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Published by the Australian Commission on Safety and Quality in Health Care in May 2021, the National Safety and Quality in Health Service (NSQHS) Standards, Second Edition, is a document made to support health services to prevent harm and improve the quality of health service provision.

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Standard 1. Governance, leadership and culture.  

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Standard 1. Governance, leadership and culture.  

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There are several criteria for the governing body in healthcare environments.

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The overarching governing body of a healthcare organisation. The governing body is required to provide leadership, set strategic directions, and define the roles and responsibilities within the workforce (NSQHS 1.01, 1.02).

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Incident management systems and open disclosure

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Incident management systems and open disclosure

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They are additionally expected to support patients and their careers by assisting them in communicating their needs and concerns.

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Incident management systems and open disclosure

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Incident management systems and open disclosure

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Governing bodies need to use an open disclosure program that is consistent with Australian standards, and they need to monitor the effectiveness of their open disclosure policies.

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The organisation additionally needs to have processes in place for receiving feedback from patients and their carers about their care and experiences.

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Feedback from staff about their understanding and use of safety and quality systems and using this information to improve the relevant procedures

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Governance, leadership and culture

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Patient safety and quality systems

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Clinical performance and effectiveness

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Safe environment for the delivery of care

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The health organisation establishes a clinical governance framework to help improve safety and quality, and they implement and monitor strategies. (NSQHS 1.03, 1.04, 1.05)

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Assists clinical staff with their delegated responsibilities and their safety and quality roles to assist in improving patient care safety and quality (NSQHS 1.06).

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The organisation needs to use systems to identify the training needs of their staff, implement the required training, asses the adherence of staff to the training and ensure it meets the necessary safety and quality standards.

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The organisation needs to enable staff to assess their performance frequently and identify areas for their self-improvement.

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Australian Commission on Safety and Quality in Health Care. (2017). National Safety and Quality Health Service Standards (2nd ed.) Australian Commission on Safety and Quality in Health Care. https://www.safetyandquality.gov.au

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Credentialing and scope of clinical practice

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Credentialing and scope of clinical practice

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Defining the scope of practice for clinical staff and ensuring they practice within it. Additionally, this scope of practise needs to be reviewed periodically to account for any new procedures and technologies.

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The organisation has a process that enables clinical staff to access the latest quality evidence and update policies and procedures to reflect this information.

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Variation in clinical practice and health outcomes

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Variation in clinical practice and health outcomes

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There needs to be procedures in place to enable the organisation and staff to pick up on outcomes that are not expected from regular treatment, as well as provide feedback to clinicians in this area and review performance against external factors.

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The organisation needs to have a way to maximise the quality and safety of their care by ensuring thorough design of their environment, maintaining infrastructure, and ensuring that equipment is fit for purpose and safe.

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They need to be able to identify spaces that have higher risks of unpredictable behaviour and minimise these risks for patients, families, carers and the workforce.