Standard 8 - Requirement (3) (e)
Where clinical care is provided – a clinical governance framework, including but not limited to the following:
i) antimicrobial stewardship
ii) minimising the use of restraint
iii) open disclosure
Intent of this requirement
Clinical governance is the set of relationships and responsibilities between the organisation’s governing body, executive, clinicians, consumers and others to achieve good clinical results. It puts systems in place for delivering safe, quality clinical care and for continuously improving services. Clinical governance usually includes involving consumers, clinicians, clinical review, training, risk management, use of information and workforce management.
This requirement describes the clinical governance and safety and quality systems that are required to maintain and improve the reliability, safety and quality of clinical care, and to improve outcomes for consumers where organisations provide clinical care. The following areas are included:
a. Antimicrobial stewardship
In Australia, the increasing number of antibiotic-resistant infections appearing in the community represents a looming public health issue. This means aged care organisations need to do their part to change those practices that have contributed to the development of resistance and implement new initiatives to reduce inappropriate antibiotic usage and resistance. Effective organisation wide systems are required for preventing, managing and controlling infections and antimicrobial resistance. This contributes to the broader national effort and improves outcomes for consumers.
b. Minimising the use of restraint
Restrictive practice is ‘any practice or intervention that has the effect of restricting the rights or freedom of movement of a person with cognitive impairment or disability, with the primary purpose of protecting the person or others from harm. Organisation wide systems are expected to limit and carefully monitor the use of restrictive practices. Where restraint is clinically necessary to prevent harm, the organisation should have systems to manage how restraints are used. This should be in line with legislation and the organisation’s policies on reporting the use of restraints.
c. Practicing open disclosure
This means organisation wide systems to support communication with consumers about incidents that have caused harm. Open disclosure usually includes an apology and explaining the facts of what happened. It also includes listening to the consumer’s experience of what happened and explaining the steps the organisation has taken to prevent it happening again.
- Do management of the organisation and members of the workforce have particular areas of responsibility for clinical leadership and systems that improve safety and quality?
- What are the systems to ensure that best practice evidence is embedded in the organisation’s clinical care?
- How does the organisation review how effective the clinical governance framework is? Does the organisation take timely actions to tackle any aspects that aren’t working well?
- Does the organisation have processes to support identifying and getting involved early when risks associated with clinical care are identified? Does it have processes for members of the workforce to identify these risks?
- How does the organisation understand and support safety and quality in the clinical services it provides? This includes how it collects and uses data to inform safety and quality.
Examples of actions and evidence
- Consumers say they receive safe, effective, quality clinical care that is right for them.
- Consumers say members of the workforce discuss their clinical care with them, including risks and benefits of any clinical treatment and the appropriate use of antibiotics.
- Consumers say if things have gone wrong, the organisation has apologised and taken steps to make sure the same thing doesn’t happen to them again or to others.
Workforce and others
- The workforce can describe their accountabilities and responsibilities for the effectiveness, safety and quality of clinical services.
- The workforce can describe how they collect data to inform clinical performance indicators, they say the indicators are meaningful and can describe how the lead to improvements in clinical care.
- The workforce say open disclosure is part of the organisation’s practice when a negative event happens. They can also describe the open disclosure process.
- Workforce orientation, training or other records that show the organisation trains the workforce in this requirement. They also show the organisation supports clinical governance leadership roles with ongoing training.
- Evidence of strategies and practices that aim to make sure antimicrobials are prescribed according to best practice guidelines.
- Records that show any use of restraint is always as a last resort, the application of restraint is documented and the safety and well-being of the consumer is being monitored by the workforce.
- Records show that the organisation has a systematic approach to clinical audit and data comparisons that supports improvements in clinical care.
- The organisation has records of governance arrangements for clinical care that is given in non-clinical care settings, or by contracted members of the workforce, or by third parties.