Standard 1
Governance for Safety and Quality in Health Service Organisations
NSQHS Standards Standard 1 - Governance for Safety and Quality in Health Service Organisations
Advisory
This page contains information about the first edition of the NSQHS standards. This edition has been superseded by the second edition that was endorsed by the Health Ministers in June 2017 and released in November 2017.
This latest edition addresses the gaps that were identified in the first edition, including mental health and cognitive impairment, health literacy, end-of-life care, and Aboriginal and Torres Strait Islander health.
Health service organisations will be assessed to the second edition from January 2019.
To find information and resources for the second edition, visit the Australian Commission on Safety and Quality in Health Care's new NSQHS Standards microsite.
Key messages
- Governance systems aim to ensure the delivery of safe, high quality care and service.
- Governance includes defining staff roles and responsibilities in relation to safety and quality improvement.
- Governance includes partnering with patients and carers and respecting their rights and decisions.
- Service and care must be evaluated and improved as necessary.
Introduction
Good governance is vital to improving safety and quality of health care services. Governance refers to the set of relationships and responsibilities established by a health service between its executive, workforce and stakeholders (including consumers). Governance incorporates the set of processes, customs, policy directives, laws and conventions affecting the way an organisation is directed, administered or controlled. It determines how health services are delivered and has a direct impact on the safety and quality of care.
While most health care in Australia is associated with good clinical outcomes, patients do not always receive all the care that is recommended to them and preventable adverse events continue to occur.
In recent years, Australian health services have increased their awareness of, and investment in, safety and quality. Health services have developed and implemented policy, educational materials and processes for improvement. These changes have improved the safety and quality of health care for patients but more still needs to be done to ensure all patients are protected from harm and receive the highest possible standard of care. Projections for total health care spending indicate that financial pressure on the health care system will continue to increase in the future.
Facts and Figures
It is difficult to determine the costs directly attributed to safety and quality lapses in health care. However, the final report of the National Health and Hospitals Reform Commission suggested that adverse events add a cost of around $2 billion annually to the health budget.
Benefits
Operational benefits include lower costs per case, improved liability claims experiences and increased staff satisfaction and retention rates.
The importance of health services partnering with patients, families, carers and consumers is recognised at a national and international level.
Patients need to be placed at the centre of their own care and the health care system more generally. In Australia, consumer-centred care is one of the three dimensions in the Australian Safety and Quality Framework for Health Care. Partnerships with patients and consumers also form the basis of a range of national and state and territory health policies and programs.
The Australian Charter of Healthcare Rights summarises the basic rights that patients and consumers are entitled to receive when accessing health care services throughout Australia. These rights are Access, Safety, Respect, Communication, Participation, Privacy and Comment.
Information above is taken directly from the Safety and Quality Improvement Guide Standard 1: Governance for Safety and Quality in Health Service Organisations, October 2012 document published in the Australian Commission on Safety and Quality in Health Care website.
Responsibilities under Standard 1 include:
- have the right skills, training, manager and organisational support to provide safe and effective care
- ensure that patients and carers understand their rights and responsibilities
- assist patients and carers to be more actively involved in decision-making about their own health care
- encourage patients and carers to be more actively involved in safety and quality improvement where appropriate
- ensure informed consent is obtained before any treatment occurs
- access and adhere to organisational policies and procedures
- have a current copy of your position description that includes your safety and quality responsibilities
- have an annual performance review that includes goals for professional development and undertake mandatory training specific to your role
- ensure completion of timely, accurate and comprehensive documentation
- participate in quality improvement activities
- assist patients and carers to understand the complaints process where necessary
- report adverse events in your risk or incident management system and implement the open disclosure process as required.
Related videos
eLearning modules
Department of Health Victoria
- Download Complaints management learning module
- Download Governance for safety and quality in health service organisations learning module
- Download Informed consent learning module (Governance for Safety and Quality in Health Service Organisations)
- Download Open disclosure and management of adverse events learning module (Governance for Safety and Quality in Health Service Organisations)
Other eLearning resources
Cairns and Hinterland HHS
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More info Best Practice Guide to Clinical Incident Management
Requires access to Queensland Health intranet (QHEPS)
Darling Downs HHS
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More info Cultural Practice Program
Requires access to Queensland Health intranet (QHEPS)
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More info Design and use of computer workstations
Requires access to Queensland Health intranet (QHEPS)
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More info Driver safety program
Requires access to Queensland Health intranet (QHEPS)
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More info Ethics, Integrity and Accountability
Requires access to Queensland Health intranet (QHEPS)
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More info Hazardous Chemical Safety
Requires access to Queensland Health intranet (QHEPS)
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More info Occupational Violence Prevention
Requires access to Queensland Health intranet (QHEPS)
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More info Prevention and Management of Musculoskeletal Disorders
Requires access to Queensland Health intranet (QHEPS)
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More info Work Health and Safety Orientation
Requires access to Queensland Health intranet (QHEPS)
Queensland Health iLearn
- More info Open Disclosure Clinician
- More info Open Disclosure Consultant
- More info Ethics, Integrity and Accountability
- More info QLD Health Introductory Aboriginal and Torres Strait Islander Cultural Practice Online Program
South Australia Digital media eLearning
Available only to South Australia Health employees
CSDS courses
Further information
Below is a full copy of the Governance for Safety and Quality in Health Service Organisations contained in the National Safety and Quality Health Service Standards. It includes the criteria, items and actions required for health services to meet this Standard and is available on the Commission’s website at www.safetyandquality.gov.au.
- Download Safety and Quality Improvement Guide Standard 1: Governance for Safety and Quality in Health Service Organisations, October 2012
Related links
- Standard 1 presentation from the Commission’s surveyor training workshops, August 2012 (PowerPoint 1.16 MB)
- Australian Charter of Healthcare Rights
- Open Disclosure Standard and support materials relevant for Criterion 1.16
- Review by Peers: A guide to professional, clinical and administrative processes
- Standard for Credentialing and Defining the Scope of Clinical Practice
- Using hospital mortality indicators to improve patient care – A guide for Boards and Chief Executives