Governance and systems for the prevention and management of pressure injuries Overview of what is required Suggested approach Examples of evidence Audit consumer clinical records for: use of pressure injury risk screening and assessment tools completed pressure injury treatment and management plans. Provide reports on workforce compliance with the pressure injury prevention and management system to the responsible individual, relevant committee and/or the governing body. 8.2 Using a risk assessment framework and reporting systems to identify, investigate and take action to reduce the frequency and severity of pressure injuries 8.2.1 An organisation-wide system for reporting pressure injuries is in use 8.2.2 Administrative and clinical data are used to regularly monitor and investigate the frequency and severity of pressure injuries 8.2.3 Information on pressure injuries is regularly reported to the highest level of governance in the health service organisation 8.2.4 Action is taken to reduce the frequency and severity of pressure injuries Many of the actions in Standard 8 are based on a Ensure that pressure injuries are included in the Policies, procedures and/or protocols that incident reporting system required under . outline processes for reporting the incidence of quality improvement cycle where: pressure injuries. policies, procedures and/or protocols for Review the information on pressure injuries pressure injury prevention and management are reported through the incident reporting system Standardised forms or templates for pressure developed (either locally or centrally) to ensure sufficient data is collected to identify injury reporting. the factors that contributed to the development the pressure injury prevention and management Reports on routine performance measures for of pressure injuries. systems are implemented locally pressure injuries, including: Review reports on pressure injuries from the frequency and severity compliance with, and performance of the incident reporting system and results of pressure injury prevention and management usage rates of specified products or investigations and include in the organisation- systems is monitored (centrally or locally) equipment. wide risk register (see ). local action is taken to improve performance. Reports on the prevalence and incidence of Ensure the workforce are trained in identifying Actions 8.2.2 and 8.2.3 relate to the monitoring pressure injuries provided to the individual or and reporting pressure injuries using the committee responsible for the pressure injury stage of the quality improvement cycle. They incident reporting system. organisation’s prevention and management system, and/or the require the following activities take place: governing body.
Governance and systems for the prevention and management of pressure injuries Overview of what is required Suggested approach Examples of evidence Audit consumer clinical records for: use of pressure injury risk screening and assessment tools completed pressure injury treatment and management plans. Provide reports on workforce compliance with the pressure injury prevention and management system to the responsible individual, relevant committee and/or the governing body. 8.2 Using a risk assessment framework and reporting systems to identify, investigate and take action to reduce the frequency and severity of pressure injuries 8.2.1 An organisation-wide system for reporting pressure injuries is in use 8.2.2 Administrative and clinical data are used to regularly monitor and investigate the frequency and severity of pressure injuries 8.2.3 Information on pressure injuries is regularly reported to the highest level of governance in the health service organisation 8.2.4 Action is taken to reduce the frequency and severity of pressure injuries Many of the actions in Standard 8 are based on a quality improvement cycle where: policies, procedures and/or protocols for pressure injury prevention and management are developed (either locally or centrally) the pressure injury prevention and management systems are implemented locally compliance with, and performance of the pressure injury prevention and management systems is monitored (centrally or locally) local action is taken to improve performance. Actions 8.2.2 and 8.2.3 relate to the monitoring stage of the quality improvement cycle. They require the following activities take place: Ensure that pressure injuries are included in the incident reporting system required under . Review the information on pressure injuries reported through the incident reporting system to ensure sufficient data is collected to identify the factors that contributed to the development of pressure injuries. Review reports on pressure injuries from the incident reporting system and results of investigations and include in the organisation- wide risk register (see ). Ensure the workforce are trained in identifying and reporting pressure injuries using the organisation’s incident reporting system. Policies, procedures and/or protocols that outline processes for reporting the incidence of pressure injuries. Standardised forms or templates for pressure injury reporting. Reports on routine performance measures for pressure injuries, including: frequency and severity usage rates of specified products or equipment. Reports on the prevalence and incidence of pressure injuries provided to the individual or committee responsible for the pressure injury prevention and management system, and/or the governing body.
Guide-to-the-NSQHS-Standards-for-community-health-services-February-2016.docx