Outcome 5.1.1

• The decisions a governing body make are informed by high-quality and accurate data and reporting from provider management. This includes the decisions they make about:
  • priorities for care
  • areas that can be improved
  • the strategic direction of the organisation
  • resources.

Put in place systems that drive safety and quality improvement.

The provider has systems to monitor and evaluate the clinical care the service provides. This includes systems that use the results from monitoring and evaluation activities to improve funded aged care services.

Put in place processes that make sure the governing body has the information it needs to set priorities, strategic directions and monitor clinical outcomes and processes.

• Put in place a schedule for reporting to the governing body on the quality of the care you’re providing (Outcome 2.3).
• Use data you collect on how the service is performing to report to the governing body. This data should include:
  • feedback from older people receiving care, their supporters, families, carers, workers and other stakeholders, including information from complaints and other types of feedback
  • clinical incidents and other clinical measures or outcomes
  • clinical trends and reporting from other similar services
  • how effective the clinical governance system is in supporting quality care and managing clinical risk
  • data collected for mandatory Quality Indicators (QI)
  • data from routine data collection, including when someone starts receiving care from your service
  • risks and incidents including serious, non-reportable and near misses, as well as how they were managed and resolved
  • hospital transfers and the reasons for transfer.
• Make sure reports for the governing body are clear and use accurate data and quality analysis.
• Make sure you have involved workers, registered health practitioners, allied health professionals and older people receiving care in developing the goals for the service. You also need to share these goals with them.

Outcome 5.1.2: Put in place processes and systems in the clinical governance framework.

A clinical governance framework describes the systems an organisation uses to support workers, registered health practitioners, allied health professionals and committees to understand and perform their roles. It also explains their responsibilities and accountabilities for providing person-centred, safe, coordinated and effective care.

• Put in place the endorsed clinical governance framework by:
  • communicating a statement from the governing body about the organisation’s culture, priorities and commitment to providing quality clinical care services to all older people, workers, registered health practitioners and allied health professionals
  • outlining the roles, responsibilities and organisational structure for safely delivering quality clinical care services in the provider’s system
  • using measures of success in clinical governance and safe and quality clinical care services and reporting on these measures
  • putting in place processes for reviewing the clinical governance framework
  • making sure plans, policies and procedures are accessible and used by workers, registered health practitioners and allied health professionals. This includes documents and systems that support the clinical governance framework and achieving safe, quality clinical care services.
  • putting in place processes for workers to help them monitor, evaluate and improve clinical care services. This can include using risk management systems
  • clearly describing roles and responsibilities for clinical governance and safe, quality clinical care services in position descriptions. This makes sure that everyone working in the service understands, including contracted registered health practitioners and allied health professionals.
• Consider the resources you need to provide care based on contemporary, evidence-based practice, including training and development for workers.
• Make sure updates or changes to practice and assessment tools are identified and assessed against current legislation, guidelines and evidence.

Monitor, review and improve clinical care services.

• The decisions a governing body makes are informed by high-quality and accurate data and reporting from provider management. This includes the decisions they make about:
  • priorities for care
  • areas that can be improved
  • the strategic direction of the organisation
  • resources.
• Use internal and external data you’ve collected about the service, to report to the governing body. This includes data on:
  • how effective clinical processes are in supporting quality clinical care services
  • care outcomes and performance
  • feedback from older people, others involved in their care and workers, including complaints
  • clinical incidents and issues and other clinical indicators
  • the diversity or people who use their service including things like cultural background or disability (Outcome 1.1).
• Present data about the service in a way that is clear and useful to the governing body, managers, workers and older people.
• Consider how you use the clinical governance framework in practice and how you review it to make sure you’re providing quality care that is person-centred, safe, coordinated and effective.
• Use information and reporting from the monitoring you do (explained above) to review and improve clinical care services.
• Consider how you can measure success. Measures could include:
  • comparing complaints data to show how you’ve improved
  • positive feedback from older people
  • evidence workers know your key policies and procedures for safe, quality clinical care services and are seen following them
  • feedback from workers show they’re satisfied in their job
  • positive feedback from visitors to the service
  • improvement in data reported through the National Mandatory Aged Care Quality Indicator program.

Outcome 5.1.3

Put in place systems for employing, contracting and managing clinical staff.

• Make sure these systems follow the processes outlined in Outcome 2.9.
• Verify and record credentials, qualifications, training and registrations.
• Make sure management and workers understand the scope of practice for clinical care staff and contractors.
• Put in place processes to make sure that contracted and visiting registered health practitioners and allied health professionals have appropriate qualifications and experience to provide clinical care services.

Put in place processes for managing clinical staff.

• Make sure position descriptions and recruitment processes clearly state the clinical skills, experience, knowledge and qualifications each role needs.
• Make sure there are processes for:
  • describing and monitoring the scope of clinical practice
  • providing clinical education and training
  • monitoring and managing performance
  • managing registered health practitioner and allied health professional registration where required
  • ensuring workers, registered health practitioners and allied health professionals are aware and using the provider’s safety and quality systems and processes
  • delegating work to support quality care, within workers’ scope of practice.
• Clearly describe roles and responsibilities for clinical governance and safe, quality clinical care services and make sure everyone working in the service understands them.
• Make sure that roles and responsibilities for clinical governance and safe, quality clinical care services are:
  • included in position descriptions
  • the terms of reference for committees
  • described in policy and process documents.

Monitor, review and improve clinical care services.

• Regularly review the organisational structure, position descriptions and contracts to make sure that roles and responsibilities for safe, quality clinical care services are clearly explained at all levels of the organisation.
• Make sure a committee or specific person has the delegated responsibility for overseeing registered health practitioner and allied health professional registration and scope of practice.
• Ask older people for feedback on the care they receive from workers.
• Make sure there are processes to address concerns workers raise about what is expected in their role.
• The provider should ensure sufficient and appropriately qualified staff are available to provide the right care. The service culture should support clinical staff to report if they are not able to meet care needs safely. Clinical staff must always work within their professional scope of practice.
• Review processes for monitoring, training and verifying competency and ensuring it aligns with evidence base practice (Outcome 2.9).

Outcome 5.1.4

Coordinated care makes sures older people have access to the clinical care services that are right for them at the right time and in the right place.

Put in place processes for agreement between health professionals and the provider.

• The provider is responsible for facilitating access to care for older people when the provider can’t meet their clinical care needs.
• These responsibilities could include:
  • working with visiting registered health practitioners and allied health professionals or practitioners to develop clear policies for procedures and practices for clinical care services
  • preparing private spaces for visits if the older person prefers
  • working with the older person to get ready for appointments and understand what has been recommended for their care and their care and services plans
  • supporting older people to access virtual care such as telehealth
  • providing registered health practitioners and allied health professionals access to clinical information systems to make sure clinical information (like assessments, medicines lists, charts and notes) are:
    • available
    • reviewed and updated
    • securely stored in the provider’s system
  • making sure workers make any needed changes after registered health practitioners and allied health professional reviews, including to medicines
  • making sure the registered health practitioner or allied health professional can access the older person’s home (if this is the provider’s responsibility) or the residential aged care home at the time of their appointment
  • making sure the clinical workers and external registered health practitioners and allied health professionals can access information about the services and level of care that the provider provides and how to refer to specialists when needed.
• Workers need to be informed and are responsible for keeping informed about any changes to an older person’s care needs after treatment or assessment by health professionals, as appropriate, and with consent of the older person or their supporter
• An agreement between health professionals and a provider could include:
  • what the older person expects and what their goals of care are
  • a list of responsibilities for clinical care services
  • what behaviours and responsibilities are expected of both groups when providing clinical care
  • the processes for providing care that is included in the provider’s clinical governance framework or the processes the provider and the registered health practitioner and allied health professional have agreed to
  • protocols for how clinical information is used including access, consent, sharing and editing
  • a timeframe to review the agreement
  • Processes for updating care and services plans and reporting feedback and incidents.

Monitor, respond and improve clinical care services.

• Ask for feedback from the older person to check that they’re satisfied with their care. Use this to improve care.
• Provide care in line with the agreed processes.
• Review agreements regularly between registered health practitioners and allied health professionals and providers to make sure they’re fit for purpose and support them to provide high-quality clinical care services.
• Review treatment and care plans regularly to make sure they are in line with contemporary, evidence-based practice.

Outcome 5.1.5

These key tasks can help all services work towards an integrated clinical information system. Consider how these can work in your service.

Use processes in Outcome 2.7 to make sure information is secure and accurate and you use it with consent. ‘Working towards’, means if you don’t yet have a clinical information system, the provider has:

• looked at available systems
• considered what they need the system to do
• developed a detailed plan to put in place a suitable system.

An effective clinical information system can support an older person’s clinical safety. It can improve communication and continuity and coordination of care between settings, registered health practitioners, allied health professionals and providers.

Using standard national terminology means that information included in an organisation’s clinical information system are interoperable with other clinical information systems. For example, the information can work with primary health provider systems and can be used for de-identified data analysis.

It also means that clinical information in an organisation’s system can be understood and used by other by registered health practitioners and allied health professionals accessing this information. Using health identifiers makes sure the right information is connected with the correct older person. It also identifies the health professional or organisation that documented or reviewed the information in the system. Not all older people have, or have access to, My Health Record. Find out if older people have My Health Record and document this information into your systems.

Put in place a system to safely use clinical information.

• Include clinical information in care and service plans and use it to plan for care and when a person transitions between care settings and also for delivery of care and support of the older person not just planning.
• Consider how outcomes of assessment from more than one registered health practitioner and allied health professional can be included in the providers clinical information system to help plan care.
• Consider how you’ve structured and organised the information you collected. Consider how you can use it securely, with the older person’s consent and in line with legislation.
• Manage clinical information using a digital clinical information system that uses conformant software and meets digital health standards.
• Consider how you can add data into systems once and use it multiple times for different purposes. For example, work towards systems that are integrated. This:
  • reduces mistakes
  • makes it easier for registered health practitioners and allied health professionals to know where to find the most up-to-date information
  • makes sure data can be used for analysis and reporting.
• Providers should consider what data they collect and why they collect it to make sure they’re collecting data for the appropriate reasons.

Put in place processes to manage clinical information.

• To safely manage clinical information, providers put in place processes for:
  • transferring information from existing systems into new systems. This helps mitigate the risk of incomplete, missing, unavailable or incorrect information in new systems.
  • medication management. The guidance for Outcome 5.3 has more information on documenting and managing medicines.
  • external registered health practitioners and allied health professionals to access the clinical information system when needed and with consent. This allows them to document outcomes of assessment and other relevant information. Also, consider how health professionals can access your clinical information system when offsite or during telehealth or virtual appointments.
  • health professionals such as registered nurses, entering clinical information in the clinical information system and using health identifiers
  • workers to access the information they need for their role with the consent of the older person or their supporter
  • registered health practitioners and allied health professionals to have access to clinical information in line with the older person’s wishes and relevant legislation
  • older people to access and review their care and services plans, if they ask to (Outcome 1.3). This should include considering displaying the plans onscreen or printing them.
  • using the healthcare provider directory when sending secure messages, referrals, discharge summaries and test results.
• Regularly review advance care plans in the provider’s clinical information system with the older person if that is their preference.
• Consider how you can support the older person to access and understand advance care planning documents.
• The provider has processes and the responsibility to:
  • ask for consent and record the outcome for sharing and accessing clinical information
  • assign and communicate roles and responsibilities for documenting and using clinical information.
• Eligible workers have health professional identifiers and use these and the older person’s individual health identifier when accessing or adding information in an older person’s My Health Record or other health record systems. Using healthcare identifiers supports interoperability (exchange of information) with nationally agreed health records and other clinical information system, such as primary health provider systems.
• Develop and put in place a security and access policy to make sure workers keep older people’s clinical information safe.

Monitor, review and improve processes for clinical information accuracy and use.

• Assess your software systems to understand how you manage and share clinical information currently.
• Identify gaps and areas where you can improve. For example, duplicating the same or similar information or manual entries that don’t use standard terminology or following the provider’s processes for recording clinical information.
• If you don’t have a system, you can use the Australian Digital Health Agency’s register of conformity to find suitable systems that meet the service’s needs.
• Use the resources on the Digital Health Agency’s website to make sure relevant clinical information is integrated with other systems using suitable software. If the provider doesn’t have a clinical information system, they need to develop a plan to find a suitable software system.
• Review processes and access requirements when you identify issues with the accuracy or security of information.
• Make sure workers, registered health practitioners and allied health professionals understand procedures for managing offline clinical information.