Specific results for criterion corrective actions are required a standard is rated partially attained (PA) or unattained (UA) specific corrective actions are recorded under the relevant criteria for the standard. The following table contains the criterion where corrective actions have been recorded. Criterion can be linked to the relevant standard by looking at the code. For example, a Criterion 1.1.1.1: Service providers demonstrate knowledge and understanding of consumer rights and obligations, and incorporate them as part of their everyday practice relates to Standard 1.1.1: Consumer Rights During Service Delivery in Outcome 1.1: Consumer Rights. If there is a message data to display” instead of a table, then no corrective actions were required as a result of this audit. “no Criterion with desired outcome Attainment Audit Evidence Audit Finding Corrective action Rating required and timeframe for completion (days) Criterion 1.2.3.5 PA Low There is evidence that quality improvement data There was not a specific link All quality was collected on a regular basis. Documentation between all quality improvement data Key components of service delivery included a written report to the GM monthly with improvement data at a is linked to the shall be explicitly linked to the quality detail of key components and outcomes. Staff facility level in a quality quality management system. meetings include health and safety and infection management meeting forum. management control (IC), but did not include complaints, system. clinical incidents, and restraint or survey/feedback findings. The facility and services manager reports that the operations 180 days meetings will recommence in early 2015 to address this. Criterion 1.2.3.6 PA Low There has been a noticed improvement in the Quality improvement data Quality collection and analyses of quality improvement was collected and analysed, improvement data Quality improvement data are data over the past two months. Documentation but had not yet been is collected, collected, analysed, and evaluated was sighted of incident reporting, complaints analysed nor results analysed and and the results communicated to management, infection control and event reported to service providers evaluated. service providers and, where reporting, being collected and analysed. appropriate, consumers.
Specific results for criterion corrective actions are required a standard is rated partially attained (PA) or unattained (UA) specific corrective actions are recorded under the relevant criteria for the standard. The following table contains the criterion where corrective actions have been recorded. Criterion can be linked to the relevant standard by looking at the code. For example, a Criterion 1.1.1.1: Service providers demonstrate knowledge and understanding of consumer rights and obligations, and incorporate them as part of their everyday practice relates to Standard 1.1.1: Consumer Rights During Service Delivery in Outcome 1.1: Consumer Rights. If there is a message “no data to display” instead of a table, then no corrective actions were required as a result of this audit. Criterion with desired outcome Attainment Rating Audit Evidence Audit Finding Corrective action required and timeframe for completion (days) Criterion 1.2.3.5 Key components of service delivery shall be explicitly linked to the quality management system. PA Low There is evidence that quality improvement data was collected on a regular basis. Documentation included a written report to the GM monthly with detail of key components and outcomes. Staff meetings include health and safety and infection control (IC), but did not include complaints, clinical incidents, and restraint or survey/feedback findings. The facility and services manager reports that the operations meetings will recommence in early 2015 to address this. There was not a specific link between all quality improvement data at a facility level in a quality management meeting forum. All quality improvement data is linked to the quality management system. 180 days Criterion 1.2.3.6 Quality improvement data are collected, analysed, and evaluated and the results communicated to service providers and, where appropriate, consumers. PA Low There has been a noticed improvement in the collection and analyses of quality improvement data over the past two months. Documentation was sighted of incident reporting, complaints management, infection control and event reporting, being collected and analysed. Quality improvement data was collected and analysed, but had not yet been analysed nor results reported to service providers Quality improvement data is collected, analysed and evaluated.
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