Victorian Department of Health Accreditation Resource

Department of Health

VICTORIAN DEPARTMENT OF HEALTH ACCREDITATION RESOURCE

OVERVIEW

Resources to implement the National Safety and Quality Health Service Standards

The Victorian Department of Health Accreditation Resource is designed to be used in addition to the Australian Commission on Quality and Safety in Health Care’s (the commission’s) resources when implementing the National Safety and Quality Health Service Standards (NSQHSS). It contains predominantly resources developed from within Victoria, as national resources are referred to in supporting tools developed by the commission.

This accreditation resource is a summary of policies, guidelines and tools that can assist health services in identifying evidence to demonstrate how you meet the NSQHSS.

These documents are working documents that can be used by health services in their planning for accreditation against the NSQHSS. They will be updated as required.

The Victorian Department of Health Accreditation Resource comprises a summary table plus a more detailed description of resources by action item of each standard in ten separate sections.

The summary of this accreditation resource can be found in the table below. Resources are grouped according to the standard they support.

Victorian Department of Health Accreditation Resource Summary Table

Standard 1: Governance for Safety and Quality in Health Service Organisations
Australian Commission on Safety and Quality in Health Care: Australian Charter of Healthcare Rights in Victoria
Australian Institute for Community Practice and Governance: Designing position descriptions for volunteers.
Dental Health Services Victoria: Clinical Guidelines in Dentistry resources
Department of Health and Ageing: Implementation guidelines for public mental health services and private hospitals
Financial Management Act 1994
Health Services Act 1988
National Health and Medical Research Council: Working with volunteers and managing volunteer programs in health care settings
Office of the Public Advocate
Public Administration Act 2004
Victorian Community Health Indicator Set
Victorian Department of Health: Chief Psychiatrist’s Guidelines
Victorian Department of Health: Clinical networks
Victorian Department of Health: Clinical Review Program auspiced by the Chief Psychiatrist’s Quality Assurance Committee
Victorian Department of Health: Clinical risk management - sentinel event program
Victorian Department of Health: Delivering on Improving Care for Aboriginal and Torres Strait Islander Patient Program
Victorian Department of Health: Victorian clinical governance policy framework
Victorian Department of Health: Victorian Health Incident Management Policy
Victorian Department of Health: Victorian legislation, regulations and links to supporting information relevant to health service providers
Victorian Department of Health: Victorian Patient Satisfaction Monitor
Victorian Department of Health: Chief Psychiatrist’s guideline: Priority access for out of home care
Victorian Department of Health: Chief Psychiatrist’s Guideline: Treatment Plans under the Mental Health Act 1986
Victorian Department of Health: Clinical Risk Management - Root cause analysis
Victorian Department of Health: Clinical Supervision Guidelines for mental health services: program management circular
Victorian Department of Health: Credentialling and defining the scope of clinical practice for medical practitioners in Victorian health servicespolicy
Victorian Department of Health: Cultural responsiveness framework

Victorian Department of Health: Developing the clinical leadership role in clinical governance: A guide for clinicians and health services

Victorian Department of Health: Early Intervention in Chronic Disease initiative
Victorian Department of Health: Office of the Chief Psychiatrist’s Guidelines on Reportable Deaths
Victorian Department of Health: Partnering for performance – a performance development and support process for senior medical staff
Victorian Department of Health: Primary Care Partnership service coordination surveys
Victorian Department of Health: Ten Tips for Safer Health Care
Victorian Department of Health: Victorian health incident management policy and guide
Victorian Department of Health: Victorian health incident management system - incident management e-learning, in-depth case review e-learning
Victorian Department of Health: Victoria’s Mental Health Services – Patients rights
Victorian Department of Health: Victorian Quality Council

Victorian Department of Health: Victorian Rural and Regional Health and Aged Care Services Division, “Doing it with us, not for us: Strategic Direction 2010-13”

Victorian Department of Health: Victorian Service Coordination Practice Manual 2009 (and forthcoming 2012 edition)
Victorian Department of Human Services and Department of Health: Reconciliation Action Plan
Victorian Department of Treasury and Finance: Victorian Risk Management Framework
Victorian Healthcare Association: Board of management Clinical Governance Reporting Guidelines and Checklist
Victorian Healthcare Association: Model Board Clinical Governance Policy and Model Clinical Governance Policy and Proceduresresources
Victorian Healthcare Association: Resources relevant to client record documentation in Community Health
Victorian Health Services Commission
Victorian Managed Insurance Authority: Compliance Management Framework
Victorian Managed Insurance Authority: Implementing clinical risk into community health
Victorian Managed Insurance Authority: Internal Audit Project..
Victorian Managed Insurance Authority: ISBAR program
Victorian Managed Insurance Authority: Junior Hospital Medical Officer checklist for patient safety
Victorian Managed Insurance Authority: Mortality Enhancement Project: Learning from Death
Victorian Managed Insurance Authority: Mortality Review Project: A standardised approach to Morbidity and Mortality review
Victorian Managed Insurance Authority: Safety Climate Survey Guidelines
Victorian Mental Health Act 1986
Standard 2: Partnering with Consumers
Cochrane Consumers and Communication Review Group
Dental Board of Australia’s Dental Guidelines on Supervision
Health Issues Centre
Health Services Act 1988
Public Record Office Victoria – Record Keeping Standards and Disposal Schedules
Victorian Department of Health: Caring together – an action plan for carer involvement in Victorian public mental health services (2006)
Victorian Department of Health: Cultural responsiveness framework
Victorian Department of Health: Delivering on Improving Care for Aboriginal and Torres Strait Islander Patient Program
Victorian Department of Health: Doing it with us not for us: Strategic direction 2010 – 2013
Victorian Department of Health: Findings of the Evaluating Effectiveness of Participation projects
Victorian Department of Health: Guidelines and other resources for The Wagner Chronic Care Model
Victorian Department of Health: How to develop a community participation plan guideline
Victorian Department of Health: Improving the Patient Experience Program
Victorian Department of Health: Quality of care reports – recommended reporting 2011 – 12
Victorian Department of Health: Strengthening Consumer Participation in Victoria’s Public Mental Health Service Action Plan 2009
Victorian Department of Health: Victorian Community Health Priority Tools
Victorian Department of Health: Victorian Patient Satisfaction Monitor and for the annual report
Victorian Department of Health: Victorian Quality Council
Victorian Department of Health: Victorian Service Coordination Practice Manual 2009 (and forthcoming 2012 edition)
Victorian Department of Human Services: Disability Action Plans
Victorian Healthcare Association: Sample clinical supervision policy and procedures
Victorian Managed Insurance Authority : Risk management tools and resources
Victorian State Services Authority: resources for managing people
Victorian Department of Human Services and Department of Health: Reconciliation Action Plan
Standard 3: Preventing and Controlling Healthcare Associated Infections
Australian Commission on Safety and Quality in Health Care: Antimicrobial Stewardship in Australian Hospitals 2011
Guidance Group: Guidance DS
South Australian Department of Health: National Antimicrobial Utilisation Surveillance Program
VICNISS Healthcare Associated Infection Surveillance Coordinating Centre: Victorian Aggregate Hand Hygiene Compliance Data
Victorian Department of Health: Cleaning Standards for Victorian Health Facilities 2011
Victorian Department of Health: Clinician’s Health Channel
Victorian Department of Health: Improving Care for Aboriginal and Torres Strait Islander People
Victorian Department of Health: Quality of Care Report
Victorian Department of Health: Start Clean Victorian Infection Control Strategy 2007-2011
Victorian Department of Health: Victorian Patient Satisfaction Monitor
IDEAS website link
Standard 4: Medication Safety
Australian Commission on Safety and Quality in Health Care: National Inpatient Medication Chart
Australian Commission on Safety and Quality in Health Care: National Medication Management Plan to document and reconcile medicines.
Drugs, Poisons and Controlled Substances Act 1981
Drugs, Poisons and Controlled Substances Regulations 2006
Guidance Group: Guidance DS
North East Valley Division of General Practice: Austin / Northern Medgap Project
Society of Hospital Pharmacists of Australia
Therapeutic Goods Administration
Victorian Department of Health: “Better Quality, Better Health Care: A safety and Quality Improvement Framework”, The Victorian Quality Council
Victorian Department of Health: Clinician’s Health Channel
Victorian Department of Health: Drugs and Poisons controls in Victoria:
Victorian Department of Health: Drugs and Poisons Controls in Victoria – Information for registered health practitioners.
Victorian Department of Health: Drugs and Poisons Controls in Victoria – Prescriber lists approved by the Minister
Victorian Department of Health: Health SMART initiative
Victorian Department of Health: High Risk Medicines Alerts
Victorian Department of Health: Improving Care for Aboriginal and Torres Strait Islander People
Victorian Department of Health: Management of Schedule 8 poisons in pharmacy
Victorian Department of Health: Medication Safety Self Assessment tools for Australian Hospitals and the Indicators for Quality Use of Medicines in Australian Hospitals
Victorian Department of Health: National Inpatient Medication Chart Initiative
Victorian Department of Health: Quality Use of Medicines Program
Victorian Department of Health: Quality Use of Medicines Program - High Risk Medicines Alerts
Victorian Department of Health: Reporting requirements on incidents and adverse events
Victorian Department of Health: Victorian Patient Satisfaction Monitor
Victorian Therapeutics Advisory Group
Victorian Therapeutics Advisory Group: “Recommendations on the security and custody of schedule 8 and schedule 4 drugs in hospitals”:
IDEAS website link
Standard 5: Patient Identification and Procedure Matching
Victorian Department of Health: Victorian Quality Council
Standard 6: Clinical Handover
Community Health Indicators Victoria
Victorian Department of Health: Improving Care for Aboriginal and Torres Strait Islander Patient Program
Victorian Department of Health: Program Logic for Primary Care Partnerships
Victorian Department of Health: Victorian Quality Council - Clinical Handover Organisation Readiness Checklist, policy and protocol content and key performance indicators
Victorian Department of Health: Victorian Quality Council - Guide to Patient Transfer: Principles and Minimum Requirements for Non-time Critical Inter-Hospital Patient Transfer
Victorian Department of Health: Victorian Quality Council - Patient Inter-Hospital Transfer Key Phases and Action Steps Checklist,Appendix 1 of the Guide to Patient Transfer: Principles and Minimum Requirements for Non-time Critical Inter-Hospital Patient Transfer
Victorian Department of Health: Victorian Service Coordination Practice Manual 2009 (and forthcoming 2012 edition)
Victorian Department of Health: Victorian Service Coordination resources and tools
Victorian Managed Insurance Authority: ISBAR program
Victorian Managed Insurance Authority: Junior Hospital Medical Officer checklist for patient safety
Victorian Managed Insurance Authority: Transfer envelope - patient handover
Standard 7: Blood and Blood Products
Australian Red Cross Blood Service– Blood fridge maintenance record
Australian Red Cross Blood Service: Fact Sheets
Australian Red Cross Blood Service: Fact Sheets – ‘I need to know about haemovigilance and patient safety
Australian Red Cross Blood Service: Resources
Australian Red Cross Blood Service: Risks and adverse events
National Blood Authority Australia: Bloodnet
National Blood Authority Australia: National haemovigilance information
New South Wales Health: Clinical Excellence Commission - Blood Watch Patient Brochures
South Australian Department of Health: BloodSafe Consumer information
Victorian Department of Health: Blood Management brochure – ‘Every drop counts’
Victorian Department of Health: Blood Matters Program - audits and reports
Victorian Department of Health: Blood Matters Program - Blood Matters policy
Victorian Department of Health: Blood Matters Program - Blood Products information and communication tools on blood and blood components
Victorian Department of Health: Blood Matters Program - Blood sampling, protocol and communication tools to promote best practice around pre transfusion blood sampling
Victorian Department of Health: Blood Matters Program - Blood transfusion policy, procedure and administration practice audit tools
Victorian Department of Health: Blood Matters Program – Consent, examples of local consent tools and policy for transfusion
Victorian Department of Health: Blood Matters Program - Consumer information
Victorian Department of Health: Blood Matters Program – Forms to improve documentation in prescription, request and administration of blood products
Victorian Department of Health: Blood Matters Program ‘Key messages to staff’ documents
Victorian Department of Health: Blood Matters Program - learning packages
Victorian Department of Health: Blood Matters Program - National Blood Supply Contingency Plan and Emergency Blood Management Plan template
Victorian Department of Health: Blood Matters Program - Patient information cards regarding reactions
Victorian Department of Health: Blood Matters Program - serious transfusion incidents reporting system
Victorian Department of Health: Blood Matters Program – storage of blood product posters
Victorian Department of Health: Blood Matters Program - transfusion interest group forum
Victorian Department of Health: Blood Matters Program - transfusion trainers/nurses job descriptions
Victorian Department of Health: Blood Storage and Handling Report 2010
Victorian Department of Health: Clinical risk management - sentinel event program
Victorian Department of Health: Handbook for Transfusion Practitioners 2010
Victorian Department of Health: Hospital Circular 07/2002 – Hospital/health service transfusion committees
Victorian Department of Health: Hospital Circular 20/2009 - Emergency Blood Management Plan
Standard 8: Preventing and Managing Pressure Injuries
Victorian Department of Health: Best care for older people everywhere – The toolkit
Victorian Department of Health: Improving Care for Aboriginal and Torres Strait Islander Patient Program
Victorian Department of Health: Improving the environment for older people in Victorian emergency departments: Audit report 2009.
Standard 9: Recognising and Responding to Clinical Deterioration in Acute Health Care
Victorian Department of Health: Improving Care for Aboriginal and Torres Strait Islander Patient Program
Victorian Department of Health will be developing an Advance Care Planning policy during 2012.
Victorian Managed Insurance Authority: Clinical risk reduction in deteriorating gynaecology patient
Victorian Managed Insurance Authority: Failure to initiate Medical Emergency Team
Standard 10: Preventing Falls and Harm from Falls
Victorian Department of Health: Best care for older people everywhere – The toolkit
Victorian Department of Health: Improving Care for Aboriginal and Torres Strait Islander Patient Program
Victorian Department of Health: Victorian Health Incident Monitoring System resources for incident reporting

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