actions are irrelevant

Assessment and remediation

  • Interim assessment – the approved accreditor conducts an interim assessment which includes:
    • Desktop review – a review of evidence submitted by the provider to demonstrate compliance with the NSQDMH Standards
    • Verification – an assessment to verify the safety and quality systems described by the provider
  • Remediation period – a period of 60 business days is allowed in order to address any areas where the service provider does not comply with the requirements of the Standards
  • Final assessment – this assessment is for the actions that were either ‘not met’ or ‘met with recommendations’ during the interim assessment

Outcome, reporting and monitoring

  • Outcome – the provider receives an outcome based on the final assessment
  • Final report – the accrediting agency delivers a final assessment report
  • Submission of data – the Commission is notified of assessment outcomes by the accrediting agency
  • Registration the Commission adds the provider to their register of accredited digital mental health service providers
  • Ongoing monitoring – the service provider continues their monitoring and continuous improvement responsibilities

Further reading and how we can help

Since April 2021 we have had a module available to help providers self-assess against the NSQDMH Standards and ensure that their documented processes are in line with the requirements of the Standards. The module is intended to help to conduct a gap analysis before beginning accreditation, and with ongoing monitoring.

The Commission has developed a resource pack for the Digital Mental Health Standards, which can be found on their website.   

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Lessons from the pandemic: how Standards have evolved

We’re now two years into the pandemic, and the care and support sector has had to make some major adjustments to their service delivery in response to the COVID-19 crisis.

A number of standards have been amended or updated with significant new changes, to provide guidance on improving and standardising infection control processes, as well as ensuring that there are processes to manage workforce capacity and disaster readiness.

We’ve updated our self-assessments in SPP to reflect these changes, and thought it would be helpful to summarise the core themes that have emerged across the different major standards.  

Core infection control and disaster response themes

The core themes that have appeared consistently in standards updates include:

  • ensuring the workforce has the capacity, skills, training and equipment to implement infection prevention and control systems,
  • planning for and sourcing an alternative workforce in the event of disruptions,
  • developing, testing and reviewing an emergency and disaster management plan,
  • reporting to the governing body on infection control processes and implementation/testing of the emergency and disaster management plan,
  • testing, fitting and training in the use of PPE,
  • training in hand hygiene, respiratory hygiene and cough etiquette,
  • implementing stringent processes for communicating relevant information to family, patients and carers,
  • undertaking routine environmental cleaning,
  • ensuring workplace policies and procedures are in line with the relevant state or territory public health requirements,
  • managing movement of staff between areas and supporting staff required to isolate, and
  • procedures for waste management including safe storage and disposal of clinical waste.

These are some key areas that service providers should be addressing to ensure they are on top of their compliance requirements. Providers should check that they are familiar with any updates to standards that apply to their organisation. SPP can assist you with this, as we always update the modules on our platform in response to changes to standards.

Here are the main standards that have been updated to incorporate infection control requirements so far:

The updated Standards

National Safety and Quality Health Service Standards (NSQHS)

Changes to the NSQHS were introduced in May 2021 and include requirements to:

  • plan for public health and pandemic risks,
  • ensure the workforce has the capacity, skills, training and equipment to implement infection prevention and control systems,
  • test, fit, train workers and use PPE, and
  • ensure policies and procedures are in line with the relevant state or territory public health requirements.

NDIS Practice Standards

In November 2021 the NDIS Commission released a number of changes to these standards, to address:

  • planning for alternative workforce arrangements in the event of disruptions,
  • developing, testing, and reviewing emergency and disaster management plans,
  • implementing infection prevention and control precautions throughout all settings,
  • ongoing training on and supplies of PPE for workers, and
  • waste management including safe disposal of clinical waste.

QIC Health and Community Service Standards

In February this year, an updated version of the QIC Standards was released, with updates addressing infection control requirements including:

  • staff training in hand hygiene,
  • infection prevention management program aligning with state and territory guidelines,
  • regular cleaning of the environment, and
  • waste management.

Australian Community Industry Standard

The Australian Community Industry Standard was also updated towards the end of last year to include the following infection prevention and control requirements:

  • workplace preparation for pandemic,
  • workforce response to pandemic consistent with advice from health authorities, and
  • implementing and documenting an outbreak management plan.

RACGP Standards for General Practitioners

The RACGP Standards have seen a number of updates throughout 2021 and more recently in 2022, with the most recent update being in February 2022. The updated requirements address:

  • increased requirements around telehealth consultations (e.g. ensuring privacy etc.),
  • managing the risk of cross infection during a home visit,
  • updated processes for isolating patients and traceability processes for identifying patients who have used instruments,
  • establishing protocols for managing outbreaks of infectious disease in line with local, state and national guidance, and
  • environmental cleaning.

Aged Care Quality Standards

While the Aged Care Quality Standards haven’t been updated with new infection control requirements, the Aged Care Quality and Safety Commission has released a number of resources to guide providers in their implementation of infection control requirements. 

Resources to help you

We’ve developed and updated a number of resources in our platform to assist providers to manage infection control requirements under the standards that apply to them, as well as implement best practice processes. Here are some examples of how we can help:

  • a module for the “First 24 hours – managing COVID-19 in a residential aged care facility”,
  • a module to guide organisations to implement COVID-safe operations based on recommendations from Safe Work Australia,
  • a module to guide organisations through the components they should address in developing infection control / respiratory outbreak plan based on recommendations from various sources including the Department of Health, the Aged Care Quality and Safety Commission, and the NDIS Quality and Safeguards Commission,
  • resource templates including:
    • an outbreak management plan checklist,
    • an information sheet for employers on staff vaccination against COVID-19,
    • first 24 hours – managing COVID-19 in a Residential Aged Care facility checklist,
    • an emergency and disaster management plan,
    • emergency and disaster management procedures,
    • working from home policy,
    • working from home agreement,
    • client risk assessment.

Want to take a closer look at our Covid-19 resources?

2021 – that’s a wrap!

It has certainly been a busy year for service providers and compliance professionals in our sector. Providers have been truly tested by the challenges of the pandemic and a changing regulatory landscape. We invite you to reflect with us on the key developments of this past year.

Child safety

In the child safety space, progress has been underway over the last couple of years to implement the recommendations of the Royal Commission into Institutional Responses to Child Sexual Abuse. We published a blog post on this topic in March of this year.

On 1 July 2021, the new Victorian Child Safe Standards were released, bringing these standards into alignment with the National Principles for Child Safe Organisations. Our mapped self-assessment for the Victorian Child Safe Standards is available on SPP.

NSW followed in a similar vein and in November 2021, legislation passed in NSW Parliament mandating compliance with the NSW Child Safe Standards by certain ‘child safe organisations’. The NSW Child Safe Standards, which also map to the National Principles, can be accessed in SPP.

At present, Australian Catholic Safeguarding Ltd is finalising the Second Edition of the National Catholic Safeguarding Standards, and we expect to be providing assessment modules of these standards early in the New Year.

Aged care

The Royal Commission into Aged Care Quality and Safety was the focal point for aged care this year, with some regulatory changes already implemented and others underway.

The Serious Incident Response Scheme (SIRS) brought in new compliance requirements for residential aged care providers in April. Our Incident Management Procedures (Aged Care SIRS) Policy can help get you up to speed on this. In correlation with SIRS, the Aged Care Quality Standards were updated to include a requirement on incident management, and our ACQS self-assessments have been updated accordingly.

Rules around use of restrictive practices changed, with shift in terminology from ‘restraints’ to ‘restrictive practices’, bringing aged care into alignment with disability regulation. Our updated Use of Restrictive Practices (Aged Care) Policy reflects this.

This year we released an educative version of the Aged Care Quality Standards on SPP, based on the Commission’s Guidance and Resources for Providers document, and which walks providers through their requirements in greater depth. We have also released the Board Governance Toolkit, a comprehensive suite of resources designed specifically to support board members to fulfil their responsibilities under the Aged Care Quality Standards.

Disability

In late 2021, the NDIS Practice Standards saw their biggest overhaul since their inception. The NDIS Quality and Safeguards Commission identified emergency and disaster management and mealtime management/swallowing problems as key focal areas for additional guidance and regulation, and brought in three new Practice Standards to reflect this. In addition, a number of Quality Indicators were added and amended, reflecting a focus on infection control, staff training, individualised risk assessments and insurance requirements. Our blog post will flesh this out for you.

All changes to the NDIS Practice Standards are available for completion in SPP, and you can choose from mapped or stand-alone modules, depending on your organisation’s needs.

Health care

The National Safety and Quality Healthcare Service Standards (Second edition) were updated in 2021, to include new requirements around infection control. We added two new modules to our NSQHS self-assessment on SPP to address the new Standard 3 – Preventing and Controlling Infections.

The Australian Commission on Safety and Quality in Health Care has also begun releasing a number of new standards, aiming to ensure a consistent approach to safe and high-quality health care across different service environments. In 2021, we added self-assessment modules for the National Safety and Quality Digital Mental Health Standards and the National Safety and Quality Primary and Community Healthcare Standards to SPP, and we will be closely tracking the development of the National Safety and Quality Mental Health Standards for Community Managed Organisations.

During 2021 we also released three new modules for the RACGP Standards for general practices (5th edition). We worked closely together with the RACGP to ensure that all of the standards, criteria and indicators in each module are reflected in detail in SPP’s self-assessments.

ISO

ISO standards are popular accreditations amongst our users, and this year we were pleased to add ISO 27001 Information Security Management Systems to SPP. ISO 27001 is an internationally recognised standard that requires organisations to implement an Information Security Management System (ISMS). The Australian federal government requires ISO 27001 certification for all providers of employment skills training and disability employment services, and a number of health and community service providers also choose to follow this standard.

All the best for the holiday period!

The past 12 months have definitely been jam-packed, and we expect 2022 will be just as busy.

We thank you all for your continued collaboration, and from everyone in the BNG team, we wish you a safe and happy holiday season.

See you next year!

Need to get on top of your compliance work?

Access a broad selection of Standards in SPP.

The new National Safety and Quality Primary and Community Healthcare Standards

The Australian Commission on Quality and Safety in Healthcare (the Commission) has recently published a new set of standards, the National Safety and Quality Primary and Community Healthcare Standards (the PCH Standards). These are a nationally consistent, consumer-centred set of safety and quality standards.

Who are these standards for and what do you need to know? Read on to find out more.

Who should follow the Primary and Community Healthcare Standards?

The Commission will be encouraging all Australian primary and community healthcare services that are directly involved in patient care to implement the PCH Standards.

The PCH Standards are applicable to services that deliver health care in a primary and/or community setting. These services address the prevention, treatment and management of illness and injury, and the preservation of physical and mental wellbeing. This includes health providers like dentists, physiotherapists, podiatrists, speech pathologists and other allied health providers.

What do the Primary and Community Standards require?

There are three Primary and Community Healthcare Standards that cover clinical governance, partnering with consumers and clinical safety.

  • Clinical Governance Standard, where clinical governance is the set of relationships and responsibilities established by a health service to ensure good clinical outcomes. It ensures that the community and healthcare services can be confident that systems are in place to deliver safe and high-quality health care, and continuously improve services.
  • Partnering with Consumers Standard, which describes the systems and strategies to create a person-centred healthcare service in which patients and consumers are:
    • Included in shared decision-making
    • Partners in their own health care
    • Involved in the development and design of quality healthcare services.
  • Clinical Safety Standard, which considers specific high-risk areas of health care commonly encountered that need to be addressed and mitigated.

Are the Primary and Community Healthcare Standards mandatory?

The PCH Standards are voluntary. They should only be applied where services are involved in the direct care of patients.

However, in some cases, accreditation against the Standards may be required by a funder of a healthcare service to satisfy regulatory or contractual obligations.

How do these standards fit in with other safety and quality standards developed by the Commission?

The Commission has developed a range of safety and quality standards, including:

  • National Safety and Quality Health Service Standards
  • National Safety and Quality Digital Mental Health Standards
  • National Safety and Quality Mental Health Standards for Community Managed Organisations (in development)

All safety and quality standards developed by the Commission are aligned in structure and intent, and focus on embedding clinical governance and consumer partnerships in safe, high-quality healthcare services.

If no standard is mandated, then a healthcare service may choose to implement the standard that is most applicable to their service context.

Primary and community services can be subject to multiple sets of standards.  The Commission intends that the PCH Standards “are used as the core safety and quality component of each set of standards, thus minimising the compliance burden across multiple sets of standards”.

Can I transition from NSQHS to the Primary and Community Healthcare Standards?

If a service is currently accredited to NSQHS on a voluntary basis, it can transition to the PCH Standards once accreditation becomes available, at time of reaccreditation.

If a service is accredited to NSQHS as part of regulatory or contractual requirements, for example, a Local Health Network, you will need to check with your regulator and/or funder.

How can I get accredited for the Primary and Community Healthcare Standards?

The Commission is developing an assessment model for healthcare services to become accredited under the Australian Health Service Safety and Quality Accreditation (AHSSQA) Scheme. It is anticipated that accreditation will become available from mid-2022.

In advance of formal accreditation, a self-assessment module for the Standards is already available on SPP. Our self-assessment module is an excellent way to familiarise yourself with, and work your way through the requirements of, the PCH Standards. The self-assessment also includes links throughout to a number of relevant resources and templates.

Further information

You can access more information from the Commission about the National Safety and Quality Primary and Community Healthcare Standards here.

Interested in the PCH Standards?

Access self-assessments for the Primary and Community Healthcare Standards on SPP.

New key standards for the digital mental health space

The National Safety and Quality Digital Mental Health (NSQDMH) Standards were released in November 2020, and are the first of their kind. Developed by the Australian Commission on Safety and Quality in Health Care in consultation with consumers, service providers, academics, regulators and technical experts, the NSQDMH Standards aim to improve the quality of digital mental health service provision, and protect service users and their support people from harm.

What is a digital mental health service?

In the current context of the COVID-19 pandemic, coupled with the rapid evolution of digital technologies, telehealth services are being used more widely than ever before. As the take-up of these digital services increases, it makes sense to improve the regulation of the digital health service provision space.

So what does a digital mental health service look like?

The NSQDMH Standards define digital mental health as a mental health, suicide prevention or alcohol and other drug (AOD) service that uses technology to facilitate engagement and deliver care. Traditionally mental health, suicide prevention and AOD were considered distinct sectors, however the NSQDMH Standards refer to these digital services collectively.

Digital mental health services include:

  • Services that provide information
  • Digital counselling services
  • Treatment services (including assessment, triage and referral services)
  • Peer-to-peer support services

Digital mental health services may be delivered by:

  • Telephone (including mobile phone)
  • Videoconferences
  • Online services (such as web chats)
  • SMS
  • Mobile health applications (apps)

What are the National Safety and Quality Digital Mental Health Standards?

The three NSQDMH Standards are:

  • Clinical and Technical Governance Standard
  • Partnering with Consumers Standard
  • Model of Care Standard

The three standards include 59 actions related to clinical and technical aspects of digital mental health services. They describe the level of care and the safeguards that a digital mental health service should provide.

The NSQDMH Standards create a nationally consistent quality assurance mechanism for digital mental health service providers. Providers can assess areas of compliance as well as areas for improvement, with respect to their safety and quality assurance systems.

The standards are modelled on the National Safety and Quality Health Service Standards (NSQHS). Providers who already meet NSQHS are only required to implement actions specific to the NSQDMH Standards, which are relevant to their service.

Implementation of the NSQDMH Standards is currently voluntary. Self-assessing against the standards is an excellent way for service providers to demonstrate best practice in this space.

To assist providers to learn more about these standards and measure themselves against them, we are pleased to offer a self-assessment for the NSQDMH Standards on SPP. Our self-assessment consists of quizzes for each action across the three standards, as well Evidence Guides and linked resources to accompany each quiz.

You can find the self-assessment for the National Safety and Quality Digital Mental Health Standards in SPP under the Standards tab > Australian National Standards.

Want to learn more?

Self- assess against the National Safety and Quality Digital Mental Health Standards on SPP.

Clinical governance

The Aged Care Quality Standards and the National Safety and Quality Health Service Standards include requirements for organisations to have a clinical governance framework, as well as policies to address infection control, antimicrobial stewardship and open disclosure processes.

It is a mandatory requirement for all Australian hospitals and day procedure services to be assessed through an independent accreditation process to determine whether they are in compliance with the National Safety and Quality Health Service Standards.

What is clinical governance?

The set of relationships and responsibilities between a health service organisation and its relevant stakeholders to guarantee good outcomes and continuously strive to improve clinical care for clients.

At its core, effective clinical governance fosters a culture within an organisation in which healthcare professionals of all levels routinely question: ‘Am I doing it right? How can I do better?’.

Purpose of clinical governance

The purpose of clinical governance is to ensure that everyone is accountable to clients and the community for delivering good clinical outcomes and meeting clinical indicators. It is an all-encompassing framework, and also includes infection prevention, antimicrobial stewardship and waste management.

Six key components of the Clinical Governance Framework

  1. Governance, leaderships and culture
  2. Partnering with clients
  3. Roles and responsibilities
  4. Client safety and quality improvement systems
  5. Clinical performance and effectiveness
  6. Safe environment for the delivery of care

Policies related to Clinical Governance can be found in the SPP Reading Room:

  • Info Sheet: Clinical Governance
  • Policy: Clinical Governance
  • Policy: Open Disclosure
  • Policy: Infection Prevention and Control
  • Policy: Antimicrobial Stewardship
  • Policy: Waste Management