The healthcare provider establishes, maintains and implements reasonable processes to improve the safety and quality of health services provided.
Outcome
- The organisation has a clear, integrated and effective governance framework for safety and quality, including risk management and clinical incident management systems.
- There are measurable reductions in preventable patient harm.
- There are measurable improvements in the quality of health services provided.
Scope
The systems, structures, processes, policies, procedures, roles, attitudes and behaviours concerned with the capacity of the health service to:
(i) manage risks to patient safety and quality of health services, and
(ii) continue to improve the safety and quality of health services provided.
Rationale
In Queensland there is a legislative duty for all healthcare providers to establish, maintain and implement reasonable processes to improve the quality of their health services (as outlined in section 20 of the
Health Quality and Complaints Commission Act 2006).
Every year, thousands of people interact safely with the Queensland healthcare system and receive quality care. However, prominent hospital inquiries [1-3], Health Quality and Complaints Commission (HQCC) complaints and investigations data, and other evidence demonstrate that patients continue to die or be unnecessarily harmed from receiving poor quality healthcare [4-6].
The majority of preventable adverse events that occur in healthcare are based in system errors rather than mistakes made by individuals. Therefore, a whole of system, coordinated, transparent and accountable approach to continuously monitoring risks and improving the safety and quality of care (that is, clear, integrated and effective governance) is the most effective known method to reduce patient harm, improve efficiency, and sustain patient and stakeholder confidence in the quality of health services [7-12].
Criteria
Governance for safety and quality
1. The healthcare provider establishes, implements and maintains a governance framework to facilitate responsibility and accountability for:
(i) managing risks to patient safety and quality of health services, and
(ii) continuing to improve the safety and quality of health services provided.
2. The governance framework:
(i) identifies and coordinates the systems, structures, processes, policies, procedures, roles, attitudes and behaviours required to facilitate accountable, safe, quality healthcare.
(ii) identifies and outlines the clinical services capability of the health service, including escalation, retrieval procedures and referral pathways [13, 14].
(iii) outlines and assigns roles, responsibility and accountability for clinical safety and quality to appropriate organisational structures and individuals at all levels of the organisation.
(iv) is integrated with the core business functions (corporate governance) of the organisation.
(v) is regularly reviewed for effectiveness and improved when required.
Risk management
3. The healthcare provider develops and implements a comprehensive risk management system consistent with published, best practice risk management guidelines and/or methodology [15].
4. The risk management system includes policies and procedures for:
(i) identifying, analysing and assessing risks that impact on clinical services
(ii) maintaining a risk register and/or risk management action plan, which includes initiatives to correct, eliminate or reduce identified safety and quality risks.
Clinical incident management
5. The healthcare provider develops, implements and evaluates a clinical incident management system, including policies and procedures, that:
(i) facilitates the identification, reporting and investigation of near misses, clinical incidents, adverse and/or sentinel events and medico-legal cases, and
(ii) interacts with the risk management system to facilitate the identification and implementation of corrective actions.
6. As part of the clinical incident management system, the healthcare provider develops and implements an open disclosure process consistent with published, best practice/evidence-based guidelines [16].
Compliance with standards
7. The healthcare provider complies with HQCC healthcare standards.
8. The healthcare provider complies with other widely recognised healthcare standards [17] [18].
Improvement
9. The healthcare provider has a system for ongoing data collection and analysis of clinical performance and patient outcomes data (e.g. from clinical pathway variance analysis, clinical performance indicators, clinical audit, craft group reviews, consumer complaints and incident reporting) and uses this information to identify, implement and monitor opportunities for improving the safety and quality of health services provided.
10. Executive management and clinical leaders ensure the recommended actions arising from internal and external monitoring and review processes (e.g. risk assessment, clinical audit, craft group reviews, root cause analysis, coronial investigations, HQCC investigations and recommendations, accreditation and other external reviews) are implemented and evaluated.
11. Executive management and clinical leaders demonstrate commitment and support for the clinical governance framework, risk management system, clinical incident management system, standards compliance and improvements in the safety and quality of health services provided.
12. Executive management and clinical leaders provide information to all relevant stakeholders and forums about the actions being taken and/or recommendations being implemented to address identified risks and areas of concern.
1.Proportion of significant risks which have an active action plan.
2.Proportion of HQCC standards where the provider has a process that aligns with the standard.
3.Proportion of HQCC standards where the provider has analysed data related to the standard.
4.Proportion of HQCC standards where the provider has implemented quality improvement initiatives.
5.Can you demonstrate that your hospital has a clear, integrated and effective governance framework for safety and quality of healthcare (consistent with criteria 1 and 2 of the HQCC Providers' duty to improve health services standard)?
6.Can you demonstrate that your hospital has a comprehensive clinical risk management system (consistent with criteria 3 and 4 of the HQCC Providers' duty to improve health services standard)?
7.Can you demonstrate that your hospital has an effective clinical incident management system including open disclosure (consistent with criteria 5 and 6 of the HQCC Providers’ duty to improve health services standard)?
Effective date
1 July 2010.
Review date
This standard will be assessed for review three years after the effective date or as required in response to identified need.
References
[1] Foster P. Queensland Health Systems Review: Final Report. 2005.
[2] Joseph AP, Hunyor SN. The Royal North Shore Hospital inquiry: an analysis of the recommendations and the implications for quality and safety in Australian public hospitals. Medical Journal of Australia. 2008;188(8):469-72.
[3] Travaglia JF, Lloyd JE, Braithwaite J. Another inquiry into public hospitals? Medical Journal of Australia. 2008;188(8):437-8.
[4] Queensland Government Health Quality and Complaints Commission. Health Quality and Complaints Commission: Annual Report 2008-09. Brisbane: HQCC 2009.
[5] Braithwaite J. We must end the silence surrounding the risks of health care. The Age. 2010 18/01/2010.
[6] Australian Commission on Safety and Quality in Healthcare. Windows into Safety and Quality in Health Care. 2009.
[7] Australian Capital Territory Community and Health Services Complaints Commissioner. Final Report of the Review of Clinical Governance Arrangements at the Canberra Hospital. 2004.
[8] Braithwaite J, Travaglia JF. An overview of clinical governance policies, practices and initiatives. Australian Health Review. 2008 February 2008;32(1):10-122.
[9] Balding C. From quality assurance to clinical governance. Australian Health Review. 2008 2008;32(3):383-91.
[10] Government of Western Australia Department of Health. Western Australian Clinical Governance Guidelines: Information series No 1.2. 2nd ed. Perth: Government of Western Australia 2005.
[11] Victoria Department of Human Services. Victorian clinical governance policy framework : Enhancing clinical care. Melbourne 2008.
[12] Standards Australia. Good governance principles - Corporate governance AS 8000-2003. 2003.
[13] Queensland Health. Clinical Services Capability Framework 2005.
[14] Queensland Health. Clinical Services Capability Framework for Licensed Private Health Facilities Companion Document 2007.
[15] Standards Australia/Standards New Zealand. AS/NZS ISO 31000: Risk Management Principles and Guidelines. 2009.
[16] Australian Commission on Safety and Quality in Healthcare. Open Disclosure Standard: A national standard for open communication in public and private hospitals, following an adverse event in health care. 2008.
[17] Australian Commission on Safety and Quality in Healthcare. Consultation Paper on the Draft National Safety and Quality Healthcare Standards. 2009.
Health Quality and Complaints Commission Healthcare Standards version 2.0 | effective 1 July 2010