A Guide for Dental Practices - BMJ Quality & Safety€¦ · · 2012-07-27Standard 3: Preventing...

National Safety and Quality Health Service Standards

A Guide for Dental PracticesPart B

Consultation DraftJuly 2012

Australian Commission on Safety and Quality in Health Care

Table of Contents: A Guide for Dental Practices-Part B Introduction ................................................................................................................. 2

Standard 1: Governance for Safety and Quality in Health Service Organisations ...... 3

Standard 2: Partnering with Consumers ................................................................... 23

Standard 3: Preventing and Controlling Healthcare Associated Infections............... 31

Standard 4: Medication Safety .................................................................................. 53

Standard 5: Patient Identification and Procedure Matching ...................................... 70

Standard 6: Clinical Handover .................................................................................. 76

Consultation Draft Ι A Guide for Dental Practices Ι Part B

Australian Commission on Safety and Quality in Health Care

Introduction Part B of the Guide for Dental Practices contains information specific to each Standard and includes:

• A description of the Standard

• A statement of intent or the desired outcome for the Standard

• The context in which the Standard must be applied

• Key criteria of the Standard

• A series of actions relevant to each criterion

• Reflective questions to clarify the intent of each criterion

• Examples of evidence

• A column to assist health services identify if further action is required.

The purpose of the evidence list is to assist a dental practice determine how it can show safety and quality processes and systems are in place, that they are reviewed, evaluated and practices are changed when necessary.

Each dental practice should interpret the evidence listed with respect to its own model of service delivery and care.

If a dental practice finds there is insufficient evidence available to demonstrate an action has been met, the ‘No’ box in the last column of the tables in the Guide is there to prompt further action that may be required to address identified gaps.

Dental practices are not expected to have every form of evidence provided as examples. You are strongly encouraged to only use enough evidence to show actions are being addressed. The evidence used would typically come from the usual improvement and business processes of the practice rather than created specifically for accreditation.

Part B should be read in conjunction with Part A of the Guide for Dental Practices. Part A contains information about the accreditation process and resources to assist dental practices prepare for accreditation.

Consultation Draft Ι A Guide for Dental Practices Ι Part B 2

Australian Commission on Safety and Quality in Health Care Standard 1: Governance for Safety and Quality in Health Service Organisations

Standard 1: Governance for Safety and Quality in Health Service Organisations Health service organisation leaders implement governance systems to set, monitor and improve the performance of the organisation and communicate the importance of the patient experience and quality management to all members of the workforce. Clinicians and other members of the workforce use the governance systems.

The intention of this Standard is to:

Create integrated governance systems that maintain and improve the reliability and quality of patient care, as well as improve patient outcomes.

Context

This Standard provides the safety and quality governance framework for health service organisations. It is expected that this Standard will apply to the implementation of all other Standards in conjunction with Standard 2, ‘Partnering with Consumers’.

Criteria to achieve the Governance for Safety and Quality in Health Service Organisations Standard:

• Governance and quality improvement systems

• Clinical practice

• Performance and skills management

• Incident and complaints management

• Patient rights and engagement



Governance and quality improvement systems

There are integrated systems of governance to actively manage patient safety and quality risks.


Actions required Reflective questions Examples of Evidence - select only examples currently in use Evidence available?

1.1 Implementing a governance system that sets out the policies, procedures and/or protocols for:

• identifying safety and quality risks • implementing performance management procedures

• collecting and reviewing performance data • ensuring compliance with legislative requirements and relevant industry standards

• implementing prevention strategies based on data analysis • communicating with and informing the clinical and non-clinical workforce

• analysing reported incidents • undertaking regular clinical audits

1.1.1 An organisation-wide management system is in place for the development, implementation and regular review of policies, procedures and/or protocols

How do we describe our decision-making and management processes to an outsider?

What documents do we use to meet legislation, regulations, business and professional requirements?

How do we know these documents are updated and used by team members?

Policies, procedures and protocols that describe the management of patient safety and quality risks specified in Standard 1.1

A brief statement of business structure or an organisational diagram that includes any committee structures

Relevant documentation from meetings that review policies, procedure and protocols

Register of completed reviews of policies, procedures and protocols including the date of any changes made

Communication of new or revised policy documents to team members

Other ____________________________________________________

No further action is required

Yes list source of evidence

1.1.2 The impact on patient safety and quality of care is considered in business decision making

How do we show that our business decisions take into account safe practice and the quality of care for patients?

Business plan that describes the potential impact on patient safety and quality of care

Relevant documentation from meetings on key decisions such as finance, strategic planning and work health and safety

Checklists or proforma documents that outline safety and quality risk or issues to be assessed in decision making

Other ____________________________________________________



1.2 The board, chief executive officer and/or other higher level of governance within a health service organisation taking responsibility for patient safety and quality of care

1.2.1 Regular reports on safety and quality indicators and other safety and quality performance data are monitored by the executive level of

How does our leadership review safe practice and the quality of care for patients?

Relevant documentation from meetings that discuss safety and quality measures and results

Review of:

• reports containing safety and quality data





governance • trends in safety and quality matters

• safety and quality issues in polices, procedures and protocols

Other ____________________________________________________

1.2.2 Action is taken to improve the safety and quality of patient care

What actions have our leadership taken to improve safe practice and the quality of care for patients?

How do they feedback on the changes to be implemented?

Revision of safety and quality action plans and strategies

Examples of improvement activities that have been implemented

Register of adverse events, incidents and near misses, includes actions to address identified risks

Communication material developed for team members, patients and carers

Other ____________________________________________________



1.3 Assigning workforce roles, responsibilities and accountabilities to individuals for:

• patient safety and quality in their delivery of health care

• the management of safety and quality specified in each of these Standards

1.3.1 Workforce are aware of their delegated safety and quality roles and responsibilities

How do we inform each team member of their roles and responsibilities for safety and quality of care?

Position descriptions, duty statements or employment contracts include safety and quality responsibilities

Orientation and education for team members on safety and quality roles and responsibilities

Attendance records of training in safety and quality matters

Organisational chart demonstrating safety and quality responsibilities, reporting lines and relationships

Relevant documentation from meetings or other forms of communication to team members about their responsibilities

Results of surveys or feedback from team members regarding safety and quality roles and responsibilities

Other ____________________________________________________



1.3.2 Individuals with delegated responsibilities are supported to understand and perform their roles and responsibilities, in particular to meet the requirements of these Standards

How do we support each team member to understand and perform their roles and responsibilities?

Relevant regulations, legislation, guidelines and standards are accessible to team members

Policies, procedures and protocols outline safety and quality roles and responsibilities for positions within the team

Feedback to team members on their work performance and roles and responsibilities

Review of incident reports and related comments from patients and carers

Other ___________________________________________________






1.3.3 Agency or locum workforce are aware of their designated roles and responsibilities

How do we inform each locum or agency team member of their roles and responsibilities for safety and quality of care?

Position descriptions, duty statements and employment contracts for locum and agency team members that include safety and quality responsibilities

Policies, procedures and protocols that outline roles and responsibilities for locum or agency team members. These may be included in an orientation manual and require sign off to indicate their understanding of the policies

Orientation and education resources for locum or agency team members on safety and quality roles and responsibilities

Induction checklists

Attendance records of training by locum or agency team members in safety and quality roles and responsibilities

Relevant documentation from meetings or other forms of communication to team members about their responsibilities

Feedback from locum or agency team members on their understanding of their roles and responsibilities

Other ___________________________________________________



1.4 Implementing training in the assigned safety and quality roles and responsibilities

1.4.1 Orientation and ongoing training programs provide the workforce with the skill and information needed to fulfil their safety and quality roles and responsibilities

What training must a new team member do to start work?

How do we provide a team member with the skills and information necessary for their roles and responsibilities?

Orientation and education resources on safety and quality roles and responsibilities

Attendance records of training in safety and quality matters

Individual professional development plans

Feedback from team members regarding their training needs

Evidence of the assessment of training needs through the review of incidents and performance data

Relevant regulations, legislation, guidelines and standards are accessible to team members

Other ___________________________________________________

Links to 1.3.1: Team member roles and responsibilities for safety and quality of care






1.4.2 Annual mandatory training programs to meet the requirements of these Standards

What training must team members do each year?

List of essential annual education and training opportunities, including on-the-job training, to be current with any new equipment, procedures or protocols

Audit of team member education and training needs matched against the requirements of the NSQHS Standards

Policy that outlines mandatory training requirements for team members in areas such as:

• work health and safety

• infection control

• medical emergency training or

• other training as required by the dental practice

Education resources and attendance records for mandatory training requirements

Other ___________________________________________________



1.4.3 Locum and agency workforce have the necessary information, training and orientation to the workplace to fulfil their safety and quality roles and responsibilities

How do we provide a locum or agency team member with the necessary skills and information to undertake their role and responsibilities?

Policies, procedures and protocols that are readily accessible to locum and agency team members

Orientation and education resources for locum and agency team members

Attendance records of training for locum or agency team members

Contracts and position descriptions for locum and agency team members

Skills appraisals of locum and agency team members

Register of locum and agency team member credentials (qualifications)

Policy, procedures and protocols for clinical supervision of locum and agency team members

Internal communication system that is accessible to locum and agency team members with information about safety and quality (for example, intranet or memos)

Other ___________________________________________________



1.4.4 Competency-based training is provided to the clinical workforce to improve safety and quality

How do we provide competency based training to clinical team members to improve our safety and quality care in the practice?

Orientation and education resources in competency based training for clinical team members to enhance safety and quality

Schedule of training for clinical team members

Attendance records and results of competency based training for clinical team members

Communication to clinical team members regarding annual mandatory






training requirements

Other ___________________________________________________

Links to 1.4.1: Orientation and ongoing training programs for team members

1.5 Establishing an organisation-wide risk management system that incorporates identification, assessment, rating, controls and monitoring for patient safety and quality

1.5.1 An organisation-wide risk register is used and regularly monitored

How do we identify, record and implement changes to reduce the risks to safe practice and quality of care for our patients?

Register of adverse events, incidents and near misses includes actions taken to address identified risks

Completed risk assessments

Review of comments and complaints, and use of these results for improvement purposes

Relevant documentation from meetings or other forms of communication to team members about risk matters

Reports of trends in safety and quality risks

Feedback from team members

Other ___________________________________________________



1.5.2 Actions are taken to minimise risks to patient safety and quality of care

What action do we take to reduce safety risks and improve the quality of care for our patients?

Relevant documentation from meetings or other forms of communication to team members about risk matters

Reviews of safety and quality measures or performance indicators with recommendations for improvement, including action plans and outcomes

Examples of improvement activities that have been implemented and evaluated

Other ___________________________________________________



1.6 Establishing an organisation-wide quality management system that monitors and reports on the safety and quality of patient care and informs changes in practice

1.6.1 An organisation-wide quality management system is used and regularly monitored

How do we plan our work, then measure our success against what we do and do it better?

How do we use quality management methods in our practice?

Policies, procedures, protocols or plans that describe a quality approach in key areas such as:

• leadership

• planning activities and introduction of changes

• roles and responsibilities

• dissemination of information and documents






• work and administrative activities

• measurement and observation of performance

• review and improvement of activities

Evaluation reports on the safety and quality of patient care and any introduced changes in practice

Reports, presentations and analysis of performance data

Position descriptions or employment contracts that require participation in quality management systems

Feedback to team members on their work performance in safety and quality matters

Use of quality management tools such as the Plan–Do–Check–Act (PDCA) cycle

Other ___________________________________________________

1.6 Establishing an organisation-wide quality management system that monitors and reports on the safety and quality of patient care and informs changes in practice

1.6.2 Actions are taken to maximise patient quality of care

What actions have we taken to ensure the highest quality of care for our patients?

Policies, procedures and protocols that that have been developed to identify and address deficiencies in care

Register of adverse events, incidents and near misses, including actions to address identified issues

Analysis of patient and carer feedback or satisfaction survey results

Review of identified areas requiring action in patient quality of care


Other ___________________________________________________





Clinical practice

Care provided by the clinical workforce is guided by current best practice.


1.7 Developing and/or applying clinical guidelines or pathways that are supported by the best available evidence

1.7.1 Agreed and documented clinical guidelines and/or pathways are available to the clinical workforce

Which clinical guidelines do we use, where do they come from and how do our team members access them?

Policies, procedures and protocols for accessing clinical guidelines

Register of clinical guidelines used by the practice

Current guidelines accessible to team members

Audit of the availability and currency of clinical guidelines to team members

Other ___________________________________________________



1.7.2 The use of agreed clinical guidelines by the clinical workforce is monitored

How do we find out if clinical team members are using agreed clinical guidelines?

Declaration of compliance by dental practitioners

Feedback to dental practitioners on their work performance

Observation of clinical practice

Other ___________________________________________________



1.8 Adopting processes to support the early identification, early intervention and appropriate management of patients at increased risk of harm

1.8.1 Mechanisms are in place to identify patients at increased risk of harm

How do we identify patients at increased risk of harm?

Audits of patient medical and dental history or other information such as whether they have a significant disability or are from a culturally and linguistically diverse (CALD) background

Policies, procedures and protocols that outline how a dental practitioner is alerted to patients at increased risk of harm

Risk profile of the dental practice that details the most likely risks and their potential impact

Completed risk assessments

Register of adverse events, incidents and near misses including actions to address identified issues

Review of patient and carer complaints

Other ___________________________________________________



1.8.2 Early action is taken to reduce the risks for at-risk patients

What action have we taken to decrease the risk of harm to our vulnerable patients?

Action plans implemented for patients identified at increased risk of harm

Declaration of compliance with measures and procedures by dental practitioners

Feedback to dental practitioners on their work performance






Observation of clinical practice

Other ___________________________________________________

1.8.3 Systems exist to escalate the level of care when there is an unexpected deterioration in health status

How do we respond to a person who needs immediate medical assistance?

Policy, procedures and protocols that describe how to respond to a medical emergency

Instructions on how to call for assistance are clearly displayed in the practice. This includes signs, posters or stickers

Orientation and education resources relating to escalation of care

Attendance records of training in medical emergency response

Other ___________________________________________________



1.9 Using an integrated patient clinical record that identifies all aspects of the patient’s care

1.9.1 Accurate, integrated and readily accessible patient clinical records are available to the clinical workforce at the point of care

How do we make our patient dental records available to clinical team members when care is provided?

How do we know our patient dental records are comprehensive and accurate?

Policy, procedures and protocols for obtaining dental records from storage, archive and other areas of the dental practice

Audits of the accessibility of patient dental records including hard copy and electronically archived patient dental records

A documented patient dental record management system

Audits of the accuracy, integration and currency of patient dental records

Other ___________________________________________________



1.9.2 The design of the patient clinical record allows for systematic audit of the contents against the requirements of these Standards.

How do we know our patient dental records are meeting the key requirements of the Standards?

Schedule of audits of patient dental records against the requirements of the NSQHS Standards

Actions taken in response to non-compliance with the NSQHS Standards

Other ___________________________________________________

Link to 1.19.1: Patient clinical records are available at the point of care





Performance and skills management

Managers and the clinical workforce have the right qualifications, skills and approach to provide safe, high quality health care.



1.10 Implementing a system that determines and regularly reviews the roles, responsibilities, accountabilities and scope of practice for the clinical workforce

1.10.1 A system is in place to define and regularly review the scope of practice for the clinical workforce

How do we know we have the right people doing the right job when providing clinical services?

How do we come to a clear understanding of what services each clinical team member may provide?

Procedures to undertake credentialing and defining scope of practice for clinical team members

Audit of position descriptions, duty statements and employment contracts against jurisdictional requirements and recommendations of clinical practice and professional guidelines. For example, evidence of training currency for the administration of intravenous sedation

Audit of policies, procedures and protocols against defined scope of practice for clinical team members

Relevant documentation from meetings or other forms of communication relating to defining scope of practice for clinical team members

Feedback to clinical team members on their work performance includes a review of the scope of practice

Other ___________________________________________________



1.10.2 Mechanisms are in place to monitor that the clinical workforce are working within their agreed scope of practice

How do we know a clinical team member works within agreed boundaries when providing care to patients?

Declaration by dental practitioners of working within their defined scope of clinical practice

Register of clinical team member qualifications

Feedback to clinical team members on their work performance

Audit of clinical team member key performance indicators

Peer Review reports

Other ___________________________________________________



1.10.3 Organisational clinical service capability, planning, and scope of practice is directly linked to the clinical service roles of the organisation

How do we match:

• what we can do

• what we plan to do and

• the agreed practice for our clinical team members

against the services

Strategic, business and quality improvement plans outline the dental practice’s overall objectives and services provided

Register of team member qualifications suitable for clinical service roles of the dental practice

Annual reports that detail the clinical service capability and clinical services provided

Evaluations of the dental practice in meeting its clinical service targets

Evaluations of the safety and quality of clinical services





and care we provide? Reports from clinical information systems

Feedback to clinical team members on their work performance

Review of key performance indicators for clinical team members

Other ___________________________________________________

1.10.4 The system for defining the scope of practice is used whenever a new clinical service, procedure or other technology is introduced

How do we assess a new clinical service, procedure or other technology before its introduction?

How do we check if any new changes will affect the services or professional practice provided by clinical team members?

Relevant documentation from meetings or other forms of communication relating to defining scope of clinical practice for new services, procedures and technologies

Procedure manuals, guidelines or similar documentation for new services, new procedures and technologies

Education resources and attendance records of training for clinical team members in new services, procedures and technologies

Observation of practice on initial use of new services, procedures and technologies

Work health and safety checks of new services, procedures and technologies

Other ___________________________________________________



1.10.5 Supervision of the clinical workforce is provided whenever it is necessary for individuals to fulfil their designated role

How do we supervise and support clinical team members to practice within agreed professional and organisational boundaries when providing patient care?

Documented roles and responsibilities of the designated principal dental practitioner

Education resources and attendance records of training for the supervision of clinical team members within the dental practice

Observational audit of clinical team members, including those under probation

Mentoring plan for a junior clinical team member

Other ___________________________________________________



1.11 Implementing a performance development system for the clinical workforce that supports performance improvement within their scope of practice

1.11.1 A valid and reliable performance review process is in place for the clinical workforce

How do we develop, support and manage the performance of each clinical team member?

A documented performance review process

Documentation or other communications relating to clinical team member performance


Performance plan for a new team member under probation or existing team member requiring additional support

Mentoring or Peer Review reports






Other ___________________________________________________

1.11.2 The clinical workforce participates in regular performance reviews that support individual development and improvement

How do we regularly review the performance of each clinical team member?

Clinical team member performance reviews

Professional development plans document training needs identified through performance reports

Mentoring or Peer Review reports

Competency records for clinical team members are consistent with requirements in practice polices, procedures and protocols

Observational audit of clinical practice

Other ___________________________________________________



1.12 Ensuring that systems are in place for ongoing safety and quality education and training

1.12.1 The clinical and relevant non-clinical workforce have access to ongoing safety and quality education and training for identified professional and personal development

What access do team members have to education and training in safe practice and quality care?

List of available education providers, courses and resources related to safety and quality

Polices and processes that describe access to ongoing training in safety and quality


Attendance records of training in safety and quality care

Communication between the principal dental practitioner and team members about education requirements

Implementation of a new quality process to increase the safety of team members and patients

Other ___________________________________________________






1.13 Seeking regular feedback from the workforce to assess their level of engagement with, and understanding of, the safety and quality system of the organisation

1.13.1 Analyse feedback from the workforce on their understanding and use of safety and quality systems

How do we get feedback from team members on safety and quality matters to review their understanding and use of our processes?

Relevant documentation from meetings with team members on safety and quality matters

Records of comments and suggestions from team members (for example, through the use of communication books)

Other ___________________________________________________



1.13.2 Action is taken to increase workforce understanding and use of safety and quality systems

What action has been taken to increase the use and understanding of our safety and quality processes by team members?

Education resources in safety and quality accessible to team members

Documented plans to increase team member knowledge on safety and quality


Communication material developed for team members, patients and cares

Attendance records of training of in safe practice and quality care

Other ___________________________________________________





Incident and complaints management

Patient safety and quality incidents are recognised, reported and analysed, and this information is used to improve safety systems.


1.14 Implementing an incident management and investigation system that includes reporting, investigating and analysing incidents, (including near misses), which all result in corrective actions

1.14.1 Processes are in place to support the workforce recognition and reporting of incidents and near misses

How do we identify, record and respond to incidents and near misses?

Polices, procedures and protocols for recognising, reporting and investigating incidents and near misses

Forms for risk assessments, and reporting incidents and near misses

A register of adverse events, incidents and near misses including actions to address identified issues

Orientation and education on recognising, reporting and investigating incidents and near misses

Attendance records of training in relation to incidents and near misses

Material that demonstrates and supports promotion of incident reporting systems

Other ___________________________________________________



1.14.2 Systems are in place to analyse and report on incidents

What is our process for reviewing information on incidents and near misses?

What can we learn from incidents and near misses?

A register of adverse events, incidents and near misses including actions to address identified issues

Relevant documentation from meetings that relate to incidents and near misses

Review of incident reports and trends in incidents and near misses

Other ___________________________________________________



1.14.3 Feedback on the analysis of reported incidents is provided to the workforce

How do we provide feedback on our incidents and near misses to team members?

Relevant documentation from meetings that provide feedback to team members on incidents and near misses

Material distributed to team members on incidents and trends

Completed risk assessments and actions taken to address identified risks are available to team members

Other ___________________________________________________



1.14.4 Action is taken to reduce risks to patients identified through the incident management system

How do we decrease the risk of an incident recurring?

Incident reports accessible to team members

Relevant documentation from meetings that review incidents and near misses

Review of incidents and near misses including actions taken to address






issues identified

Communication material developed for the workforce, patients and carers

Other ___________________________________________________

1.14.5 Incidents and analysis of incidents are reviewed at the highest level of governance in the organisation

How does our leadership review any incidents and near misses?

Record or report of evidence-based interventions that have been initiated for identified risks

Relevant documentation from meetings that detail strategies and actions to address incidents and near misses

Strategic, business and quality improvement plans use information based on incident management processes

Communications to team members, such as documents, reports, and updates on safety and quality plans and strategies

Other ___________________________________________________



1.15 Implementing a complaints management system that includes partnership with patients and carers

1.15.1 Processes are in place to support the workforce to recognise and report complaints

How do we identify, report and deal with our patient complaints?

Policies, procedures and protocols for collecting and reporting patient and carer complaints

Feedback forms available to patients and carers

Secure comments and complaints box in publically accessible places

Brochures or information sheets that outline internal and external complaints mechanisms

Register of complaints, including actions taken to address identified issues

Education resources and attendance records of training in complaints management

Other ___________________________________________________



1.15.2 Systems are in place to analyse and implement improvements in response to complaints

What could we learn from complaints and patient feedback that will lead to better outcomes?

Review of feedback and trends in patient and carer complaints

Reports or briefings on the analysis of complaints

Complaints register with responses recorded and actions taken

Reports to owners, regulators, insurers and team members referring to complaints and patient feedback

Other ___________________________________________________






1.15.3 Feedback is provided to the workforce on the analysis of reported complaints

How do we keep team members informed of trends in reported complaints and patient feedback?

Relevant documentation from meetings about patient and carer complaints

Material provided to team members on complaints and trends in complaints

Record or report of initiated evidence-based interventions for complaints and identified risks

Record of prompt and constructive responses to suggestions and complaints

Evaluations of the effectiveness of responses and improvements in services

Other ___________________________________________________



1.15.4 Patient feedback and complaints are reviewed at the highest level of governance in the organisation

How does our leadership review complaints and patient feedback?

Relevant documentation from meetings reviewing complaint matters

Strategic, business and quality improvement plans are based on patient and carer feedback, including complaint management processes

Description of complaints and trends presented in forums and formats, such as posters and team meetings

Other ___________________________________________________



1.16 Implementing an open disclosure process based on the national open disclosure standard

1.16.1 An open disclosure program is in place and is consistent with the national open disclosure standard

How do our open disclosure processes align with the national open disclosure standard?

Policies, procedures and protocols that are consistent with the principles and processes outlined in the national open disclosure standard

Audit of open disclosure processes used in the dental practice

Other ___________________________________________________



1.16.2 The clinical workforce are trained in open disclosure processes

How do we train team members in our open disclosure processes?

Relevant documentation from meetings or other communication to team members that provides education and information on open disclosure processes

Attendance records of education and training in open disclosure processes

Other ___________________________________________________





Patient rights and engagement

Patient rights are respected and their engagement in their care is supported.


1.17 Implementing through organisational policies and practices a patient charter of rights that is consistent with the current national charter of healthcare rights

1.17.1 The organisation has a charter of patient rights that is consistent with the current national charter of healthcare rights

How consistent is our approach to healthcare rights with the Australian Charter of Healthcare Rights?

Documented charter of healthcare rights used by the practice. This may include a brochure incorporating the rights and responsibilities of patients, carers and team members

Review of the practice’s charter of healthcare rights against the Australian Charter of Healthcare Rights

Other ___________________________________________________



1.17.2 Information on patient rights is provided and explained to patients and carers

How do we provide and explain information to patients and carers on their healthcare rights?

Documented charter of healthcare rights used by the practice

Charter of healthcare rights displayed in reception and waiting areas

Brochures, information sheets or other documents given to patients and carers that explain the charter of healthcare rights

Charter of healthcare rights translated into other appropriate languages

Patient registration checklist that includes the provision and explanation of a patient’s charter of rights

Other ___________________________________________________



1.17.3 Systems are in place to support patients who are at risk of not understanding their healthcare rights

How do we identify people who through disability, circumstance, age or culture may not understand their healthcare rights?

How do we support people who may not understand their healthcare rights?

Patient dental records identify and record relevant patient medical and social history

Brochures or information sheets in languages other than English are given to patients and carers to explain their healthcare rights

A register of interpreter, advocacy and support services is available for team members, patients and carers.

Team members, patients and cares are aware of how to access interpreter, advocacy and support services

Other ___________________________________________________






1.18 Implementing processes to enable partnership with patients in decision about their care, including informed consent to treatment

1.18.1 Patients and carers are partners in the planning for their treatment

How do we involve patient and carers in decisions about their care, and seek and confirm their consent to treatment?

Policies, procedures and protocols on communicating and providing information to patients and carers

Examples of written consent provided by patients or carers

Observational audit of obtaining patient or carer consent

Feedback from patients and carers on treatment planning

Results of patient and carer experience surveys on their participation in making decisions about their treatment

Other ___________________________________________________



1.18.2 Mechanisms are in place to monitor and improve documentation of informed consent

How do we know our patient and carer consent documentation and processes are being applied correctly?

How do we improve our patient and carer consent documentation and processes?

Relevant documentation from meetings or other forms of communication to team members outlining the requirements for informed consent

Analysis of patient and carer survey results on informed consent matters

Audit of informed consent forms

Observational audit of consent processes

Education resources and attendance records of training in consent matters

Other ___________________________________________________



1.18.3 Mechanisms are in place to align the information provided to patients with their capacity to understand

Not applicable to dental practices



1.18.4 Patients and carers are supported to document clear advance care directives and/or treatment-limiting orders







1.19 Implementing procedures that protect the confidentiality of patient clinical records without compromising appropriate clinical workforce access to patient clinical information

1.19.1 Patient clinical records are available at the point of care

How do we make a patient’s dental record available to clinical team members when care is provided?

Policies, procedures and protocols that describe the retrieval of archived patient dental records

Observational audit of patient dental record availability

Access to patient dental records

Documented patient dental record management system

Link to 1.9.1 Accurate, integrated and readily accessible patient clinical records are available to clinical team members at the point of care



1.19.2 Systems are in place to restrict inappropriate access to and dissemination of patient clinical information

How do we ensure the privacy and confidentiality of our patient information is protected from unauthorised access or distribution, in line with relevant legislation, guidelines and organisational policy?

Team members advised of their obligations regarding privacy and confidentiality or have signed a confidentiality agreement

Code of conduct that includes privacy and confidentiality of patient information

Secure storage of patient information, including password protected access to electronic patient information

Secure archival storage system of patient information

Policies, procedures and protocols on sharing patient information by telephone, electronic or other methods that are consistent with federal and state or territory privacy legislation, health department and insurer requirements.

Patient dental records include patient or carer consent prior to transfer of information to national registers or ethics approval for research activities

Other ___________________________________________________



1.20 Implementing well designed, valid and reliable patient experience feedback mechanisms and using these to evaluate the health service performance

1.20.1 Data collected from patient feedback systems are used to measure and improve health services in the organisation

How do we obtain patient and carer feedback on care and services we provide?

How do we use patient and carer feedback to improve our performance in delivering care and services?

Documented patient feedback system

Review of patient and carer experience survey results and feedback, including complaints

Register of patient and carer comments and complaints, including actions taken to address identified issues

Strategic, business and quality improvement plans describe how patient and carer feedback is used to improve the delivery of care and services

Other ___________________________________________________





Resources

1. Australian Charter of Healthcare Rights. Commonwealth of Australia, 2008. (Accessed 8 June 2012, at http://www.safetyandquality.gov.au/our-work/national-perspectives/charter-of-healthcare-rights/.)

2. Australian Safety and Quality Framework for Health Care. ACSQHC, 2010. (Accessed 8 June, 2012, at http://www.safetyandquality.gov.au/our-work/national-perspectives/australian-safety-and-quality-framework-for-health-care/.)

3. Guidelines for Good Practice on Consent for Care in Dentistry. Australian Dental Association Inc. 2005 (Accessed 28 June 2012, at http://www.ada.org.au/app_cmslib/media/lib/0703/m52394_v1_ggp2consentforcareindentistry.pdf.)

4. Guidelines for Good Practice on Emergencies in Dental Practice. Australian Dental Association Inc. 2005 (Accessed 28 June 2012, at http://www.ada.org.au/app_cmslib/media/lib/0703/m52398_v1_ggp3emergencies.pdf.)

5. Guidelines for Good Practice on Patient Information and Records. Australian Dental Association Inc. 2006 (Accessed 28 June 2012, at http://www.ada.org.au/app_cmslib/media/lib/0703/m52390_v1_ggp1patientiforecordsamended.pdf.)

6. Open Disclosure Standard: A National Standard for Open Communication in Public and Private Hospitals, Following an Adverse Event in Health Care. Canberra, 2003. (Accessed 8 June, 2012, at http://www.safetyandquality.gov.au/our-work/open-disclosure/the-open-disclosure-standard/)

7. Standard for Credentialling and Defining the Scope of Clinical Practice for Medical Practitioners. Australian Council for Safety and Quality in Health Care (Accessed 8 June 2012, 08June, at http://www.health.gov.au/internet/safety/publishing.nsf/Content/a-zpublicationss-u/$File/credentl.pdf)


Australian Commission on Safety and Quality in Health Care Standard 3 Preventing and Controlling Healthcare Associated Infections

Standard 2: Partnering with Consumers Leaders of a health service organisation implement systems to support partnering with patients, carers and other consumers to improve the

safety and quality of care. Patients, carers, consumers, clinicians and other members of the workforce use the systems for partnering with

consumers.


Create a health service that is responsive to patient, carer and consumer input and needs.

Context

This Standard provides the framework for active partnership with consumers by health service organisations. It is expected that this Standard will apply in conjunction with Standard 1, ‘Governance for Safety and Quality in Health Service Organisations’, in the implementation of all other Standards.

Criteria to achieve the Partnering with Consumers Standard:

• Consumer partnership in service planning

• Consumer partnership in designing care

• Consumer partnership in service measurement and evaluation



Consumer partnership in service planning

Governance structures are in place to form partnerships with consumers and/or carers.


2.1 Establishing governance structures to facilitate partnership with consumers and/or carers

2.1.1 Consumers and/or carers are involved in the governance of the health service organisation

How could patients, their carers or other consumers be involved in the governance processes of the practice?

Policies, procedures and protocols that describe the mechanisms for involving patients, carers and consumers

Resources made available to patients, consumers and carers to enable their involvement in the governance processes of the practice

Other ____________________________________________________



2.1.2 Governance partnerships are reflective of the diverse range of backgrounds in the population served by the health service organisation, including those people that do not usually provide feedback

How could we ensure that patients, their carers or other consumers involved in the practice reflect the diversity of our practice population?

A review of patient demographics to ensure an understanding of relevant minority groups attending the practice

Examples of methods used to engage with people from diverse backgrounds and people that do not usually provide feedback. These may include morning teas, patient or telephone surveys and small focus group discussions

Other ____________________________________________________






2.2 Implementing policies, procedures and/or protocols for partnering with patients, carers and consumers in:

• strategic and operational/services planning

• decision making about safety and quality initiatives

• quality improvement activities

2.2.1 The health service organisation establishes mechanisms for engaging consumers and/or carers in the strategic and/or operational planning for the organisation

How could patients, their carers or other consumers be involved in strategic and operational planning of the practice?

Relevant documentation from meetings or other communications relating to the involvement of patients, carers and consumers about planning for delivery of care by the dental practice

Examples of decisions made with patients, carers and consumers

Consultation approaches and reports detailing involvement of patients, carers and consumers in decision making about planning the delivery of care by the dental practice

Other ____________________________________________________



2.2.2 Consumers and/or carers are actively involved in decision making about safety and quality

How could patients, their carers or other consumers be involved in decision making for safety and quality matters for the practice?

Relevant documentation from meetings or other communications relating to the involvement of patients, carers and consumers about safety and quality matters

Examples of decisions made with patients, carers and consumers

Consultation approaches and reports detailing involvement of patients, carers and consumers in decision making for safety and quality matters

Other ____________________________________________________



2.3 Facilitating access to relevant orientation and training for consumers and/or carers partnering with the organisation

2.3.1 Health service organisations provide orientation and ongoing training for consumers and/or carers to enable them to fulfil their partnership role

How could we assist or support a patient, carer or other consumer to be involved in the practice?

Information sheets, brochures for patients, carers and consumers or other communications which outline roles and responsibilities, key policies and other relevant information about the dental practice

Orientation and training for patients, carers and consumers relating to partnering with the dental practice

Feedback on consumer training sessions

Other ____________________________________________________






2.4 Consulting consumers on patient information distributed by the organisation

2.4.1 Consumers and/or carers provide feedback on patient information publications prepared by the health service organisation (for distribution to patients)

How do we get feedback on the written material we provide to our patients?

Results and reports of feedback on patient, carer and consumer information

Documented outcomes of focus group meetings, surveys or other consultation on information material provided to patients, cares and consumers

Other ____________________________________________________



2.4.2 Action is taken to incorporate consumer and/or carers’ feedback into publications prepared by the health service organisation for distribution to patients

What actions have we taken to include feedback we have received into the publications we provide to our patients?

Relevant documentation from meetings or other communication relating to feedback and publications

Reports on consultation approaches used to collect feedback from patients, cares and consumers and how it has been used to improve publications

Examples of changes that have been made to patient, carer and consumer information following feedback

Other ____________________________________________________





Consumer partnership in designing care

Consumers and/or carers are supported by the health service organisation to actively participate in the improvement of the patient experience and patient health outcomes.


2.5 Partnering with consumers and/or carers to design the way care is delivered to better meet patient needs and preferences

2.5.1 Consumers and/or carers participate in the design and redesign of health services

How could patients, their carers or other consumers participate in projects about the delivery of care in the practice?

Relevant documentation from meetings with patients, carers, community groups or other parties

Examples of consultation approaches used to gather contributions from patients, carers and consumers

Project planning and implementation reports detailing patient, carer and consumer involvement

Examples of new or revised dental programs, policy, procedures and protocols based on patient and carer feedback

Other ____________________________________________________



2.6 Implementing training for clinical leaders, senior management and the workforce on the value of and ways to facilitate consumer engagement and how to create and sustain partnerships

2.6.1 Clinical leaders, senior managers and the workforce access training on patient-centred care and the engagement of individuals in their care

What access do our leadership and team members have to training on patient-centred care and engagement with individuals?

List of available education providers, courses and resources related to patient-centred care

Access to ongoing training in patient-centred care and engagement with individuals

Communication between the principal dental practitioner and team members about education requirements on patient-centred care

Individual professional development plans that identify training needs related to patient-centred care

Education resources and attendance records of training related to patient-centred care

Other ____________________________________________________






2.6.2 Consumers and/or carers are involved in training the clinical workforce

How could we involve patients, carers or other consumers in the training of our team members?

Relevant documentation regarding patient, carer and consumer engagement in training content for team members

Feedback from patients, carers and consumers that have informed what training is delivered to team members

Other ____________________________________________________





Consumer partnership in service measurement and evaluation

Consumers and/or carers receive information on the health service organisation’s performance and contribute to the ongoing monitoring, measurement and evaluation of performance for continuous quality improvement.


2.7 Informing consumers and/or carers about the organisation’s safety and quality performance in a format that can be understood and interpreted independently

2.7.1 The community and consumers are provided with information that is meaningful and relevant on the organisation’s safety and quality performance

How do we inform patients and community about our performance in safety and quality matters?

Information sheets or other publications (such as annual reports or newsletters) that list the results of the dental practice’s performance measures in safety and quality

Feedback on safety and quality information that is distributed to the public. This can be collected by focus groups or consumer surveys

List of safety and quality measures used by the dental practice

Other ____________________________________________________



2.8 Consumers and/or carers participating in the analysis of safety and quality performance information and data, and the development and implementation of action plans

2.8.1 Consumers and/or carers participate in the analysis of organisational safety and quality performance

How could we engage with patients, their carers or other consumers in the review of our performance in safety and quality matters?

Relevant documentation from meetings with patients, carers, community groups or other parties relating to the review of the dental practice’s performance

Other ____________________________________________________



2.8.2 Consumers and/or carers participate in the planning and implementation of quality improvements

How could we engage with patients, their carers or other consumers in the planning and undertaking of our quality improvement activities?

Relevant documentation from meetings with patients, carers, community groups or other parties relating to quality improvement activities in the dental practice

Examples of quality improvement activities identified by patients and consumers

Other ____________________________________________________






2.9 Consumers and/or carers participating in the evaluation of patient feedback data and development of action plans

2.9.1 Consumers and/or carers participate in the evaluation of patient feedback data

How could we include patients, their carers or other consumers in the evaluation of our patient feedback?

Reports on consultation approaches that detail patient, carer and consumer involvement

Examples of improvement activities put forward by patients, carers and consumer that have been added to a quality plan

Recommendations made to the principal dental practitioner that have been put forward by consumers

Other ____________________________________________________



2.9.2 Consumers and/or carers participate in the implementation of quality activities relating to patient feedback data

How could we include patients, their carers or other consumers in undertaking improvement activities formed through the use of patient feedback information?

Relevant documentation from meetings or other communications relating to improvement activities

Consultation approaches and reports detailing patient, carer and consumer involvement in improvement activities

Project planning and implementation reports detailing patient, carer and consumer involvement

Other ____________________________________________________



Resources

1. Australian Commission on Safety and Quality in Health Care. Development of a Consumer Engagement Strategy for the Commission: Consultation Report. Sydney. ACSQHC, 2008. (Accessed 8 June 2012, at http://www.safetyandquality.gov.au/wp-content/uploads/2012/01/Development-of-a-consumer-engagement-statement-for-the-Commission.pdf.)

2. Commonwealth of Australia. Consumer Focus Collaboration Consumer participation in accreditation: A Resource Guide for Organisations 2000. Canberra, 2001. (Accessed 8 June 2012, at http://www.healthissuescentre.org.au/documents/items/2008/08/226138-upload-00001.pdf.)

3. Commonwealth of Australia. Principles for the appointment of consumer representatives: A process for Governments and Industry. Canberra, 2005. (Accessed 8 June 2012, at http://archive.treasury.gov.au/documents/994/PDF/consumer_reps.pdf.)

4. Department of Human Services. Doing it with us not for us: Participation Policy 2006–2009. Victoria 2005 (Accessed 08 June 2012, http://www.health.vic.gov.au/consumer/pubs/doing.htm.)

5. National Resource Centre for Consumer Participation in Health. Information Series - Methods and models for consumer participation 2004 (Accessed 8 June 2012, at http://www.healthissuescentre.org.au.)



Standard 3: Preventing and Controlling Healthcare Associated Infections: Clinical leaders and senior managers of a health service organisation implement systems to prevent and manage healthcare associated infections and communicate these to all workforce to achieve appropriate outcomes. Clinicians and other members of the workforce use the healthcare associated infection prevention and control systems.


Prevent patients from acquiring preventable healthcare associated infections and effectively manage infections when they occur by using evidence-based strategies.

Context

It is expected that this Standard will be applied in conjunction with Standard 1, ‘Governance for Safety and Quality in Health Service Organisations requirements’ and Standard 2, ‘Partnering with Consumers’.

Criteria to achieve the Preventing and Controlling Healthcare Associated Infections Standard:

• Governance and systems for infection prevention, control and surveillance

• Infection prevention and control strategies

• Managing patients with infections or colonisations

• Antimicrobial stewardship

• Cleaning, disinfection and sterilisation

• Communicating with patients and carers



Governance and systems for infection prevention, control and surveillance

Effective governance and management systems for healthcare associated infections are implemented and maintained.


3.1 Developing and implementing governance systems for effective infection prevention and control to minimise the risk to patients of healthcare associated infections

3.1.1 A risk management approach is taken when implementing policies, procedures and/or protocols for:

• standard infection control precautions

• transmission-based precautions

• aseptic technique

• safe handling and disposal of sharps

• prevention and management of occupational exposure to blood and body substances

• environmental cleaning and disinfection

• antimicrobial prescribing

• outbreaks or unusual clusters of communicable infection

• processing of reusable medical devices

• single-use devices

• surveillance and reporting of data

Are our infection prevention and control policies, procedures and protocols consistent with national guidelines?

How do our policies, procedures and protocols for infection prevention and control ensure risks are identified and managed?

Policies, procedures and protocols that address items listed in 3.1.1 are accessible to team members and included in the practice infection prevention and control manual. They:

• are referenced to the Australian Guidelines for the Prevention and Control of Infections in Health Care, best practice, regulatory and legislative requirements, and relevant jurisdictional protocols

• provide links to relevant resource materials

• include a register of completed reviews and the date of any changes made

Risk assessment tools used in the dental practice

Other _____________________________________________________

Links to Standards 1: Governance for Safety and Quality in Health Service Organisations






where relevant

• reporting of communicable and notifiable diseases

• provision of risk assessment guidelines to workforce

• exposure-prone procedures

3.1.2 The use of policies, procedures and/or protocols is regularly monitored

How do we find out if our infection prevention and control measures are being used by our team?

Relevant documentation from meetings or other communications relating to monitoring of infection control measures

Audit checklist, or other documentation, that demonstrates the dental practice is monitoring compliance with its infection control policy on a periodic basis

Declaration by team members that they comply with infection control measures

Observational audit of infection control measures in use

Other _____________________________________________________



3.1.3 The effectiveness of the infection prevention and control systems is regularly reviewed at the highest level of governance in the organisation

How does our leadership know about our performance in infection prevention and control measures?

Relevant documentation from meetings or other communications to leadership that relate to monitoring of infection prevention and control measures

Checklists, memos or other documentation that demonstrates the principal dental practitioner monitors and reviews the effectiveness of the practice’s systems

Reports of interventions that have been initiated for identified risks in infection prevention and control systems

Other _____________________________________________________



3.1.4 Action is taken to improve the effectiveness of infection prevention and control policies, procedures and/or protocols

What action have we taken to improve the outcomes of our infection prevention and control performance?

Policies, procedures and protocols on infection control are accessible to team members

Infrastructure (such as hand basins), instruments (such as sterile packs) and other equipment (such as solutions, sharp containers) necessary to comply with practice polices, procedures and protocols are available to team members

Register of quality improvement actions and activities undertaken in infection control practices






Attendance records for education and training in infection control updates

Other _____________________________________________________

3.2 Undertaking surveillance of healthcare associated infections

3.2.1 Surveillance systems for healthcare associated infections are in place

How do we identify our health care associated infections?

Reports of specific trends relating to healthcare associated infections, for example:

• Needle stick injuries reported over a period

• Surveillance systems for infections on discharge for specified practice surgical procedures (if appropriate)

• Non line-associated blood stream infections (this may be applicable in a dental practice, however the patient may need medical management in a hospital setting)

• Antimicrobial resistant organisms (this may be applicable in a dental practice and will require medical management)

Other _____________________________________________________



3.2.2 Healthcare associated infections surveillance data are regularly monitored by the delegated workforce and/or committees

How is healthcare associated infection data reported in the practice?

Relevant documentation from meetings and other communications that relate to healthcare associated infection surveillance. This can include meetings with team members or the work health and safety committee

Reports or reviews for the principal dental practitioner on the frequency of exposure incidents, such as sharps injuries

Indicator reports on occupational exposures reviewed by leadership or the work health and safety committee

Other _____________________________________________________






3.3 Developing and implementing systems and processes for reporting, investigating and analysing health care associated infections, and aligning these systems to the organisation’s risk management strategy

3.3.1 Mechanisms to regularly assess the healthcare associated infection risks are in place

How do we identify, report and manage healthcare associated infection risks or incidents?

What could we learn from healthcare related infection incidents?

Job descriptions include accountability for risk assessment of healthcare associated infection

The Australian Guidelines for the Prevention and Control of Infections in Health Care is accessible to team members responsible for assessing healthcare associated risks

Relevant documentation from meetings or other communications that relate to healthcare associated infection risks

Records of healthcare associated infection incidents collected and reviewed

Completed risk assessment documents

Risk management plan that records action taken to address identified healthcare associated infection risks

Other _____________________________________________________



3.3.2 Action is taken to reduce the risks of healthcare associated infection

How do we use this information to decrease the risks of healthcare related infections or prevent incidents recurring?

How do we inform team members of our healthcare related infection risks and incidents?

Relevant documentation from meetings or other communications that relate to decreasing the risk of healthcare associated infections

Risk management plan or risk register that records action taken to address identified healthcare associated infection risks

Examples of improvement activities, such as signage about hand hygiene

Documented emergency plan for common healthcare associated infection outbreaks, for example respiratory diseases such as seasonal influenza

Other _____________________________________________________






3.4 Undertaking quality improvement activities to reduce healthcare associated infections through changes to practice

3.4.1 Quality improvement activities are implemented to reduce and prevent healthcare associated infections

What improvement activities have we undertaken to reduce or prevent healthcare related infections?

Relevant documentation from meetings or other communications that relate to preventing or reducing incidence of healthcare associated infections

Review of incidents related to risk of healthcare associated infections and any actions taken

Register of improvement activities relating to the reduction of infection risks and introduction of control measures

Other _____________________________________________________



3.4.2 Compliance with changes in practice are monitored

How could we find out if team members accept changes to our work practises?

Relevant documentation from meetings or other communications to team members that relate to accepting changes to work practices

Usage rates of specified products and equipment such as hand hygiene products, cleaning and disinfecting products, and personal protective equipment

Observational audit of team member performance

Education resources and attendance records of training in practice changes

Feedback from team members on their knowledge and understanding of new procedures

Other _____________________________________________________



3.4.3 The effectiveness of changes to practice are evaluated

How could we know if any changes we make to processes or procedures are accepted and improve the outcome?

Relevant documentation from meetings or other communications that relate to the effectiveness of changes to work place practices

A review of outcomes following the introduction of improvement activities

Observational audit of team member performance

Other _____________________________________________________





Infection prevention and control strategies

Strategies for the prevention and control of healthcare associated infections are developed and implemented.


3.5 Developing, implementing and auditing a hand hygiene program consistent with the current national hand hygiene initiative

3.5.1 Workforce compliance with current national hand hygiene guidelines is regularly audited

How do we measure hand hygiene compliance with the national hand hygiene guidelines?

Policies, procedures and protocols for hand hygiene activities are consistent with the national hand hygiene initiative and are available to team members

Audit of the types of products available for hand hygiene

Declaration of compliance by team members

Observational audit of hand hygiene compliance with the 5 Moments for Hand Hygiene by the principal dental practitioner or appropriate delegate

Audit of the amounts of hand hygiene products used

Education resources and attendance records of completed hand hygiene training consistent with guidelines such as the Australian Guidelines for the Prevention and Control of Infections in Health Care

Other _____________________________________________________

Links to Standards 1: Governance for Safety and Quality in Health Service Organisations



3.5.2 Compliance rates from hand hygiene audits are regularly reported to the highest level of governance in the organisation

How does our leadership know our hand hygiene compliance rates?

Audit results of hand hygiene performance

Relevant documentation from meetings or other communications relating to reviews of hand hygiene matters

Review of equipment, supplies and products required to comply with hand hygiene requirements

Declaration of compliance by team members

Documented process for reporting infection control breaches, such as non-compliance with hand hygiene requirements

Other _____________________________________________________






3.5.3 Action is taken to address non-compliance, or the inability to comply, with the requirements of the current national hand hygiene guidelines

What actions have we taken to improve compliance with the requirements of hand hygiene guidelines?

Relevant documentation from meetings or other communications relating to hand hygiene strategies and actions

Amendments to policies, procedures, protocols or work practices that address issues of hand hygiene non-compliance

A risk register that includes actions to address identified risks in hand hygiene compliance

Examples of improvement activities that have been implemented and evaluated to address non-compliance with current national hand hygiene guidelines


Other _____________________________________________________



3.6 Developing, implementing and monitoring a risk-based workforce immunisation program in accordance with the current National Health and Medical Research Council Australian immunisation guidelines

3.6.1 A workforce immunisation program that complies with current national guidelines is in use

Is our immunisation program consistent with the National Health and Medical Research Council immunisation guidelines?

Policies, procedures and protocols that are consistent with national guidelines and jurisdictional legislation

Register, report or review of vaccination to demonstrate team members compliance rates

Authorised personnel have access to documents that:

• identify the requirements for vaccination as part of recruitment of team members or placement of contractors and students

• demonstrate the maintenance of vaccination status of existing team members

• record immunisation refusals and the risk management response to refusals

Information relating to prevention strategies and risks associated with vaccine preventable diseases are available for team members, patients and carers

Agreements with external providers or other organisations for the provision of vaccination services (if relevant)

Other _____________________________________________________






3.7 Promoting collaboration with occupational health and safety programs to decrease the risk of infection or injury to healthcare workers

3.7.1 Infection prevention and control consultation related to occupational health and safety policies, procedures and/or protocols are being implemented to address:

• communicable disease status

• occupational management and prophylaxis

• work restrictions

• personal protective equipment

• assessment of risk to healthcare workers for occupational allergy

• evaluation of new products and procedures

Do our infection prevention and control activities include measures to reduce our occupational health and safety risks?

Policies, procedures and protocols for the management of occupational exposures (such as sharps injury and reporting communicable disease status) that address vaccination refusal and work placement or procedure restrictions. Such information is stored and accessed in keeping with confidentiality provisions.

Risk assessments for team members undertaking exposure prone procedures

Occupational exposure data that is used to support the introduction of safety devices and equipment to minimise risks to team members and patients

Records of screening for skin conditions related to dermatitis or allergy to personal protective equipment (e.g. latex gloves, skin antiseptics or hand hygiene products)

Attendance record of team members who have completed training and competency assessments in the use of personal protective equipment which may include gloves, gowns, plastic aprons, face shields, protective eye wear and masks

Education resources and training that support the appropriate rescheduling of elective treatment on the basis of patients reporting illness, such as respiratory tract infections, varicella or pertussis

Information from monitoring team members who may be infected or colonised with an infectious agent

Audits of the usage of personal protective equipment

Vaccination policy or program consistent with current Australian immunisation guidelines

Protocol for post-exposure management and prophylaxis following blood borne virus parenteral exposures.

Other_____________________________________________________






3.8 Developing and implementing a system for use and management of invasive devices based on the current national guidelines for preventing and controlling infections in health care

3.8.1 Compliance with the system for the use and management of invasive devices is monitored

How do we know team members are safely using and maintaining invasive devices to reduce the infection risk to patients?

Policies, procedures and protocols for use of invasive devices based on regulations, national or professional guidelines

Strategic plan that incorporates invasive device risks for the practice

A batch control number system for reusable invasive medical devices such as surgical dental instruments used in critical (i.e. sterile) sites.

Batch control numbers recorded in patient dental records following use of devices in dental surgical procedures if required by the manufacturer or specified in international or national standards

Observation and audit of the integrity of critical instruments storage and packaging

Other_____________________________________________________



3.9 Implementing protocols for invasive device procedures regularly performed within the organisation

3.9.1 Education and competency-based training in invasive devices protocols and use is provided for the workforce who perform procedures with invasive devices

How do we educate and train relevant members of our practice to use and reduce the risk of harm from invasive devices?

Orientation and ongoing education resources for the use and management of invasive devices

Attendance records of training related to invasive devices

Evaluations of education and competency-based training needs

Other_____________________________________________________



3.10 Developing and implementing protocols for aseptic technique

3.10.1 The clinical workforce is trained in aseptic technique

How do we know the clinical team members are trained in aseptic technique?

Policies, procedures and protocols on aseptic techniques that is consistent with relevant best practice and guidelines

Education resources and records of attendance at training by team members on aseptic technique

Training schedule for ongoing education and training of team members who perform procedures requiring aseptic technique


Other_____________________________________________________






3.10.2 Compliance with aseptic technique is regularly audited

How do we find out if our clinician team members routinely follow aseptic technique when required?

Policies, procedures and protocols on aseptic technique consistent with national and professional guidelines

Declaration by clinical team members of complying with aseptic technique

Observational audit of procedures of aseptic technique

Plans or reports detailing routine measures to audit compliance

Records of annual assessment of compliance with aseptic technique

Training attendance records of clinical team members in aseptic technique

Other_____________________________________________________



3.10.3 Action is taken to increase compliance with aseptic technique protocols

What action have we taken to improve team member’s compliance with aseptic technique?

Relevant documentation from meetings or other communications related to improvements in the use of aseptic technique

Education resources and attendance records of training in aseptic technique

Reviews of accessibility to infrastructure, instruments, and other equipment necessary to comply with policies, procedures and protocol

Examples of improvement activities that have been implemented and reviewed to increase the use of aseptic technique


Other_____________________________________________________





Managing patients with infections or colonisations

Patients presenting with, or acquiring an infection or colonisation during their care are identified promptly and receive the necessary management and treatment.



3.11 Implementing systems for using standard precautions and transmission- based precautions

3.11.1 Standard precautions and transmission-based precautions consistent with the current national guidelines are in use

Are our standard precautions and transmission-based precautions consistent with national guidelines?

Policies, procedures and protocols for standard and transmission-based precautions consistent with the Australian Guidelines for the Prevention and Control of Infections in Health Care

An infection prevention and control manual that:

• includes safe work practices included under standard precautions

• identifies the types of conditions and situations for which transmission-based precautions are required

• is in accordance with the current jurisdictional requirement

• is accessible to team members

Observational audit of workplace practices and equipment usage

Education resources and attendance records of training in standard and transmission-based precautions

Standardised signage and other information resources consistent with current national guidelines for standard and transmission based precautions is accessible to team members

Other_____________________________________________________

Links to Standard 1: Governance for Safety and Quality in Health Service Organisations



3.11.2 Compliance with standard precautions is monitored

How do we know if team members consistently follow standard precautions?

Declaration of compliance with standard precautions by team members

Observation of team member compliance with standard precautions

Annual assessments of clinical team member compliance with standard precautions (for example, environmental cleaning, hand hygiene practices, and use of personal protective equipment)

Inventory of equipment available for use in standard precautions

Other_____________________________________________





Links to Standard 3.1 effective infection prevention and control to minimise risks to patients of healthcare associated infections

3.11.3 Action is taken to improve compliance with standard precautions

What action has been taken to improve the use of standard precautions by team members?

Relevant documentation from meetings or other communications with team members on approaches to improve the use of standard precautions

Education materials such as brochures, pamphlets or posters on the use of standard precautions

Attendance records of training in standard precautions

Provision of infrastructure, instruments and other equipment necessary to comply with policies, procedures and protocols


Other___________________________________________



3.11.4 Compliance with transmission-based precautions is monitored

How do we find out if team members correctly use transmission-based precautions?

Declaration of compliance with transmission-based precautions by team members

Observation of team member compliance with transmission-based precautions

Annual assessments of clinical team member compliance with transmission-based precautions (for example, environmental cleaning, hand hygiene practices and use of personal protective equipment)

Inventory of equipment available for use in transmission-based precautions

Policy for managing patients known to require transmission-based precautions to ensure patient and team member safety

Other_____________________________________________



3.11.5 Action is taken to improve compliance with transmission-based precautions

What action has been taken to improve the use of transmission-based precautions by team members?

Relevant documentation from meetings or other communications with team members on approaches to improve the use of transmission-based precautions

Education materials such as brochures, pamphlets or posters on the use of transmission-based precautions

Attendance records of training in the use of standard precautions

Inventory of infrastructure, instruments and other equipment necessary to comply with policies, procedures and protocols

A risk register that includes actions to address identified risks with transmission-based precautions

Other_____________________________________________






3.12 Assessing the need for patient placement based on the risk of infection transmission

3.12.1 A risk analysis is undertaken to consider the need for transmission-based precautions including:

• accommodation based on the mode of transmission

• environmental controls through air flow

• transportation within and outside the facility

• cleaning procedures

• equipment requirements

How do we determine when we need to apply transmission-based precautions?

Policies, procedures and protocols based on risk assessment, analysis and risk management processes

An infection prevention and control manual that identifies the types of conditions and situations for which transmission-based precautions are required is accessible to team members

Risk assessments for the management of patients with known or suspected infectious diseases

A review of the layout of the practice, maintenance and air handling system requirements

Other_____________________________________________



3.13 Developing and implementing protocols relating to the admission, receipt and transfer of patients with an infection

3.13.1 Mechanisms are in use to check for pre-existing healthcare associated infection or communicable disease on presentation for care

How do we check the infectious status of a patient on presentation for care?

Policies, procedures and protocols on identifying pre-existing healthcare associated infection or communicable disease

Medical history form or equivalent document to assess the infection control risk of patients

Other_____________________________________________

Links to Standard 6: Clinical Handover



3.13.2 A process for communicating a patient’s infectious status is in place whenever responsibility for care is transferred between service providers or facilities

How do we alert other health service providers and carers of the infectious status of a patient at referral or transfer of care?

Policies, procedures and protocols requiring notification of communicable diseases at patient referral or transfer of care

Referral documentation that requires the identification of significant medical history findings, including infectious status

Other_____________________________________________

Links to Standard 6: Clinical Handover





Antimicrobial stewardship

Safe and appropriate antimicrobial prescribing is a strategic goal of the clinical governance system.


3.14 Developing, implementing and regularly reviewing the effectiveness of the antimicrobial stewardship system

3.14.1 An antimicrobial stewardship program is in place

What systems, processes and structures do we have in place to support appropriate prescribing and use of antimicrobials?

Policies, procedures and protocols that relate to antimicrobial stewardship are based on national guidelines, jurisdictional legislation and codes, and directives from health agencies

Relevant documentation from meetings or other communications that relate to antimicrobial stewardship

Observation that guides such as the Therapeutic Guidelines: Antibiotic and Therapeutic Guidelines: Oral and Dental Antibiotic are available to the prescribers

Education resources and records of attendance at training by prescribers administering antimicrobials on antimicrobial usage, development of resistance and judicious prescribing

Audit of antimicrobial usage

Restriction, approval or review systems to guide the use of broad spectrum antimicrobials (where relevant)

Referral process to infectious disease physician or clinical microbiologist (where relevant)

Other_____________________________________________

Links to Standard 1: Governance for Safety and Quality in Health Service Organisations and Standard 4: Medication Safety



3.14.2 The clinical workforce prescribing antimicrobials have access to current endorsed therapeutic guidelines on antibiotic usage

In what ways do we provide access to current endorsed therapeutic guidelines for clinical team members who prescribe antibiotics?

Endorsed guidelines from the National Health and Medical Research Council are accessible to clinical team members. These include:

• Therapeutic Guidelines: Antibiotic

• Therapeutic Guidelines: Oral and Dental Antibiotic

Other_____________________________________________

Links to Standard 4: Medication Safety






3.14.3 Monitoring of antimicrobial usage and resistance is undertaken

Not applicable to dental practices No further action is required


3.14.4 Action is taken to improve the effectiveness of antimicrobial stewardship

Not applicable to dental practices No further action is required




Cleaning, disinfection and sterilisation

Healthcare facilities and the associated environment are clean and hygienic. Reprocessing of equipment and instrumentation meets current best practice guidelines.


3.15 Using risk management principles to implement systems that maintain a clean and hygienic environment for patients and healthcare workers

3.15.1 Policies, procedures and/or protocols for environmental cleaning that address the principles of infection prevention and control are implemented, including:

• maintenance of building facilities

• cleaning resources and services

• risk assessment for cleaning and disinfection based on transmission- based precautions and the infectious agent involved

• waste management within the clinical environment

• laundry and linen transportation, cleaning and storage

• appropriate use of personal protective equipment

How do we maintain a clean and hygienic environment for patients?

Policies, procedures and protocols that relate to environmental cleaning are consistent with current guidelines such as the Australian Guidelines for the Prevention and Control of Infections in Health Care

Infection prevention and control manual that includes information on environmental cleaning

Waste management plan that:

• conforms to local, state or territory regulations and standards

• includes actions to address identified risks

Environmental risk assessment that includes action to address identified risks

Service schedules for patient care equipment e.g. procedure chair, water lines and anti-retraction valves

Relevant documentation from meetings or other communications relating to cleaning matters

Cleaning schedules related to workplace rooms, areas and facilities

Material safety data sheets or chemical register of cleaning resources utilised

Communication book between cleaners and the dental practice

Audit of the use of personal protective equipment

Observational audit of cleaning services and standards

Register of improvement activities for building and infrastructure maintenance

Other_____________________________________________

Links to Standard 1: Governance for Safety and Quality in Health Service Organisations






3.15.2 Policies, procedures and/or protocols for environmental cleaning are regularly reviewed

How do we ensure our cleaning policies, procedures and protocols are effective?

Reviews and updates of:

• policies, procedures and protocols on cleaning matters

• infection prevention and control manuals

• cleaning contracts that are consistent with policy documents for external providers (if relevant)

Relevant documentation from meetings or other communications relating to cleaning matters

Schedule of audits and reviews for cleaning procedures

Sign-off list or register of completed audits and reviews on cleaning matters by principal dental practitioner

Other_____________________________________________



3.15.3 An established environmental cleaning schedule is in place and environmental cleaning audits are undertaken regularly

What action have we taken to maintain cleaning standards and services?

Cleaning schedules that are consistent with current guidelines such as the Australian Guidelines for the Prevention and Control of Infections in Health Care

Work instructions and job descriptions

Results of environmental cleaning audits

Reviews of cleaning contracts and compliance with cleaning schedules

Other_____________________________________________






3.16 Reprocessing reusable medical equipment, instruments and devices in accordance with relevant national or international standards and manufacturers’ instructions

3.16.1 Compliance with relevant national or international standards and manufacturer’s instructions for cleaning, disinfection and sterilisation of reusable instruments and devices is regularly monitored

How do we know if the reprocessing of reusable medical devices happens in accordance with national standards and manufacturer’s instructions?

Relevant documentation from meetings or other communications relating to cleaning and processing of instruments

Attendance records of training in the cleaning and reprocessing of instruments

Records of sterilisation verifying reprocessing is consistent with legislation and jurisdictional requirements

Maintenance schedules for sterilising equipment

Audits of monitoring systems for sterilisers

Risk assessments where there are deviations in the requirements of relevant standards and the manufacturer’s instructions

Observational audit of cleaning, disinfection and sterilisation processes

Results for sterile stock integrity and supply audits

Other_____________________________________________



3.17 Implementing systems to enable the identification of patients on whom the reusable medical devices have been used

3.17.1 A traceability system that identifies patients who have a procedure using sterile reusable medical instruments and devices is in place

How do we identify patients and procedures where sterile reusable instruments and devices have been used?

Policies, procedures and protocols that require a batch control number system for reusable sterile medical devices used on a patient at a critical (i.e. sterile) site for dental surgery, where this is a requirement by the manufacturer, or by relevant international or national guidelines and standards

Traceability systems used during the reprocessing of reusable items

Batch control numbers that link the batch of sterile instruments used in invasive procedures are recorded in patient dental records

Other_____________________________________________






3.18 Ensuring workforce who decontaminate reusable medical devices undertake competency-based training in these practices

3.18.1 Action is taken to maximise coverage of the relevant workforce trained in a competency-based program to decontaminate reusable medical devices

What training have we provided to relevant team members to decontaminate reusable instruments and devices?

Policies, procedures and protocols to decontaminate reusable medical instruments are consistent with best practice and guidelines, such as the Australian Guidelines for the Prevention and Control of Infections in Health Care

International or national standards and guidelines are accessible to team members


Education resources and records of attendance at training by team members on decontamination of reusable instruments and devices

Training schedule for ongoing education and training of team members on decontamination of reusable instruments and devices

Relevant and current standards and guidelines are accessible to team members

Other_____________________________________________





Communicating with patients and carers

Information on healthcare associated infection is provided to patients, carers, consumers and service providers.


3.19 Ensuring access to consumer-specific information on the management and reduction of healthcare associated infections is available at the point of care

3.19.1 Information on the organisation’s corporate and clinical infection risks and initiatives implemented to minimise patient infection risks is provided to patients and/or carers

How could we tell patients, carers or other consumers about our work to decrease infection risks to patients?

Risk alert information and materials provided to patients and carers. For example, respiratory precautions during influenza season

Public health risk alert material placed on display in areas such as reception and waiting areas

Web-based or printed information sheets, posters and pamphlets that inform patients and carers about infection prevention and control precautions such as hand hygiene

Other_____________________________________________

Links to Standard 2: Partnering with Consumers



3.19.2 Patient infection prevention and control information is evaluated to determine if it meets the needs of the target audience

How do we collect patient and carer feedback on our infection prevention and control information?

Patient and carer information on infection prevention and control that has been:

• produced by the dental practice and subjected to consumer consultation processes and evaluation

• provided to the dental practice by professional dental associations or relevant commercial bodies and has had consumer input and evaluation

Analysis of patient and carer comments, suggestions and complaints

Results of feedback from patient and carer experience surveys

Other_____________________________________________

Links to Standard 2: Partnering with Consumers





Resources

1. Antibiotic Expert Group. Therapeutic guidelines: antibiotic. Version 14. Melbourne: Therapeutic Guidelines Limited; 2010.

2. Australian College of Operating Room Nurses. Aseptic Non-Touch Technique (ANTT) Standards for Periooperative Nursing 2010-2011. South Australia. ACORN. 2010. (Copies can be purchased from ACORN website http://www.acorn.org.au/about-acorn-standards.html.)

3. Australian Commission on Safety and Quality in Health Care. Antimicrobial Stewardship in Australian Hospitals, 2010.

4. ADA Guidelines for Infection Control. Second Edition. Australian Dental Association. (Accessed 4 July 2012, at http://www.ada.org.au/publications/guideinfectcont.aspx)

5. Australian/New Zealand Standard AS/NZS 4815 2006 Office-based health care facilities – Reprocessing of reusable medical and surgical instruments and equipment, and maintenance of the associated environment (currently under review). Available for purchase at www.standards.co.nz

6. Australian/New Zealand Standard AS/NZS 4187 2003. Cleaning, disinfecting and sterilising reusable medical and surgical instruments and equipment, and maintenance of associated environments in health care facilities (currently under review). Available for purchase at www.standards.co.nz

7. Duguid M, Cruickshank M, editors. Antimicrobial Stewardship in Australian Hospitals. Sydney: Australian Commission on Safety and Quality in Health Care, 2011.

8. 5 Moments for Hand Hygiene. Hand Hygiene Australia, 2011. (Accessed 8 June 2012, at http://www.hha.org.au/home/5-moments-for-hand-hygiene.aspx.)

9. Guidelines on Infection Control. Dental Board of Australia. (Accessed 08 June 2012, at http://www.dentalboard.gov.au)

10. Healthcare Associated Infection (HAI) Program. Australian Commission on Safety and Quality in Health Care (Accessed 08 June 2012, at http://www.safetyandquality.gov.au/our-work/healthcare-associated-infection/)

11. National Health and Medical Research Council. Australian Guidelines for the Prevention and Control of Infections in Healthcare. Canberra: NHMRC, 2010.

12. National Health and Medical Research Council. The Australian Immunisation Handbook 9th Edition Canberra, ACT. Australian Government 2008.

13. Oral and Dental Expert Group. Therapeutic guidelines: oral and dental. Version 2. Melbourne: Therapeutic Guidelines Limited; 2012


http://www.acorn.org.au/about-acorn-standards.html.

Australian Commission on Safety and Quality in Health Care Standard 4: Medication Safety


Standard 4: Medication Safety Clinical leaders and senior managers of a health service organisation implement systems to reduce the occurrence of medication incidents, and improve the safety and quality of medicine use. Clinicians and other members of the workforce use the systems to safely manage medicines.


Ensure competent clinicians safely prescribe, dispense and administer appropriate medicines to informed patients and carers.

Context

It is expected that this Standard will be applied in conjunction with Standard 1 ‘Governance for Safety and Quality in Health Service Organisations’ and Standard 2 ‘Partnering with Consumers’.

Criteria to achieve the Medication Safety Standard:

• Governance and systems for medication safety

• Documentation of patient information

• Medication management processes

• Continuity of medication management



Criterion: Governance and systems for medication safety

Health service organisations have mechanisms for the safe prescribing, dispensing, supplying, administering, storing, manufacturing, compounding and monitoring of the effects of medicines. Actions required Reflective questions Examples of Evidence - select only examples currently in use Evidence available?

4.1 Developing and implementing governance arrangements and organisational policies, procedures and/or protocols for medication safety, which are consistent with national and jurisdictional legislative requirements, policies and guidelines

4.1.1 Governance arrangements are in place to support the development, implementation and maintenance of organisation- wide medication safety systems

How does our leadership take responsibility for the safe and legal use of medicines?

Relevant documentation from meetings or other communications relating to medication safety processes

Documented consideration of the business changes necessary to support the development, implementation and maintenance of practice-wide medication safety systems

Designated responsibility for the development, implementation and maintenance of practice-wide medication safety systems

Identification and review of patient safety and quality risks, including action taken to improve the development, implementation and maintenance of practice-wide medication safety systems

Training and support of team members to ensure competency in the performance of their role and duties in the medication management system

Other _____________________________________________________



4.1.2 Policies, procedures and/or protocols are in place that are consistent with legislative requirements, national, jurisdictional and professional guidelines

How consistent is the way we order, store prescribe, administer, supply and dispose of medicines with regulations and professional guidelines?

Policies, procedures and protocols that:

• are based on best practice and identified legislative requirements, including Australian Pharmaceutical Advisory Council, Commonwealth Department of Health and Ageing, Therapeutic Goods Authority and state health department Acts or regulations, nursing, medical and pharmacy professional guidelines

• include the date the policy was implemented and scheduled review date

• provide links to relevant resource material

• incorporate approved policy, procedure and protocol amendments following review of incidents, and national changes in guidelines or policy

specif• y the mechanism for checking compliance with medication policy

Other _____________________________________________________






4.2 Undertaking a regular, comprehensive assessment of medication use systems to identify risks to patient safety and implementing system changes to address the identified risks

4.2.1 The medication management system is regularly assessed

How do we find out the risks associated with medication management for a patient and the medicines used in our work place?

Relevant documentation from meetings or other communications relating to medication safety processes

Risk assessment tools, such as the Medication Risk Identification section of National Medication Management Plan (MMP)

Separate risk assessments, registers and action plans have been completed for each unit or service area in the dental practice

Reports or data from internal audits of high risk areas, for example medication reconciliation practice

Other _____________________________________________________



4.2.2 Action is taken to reduce the risks identified in the medication management system

What action have we taken to reduce the risks associated with medication management for patients and medicines used in our work place?

Risk register or individual action plans to reduce medication risks

Reports on medication management issues made available to team members and presented to leadership or principal dental practitioner

A uniform medication documentation process implemented throughout the dental practice

Analysis of medication management data from the incidence reporting system and actions taken to address identified risks

Response to medication management errors, adverse events, incidents and near misses recorded

An antibiotic stewardship program in use

Other _____________________________________________________



4.3 Authorising the relevant clinical workforce to prescribe, dispense and administer medications

4.3.1 A system is in place to verify that the clinical workforce have medication authorities appropriate to their scope of practice

How do team members find out who has authority to prescribe, administer or supply medicines?

Policies, procedures and protocols incorporating scope of practice for clinical team members in medication management. These are reviewed in line with legislation requirements

A register of clinical team members with authority to prescribe, administer and supply medicines

Audit of the incident reporting system and compliance monitoring system to verify compliance with authorisations to prescribe, administer or supply medicines

Other _____________________________________________________






4.3.2 The use of the medication authorisation system is regularly monitored

How do we find out if the medication authority system is used?

Relevant documentation from meetings or other communications relating to medication authorisation processes

Other ____________________________________________________



4.3.3 Action is taken to increase the effectiveness of the medication authority system

What action have we taken to improve the usefulness and reliability of our medication authority system?

Relevant documentation from meetings or other communications relating to the improvement of medication authorisation processes

Other _____________________________________________________






4.4 Using a robust organisation-wide system of reporting, investigating and managing change to respond to medication incidents

.4.1 Medication incidents are regularly monitored, reported and investigated

How do we identify and respond to an adverse medicines incident?

What could we learn from an adverse medicines incident?

How do we decrease the risk of an adverse medicines incident recurring?

How do we keep team members informed of our adverse medicines incidents?

Relevant documentation from meetings or other communications relating to adverse medicines incidents

Forms for reporting adverse medicines incidents

Other _____________________________________________________



4.4.2 Action is taken to reduce the risk of adverse medication incidents

What action have we taken to decrease the risk of adverse medicines incidents?

Relevant documentation from meetings or other communications relating to action taken to reduce the risk of an adverse medicines incidents

Audit of compliance with policies, procedures and protocols relating to adverse medicines incidents

Education resources on changes to policy, procedures and documentation processes relating to adverse medicines incidents

Attendance records of training in changes to policy, procedures and documentation processes relating to adverse medicines incidents

Relevant resources (for example MIMS, Therapeutic Guidelines, and Injectable Guidelines) accessible to team members

Other _____________________________________________________






4.5 Undertaking quality improvement activities to improve the safety of medicines use

4.5.1 The performance of the medication management system is regularly assessed

How could we find out about the performance of our medication safety processes?

Relevant documentation from meetings or other communications relating to the performance of medication safety processes

Observational audit of dental practitioner performance of medication safety processes

Medication improvement activities are documented in action plans, a risk register, dental practice plan or equivalent documents. This may include registering new initiatives and innovations, and detailing processes for monitoring

Data available to demonstrate medication safety improvements in the dental practice

Key performance indicators (KPIs) for safe medication management are known to team members and are routinely monitored

Key performance indicator reports on safe medication management

Other _____________________________________________________



4.5.2 Quality improvement activities are undertaken to reduce the risk of patient harm and increase the quality and effectiveness of medicines use

What action could we take to improve our medication safety processes?

Relevant documentation from meetings or other communications that include rates of medication adverse events, incidents and near misses, and any improvement actions

Education resources on the quality use of medications and tools to assist with the implementation of improvement strategies

Attendance records of training in medication safety

Other _____________________________________________________





Criterion: Documentation of patient information

The clinical workforce accurately records a patient’s medication history and this history is available throughout the episode of care.


4.6 The clinical workforce taking an accurate medication history when a patient presents to a health service organisation, or as early as possible in the episode of care, which is then available at the point of care

4.6.1 A best possible medication history is documented for each patient

How do we record the medication history for each patient in their dental record?

Relevant documentation from meetings or other communications relating to the documentation of medication history for patients

Audit of medication history and medication reconciliation documentation to assist with assessment and care delivery

Medication assessment documented as part of the patient’s visit

Patient dental records include a section for medication history to be completed by the dental practitioner

Patient dental records audit for a standardised system to record medication history and legibility

Other _____________________________________________________



4.6.2 The medication history and current clinical information is available at the point of care

How do we make available a patient’s dental record where care is provided?

Policies, procedures and protocols on the management of patient dental records and medication history

Patient’s medication history is accessible at the point of care

Medication history recorded in patient dental records

Other _____________________________________________________



4.7 The clinical workforce documenting the patient’s previously known adverse drug reactions on initial presentation and updating this if an adverse reaction to a medicine occurs during the episode of care

4.7.1 Known medication allergies and adverse drug reactions are documented in the patient clinical record

How do we record our patient’s allergy and adverse drug status in their dental record?

How do we know dental practitioners ask about allergy and adverse drug reactions and record the results?

Policies, procedures and protocols for documenting and managing patient allergies and adverse drug reactions

Audit of patient dental records for the recording of patient allergy status and adverse drug reactions.

Examples of improvements taken to address identified issues

Other _____________________________________________________






4.7.2 Action is taken to reduce the risk of adverse reactions

What action have we taken to decrease the risk of adverse reactions?

Policies, procedures and protocols to identify patient adverse drug reactions

Relevant documentation from meetings or other communications related to action taken to decrease the risk of adverse reactions

Audit of medication documentation to determine the number of patients administered a medication to which they have had an allergy or previous adverse drug reaction

Use of an adverse drug reactions reporting mechanism

Documentation of adverse drug reactions in patient records

Review of adverse drug reactions data on a systematic basis by specified team members, with recommendations for system improvement where appropriate

Review of reports on adverse events, incidents and near misses on adverse reactions

Education resources and attendance records of training in allergies and adverse drug reactions

Recommendations for system improvement where appropriate. This may include:

• updating patient records on presentation

• audit of patient dental records and action taken

Other _____________________________________________________



4.7.3 Adverse drug reactions are reported within the organisation and to the Therapeutic Goods Administration

How do we report adverse drug reactions?

How consistent is our reporting of adverse drug reactions with Therapeutic Goods Administration (TGA) guidelines?

Policies, procedures and protocols for identifying, recording and reporting adverse drug reactions

Other _____________________________________________________






4.8 The clinical workforce reviewing the patient’s current medication orders against their medication history and prescriber’s plan, and reconciling any discrepancies

4.8.1 Current medicines are documented and reconciled at admission and transfer of care between healthcare settings

How could we find out if dental practitioners, who may prescribe, administer or supply medicines record that information and consider their actions with regard to the patient’s medication history and reconcile any discrepancies?

Relevant documentation from meetings or other communications relating to the documentation and reconciliation of patient medications on presentation for care and transfer of care

Audit of patient clinical records in relation to current medicines reconciled on presentation for care and transfer of care. (This could focus on high-risk patients such as those aged 65 years and over)

Examples of improvement actions, such as use of a modified medication management plan

Other _____________________________________________________





Criterion: Medication management processes

The clinical workforce is supported for the prescribing, dispensing, administering, storing, manufacturing, compounding and monitoring of medicines.


4.9 Ensuring that current and accurate medicines information and decision support tools are readily available to the clinical workforce when making clinical decisions related to medicines use

4.9.1 Information and decision support tools for medicines are available to the clinical workforce at the point of care

What support tools for information and decision making in medication management do we need?

How do dental practitioners access support tools where care is provided?

Information and support tools in medication management accessible to clinical team members

Relevant documentation from meetings or other communications relating to support tools for information and decision making in medication management

Observational audit of the use of information and decision support tools in medication management

Audit of medication history documented in patient dental records

Other _____________________________________________________



4.9.2 The use of the information and decision support tools are regularly reviewed

How do we know our information and support tools are current and useful to clinical team members?

Policy, procedures and protocols on prescribing medication within the dental practice


Observational audit of the use of decision support tools related to medicines use

Feedback from clinical team members on the value of support tools related to medicines use

Restriction, approval or review system to guide the use of restricted medications

Other _____________________________________________________






4.9.3 Action is taken to improve the availability and effectiveness of information and decision support tools

What action have we taken to improve the availability and effectiveness of our support tools for information and decision making in medication management?


Feedback from clinical team members, patients and carers regarding the accessibility and effectiveness of support tools


Review of medication management tools and resources by relevant team members and appropriate changes made in line with feedback, legislation and best practice

Other _____________________________________________________



4.10 Ensuring that medicines are distributed and stored securely, safely and in accordance with the manufacturer’s directions, legislation, jurisdictional orders and operational directives

4.10.1 Risks associated with secure storage and safe distribution of medicines are regularly reviewed

How do we identify, report and manage risks associated with the storage of medicines in our work place?

Policies, procedures and protocols for the safe distribution and storage of medicines

Relevant documentation from meetings or other communications relating to risks of storage and distribution of medicines

Other _____________________________________________________



4.10.2 Action is taken to reduce the risks associated with storage and distribution of medicines

What action have we taken to decrease the risks associated with the storage of medicines in our work place?

Review of policies, procedures and protocols on the storage and distribution of medicines

Relevant documentation from meetings or other communications relating to actions taken to decrease the risks associated with the storage and distribution of medicines

Systems that record those who access medication supply areas and record the removal of medications

Other _____________________________________________________






4.10.3 The storage of temperature-sensitive medicines is monitored

Not applicable for dental practices



4.10.4 A system that is consistent with legislative and jurisdictional requirements for the disposal of unused, unwanted or expired medications is in place

How consistent are our processes for disposal of unwanted medicines with jurisdictional requirements and the manufacturer’s instructions?

Policies, procedures and protocols for the disposal of unused, unwanted or expired medications

Relevant documentation from meetings or other communications relating to disposal of unused, unwanted or expired medicines

Orientation and education resources on disposal of unused, unwanted or expired medicines

Attendance records of training in disposal of unused, unwanted or expired medicines

Other _____________________________________________________



4.10.5 The system for disposal of unused, unwanted or expired medications is routinely monitored

How do we find out if the disposal of medicines is being done correctly?

Observational audit of the disposal of unused, unwanted or expired medicines

Declaration by team members of compliance with correct disposal methods of unwanted medicines

Other _____________________________________________________



4.10.6 Action is taken to increase compliance with the system for storage, distribution and disposal of medications

What action have we taken to support team members in the correct disposal of medicines?

Relevant documentation from meetings or other communications related to compliance issues in the disposal of unused, unwanted or expired medicines

Orientation and education resources on disposal of unused, unwanted or expired medicines

Attendance records of training in the disposal of unused, unwanted or expired medicines

Other _____________________________________________________






4.11 Identifying high-risk medicines in the organisation and ensuring they are stored, prescribed, dispensed and administered safely

4.11.1 The risks for storing, prescribing, dispensing and administration of high-risk medicines are regularly reviewed

Which high-risk medicines do we store, prescribe, administer or supply?

How do we identify, report and manage the risks associated with high-risk medicines?

Relevant documentation from meetings or other communications relating to the review of risks associated with the storage, prescribing, administering and supplying of high-risk medicine

Audit of compliance with prescribing, administrating and supplying high-risk medications policy

Register of dental practitioners who have authority to prescribe high-risk medications

Reviews of the risks associated with the storage, prescribing, administering and supplying of high-risk medicine undertaken in conjunction with work health and safety policies, procedures and protocols

Review of incident reports and trends relating to high-risk medicines and the implementation of appropriate responses

Other _____________________________________________________



4.11.2 Action is taken to reduce the risks of storing, prescribing, dispensing and administering high-risk medicines

What action have we taken to decrease the risks associated with our high-risk medicines?

Relevant documentation from meetings or other communications relating to actions taken to decrease risks associated with the storage, prescribing, administering or supplying of high-risk medicine

Orientation and education resources to decrease risks associated with the storage, prescribing, administering or supplying of high-risk medicine

Attendance records of training to decrease risks associated with the storage, prescribing, administering or supplying of high-risk medicine

Systems within the dental practice for separation of look-alike, sound-alike medications

Other _____________________________________________________





Criterion: Continuity of medication management

The clinician provides a complete list of a patient’s medicines to the receiving clinician and patient when handing over care of changing medicines. 4.12 Ensuring a current comprehensive list of medicines, and the reason(s) for any change, is provided to the receiving clinician and the patient during any clinical handovers

4.12.1 A system is in use that generates and distributes a current and comprehensive list of medicines and explanation of changes in medicines


No further action is required Yes list source of evidence

4.12.2 A current and comprehensive list of medicines is provided to the patient and/or carer when concluding an episode of care



4.12.3 A current comprehensive list of medicines is provided to the receiving clinician during clinical handover



4.12.4 Action is taken to increase the proportion of patients and receiving clinicians that are provided with a current comprehensive list of medicines during clinical handover





Criterion: Communication with patients and carers

The clinical workforce informs patients about their options, risks and responsibilities for an agreed medication management plan.


4.13 The clinical workforce informing patients and carers about medication treatment options, benefits and associated risks

4.13.1 The clinical workforce provides patients with patient-specific medicine information, including medical treatment options, benefits and associated risks

How do we inform our patients about their care options including the use of medicines?

Relevant documentation from meetings or other communications relating to the provision of patient-specific medicine information, including medication treatment options, benefits and associated risks

Patient dental records show that medicines information was provided to patients

Examples of material provided to patients and carers on medicines, such as brochures, fact sheets and appropriate websites

Audit of documentation provided to patients and carers that may be contained in patient dental records or stored on computer systems

Feedback from patients and carers on the provision of patient-specific medicine information, including medication treatment options, benefits and associated risks

Other _____________________________________________________



4.13.2 Information that is designed for distribution to patients is readily available to the clinical workforce

How do we make available information to a patient or carer about care options?

Education materials and resources provided to patients and carers by team members such as brochures, handouts and fact sheets

Observational audit of the availability or patient and carer information material

Feedback from patients and carers on the suitability of information provided by the dental practice

Orientation and education resources on patient and carer information material

Other _____________________________________________________






4.14 Developing a medication management plan in partnership with patients and carers

4.14.1 An agreed medication management plan is documented and available in the patient’s clinical record




4.15 Providing current medicines information to patients in a format that meets their needs whenever new medicines are prescribed or dispensed

4.15.1 Information on medicines is provided to patients and carers in a format that is understood and meaningful




4.15.2 Action is taken in response to patient feedback to improve medicines information distributed by the health service organisation to patients





Resources

1. Australian Pharmaceutical Advisory Council (APAC), Guiding principles for medication management in the community. Canberra: Commonwealth of Australia 2006

2. Australian Pharmaceutical Advisory Council (APAC), Guiding principles to achieve continuity in medication management. Canberra: Commonwealth of Australia 2005

3. Group Medication Safety Self Assessment for Australian Hospitals. Clinical Excellence Commission and NSW Therapeutic Advisory (Accessed 2012, 08 June, at http://www.cec.health.nsw.gov.au/programs/mssa.)

4. Indicators for Quality Use of Medicines in Australian Hospitals. NSW Therapeutic Advisory Group (Accessed 2012, 08 June, http://www.cec.health.nsw.gov.au/programs/medication-safety.)

5. Medication Safety Self Assessment for Antithrombotic Therapy in Australian Hospitals. Clinical Excellence Commission and NSW Therapeutic Advisory Group (Accessed 2012, 08 June, at http://mssa.cec.health.nsw.gov.au/at2/MSSAT_introduction.html.)

6. National Medicines Policy (2000) (Accessed 2012, 08 June, http://www.health.gov.au/internet/publishing.nsf/content/nmp-objectives-policy.htm.)

7. Additional information on high risk medications can be found at the Institute for Safe Medication Practices (ISMP) http://www.ismp.org


Australian Commission on Safety and Quality in Health Care Standard 5: Patient Identification and Procedure Matching

Standard 5: Patient Identification and Procedure Matching Clinical leaders and senior managers of a health service organisation establish systems to ensure the correct identification of patients and correct matching of patients with their intended treatment. Clinicians and other members of the workforce use the patient identification and procedure matching systems.


Correctly identify all patients whenever care is provided and correctly match patients to their intended treatment.

Context

It is expected that this Standard will be applied in conjunction with Standard 1, ‘Governance for Safety and Quality in Health Service Organisations’ and Standard 2, ‘Partnering with Consumers’.

Criteria to achieve the Patient Identification and Procedure Matching Standard:

• Identification of individual patients

• Processes to transfer care

• Processes to match patients and their care



Criterion: Identification of individual patients

At least three approved patient identifiers are used when providing care, therapy or services.


5.1 Developing, implementing and regularly reviewing the effectiveness of a patient identification system including the associated policies, procedures and/or protocols that:

• define approved patient identifiers

• require at least three approved patient identifiers on registration or admission

• require at least three approved patient identifiers when care, therapy or other services are provided

• require at least three approved patient identifiers whenever clinical handover, patient transfer or discharge documentation is generated

5.1.1 Use of an organisation-wide patient identification system is regularly monitored

How do we ensure that the identity of the patient is maintained throughout their treatment?

How do we know if team members correctly use our patient identification processes?

Policy that lists the dental practice’s approved patient identifiers. For example, full name (family and given names), date of birth and address as stated by the patient

Policies, procedures and protocols regarding the use of at least three approved patient identifiers:

• on presentation of care

• when dental care is provided

• whenever referral or patient transfer documents are generated

Observational audits of patient identification procedures

Compliance and ongoing monitoring of patient identification and procedure matching requirements documented in patient dental records

Other ______________________________________________________



5.1.2 Action is taken to improve compliance with the patient identification matching system

What action have we taken to improve team members’ compliance with our patient identification matching processes?

Register of reviewed policies, procedures and protocols on patient identification and procedure matching processes that include the date disseminated to team members

Sign off sheets in policies to ensure they have been read, understood and implemented by team members

Policy that lists the training requirements for patient identification and procedure matching processes

Orientation and education resources in patient identification and procedure matching matters

Attendance records of training in patient identification and procedure






matching matters

Other _____________________________________________________

5.2 Implementing a robust organisation-wide system of reporting, investigation and change management to respond to any patient care mismatching events

5.2.1 The system for reporting, investigating and analysis of patient care mismatching events is regularly monitored

How do we identify, record and deal with patient mismatching events and near misses?

How do we keep team members informed of patient care mismatching events and near misses?

Mechanisms to record incidents of mismatching and wrong site practice such as:

• Incident reporting forms

• A register that is reviewed and amended as necessary following a mismatching incident. This should include what action is taken to prevent the incident occurring again, with a sign off column for the team member who has committed the breach and been counselled

Relevant documentation from meetings or other communications that relate to the regular review of mismatching incidents and wrong site practice

Other ______________________________________________________



5.2.2 Action is taken to reduce mismatching events

What action have we taken to decrease the number of mismatching events and near misses and the risk of these recurring?

Relevant documentation of meetings or other communications to team members relating to reviews of adverse events, incidents and near misses on mismatching events

Review of incidents and trends in mismatching events displayed in areas accessible to team members

Review of risk register following a mismatching event and any actions taken to address identified issues

Other ______________________________________________________



5.3 Ensuring that when a patient identification band is used, it meets the national specifications for patient identification bands

5.3.1 Inpatient bands are used that meet the national specifications for patient identification bands






Criterion: Processes to transfer care

A patient’s identity is confirmed using three approved patient identifiers when transferring responsibility for care.


5.4 Developing, implementing and regularly reviewing the effectiveness of the patient identification and matching system at patient handover, transfer and discharge

5.4.1 A patient identification and matching system is implemented and regularly reviewed as part of structured clinical handover, transfer and discharge processes

How do we know if patient identification and matching processes are used at referral or transfers of care?

Policies, procedures and protocols for patient referral or transfer of care that include:

• the use of three patient identifiers

• requirement for all team members to reconfirm the three patient identifiers whenever a dental practitioner takes on the care of a patient

Audit of patient dental records to confirm the use of three patient identifiers

Other ______________________________________________________





Criterion: Processes to match patients and their care

Health service organisations have explicit processes to correctly match patients with their intended care.


5.5 Developing and implementing a documented process to match patients to their intended procedure, treatment or investigation and implementing the consistent national guidelines for patient procedure matching protocol or other relevant protocols

5.5.1 A documented process to match patients and their intended treatment is in use

Are our written processes for matching a patient and their intended care consistent with the national guidelines?

Policies, procedures and protocols for when a specific patient identification procedure is to be used by team members. This may include:

• correct site, correct patient, correct procedure protocols

• surgical safety checklist

• referral or transfer of care checklist

Audit of patient dental records to confirm the use of patient procedure matching protocols

Other ______________________________________________________



5.5.2 The process to match patients to any intended procedure, treatment or investigation is regularly monitored

How do we know if our patient identification and procedure matching processes are being followed?

Audit of compliance by dental practitioners to matching processes

Observational audit of patient identification and procedure matching processes by team members in the clinical setting

Observational audit of patient involvement in identifying the correct site for their dental procedure

Review of policies, procedures and protocols to ensure routine correct site identification where there is the potential for error

Other ______________________________________________________







5.5.3 Action is taken to improve the effectiveness of the process for matching patients to their intended procedure, treatment or investigation

What action has been taken to improve our patient identification and procedure matching processes?

Policies, procedures and protocols for patient identification and procedure matching are reviewed and updated

Register of patient identification and procedure matching improvement activities and action plans

Examples of improvement activities that have been implemented and evaluated to improve patient identification and procedure matching processes

Relevant documentation from meetings or other communications to team members about patient identification and procedure matching improvement activities

Other ______________________________________________________



Resources

1. Ensuring Correct Patient, Correct Site, Correct Procedure in Oral Surgery, 2008. (Accessed 12 June 2012, at

http://www.safetyandquality.gov.au/wp-content/uploads/2012/01/Protocol_OralSurgery.pdf.)

2. Standards Australia. HB 222-2006 Australian Health Care Client and Provider Identification Handbook. Sydney: Standards Australia, 2006.

3. Standards Australia. AS5017-2006 Health Care Client Identification. Sydney: Standards Australia, 2006.

Australian Commission on Safety and Quality in Health Care Standard 6: Clinical Handover

Standard 6: Clinical Handover Clinical leaders and senior managers of a health service organisation implement documented systems for effective and structured clinical handover. Clinicians and other members of the workforce use the clinical handover systems.

Clinical handover is the transfer of professional responsibility and accountability for some or all aspects of care for a patient or group of patients, to another person or professional group on a temporary or permanent basis12.


Ensure there is timely, relevant and structured clinical handover that supports safe patient care.

Context

It is expected that this Standard will be applied in conjunction with Standard 1, ‘Governance for Safety and Quality in Health Service Organisations’ and Standard 2, ‘Partnering with Consumers’.

Criteria to achieve the Clinical Handover Standard:

• Governance and leadership for effective clinical handover

• Clinical handover processes

• Patient and carer involvement in clinical handover



Criterion: Governance and leadership for effective clinical handover

Health Service organisations implement clinical handover systems.


6.1 Developing and implementing an organisational system for structured clinical handover that is relevant to the healthcare setting and specialities, including:

• documented policy, procedures and/or protocols

• agreed tools and guides

6.1.1 Clinical handover policies, procedures and/or protocols are used by the workforce and regularly monitored

How do we describe our process for clinical handover resulting in a transfer of care and accountability to another healthcare practitioner or organisation?

How do we know that our clinical handovers are being done correctly?

Policies, procedures and protocols for clinical handover occuring between practitioners within the practice and outside of the dental practice

Audit of the use of clinical handover tools and processes such as:

• checklists

• transfer forms

• referral proforma documents

• database entries

Other ______________________________________________________



6.1.2 Action is taken to maximise the effectiveness of clinical handover policies, procedures and/or protocols

What action have we taken to improve the guidance to team members on clinical handover?

Relevant documentation from meetings or other communications to team members regarding clinical handover matters

Education resources and training sessions on referral or patient transfer matters

Other ______________________________________________________



6.1.3 Tools and guides are periodically reviewed

What tools and guides do we use to assist in clinical handover and how often do we review them?

A system for checking patient dental records for clinical handover processes

Tools and guides on clinical handover are reviewed, updated or modified in line with best practice guides or emerging information

Other ______________________________________________________





Criterion: Clinical handover processes

Health service organisations have in place documented and structured clinical handover processes in place.


6.2 Establishing and maintaining structured and documented processes for clinical handover

6.2.1 The workforce has access to documented structured processes for clinical handover that include:

• preparing for handover, including setting the location and time whilst maintaining continuity of patient care

• organising relevant workforce members to participate

• being aware of the clinical context and patient needs

• participating in effective handover resulting in transfer of responsibility and accountability for care

What could be the best clinical handover processes to use for our patients?

How could we document and keep our clinical handover processes current?

Policy and guideline documentation on clinical handover included in orientation resources or manuals

Education resources and attendance records of training clinical handover processes

Tools and resources associated with the structured clinical handover process are available to team members. For example clinical handover sheets in patient dental records

Other ______________________________________________________






6.3 Monitoring and evaluating the agreed structured clinical handover processes, including:

• regularly reviewing local processes based on current best practice in collaboration with clinicians, patients and carers

• undertaking quality improvement activities and acting on issues identified from clinical handover reviews

• reporting the results of clinical handover reviews at executive level of governance

6.3.1 Regular evaluation and monitoring processes for clinical handover are in place

How could we find out if our clinical handover processes are working and improving?

Relevant documentation from meetings or other communications to team members on clinical handover matters

Declaration of compliance by dental practitioners with clinical handover processes

Observational audit of team member compliance with clinical handover processes

Audit of patient dental records for compliance with clinical handover processes

Review of clinical handover incidents and use of these for improvement purposes

Other ______________________________________________________



6.3.2 Local processes for clinical handover are reviewed in collaboration with clinicians, patients and carers


6.3.3 Action is taken to increase the effectiveness of clinical handover

What action could we take to improve of our clinical handover processes?

Review of documents and procedures for clinical handover and any action taken including:

• a flow chart mapping current clinical handover processes

• the identification of where and how processes occur and who is involved

• points in the patient’s treatment where clinical handover occurs

• the identification of risks and gaps to prioritise improvement actions

Other ______________________________________________________






6.3.4 The actions taken and the outcomes of local clinical handover reviews are reported to the executive level of governance

How does our leadership know about our clinical handover actions, incidents and reviews?

Register of incidents and adverse events for clinical handover, including actions taken to address identified issues

Relevant documentation from meetings or other communications to leadership confirming reviews of clinical handover actions and outcomes

Documented patient complaints and feedback regarding lapses in clinical handover and communication

Other ______________________________________________________



6.4 Implementing a robust organisation-wide system of reporting, investigation and change management to respond to any clinical handover incidents

6.4.1 Regular reporting, investigating and monitoring of clinical handover incidents is in place

How do we identify, record and respond to clinical handover incidents?

What could we learn from these incidents?

How do we decrease the risk of these incidents?

How do we keep all team members informed clinical handover incidents?

Policy, procedures and protocols for recognising and reporting adverse events, incidents and near misses relating to clinical handover

Incident and near-miss reporting forms relating to clinical handover

Register of the most common adverse events, incidents and near misses relating to clinical handover

Relevant documentation from meetings or other communications relating to clinical handover adverse events, incidents and near misses

Education resources and attendance records of training in adverse events, incidents and near misses relating to clinical handover

Material that demonstrates and supports promotion of adverse events and incident reporting systems relating to clinical handover

Other ______________________________________________________






6.4.2 Action is taken to reduce the risk of adverse clinical handover incidents

What action could we take to decrease the risk of clinical handover incidents recurring?

Relevant documentation from meetings or other communications to team members related to decreasing the risks of clinical handover, incidents or near misses

Incident reports relating to clinical handover are accessible to team members

Review of trends in adverse events, incidents and near misses relating to clinical handover on display in areas accessible to team members

Relevant communications with the patient or carer documented in patient records

Other ______________________________________________________





Criterion: Patient and carer involvement in clinical handover

Health service organisations establish mechanisms to include patients and carers in clinical handover process


6.5 Developing and implementing mechanisms to include patients and carers in the clinical handover process that are relevant to the healthcare setting

6.5.1 Mechanisms to involve a patient and, where relevant, their carer in clinical handover are in use

How could we include a patient or their carer in the clinical handover process?

Relevant documentation from meetings or other communications confirming reviews of clinical handover actions and outcomes

Observational audit of clinical handover

Documented consumer feedback on clinical handover processes

Information material (such as leaflets) for patients and carers on their roles in clinical handover consistent with the Australian Charter of Healthcare Rights

Patient and carer views or input on health status and treatment plans noted in patient dental records

Other ______________________________________________________



Resources

1. Australian Commission on Safety and Quality in Health Care. Safety and Quality Improvement Guide Standard 6: Clinical handover.

Sydney. ACSQHC 2012

2. Australian Commission on Safety and Quality in Health Care. OSSIE Guide to Clinical Handover Improvement. Sydney: ACSQHC 2010.

3. Australian Commission on Safety and Quality in Health Care. Implementation Toolkit for Clinical Handover Improvement. Sydney: ACSQHC, 2011.

4. Australian Medical Association. Safe Handover: Safe Patients. Guidance on clinical handover for clinicians and managers 2006 (Accessed 28 June 2012, at http://ama.com.au/node/4064.)


A Guide for Dental Practices - BMJ Quality & Safety€¦ · · 2012-07-27Standard 3: Preventing...

Documents

Transcript of A Guide for Dental Practices - BMJ Quality & Safety€¦ · · 2012-07-27Standard 3: Preventing...