Beruflich Dokumente
Kultur Dokumente
Heather Wellington
Accrediting Agencies Surveyor Workshop, 12 August, 2012
The context
Clinical governance
• A system through which organisations are
accountable for continuously improving the quality
of their services and safeguarding high standards
of care. This is achieved by creating an
environment in which there is transparent
responsibility and accountability for maintaining
standards and by allowing excellence in clinical
care to flourish
Why have a Standard about governance for
safety and quality?
Evidence base:
• Considerable literature and expert opinion about the
need for a ‘systems approach’ to governance
• The community expects that ‘someone’ is ensuring
appropriate systems are in place and working well
• Evidence of safety and quality performance
challenges in health care
• Multiple case studies of clinical governance failure
• Evidence that capability in good governance of
safety and quality is still developing – reviews have
confirmed variable performance
The Standard
Why?
• Evidence suggests a significant correlation between
the governance system of a health organisation and
the level of performance achieved within that
organisation
Michel S. Putting quality first in the boardroom. The King’s Fund. 2010.
Available at: http://www.kingsfund.org.uk/publications/putting_quality.html
What?
• Establish an organisation-wide management
system for the development, implementation and
regular review of policies, procedures and/or
protocols(1.1.1)
What?
• The executive level of governance monitors reports on safety
and quality indicators and other safety and quality performance
data (1.2.1)
• Action is taken to improve the safety and quality of care (1.2.2)
1. Governance and quality improvement
systems
1.3: Assigning workforce roles, responsibilities and
accountabilities to individuals for:
Why?
• Systems for delegating and exercising authority, accountability
and responsibility are essential elements of good clinical
governance.
• Authority refers to the scope given to staff at each level of the
organisation to carry out their responsibilities, the individual’s
authority to act, the resources available and the boundaries of
their role.
• Accountability requires clear definition of the responsibilities of
individuals, functions and committees for safe, high quality
services.
• Effective governance also requires personal responsibility,
where staff accept personal ownership of their actions and their
role in the safety and quality of services provided by their
organisation
1. Governance and quality improvement
systems
What?
• Effective delegation of safety and quality roles and
responsibilities (1.3.1)
• Support for individuals with delegated roles and
responsibilities to perform, in particular to meet the
requirements of the Standards (1.3.2)
• Ensuring agency or locum workers are aware of their
designated roles and responsibilities (1.3.3)
1. Governance and quality improvement
systems
1.4: Implementing training in the assigned safety and quality
roles and responsibilities
Why?
• Health care workers who are educated and trained to
work together can reduce risks to patients, themselves
and their colleagues and when they manage incidents
proactively and maximise opportunities to learn from
adverse events and near misses. Organisations also have
a responsibility to provide the appropriate systems and
support to enable their workforce to learn and apply the
skills and knowledge required for patient safety.
What?
• Providing the workforce with the skill and information
needed to fulfil their safety and quality roles and
responsibilities (1.4.1)
• Providing annual mandatory training programs to meet the
requirements of the Standards (1.4.2)
• Providing locum and agency workforce with the necessary
information, training and orientation to the workplace to
fulfil their safety and quality roles and responsibilities
(1.4.3)
• Providing competency-based training to the clinical
workforce to improve safety and quality (1.4.4)
1. Governance and quality improvement
systems
1.5: Establishing an organisation-wide risk management
system that incorporates identification, assessment, rating,
controls and monitoring for patient safety and quality
Why?
• Risk management is an essential component of
clinical governance as provision of care carries an
element of risk to patients, providers and the
organisation within which care is delivered
What?
• Establishment and monitoring/maintaining of an
organisation-wide risk register (1.5.1)
• Taking actions to minimise risks to patient safety and
quality of care (1.5.2)
1. Governance and quality improvement
systems
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
Why?
• A planned, systematic approach to defining quality,
monitoring quality, designing and implementing quality
initiatives and evaluating outcomes is necessary when
there are complex, inter-dependent systems
What?
• Establishment and monitoring/maintaining of an
organisation-wide quality management system (1.6.1)
• Taking actions to maximise patient safety and quality of
care (1.6.2)
2. 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 evidenceand implementing
mechanisms to escalate care and call for emergency assistance
where there are concerns that a patient’s condition is deteriorating
Why?
• Research has shown that clinical practice guidelines
can be effective in bringing about change and
improving health outcomes.
What?
• Making agreed and documented clinical guidelines
and/or pathways available to the clinical workforce
(1.7.1)
• Monitoring the use of agreed clinical guidelines by the
clinical workforce (1.7.2)
2. Care provided by the clinical workforce is
guided by current best practice
1.8 Adopting processes to support the early identification, early
intervention and appropriate management of patients at increased
risk of harm
Why?
• Evidence shows that warning signs preceding adverse events
in hospital settings are not always recognised or acted upon
What?
• Establish mechanisms to identify patients at increased risk of
harm (1.8.1)
• Take early action to reduce the risks for at-risk patients (1.8.2)
• Establish systems to escalate the level of care when there is an
unexpected deterioration in health status (1.8.3)
2. Care provided by the clinical workforce is
guided by current best practice
1.9 Using an integrated patient clinical record that identifies all
aspects of the patient’s care
Why?
• The patient clinical record acts as both a tool for
critical communication and a historical record of care,
for quality and medico-legal purposes
What?
• Ensure accurate, integrated and readily accessible
patient clinical records are available to the clinical
workforce at the point of care (1.9.1)
• Ensure the design of the patient clinical record allows
for systematic audit of the contents against the
requirements of the Standards (1.9.2)
3. Managers and the clinical workforce have
the right qualifications, skills and approach
1.10 Implementing a system that determines and regularly reviews
the roles, responsibilities, accountabilities and scope of practice
for the clinical workforce
Why?
• There have been multiple reported occasions when
clinicians have worked outside their or their organisation’s
level of competence, resulting in significant patient harm
• Health ministers have endorsed a national standard for
credentialling and scope of practice for senior medical
practitioners
• Responsibility for ensuring clinicians work within an
appropriate scope of clinical practice rests at various
levels in the system, including with the governing body.
Ultimately, this is an organisational governance
responsibility
3. Managers and the clinical workforce have
the right qualifications, skills and approach
What?
• Ensure a system is in place to define and regularly review the
scope of practice for the clinical workforce (1.10.1)
• Ensure mechanisms are in place to monitor that the clinical
workforce are working within their agreed scope of practice
(1.10.2)
• Ensure organisational clinical service capability, planning and
scope of practice is directly linked to the clinical service roles of
the organisation (1.10.3)
• Ensure the system for defining the scope of practice is used
whenever a new clinical service, procedure or other technology
is introduced (1.10.4)
• Ensure supervision of the clinical workforce is provided
whenever it is necessary for individuals to fulfil their designated
role (1.10.5)
3. Managers and the clinical workforce have
the right qualifications, skills and approach
1.11 Implementing a performance development system for the clinical
workforce that supports performance improvement within their
scope of practice
Why?
• There is strong evidence that implementation of well-
designed performance management systems can enhance
the achievement of individual and organisational goals
What?
• Implement a valid and reliable performance review process
for the clinical workforce(1.11.1)
• Ensure the clinical workforce participates in regular
performance reviews that support individual development
and improvement (1.11.2)
3. Managers and the clinical workforce have
the right qualifications, skills and approach
1.12 Ensuring that systems are in place for ongoing safety and quality
education and training
Why?
• Health care workers who are educated and trained to
work together can reduce risks to patients,
themselves and their colleagues and when they
manage incidents proactively and maximise
opportunities to learn from adverse events and near
misses
• Organisations also have a responsibility to provide
the appropriate systems and support to enable their
workforce to learn and apply the skills and
knowledge required for patient safety
3. Managers and the clinical workforce have
the right qualifications, skills and approach
What?
Why?
• The effectiveness of education and training systems
needs to be monitored
What?
• Analyse feedback from the workforce on their
understanding and use of safety and quality systems
(1.13.1)
• Take action to increase workforce understanding and
use of safety and quality system(1.13.2)
4. Patient safety and quality incidents are recognised, reported
and analysed and information is used to improve safety
Why?
• Research has shown that adverse patient events can be
detected, and their frequency reduced, using multiple
detection methods and clinical improvement strategies as
part of an integrated clinical risk management program
4. Patient safety and quality incidents are recognised, reported
and analysed and information is used to improve safety
What?
• Establish processes are to support the workforce
recognition and reporting of incidents and near misses
(1.14.1)
• Establish systems to analyse and report on incidents
(1.14.2)
• Provide feedback on the analysis of reported incidents
to the workforce (1.14.3)
• Take action to reduce risks to patients identified
through the incident management system (1.14.4)
• Review incidents and analysis of incidents at the
highest level of governance in the organisation (1.14.5)
4. Patient safety and quality incidents are recognised, reported
and analysed and information is used to improve safety
Why?
• Complaints are an important improvement opportunity
• Consumers have a right to be engaged
• Consumers can contribute to finding system solutions
What?
• Processes are in place to support the workforce to recognise and
report complaints (1.15.1)
• Systems are in place to analyse and implement improvements in
response to complaints (1.15.2)
• Feedback is provided to the workforce on the analysis of reported
complaints (1.15.3)
• Patient feedback and complaints are reviewed at the highest level of
governance in the organisation (1.15.4)
4. Patient safety and quality incidents are recognised, reported
and analysed and information is used to improve safety
Why?
• Consumers expect honest disclosure and discussion when things go
wrong
• Open disclosure is an element of an integrated positive safety and
quality culture
• Health ministers have endorsed the national open disclosure standard
What?
• Implement an open disclosure program, consistent with the national
open disclosure standard (1.16.1)
• Train the clinical workforce in open disclosure processes (1.16.2)
5. 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
Why?
• Stating consumer rights, even in a non-enforceable statement,
provides a basis for those rights to be implemented
• There is broad recognition of the need for the health care
system to be ‘consumer focused’ but there is significant
evidence that this is not yet achieved
• A charter of healthcare rights provides a basis for implementing
strategies to support those rights
• Patients and carers can be assisted and encouraged to engage
in healthcare safety and quality if they understand their rights
5. Patient rights are respected and their
engagement in their care is supported
What?
• Adopt a charter of patient rights that is consistent
with the current national charter of healthcare
rights(1.17.1)
• Provide and explain information on patient rights to
patients and carers (1.17.2)
• Establish systems to support patients who are at
risk of not understanding their healthcare rights
(1.17.3)
5. Patient rights are respected and their
engagement in their care is supported
1.18 Implementing processes to enable partnership with patients in
decisions about their care, including informed consent to treatment
Why?
• Patients have a legal right to consent, or refuse consent
• Informed patients can contribute to better decision-making
What?
• Engage patients and carers as partners in the planning for their treatment
(1.18.1)
• Establish mechanisms to monitor and improve documentation of informed
consent (1.18.2)
• Establish mechanisms to align the information provided to patients with
their capacity to understand (1.18.3)
• Support patients and carers to document clear advance care directives
and/or treatment-limiting orders (1.18.4)
5. Patient rights are respected and their
engagement in their care is supported
1.19 Implementing procedures that protect the confidentiality of patient
clinical records without compromising appropriate clinical workforce access
to patient clinical information
Why?
• Patients have a legal right to privacy and confidentiality
• Clinicians need access to relevant information to plan and deliver
quality care
What?
• Ensure patient clinical records are available at the point of care (1.19.1)
• Establish systems to restrict inappropriate access to and
dissemination of patient clinical information (1.19.2)
5. Patient rights are respected and their
engagement in their care is supported
1.20 Implementing well designed, valid and reliable patient experience
feedback mechanisms and using these to evaluate the health service
performance
Why?
• Patient feedback is a rich source of information about safety and
quality of care and improvement opportunities
• Systematic collection provides different data from ad hoc complaints
and compliments
What?
• Use data collected from patient feedback systems to measure and
improve health services in the organisation(1.20.2)
General issues