Service/Unit Staff are familiar with Staff interview Onsite IA+Clinical the process for reporting incidents Expert and for open disclosure Root casue analysis of serious Sample of highest category incidents have had root cause Report review Onsite Clinical incidents or adverse events is analysis undertaken Expert undertaken in the Service/Unit (*record evidence in worksheet) QUALITY IMPROVEMENT Responsibility for All relevant responsbilities for quality e.g. Responsibilities for PD’s of managers Offsite/ onsite IA quality improvement have been allocated in Service/Unit and staff, quality plan oversight and implementation is clearly assigned in and individuals understand and enact Staff interview Audits and Clinical audits the Service/Unit their responsbilities in relation to quality Monitoring and reporting on quality Development of clinical pathways Sentinel event monitoring Complaint investigation and resolution The accountability and Clear accountabilities for the service Evidence of scheduled reports or reporting framework Document review Onsite IA+Clinical reporting mechanisms quality of care are reflected through with specification of reporting frequency, accountability Expert for quality of care in relevant metrics/reports provided and responsibility. Data reported may include: the Service/Unit are in line with a reporting framework Mandatory indicators - Victorian Minimum documented and to the board, relevant committees Dataset and SOP KPI’s followed and management in relation to the non mandatory indicators– ACHS Clinical Service/Unit quality of care? Indicators Clinical audit reports
Service/Unit Staff are familiar with the process for reporting incidents and for open disclosure Staff interview Onsite IA+Clinical Expert Root casue analysis of serious incidents or adverse events is undertaken in the Service/Unit Sample of highest category incidents have had root cause analysis undertaken (*record evidence in worksheet) Report review Onsite Clinical Expert QUALITY IMPROVEMENT Responsibility for quality improvement is clearly assigned in the Service/Unit All relevant responsbilities for quality have been allocated in Service/Unit and individuals understand and enact their responsbilities in relation to quality e.g. Responsibilities for quality plan oversight and implementation Audits and Clinical audits Monitoring and reporting on quality Development of clinical pathways Sentinel event monitoring Complaint investigation and resolution PD’s of managers and staff, Staff interview Offsite/ onsite IA The accountability and reporting mechanisms for quality of care in the Service/Unit are documented and followed Clear accountabilities for the service quality of care are reflected through relevant metrics/reports provided in line with a reporting framework to the board, relevant committees and management in relation to the Service/Unit quality of care? Evidence of scheduled reports or reporting framework with specification of reporting frequency, accountability and responsibility. Data reported may include: Mandatory indicators - Victorian Minimum Dataset and SOP KPI’s non mandatory indicators– ACHS Clinical Indicators Clinical audit reports Document review Onsite IA+Clinical Expert
vmia-generic-internal-clinical-audit-tool-iact-d17-46220.docx