Standard 3 - Requirement (3) (e)
Information about the consumer’s condition, needs and preferences is documented and communicated within the organisation, and with others where responsibility for care is shared.
Intent of this requirement
This requirement focuses on the communication processes that organisations are expected to have, so that their workforce has information about delivering safe and effective personal and clinical care and understanding the consumer’s condition, needs, goals and preferences. The information the workforce has access to should help them provide and coordinate care that respects the consumer’s choices. Good information management systems mean the consumer doesn’t have to keep repeating their story.
If organisations transfer important information about a consumer’s care within and between organisations that are responsible for the consumer’s care and services, they can improve outcomes for the consumer. If the consumer’s condition, needs, goals and preferences are known to those involved in the consumer’s care it will:
- improve the safety, effectiveness and consistency of care and reduce the risk of harm
- improve the consumer’s experience of care and deliver care which reflects their choices.
There are many different situations where this requirement applies. Including how an organisation communicates information about a consumer’s condition, needs, goals and preferences:
- if their regular member of the workforce changes
- when members of the workforce change between work shifts
- when a consumer is transferred to hospital for specialist treatment
- when the consumer’s condition, needs, goals or preferences have changed.
How information is communicated can vary, but the method needs to be efficient and fit the situation. Organisations need to collect and share consumer’s personal information in a way that complies with relevant privacy legislation. The organisation is also expected to find ways to include consumers, their representatives and others the consumer wants involved, in communication processes.
- What communication systems does the organisation use to make information easily available to relevant agency staff, substitute general practitioners, paramedics and others? This is vital for anyone who needs to provide personal or clinical care without already knowing the consumer.
- When two or more organisations share care, or where there are integrated services, what arrangements does the organisation have to share relevant information promptly? How do they plan and deliver care? How does handover occur?
- What tools and supports does the organisation provide for the workforce to understand and communicate consumer-centred information? This should provide a complete picture of a consumer’s care needs and preferences.
- How does the organisation support the workforce to see that part of their job is to work together to improve day-to-day care and be clear on instructions on how to best support consumers?
- What systems does the organisation have in place to include consumers, representatives and others they want to include, in communications about their care?
Examples of actions and evidence
- Consumers say they are fully informed and able to consent to information being shared with others about them.
- Consumers say their personal or clinical care is consistent. They have continuity of care and don’t have to repeat their story or their preferences to multiple people.
- Consumers say the organisation coordinates their personal or clinical care well. They benefit from different organisations working together and sharing information about them.
- Consumers say they have quality personal or clinical care because the workforce and relevant others have correct and up-to-date information. This includes replacement workforce members and those from different organisations.
- Consumer representatives say that the organisation has processes to support continuity of care. It also has processes to communicate important information about a consumer’s care and how it delivers it.
Workforce and others
- The workforce can describe how the organisation tells them about a consumer’s condition, needs, goals and preferences as it relates to their own roles, duties and responsibilities. The workforce can also describe how they share this information.
- Relevant members of the workforce show a clear understanding of information sharing and different types of consent.
- Relevant members of the workforce can describe how accurate, up-to-date and relevant information is shared with others as consumers move between care settings, such as between home and hospital.
- The workforce can describe the different situations where they shared care documents or communicated information about the consumer’s condition, needs and preferences and how they complied with relevant privacy obligations.
- Workforce orientation, training or other records that show how the organisation supported the workforce to meet this requirement.
- Evidence of an effective system to manage information that keeps suitable controls over privacy and is in line with relevant legislation.
- Evidence that the organisation is actively communicating with others, internally and externally, to make sure that care and services are delivered without any disruptions.
- Evidence that the organisation monitors how the workforce manages information in relation to information gaps, pending and missing information and that follow up occurs.
- Records reflect how the organisation asks for consent to release or share information using methods suitable for each consumer and in accordance with Privacy legislation.
- Evidence that relevant members of the workforce have access to consumer records.
- Consumer care and service plans show evidence of updates, reviews and communication alerts. This includes information from multiple sources, updates from reassessments and their results.
- Policies and procedures that show how the organisation communicates important information about a consumer when they share the responsibility for their care with other providers, or have transferred a consumer to another organisation.