Governance and quality improvement systems Overview of what is required Suggested approach Examples of evidence 1.1 Implementing a governance system that sets out the policies, procedures and/or protocols for: establishing and maintaining a clinical governance framework identifying safety and quality risks collecting and reviewing performance data implementing prevention strategies based on data analysis analysing reported incidents implementing performance management procedures ensuring compliance with legislative requirements and relevant industry standards communicating with and informing the clinical and non-clinical workforce 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 This action relates to all policies, procedures Identify the system for developing, Policies, procedures and/or protocols and/or protocols for the NSQHS Standards. implementing and reviewing the policies, that address the areas identified in . procedures and/or protocols used by your Register or list of policies, procedures and/or Policies, procedures and/or protocols may be community health service. Responsibilities for protocols that details implementation date, date developed at different levels within your this may sit with the overarching health service policy documents were amended or due for community health service, but need to be organisation. review, a prioritised schedule for future reviews integrated into a single system to ensure their and persons/position or committee responsible. If the health service organisation has a utility. system in place, ensure that local procedures Results of audits of policy documents, Your community health service should ensure or work instructions for your community health consumer clinical records and clinical practice that policies, procedures and/or protocols: service are consistent with the overarching that have resulted in a change to policies, are based on evidence and good practice policies, procedures and/or protocols. procedures or protocols. are regularly reviewed and updated If no system is in place, develop policies, Relevant documentation of committee incorporate any legislative requirements or procedures and/or protocols for your structures and roles with responsibilities for industry standards that must be met. community health service that specify: policy, procedure and protocol development. Your community health service should have: the roles, responsibilities and accountabilities Memos, newsletters or other communication procedures in place that comply with the for each manager material provided to the workforce about new or policies organisation’s revised policies, procedures or protocols. the position(s) with delegations for mechanisms to monitor the use of procedures implementing, amending or endorsing by the workforce policies.
Overview of what is required Suggested approach Examples of evidence 1.1 Implementing a governance system that sets out the policies, procedures and/or protocols for: establishing and maintaining a clinical governance framework identifying safety and quality risks collecting and reviewing performance data implementing prevention strategies based on data analysis analysing reported incidents implementing performance management procedures ensuring compliance with legislative requirements and relevant industry standards communicating with and informing the clinical and non-clinical workforce 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 This action relates to all policies, procedures and/or protocols for the NSQHS Standards. Policies, procedures and/or protocols may be developed at different levels within your community health service, but need to be integrated into a single system to ensure their utility. Your community health service should ensure that policies, procedures and/or protocols: are based on evidence and good practice are regularly reviewed and updated incorporate any legislative requirements or industry standards that must be met. Your community health service should have: procedures in place that comply with the organisation’s policies mechanisms to monitor the use of procedures by the workforce Identify the system for developing, implementing and reviewing the policies, procedures and/or protocols used by your community health service. Responsibilities for this may sit with the overarching health service organisation. If the health service organisation has a system in place, ensure that local procedures or work instructions for your community health service are consistent with the overarching policies, procedures and/or protocols. If no system is in place, develop policies, procedures and/or protocols for your community health service that specify: the roles, responsibilities and accountabilities for each manager the position(s) with delegations for implementing, amending or endorsing policies. Policies, procedures and/or protocols that address the areas identified in . Register or list of policies, procedures and/or protocols that details implementation date, date policy documents were amended or due for review, a prioritised schedule for future reviews and persons/position or committee responsible. Results of audits of policy documents, consumer clinical records and clinical practice that have resulted in a change to policies, procedures or protocols. Relevant documentation of committee structures and roles with responsibilities for policy, procedure and protocol development. Memos, newsletters or other communication material provided to the workforce about new or revised policies, procedures or protocols. Governance and quality improvement systems
Guide-to-the-NSQHS-Standards-for-community-health-services-February-2016.docx