Accreditation Readiness – Std of the Fortnight – Clinical Governance

Fact Sheet #6: Clinical Governance (Standard 1)

• What is the intention of Standard 1?

  

  The Clinical Governance Standard aligns with the governance of Best Care and aims to ensure that there are systems in place within Western Health to maintain and improve the reliability, safety and quality of health care.

  Western Health Best Care framework is an approach to clinical governance that focuses on care from the perspective of our patients and absorbs and supports our in-house quality requirements and external frameworks, standards and programs.

• How do you provide Best Care?
  • I communicate with patients and their families and am sensitive to their needs and preferences.
  • I am an active team player and look for ways to do things better.
  • I am competent in what I do and motivated to provide the best care and services possible.
  • I keep patients from harm.

  

   

• How would you access a policy or guideline at Western Health?
  • Live Best Care Site – PROMPT

  

   

• How do you utilise the quality and safety systems at Western Health?
  • Maintain competence for your scope of practice.
  • Refer to Policies & Procedures on PROMPT.
  • Escalate issues and concerns to your line manager.
  • Complete Incident Reports in RiskMan.
  • Participate in Quality Improvement Projects/Activities.
  • Complete Audits.
  • Reviewing KHWD boards.

   

• How do you report and follow-up an incident?
  • Report NUM/NIC of any incidents.
  • Log all incidents or near misses on Riskman.

   

   

   

• How do you activate and respond to an Emergency?

  Dial 2222 or your approved local area number in case of emergency and describe what action should be taken:

  • Red – Fire/smoke
  • Orange – Evacuation
  • Blue – Medical Emergency
  • Purple – Bomb threat
  • Yellow – Internal Emergency
  • Black – Armed Threat
  • Grey – Unarmed threat
  • Brown – External Emergency

   

• What mandatory training is required to be kept up-to-date?

  For all WH staff:

  • Fire and Emergency Procedures
  • Hand Hygiene
  • General Manual Handling
  • Occupational Violence & Aggression

  For specific roles:

  Depending on your role, other mandatory training is required – please refer to Mandatory Training procedure in PROMPT

  

   

• How do the multi-disciplinary team document patient risks?
  • In the electronic medical record, complete Comprehensive Care Risks Assessments and actioning care sets as appropriate.
• What information can i expect to see on the KHWD boards?
  • Patient feedback – compliments & complaints.
  • Performance metrics – audit results, mandatory training, incident trends, key performance indicators.
  • Quality improvement projects.

   

• How do you report a hazard you have identified, such as a spill on the floor, which may cause someone to fall?
  • Notify NUM/NIC of any hazard or risk.
  • Report to appropriate department if needed.
  • Log all hazards or potential risks on Riskman.

  

• How often should you have a performance review?

  Every 12 months.

• Being Accreditation Ready means that …

  

• Being Accreditation Ready means that in your area …

  

• Reflection...
  • What are the key clinical/non clinical risks in your area?.
  • What quality improvement projects have you undertaken in your area in the past 12 months?.
• Are there resources I can access?

  Various FAQs and Resources are available on the Live Best Care site. Click here  or use the QR code below to access the site.

  

   

   

• Survey...

  Have a go at a quick survey on Clinical Governance! Click here or on the QR Code to access the survey.

  

   

   

• Accreditation Readiness Hint- Standard 1:

  The good news is we are already providing Best Care and living up to the requirements of NSQHS Std 1 on Clinical Governance in our everyday work! This year’s Accreditation Survey is simply a chance to show once again how well we maintain and improve the reliability, safety and quality of health care