National Safety andQuality Health ServiceStandardsSecond editionPublished by the Australian Commission on Safety and Quality in Health CareLevel 5, 255 Elizabeth Street, Sydney NSW 2000Phone: (02) 9126 3600Fax: (02) 9126 3613Email: [email protected]: www.safetyandquality.gov.auISBN: 978-1-925665-17-8© Australian Commission on Safety and Quality in Health Care 2017All material and work produced by the Australian Commission on Safety and Quality in Health Care is protectedby copyright. The Commission reserves the right to set out the terms and conditions for the use of such material.As far as practicable, material for which the copyright is owned by a third party will be clearly labelled. TheCommission has made all reasonable efforts to ensure that this material has been reproduced in this publicationwith the full consent of the copyright owners.With the exception of any material protected by a trademark, any content provided by third parties, and whereotherwise noted, all material presented in this publication is licensed under a Creative Commons AttributionNonCommercial-NoDerivatives 4.0 International licence.Enquiries about the licence and any use of this publication are welcome and can be sent [email protected] Commissions preference is that you attribute this publication (and any material sourced from it) using thefollowing citation:Australian Commission on Safety and Quality in Health Care. National Safety and Quality Health ServiceStandards. 2nd ed. Sydney: ACSQHC; 2017.DisclaimerThe content of this document is published in good faith by the Australian Commission on Safety and Qualityin Health Care for information purposes. The document is not intended to provide guidance on particularhealthcare choices. You should contact your healthcare provider on particular healthcare choices.This document includes the views or recommendations of its authors and third parties. Publication ofthis document by the Commission does not necessarily reflect the views of the Commission, or indicate acommitment to a particular course of action. The Commission does not accept any legal liability for any injury,loss or damage incurred by the use of, or reliance on, this document.AcknowledgementThe Commission would like to thank all of our partners for their contributions to the development of the NSQHSStandards and their continuing commitment to improving safety and quality across the Australian healthcaresystem.This document was released in November 2017.ContentsIntroduction 1Clinical Governance Standard 3Partnering with Consumers Standard 13Preventing and Controlling Healthcare-Associated Infection Standard 21Medication Safety Standard 29Comprehensive Care Standard 37Communicating for Safety Standard 47Blood Management Standard 55Recognising and Responding to Acute Deterioration Standard 61Glossary 67References 77 NSQHS Standards 1IntroductionThe National Safety and Quality Health Service(NSQHS) Standards were developed by theAustralian Commission on Safety and Quality inHealth Care (the Commission) in collaboration withthe Australian Government, states and territories,the private sector, clinical experts, patients andcarers. The primary aims of the NSQHS Standardsare to protect the public from harm and to improvethe quality of health service provision. They providea quality assurance mechanism that tests whetherrelevant systems are in place to ensure that expectedstandards of safety and quality are met.There are eight NSQHS Standards, which coverhigh-prevalence adverse events, healthcareassociated infections, medication safety,comprehensive care, clinical communication, theprevention and management of pressure injuries,the prevention of falls, and responding to clinicaldeterioration. Importantly, these NSQHS Standardshave provided a nationally consistent statementabout the standard of care consumers can expectfrom their health service organisations.The eight NSQHS Standards are:Clinical Governance, which describes theclinical governance, and safety and qualitysystems that are required to maintain andimprove the reliability, safety and quality ofhealth care, and improve health outcomesfor patients.Partnering with Consumers, whichdescribes the systems and strategies tocreate a person-centred health system byincluding patients in shared decisionmaking, to ensure that patients are partnersin their own care, and that consumers areinvolved in the development and design ofquality health care.Preventing and Controlling HealthcareAssociated Infection, which describes thesystems and strategies to prevent infection,to manage infections effectively when theyoccur, and to limit the development ofantimicrobial resistance through prudentuse of antimicrobials, as part of effectiveantimicrobial stewardship.Medication Safety, which describes thesystems and strategies to ensure thatclinicians safely prescribe, dispense andadminister appropriate medicines toinformed patients, and monitor use of themedicines.Comprehensive Care, which describes theintegrated screening, assessment and riskidentification processes for developing anindividualised care plan, to prevent andminimise the risks of harm in identifiedareas.Communicating for Safety, whichdescribes the systems and strategies foreffective communication between patients,carers and families, multidisciplinary teamsand clinicians, and across the health serviceorganisation.Blood Management, which describes thesystems and strategies for the safe,appropriate, efficient and effective care ofpatients own blood, as well as othersupplies of blood and blood products.Recognising and Responding to AcuteDeterioration, which describes the systemsand processes to respond effectively topatients when their physical, mental orcognitive condition deteriorates.Each standard contains: A description of the standard A statement of intent A list of criteria that describe the key areascovered by the standard Explanatory notes on the content of the standard Item headings for groups of actions in eachcriterion Actions that describe what is required to meetthe standard.2 NSQHS StandardsThe NSQHS Standards require theimplementation of organisation-wide systemsfor clinical governance, partnering withconsumers, healthcare-associated infections,medication safety, comprehensive care, effectivecommunication, blood management, andrecognising and responding to acute deterioration.The Clinical Governance Standard and thePartnering with Consumers Standard set theoverarching system requirements for the effectiveimplementation of the remaining six standards,which consider specific high-risk clinical areasof patient care. The NSQHS Standards describethe patient care journey and are designed tobe implemented in an integrated way. Similarimplementation strategies apply to multiple actionsacross the NSQHS Standards. It is important toidentify the links between actions across each ofthe eight NSQHS Standards. This will help healthservice organisations to ensure that their safetyand quality systems are integrated, and reduce theduplication of effort in implementing the eightstandards separately.Important improvements in the safety and qualityof patient care have been documented followingimplementation of the first edition of the NSQHSStandards from 2011, including: A decline in the Staphylococcus aureusbacteraemia rate per 10,000 patient days undersurveillance between 2010 and 2014, from 1.1 to0.87 cases A drop in the yearly number of methicillinresistant S. aureus bacteraemia cases between2010 and 2014, from 505 to 389 A decline of almost one-half in the national rateof central line-associated bloodstream infectionsbetween 201213 and 201314, from 1.02 to 0.6per 1,000 line days. Greater prioritisation of antimicrobialstewardship activities in health serviceorganisations Better documentation of adverse drug reactionsand medication history Reduction in yearly red blood cell issues by theNational Blood Authority between mid-2010 andmid-2015, from approximately 800,000 units to667,000 units Declining rates of in-hospital cardiac arrest andintensive care unit admissions following cardiacarrests.The Commission has worked closely with partnersto review the NSQHS Standards and develop thesecond edition, embedding person-centred careand addressing the needs of people who may beat greater risk of harm. The NSQHS Standards(second edition) set requirements for providingcomprehensive care for all patients, and includeactions related to health literacy, end-of-life care,care for Aboriginal and Torres Strait Islander people,and care for people with lived experience of mentalillness or cognitive impairment.More informationA range of other supporting resources to assisthealth service organisations to implementthe NSQHS Standards are available on theCommissions website.The Advice Centre provides support for healthservice organisations, surveyors and accreditingagencies on NSQHS Standards implementation.Email: [email protected]: 1800 304 0561Clinical GovernanceStandard4 Clinical Governance Standard NSQHS StandardsClinical Governance StandardLeaders of a health service organisation have a responsibility to thecommunity for continuous improvement of the safety and qualityof their services, and ensuring that they are person centred, safe andeffective.Intention of this standardTo implement a clinical governance framework that ensures that patients andconsumers receive safe and high-quality health care.CriteriaGovernance, leadership and cultureLeaders at all levels in the organisation set up and use clinical governance systems toimprove the safety and quality of health care for patients.Patient safety and quality systemsSafety and quality systems are integrated with governance processes to enableorganisations to actively manage and improve the safety and quality of health carefor patients.Clinical performance and effectivenessThe workforce has the right qualifications, skills and supervision to provide safe, highquality health care to patients.Safe environment for the delivery of careThe environment promotes safe and high-quality health care for patients.NSQHS Standards Clinical Governance Standard 5Explanatory notesThorough research has identified the elements ofan effective clinical governance system and theeffect of good clinical governance on health serviceperformance.1 Research in Australia2 and overseas3notes the importance of leaders in influencing thequality of care by supporting the workforce, shapingculture, setting direction, and monitoring progressin safety and quality performance. Engagingmanagers and clinicians in governance and qualityimprovement activities is important for aligningclinical and managerial priorities.4Clinical governance is the set of relationships andresponsibilities established by a health serviceorganisation between its department of health(for the public sector), governing body, executive,clinicians, patients, consumers and otherstakeholders to ensure good clinical outcomes.5It ensures that the community and health serviceorganisations can be confident that systems are inplace to deliver safe and high-quality health careand continuously improve services.Clinical governance is an integrated componentof corporate governance of health serviceorganisations. It ensures that everyone fromfrontline clinicians to managers and members ofgoverning bodies, such as boards is accountableto patients and the community for assuring thedelivery of health services that are safe, effective,integrated, high quality and continuouslyimproving.Each health service organisation needs to put inplace strategies for clinical governance that considerits local circumstances.This standard includes actions related to the role ofleaders and others in safety and quality, Aboriginaland Torres Strait Islander health and e-health.To support the delivery of safe and high-qualitycare for patients and consumers, the AustralianCommission on Safety and Quality in Health Care(the Commission) has developed the NationalModel Clinical Governance Framework.5 Healthservice organisations should refer to the frameworkfor more details on clinical governance, and theassociated roles and responsibilities.6 Clinical Governance Standard NSQHS StandardsGovernance, leadership and cultureLeaders at all levels in the organisation set up and use clinical governance systems to improve the safety andquality of health care for patients. ItemActionGovernance,leadership andculture1.1 The governing body:a. Provides leadership to develop a culture of safety and qualityimprovement, and satisfies itself that this culture exists within theorganisationb. Provides leadership to ensure partnering with patients, carers andconsumersc. Sets priorities and strategic directions for safe and high-quality clinicalcare, and ensures that these are communicated effectively to theworkforce and the communityd. Endorses the organisations clinical governance frameworke. Ensures that roles and responsibilities are clearly defined for thegoverning body, management, clinicians and the workforcef. Monitors the action taken as a result of analyses of clinical incidentsg. Reviews reports and monitors the organisations progress on safetyand quality performance1.2 The governing body ensures that the organisations safety and qualitypriorities address the specific health needs of Aboriginal and Torres StraitIslander peopleOrganisationalleadership1.3 The health service organisation establishes and maintains a clinicalgovernance framework, and uses the processes within the framework todrive improvements in safety and quality1.4 The health service organisation implements and monitors strategies tomeet the organisations safety and quality priorities for Aboriginal andTorres Strait Islander people1.5 The health service organisation considers the safety and quality of healthcare for patients in its business decision-makingClinical leadership1.6 Clinical leaders support clinicians to:a. Understand and perform their delegated safety and quality roles andresponsibilitiesb. Operate within the clinical governance framework to improve thesafety and quality of health care for patients NSQHS Standards Clinical Governance Standard 7Patient safety and quality systemsSafety and quality systems are integrated with governance processes to enable organisations to activelymanage and improve the safety and quality of health care for patients. ItemActionPolicies andprocedures1.7 The health service organisation uses a risk management approach to:a. Set out, review, and maintain the currency and effectiveness of,policies, procedures and protocolsb. Monitor and take action to improve adherence to policies, proceduresand protocolsc. Review compliance with legislation, regulation and jurisdictionalrequirementsMeasurementand qualityimprovement1.8 The health service organisation uses organisation-wide qualityimprovement systems that:a. Identify safety and quality measures, and monitor and reportperformance and outcomesb. Identify areas for improvement in safety and qualityc. Implement and monitor safety and quality improvement strategiesd. Involve consumers and the workforce in the review of safety andquality performance and systems1.9 The health service organisation ensures that timely reports on safety andquality systems and performance are provided to:a. The governing bodyb. The workforcec. Consumers and the local communityd. Other relevant health service organisationsRisk management1.10 The health service organisation:a. Identifies and documents organisational risksb. Uses clinical and other data collections to support risk assessmentsc. Acts to reduce risksd. Regularly reviews and acts to improve the effectiveness of the riskmanagement systeme. Reports on risks to the workforce and consumersf. Plans for, and manages, internal and external emergencies anddisasters 8 Clinical Governance Standard NSQHS Standards ItemActionIncidentmanagementsystems and opendisclosure1.11 The health service organisation has organisation-wide incidentmanagement and investigation systems, and:a. Supports the workforce to recognise and report incidentsb. Supports patients, carers and families to communicate concerns orincidentsc. Involves the workforce and consumers in the review of incidentsd. Provid
es timely feedback on the analysis of incidents to the governingbody, the workforce and consumerse. Uses the information from the analysis of incidents to improve safetyand qualityf. Incorporates risks identified in the analysis of incidents into the riskmanagement systemg. Regularly reviews and acts to improve the effectiveness of the incidentmanagement and investigation systems1.12 The health service organisation:a. Uses an open disclosure program that is consistent with the AustralianOpen Disclosure Framework6b. Monitors and acts to improve the effectiveness of open disclosureprocessesFeedback andcomplaintsmanagement1.13 The health service organisation:a. Has processes to seek regular feedback from patients, carers andfamilies about their experiences and outcomes of careb. Has processes to regularly seek feedback from the workforce on theirunderstanding and use of the safety and quality systemsc. Uses this information to improve safety and quality systems1.14 The health service organisation has an organisation-wide complaintsmanagement system, and:a. Encourages and supports patients, carers and families, and theworkforce to report complaintsb. Involves the workforce and consumers in the review of complaintsc. Resolves complaints in a timely wayd. Provides timely feedback to the governing body, the workforce andconsumers on the analysis of complaints and actions takene. Uses information from the analysis of complaints to informimprovements in safety and quality systemsf. Records the risks identified from the analysis of complaints in the riskmanagement systemg. Regularly reviews and acts to improve the effectiveness of thecomplaints management system NSQHS Standards Clinical Governance Standard 9 ItemActionDiversity andhigh-risk groups1.15 The health service organisation:a. Identifies the diversity of the consumers using its servicesb. Identifies groups of patients using its services who are at higher risk ofharmc. Incorporates information on the diversity of its consumers and higherrisk groups into the planning and delivery of careHealthcarerecords1.16 The health service organisation has healthcare record systems that:a. Make the healthcare record available to clinicians at the point of careb. Support the workforce to maintain accurate and complete healthcarerecordsc. Comply with security and privacy regulationsd. Support systematic audit of clinical informatione. Integrate multiple information systems, where they are used1.17 The health service organisation works towards implementing systems thatcan provide clinical information into the My Health Record system that:a. Are designed to optimise the safety and quality of health care forpatientsb. Use national patient and provider identifiersc. Use standard national terminologies1.18 The health service organisation providing clinical information into the MyHealth Record system has processes that:a. Describe access to the system by the workforce, to comply withlegislative requirementsb. Maintain the accuracy and completeness of the clinical informationthe organisation uploads into the system 10 Clinical Governance Standard NSQHS StandardsClinical performance and effectivenessThe workforce has the right qualifications, skills and supervision to provide safe, high-quality health careto patients. ItemActionSafety and qualitytraining1.19 The health service organisation provides orientation to the organisationthat describes roles and responsibilities for safety and quality for:a. Members of the governing bodyb. Clinicians, and any other employed, contracted, locum, agency,student or volunteer members of the organisation1.20 The health service organisation uses its training systems to:a. Assess the competency and training needs of its workforceb. Implement a mandatory training program to meet its requirementsarising from these standardsc. Provide access to training to meet its safety and quality training needsd. Monitor the workforces participation in training1.21 The health service organisation has strategies to improve the culturalawareness and cultural competency of the workforce to meet the needsof its Aboriginal and Torres Strait Islander patientsPerformancemanagement1.22 The health service organisation has valid and reliable performance reviewprocesses that:a. Require members of the workforce to regularly take part in a review oftheir performanceb. Identify needs for training and development in safety and qualityc. Incorporate information on training requirements into theorganisations training systemCredentialing andscope of clinicalpractice1.23 The health service organisation has processes to:a. Define the scope of clinical practice for clinicians, considering theclinical service capacity of the organisation and clinical services planb. Monitor clinicians practices to ensure that they are operating withintheir designated scope of clinical practicec. Review the scope of clinical practice of clinicians periodicallyand whenever a new clinical service, procedure or technology isintroduced or substantially altered1.24 The health service organisation:a. Conducts processes to ensure that clinicians are credentialed, whererelevantb. Monitors and improves the effectiveness of the credentialing process NSQHS Standards Clinical Governance Standard 11 ItemActionSafety andquality roles andresponsibilities1.25 The health service organisation has processes to:a. Support the workforce to understand and perform their roles andresponsibilities for safety and qualityb. Assign safety and quality roles and responsibilities to the workforce,including locums and agency staff1.26 The health service organisation provides supervision for clinicians toensure that they can safely fulfil their designated roles, including access toafter-hours advice, where appropriateEvidence-basedcare1.27 The health service organisation has processes that:a. Provide clinicians with ready access to best-practice guidelines,integrated care pathways, clinical pathways and decision support toolsrelevant to their clinical practiceb. Support clinicians to use the best available evidence, including relevantclinical care standards developed by the Australian Commission onSafety and Quality in Health CareVariation inclinical practiceand healthoutcomes1.28 The health service organisation has systems to:a. Monitor variation in practice against expected health outcomesb. Provide feedback to clinicians on variation in practice and healthoutcomesc. Review performance against external measuresd. Support clinicians to take part in clinical review of their practicee. Use information on unwarranted clinical variation to informimprovements in safety and quality systemsf. Record the risks identified from unwarranted clinical variation in therisk management system 12 Clinical Governance Standard NSQHS StandardsSafe environment for the delivery of careThe environment promotes safe and high-quality health care for patients. ItemActionSafe environment1.29 The health service organisation maximises safety and quality of care:a. Through the design of the environmentb. By maintaining buildings, plant, equipment, utilities, devices and otherinfrastructure that are fit for purpose1.30 The health service organisation:a. Identifies service areas that have a high risk of unpredictablebehaviours and develops strategies to minimise the risks of harm forpatients, carers, families, consumers and the workforceb. Provides access to a calm and quiet environment when it is clinicallyrequired1.31 The health service organisation facilitates access to services and facilitiesby using signage and directions that are clear and fit for purpose1.32 The health service organisation admitting patients overnight has processesthat allow flexible visiting arrangements to meet patients needs, when it issafe to do so1.33 The health service organisation demonstrates a welcoming environmentthat recognises the importance of the cultural beliefs and practices ofAboriginal and Torres Strait Islander people 2Partnering withConsumers Standard14 Partnering with Consumers Standard NSQHS StandardsPartnering with ConsumersStandardLeaders of a health service organisation develop, implement andmaintain systems to partner with consumers. These partnershipsrelate to the planning, design, delivery, measurement and evaluation ofcare. The workforce uses these systems to partner with consumers.Intention of this standardTo create an organisation in which there are mutually valuable outcomes by having: Consumers as partners in planning, design, delivery, measurement and evaluation ofsystems and services Patients as partners in their own care, to the extent that they choose.CriteriaClinical governance and quality improvement systems tosupport partnering with consumersSystems are designed and used to support patients, carers, families and consumers to bepartners in healthcare planning, design, measurement and evaluation.Partnering with patients in their own careSystems that are based on partnering with patients in their own care are used to supportthe delivery of care. Patients are partners in their own care to the extent that they choose.Health literacyHealth service organisations communicate with patients in a way that supports effectivepartnerships.Partnering with consumers in organisational design andgovernanceConsumers are partners in the design and governance of the organisation.NSQHS Standards Partnering with Consumers Standard 15Explanatory notesEffective partnerships exist when people are treatedwith dignity and respect, information is sharedwith them, and participation and collaboration inhealthcare processes are encouraged and supportedto the extent that people choose.7Different types of partnerships with patients andconsumers exist within the healthcare system.These partnerships are not mutually exclusive,and are needed at all levels to ensure that a healthservice organisation achieves the best possibleoutcome for all parties.8 Partnerships withpatients and consumers comprise many different,interwoven practices that reflect the three key levelsat which partnerships are needed9:1. At the level of the individualPartnerships relate to the interaction betweenclinicians and patients when care is provided.At this level, a partnership involves providingcare that is respectful; sharing information inan ongoing way; working with patients, carersand families to make decisions and plan care;and supporting and encouraging patients intheir own care.2. At the level of a service, department or programof carePartnerships relate to the organisation anddelivery of care within specific areas. At thislevel, a partnership involves the participationof patients, carers, families and consumers inthe overall design of the service, departmentor program. This could be as full members ofquality improvement and redesign teams, andparticipating in planning, implementing andevaluating change.3. At the level of the health servicePartnerships relate to the involvement ofconsumers in overall governance, policy andplanning. This level overlaps with the previouslevel, since a health service is made up of variousservices, departments and programs. At thislevel, partnerships relate to the involvement ofconsumers and consumer representatives asfull members of key organisational governancecommittees in areas such as patient safety,facility design, quality improvement, patientor family education, ethics and research. Thislevel can also involve partnerships with localcommunity organisations and members of localcommunities.Delivering care that is based on partnershipsprovides many benefits for patients, consumers,clinicians, health service organisations and thehealth system. Effective partnerships, a positiveexperience for patients, and high-quality health careand improved safety are linked.9-11 The involvementof patients and consumers in planning, delivery,monitoring and evaluation can also have a positiveeffect on service planning and development,information development and dissemination, andthe attitudes of healthcare providers.9,12,13 Deliveringhealth care that is based on partnerships can resultin reduced hospital costs, lower cost per case andreduced length of stay.14,1516 Partnering with Consumers Standard NSQHS StandardsClinical governance and quality improvement systems tosupport partnering with consumersSystems are designed and used to support patients, carers, families and consumers to be partners inhealthcare planning, design, measurement and evaluation. ItemActionIntegrating clinicalgovernance2.1 Clinicians use the safety and quality systems from the Clinical GovernanceStandard when:a. Implementing policies and procedures for partnering with consumersb. Managing risks associated with partnering with consumersc. Identifying training requirements for partnering with consumersApplying qualityimprovementsystems2.2 The health service organisation applies the quality improvement systemfrom the Clinical Governance Standard when:a. Monitoring processes for partnering with consumersb. Implementing strategies to improve processes for partnering withconsumersc. Reporting on partnering with consumers NSQHS Standards Partnering with Consumers Standard 17Partnering with patients in their own careSystems that are based on partnering with patients in their own care are used to support the delivery of care.Patients are partners in their own care to the extent that they choose. ItemActionHealthcare rightsand informedconsent2.3 The health service organisation uses a charter of rights that is:a. Consistent with the Australian Charter of Healthcare Rights16b. Easily accessible for patients, carers, families and consumers2.4 The health service organisation ensures that its informed consentprocesses comply with legislation and best practice2.5 The health service organisation has processes to identify:a. The capacity of a patient to make decisions about their own careb. A substitute decision-maker if a patient does not have the capacity tomake decisions for themselvesSharing decisionsand planning care2.6 The health service organisation has processes for clinicians to partner withpatients and/or their substitute decision-maker to plan, communicate, setgoals, and make decisions about their current and future care2.7 The health service organisation supports the workforce to formpartnerships with patients and carers so that patients can be activelyinvolved in their own care 18 Partnering with Consumers Standard NSQHS StandardsHealth literacyHealth service organisations communicate with consumers in a way that supports effective partnerships. ItemActionCommunicationthat supportseffectivepartnerships2.8 The health service organisation uses communication mechanisms that aretailored to the diversity of the consumers who use its services and, whererelevant, the diversity of the local community2.9 Where information for patients, carers, families and consumers abouthealth and health services is developed internally, the organisationinvolves consumers in its development and review2.10 The health service organisation supports clinicians to communicate withpatients, carers, families and consumers about health and health care sothat:a. Information is provided in a way that meets the needs of patients,carers, families and consumersb. Information provided is easy to understand and usec. The clinical needs of patients are addressed while they are in thehealth service organisationd. Information needs for ongoing care are provided on discharge NSQHS Standards Partnering with Consumers Standard 19Partnering with consumers in organisational designand governanceConsumers are partners in the design and governance of the organisation. ItemActionPartnershipsin healthcaregovernanceplanning, design,measurementand evaluation2.11 The health service organisation:a. Involves consumers in partnerships in the governance of, and todesign, measure and evaluate, health careb. Has processes so that the consumers involved in these partnershipsreflect the diversity of consumers who use the service or, whererelevant, the diversity of the local community2.12 The health service organisation provides orientation, support andeducation to consumers who are partnering in the governance, design,measurement and evaluation of the organisation2.13 The health service