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Accreditation Report

Quality Innovation Performance Accreditation Report

© QIP 2017 Torres and Cape Hospital and Health Service TCHHS – Accreditation Report

Thursday, 7 December 2017 | 1

Assessment Details

Health Service Name Torres and Cape Hospital and Health Service TCHHS

Health Service ID HP1007

Accreditation Contact Mr Leigh Broad

Standards QIC Health and Community Services Standards

Assessor

Mr Anastasios Kambouris Ms Nicole McKenzie Dr John Scott Phipps Mr David Stevens

Date of Assessment Monday, 4 September 2017

Assessment Location Level 9, Citi Central Building 45-48 Sheridan Street CAIRNS QLD 4870

Accreditation Status

Accreditation Decision Accredited

Accreditation Decision Maker Kate Lord

Decision Maker Signature

Date 7 December 2017

Actions Due By Date 1 November 2017 – 1 November 2021

This assessment was conducted according to the requirements of the QIC Health and Community Services

Standards and Accreditation Program. The health service is required to maintain compliance with these

standards throughout the accredited period.

Disclaimer

The information contained in this report is based on evidence provided by the participating organisation and its representatives at the time of

the accreditation assessment and where applicable any further subsequent information that the organisation supplied through the reporting

process. Accreditation issued by Quality Innovation Performance (QIP) or the Quality Improvement Council (QIC) does not guarantee the safety,

quality or acceptability of a participating organisation or its services or programs, or that legislative and funding requirements are being, or will

be, met.




Foreword

Accreditation is independent recognition that an organisation, practice, service, program or activity meets

the requirements of defined criteria or standards. Accreditation provides quality and performance

assurance for owners, managers, staff, funding bodies and consumers.

The achievement of accreditation is measured against the sector specific Standards which have been set as

the minimum benchmark for quality. Compliance with the Standards is demonstrated through an

independent assessment.

Accreditation can help an organisation to:

• Provide independent recognition that the organisation is committed to safety and quality

• Foster a culture of quality

• Provide consumers with confidence

• Build a more efficient organisation using a systematic approach to quality and performance

• Increase capability

• Reduce risk

• Provide a competitive advantage over organisations that are not accredited, and

• Comply with regulatory requirements, where relevant.

Continuous quality improvement (CQI) underpins all AGPAL/QIP accreditation programs and the

organisation/practice/service through:

• Looking for ways to improve as an essential activity of everyday practice

• Consistently achieving and maintaining quality care that meets consumer/patient needs

• Monitoring outcomes in consumer/patient care and seeking opportunities to improve both the care and

its results.

• Constantly striving for best practice by learning from others to increase the efficiency and effectiveness of

processes

The following report is based on an independent assessment of the service’s performance against QIC

Health and Community Services Standards. The report includes compliance level ratings for each indicator,

criteria and standard and includes explanatory notes for key findings. Where an indicator is not rated as

‘met’, corrective action is specified.




Executive Summary

The Torres and Cape Hospital and Health Service (hereafter referred to as TCHHS) is the principle provider

of hospital and community based public health care services to peoples in Torres Strait and Cape York

communities of Queensland. This includes a significant Aboriginal and Torres Strait Islander population.

TCHHS was established as a statutory body under the authority of the Hospital and Health Boards Act 2011

(the Act) on 1 July 2014 with the amalgamation of Torres Strait Northern Peninsula Hospital and Health

Service (HHS) and Cape York HHS. A formal Service Agreement is in place between TCHHS and the

Queensland Department of Health which defines key performance indicators for the quality and quantity of

health services provided under the Performance Management Framework.

As one of 16 hospital and health services across the state of Queensland, TCHHS serves an estimated

resident population of approximately 26,000 people with a health service catchment of 130,000 square

kilometres including communities on 18 Torres Strait Islands. Approximately 66 per cent of the population

identify as Aboriginal and/or Torres Strait Islander. TCHHS is comprised of 31 primary health care centres,

two hospitals, (Thursday Island and Bamaga), a multi-purpose health service in Cooktown and an integrated

health service in Weipa. The HHS is operationally divided in to two sectors: Northern and Southern with a

regional hub office in Cairns. The Torres Strait islands are further divided into five culturally distinct

clusters. The TCHHS has over 900 employees and supports a full suite of health specialties as well as

outreach teams and visiting specialist services from other Health Services and non-government providers.

Thursday Island Hospital provides 32 beds and its hospital services include emergency care, general

medicine, maternity, paediatrics, surgery and a higher dependency area, which is not yet at Clinical Services

Capability Framework requirements for intensive care provision. It also offers allied health services, visiting

specialist services, outreach services, community health as well as home and community care.

As outlined in the TCHHS Service Plan 2016-2026, the vision of the organisation is “Healthy people and

communities in the Torres Strait, Northern Peninsula Area and across Cape York”. The many and varied

services provided throughout the rural and remote facilities of the TCHHS creates a number of unique and

complex challenges for the organisation. These include variation in population distribution, distance and

access to the health service, availability and sustainability of an appropriately trained and skilled workforce

that is reflective of the community being served, and aging of health service infrastructure and buildings.

Providing quality care to rural and remote populations across the TCHHS is further challenged by high levels

of socio-economic disadvantage and its implications for population health including reduced life expectancy

chronic disease and obesity.

The major challenges specific to TCHHS relating to the National Standards are in the areas of governance,

provision of culturally appropriate services and programs and sustaining relationships with external primary

health care providers. In terms of governance, a recurring issue identified was the potential for local focus

of services with limited collaboration with adjoining health care organisations. The geographic

disbursement of the workforce in relatively isolated communities increases this risk. A governance

framework that encouraged greater collaboration would help mitigate this risk. While it is noted that a plan

is in place for significant investment in health infrastructure in some areas there was no overall masterplan




in place for preventative maintenance and refurbishment of many of the TCHHS facilities. There is also

scope for a more robust system for scheduling of preventative maintenance.

While TCHHS is strongly committed to the provision of culturally appropriate services it was noted that,

whereas in the Northern Sector the communities had been involved in the external and internal design of

the facilities, this was not so evident in the Southern Sector. This could be improved with greater

community engagement in the design of facilities and services. The provision of services is further impacted

across the TCHHS by the lack of integration of information systems. For example, the excellent work in the

management of tuberculosis is supported by two standalone databases that are not integrated with each

other or other health information systems. Plans for the introduction of a new patient information system

were described during the survey and should go some way to address these issues.

The move to Aboriginal and Torres Strait Islander community control of some health services has come

about through a cooperative approach to service delivery, rather than a competitive one. It is built on the

premise of ‘What can we do together’. However, issues were identified with information sharing across

different parts of the community controlled health services and with other external providers such as

Queensland Offender Health Services and Cairns Hospital. The organisation is working to improve

information sharing.

Whilst many achievements have been identified in this accreditation assessment report, particular

strengths of the organisation include the significant investment that has been made in embedding a culture

of safety and quality, an established alignment between the vision, purpose and values of the organisation

and the current Service Plan, a strong commitment to Aboriginal and Torres Strait Islander education and

employment, a skilled and competent workforce who listen to and actively engage with consumers and

carers, training and expanding the scope of practice for clinical health employees and the depth of cultural

competence exhibited by the staff. In addition, TCHHS provides a warm and welcoming face to both

consumers and visitors and makes a positive contribution to community life.

The Accreditation Team would like to thank the Board of Members, the CEO Mr Michael Lok and all staff in

particular Mr Leigh Broad and Ms Isobel Moase for their hospitality and willing cooperation that greatly

assisted our work. We also thank all the TCHHS staff across the organisation for their openness and

participation in the accreditation process.

The Accreditation Team acknowledges the traditional owners and custodians of the land and we pay our

respects to Elders past, present and future leaders.




Assessment Ratings

Four levels of attainment are used consistently throughout this report to give an overall rating for each

Standard. The levels of attainment are:

• Exceeded

• Met

• Met in Part

• Not Met

In order to meet accreditation requirements all the Standards must be met.

Summary of Ratings

Overall Assessment of Standards

Standard Rating

1 Building Quality Organisations Met

2 Providing Quality Services and Programs Met

3 Sustaining Quality External Relationships Met




Summary of Quality Improvement Recommendations

Recommendations

Criterion Recommendations

1.1 Governance Governance Documents/Records: There has not been a consistent plan for, and participation in Board Training specific to the context of the TCHHS. CQI Recommendation: 1. Review Board Training requirements and areas where whole of Board participation is required versus selected members who would benefit from education and training to support them in their role. Consumer Interview: Community engagement in the development and review of the health services could be strengthened in some of the communities visited. CQI Recommendation: 1. Invite community members to assist in developing a rights and responsibilities poster. 2. Invite the community members to suggest artwork and colours for the outside and reception/consulting areas. 3. Ensure that appropriate consultation occurs with communities when preparing new facilities. Evaluation and Feedback Documents/Records: CQI Recommendation: 1. Consider ways in which the community and stakeholders can be included in formal evaluation of strategic goals and performance. The organisation does not have a comprehensive "map" of partnerships and collaborations for each region. CQI Recommendation: 1. It is recommended that the organisation develops a "map" of partnerships and collaborations for each region across the health service to facilitate better strategic planning. Board Interview: While there is good evidence that all Board Members are offered governance and Board training, the target for minimum participation expected for each Board Member remains unclear. CQI Recommendation: 1. The program of Board development should include a target





for minimum participation expected for each Board Member. This information could be included in the annual review of Board performance. Workforce planning has to date involved mainly senior management. The organisation is currently in the process of master planning. CQI Recommendation: 1. It is recommended that the Board and senior management ensure that workforce strategy and planning be more transparent so that all levels of the organisation have an opportunity to participate in planning. 2. Develop a strategic plan for building and infrastructure replacement/refurbishment – presently reactive and “filling the gaps”. Management Interview: The organisation is starting the process of developing a plan for regionalisation to place key staff and functions into regions and communities. CQI Recommendation: 1.The Board are encouraged to conduct a feasibility study on the cost and projected benefits of regionalisation, and possible risks and impact on the workforce and communities.

1.2 Management Systems Governance Documents/Records: The organisation has undergone and is continuing to experience significant periods of change and growth. CQI Recommendation: 1. It is recommended that the organisation consider the development of a Growth Management plan to align with the operational plan for each community. Regionalisation of the workforce may reinforce regionalised thinking. CQI Recommendation: 1. All health clinics are different and consideration needs to be given to the feasibility of the types of services, training and local policies. 2. Consideration of strategies for maintaining connection to broader workforce and disciplines in other regions such as communities of practice. Service Development, Delivery and Management Documents/Records: The organisation faces an ongoing challenge of retaining staff





in the remote communities and filling specific positions. Apart from nursing, indigenous health care workers, administration, and specialist clinical staff are harder to maintain permanent personnel, particularly for the most remote community health clinics. This has obvious strategic consequences for the organisation. The development and trial of Health Action Teams (HAT's) has shown promise in driving change and enhancing clinical practice. CQI Recommendation: 1. Strengthen strategic planning around workforce planning. This may include: a) the set up of an 'Alumini' association of ex-staff who the organisation can keep in touch with and invite back to fill positions. b) providing more graduate places for various disciplines. c) working with other services and businesses in each community to share a casual pool of administration staff to provide enough hours and variety for a feasible relief or permanent role. d) promoting the potential career pathway, training and work opportunities for indigenous health care workers. 2. Evaluate what are the 'success factors' for the HAT'S to ensure the projected roll out across the Torres and Cape is effective.

1.3 Human Resources HRM Documents/Records: Aboriginal and Torres Strait Islander Health Workers (ATSIHW’s) with isolated practice authorisation have an important role within the TCHHS. However, at the time of the Accreditation Survey there were only 8 ATSIHW’s with isolated practice authorisation employed by the organisation. The Accreditation Team were informed that this has resulted in deficiencies in staffing in specified isolated locations in the Northern Sector. CQI Recommendation: 1. Review workforce practice, strategies and plans to ensure that the organisation contributes to the attraction, retention and development of ATSIHW’s with isolated practice authorisation. Management Interview: The TCHHS recognises that ATSIHW’s play a vital role in improving the health outcomes of Aboriginal and Torres Strait Islander people. A number of strategies are in place to achieve sustainable employment outcomes for ATSIHW’s including specific recruitment and training initiatives. This process could be further improved by including ATSIHW’s





workforce vacancies as a standing agenda item at Workforce Planning meetings. CQI Recommendation: 1. Consider including ATSIHW’s workforce vacancies as a standing agenda item at Workforce Planning meetings in order to actively manage the workforce and identify any gaps between workforce projections and the available supply of staff. This information could be reported to the Board. TCHHS recognises that young people are at higher risk of developing sexually transmitted infections (STI's) and that STI screening in young people presents a number of additional challenges for the health professional that are not usually encountered when screening adults for the same infections. In response, the organisation has implemented a ‘Guide to Offering STI Testing to People Aged < 16 years Attending Clinical Services’. However, interview with health professionals across the TCHHS suggests ambiguities in the current interpretation of this document. These include the required qualifications of the health professional able to perform a 'Gillick Competency' assessment, training in issues related to capacity and consent for people aged less than 16 years and information sharing with other agencies including the Department of Community, Child Safety and Disability Services. CQI Recommendation: 1. Review the program for staff support and training to ensure that ‘STI screening for people aged < 16 years’ is delivered according to the ‘Guide to Offering STI Testing to People Aged < 16 years Attending Clinical Services.’ Interview with staff across the Northern and Southern sectors suggests that few clinicians have received training in forensic examination and collection of forensic specimens outside of the Cairns-based hub. This has the potential to compromise the forensic investigation process, justice system outcomes and the mental and physical well being of the patient. CQI Recommendation: 1. While it is noted that TCHHS currently do not have the ‘sustainable expertise to deliver forensic investigation services’ the alternative of sending patients to Cairns for this service would appear likely to potentially increase the trauma to victims of sexual assault. It is suggested that TCHHS take this into account when prioritising the areas for staff education.





Staff Interview: A number of TCHHS management staff reported a delay in receiving clinical audit results conducted outside of the Cairns-based hub. This was perceived to be a result of low computer literacy levels among some staff members rather than difficulties with physical access or connectivity. CQI Recommendation: 1. A computer literacy course that considers important cultural factors that may influence motivation for acquiring computer skills would help to ensure the timely submission of clinical audit results. A common concern of staff and community members on the outer islands of the Northern Sector was the limited information provided about locum staff. One staff member stated "we don’t know who we’re getting and it makes us worry if they haven’t been here before.” Some community members reported feeling anxious when a regular staff member left the island for leave or training purposes. CQI Recommendation: 1. Consider providing regular staff with further information on the experience and skill set of locum staff prior to their arrival. This information could then be communicated to the local community. A common concern outside of the Cairns-based hub was lack of administrative support for key positions. One staff member reported feeling “swamped” by paperwork which compromised her ability to perform in her assigned role. The Accreditation Team would like to highlight the lack of administrative support for the Nursing Director at Bamaga Hospital as a particular area of need. CQI Recommendation: 1. Review administrative support for key positions across the organisation. The ATSIHW’s interviewed described a number of factors that increased the difficulty of their day to day work. These included managing requests for support outside of working hours, dealing with grief and loss, setting boundaries and working with family members. These difficulties were more prominent for ATSIHW’s living in remote locations with most relying on their co-workers or family for support. Of the employees interviewed, both ATSIHW’s and non-ATSIHW’s, none were able to identify ATSIHW’s employee support services outside of the Employee Assistance Program (EAP).





ATSIHW’s are likely to experience additional difficulties within the workforce, particularly those individuals who are living and working in remote communities. CQI Recommendation: 1. A range of resources are available to support ATSIHW’s well-being and all staff should be made aware of these resources. Staff interview suggests that additional support is required for staff members who are returning to a role after extended leave, secondment or other absence. This is also likely to apply to existing staff members who are relocated to a new position or role. CQI Recommendation: 1. Review the current time frames for a refresher induction for staff members returning to work after a long absence. Existing staff members who are changing roles may need further induction training in order to understand their new duties, processes and occupational health and safety requirements. TCHHS supports ATSIHW’s to achieve Certificate III and IV in Aboriginal and/or Torres Strait Islander Primary Health Care. Staff interviewed at one site in the Northern Sector stated that these qualifications “are all about Aboriginal people” with little consideration of the great diversity between Aboriginal and Torres Strait Islander cultural groups. CQI Recommendation: 1. Liaise with the course provider to ensure that the syllabus is culturally appropriate and inclusive of both Aboriginal and Torres Strait Islander People.

1.4 Physical Resources Financial Documents/Records: The evidence provided failed to demonstrate that a robust system is in place for the scheduling of preventative maintenance. CQI Recommendation: 1. Develop a more robust system for the scheduling of preventative maintenance Facilities and Equipment: The surveyors identified items which require attention under preventative maintenance. The TI generator diesel fuel storage tank has been isolated for 6 months; only an informal agreement with other fuel supply





source. There is a guarantee for second back-up generator [if required] with the mains supplier but only if the supplier interrupts the supply, not if there is a storm. There are no communication devices [hand held radios] between the chief fire warden and the various other wardens reported at Thursday Island. Ageing equipment – UPS and generator failure identified as responsible factors for spike in cold chain breech. A site inspection of Bamaga hospital found that the storage shed for propane gas cylinders is located next to the helicopter landing zone. CQI Recommendations: 1. It is recommended that the organisation: a) Reviews the sound proofing of the interview room of the mental health service at Bamaga or moves interviews to another room. b) Review PPE signage across the sites to ensure that it is specific, uniform and appropriately sited and that all staff and VMO's receive education on the appropriate selection of PPE. c) Ensure the equipment and drainage at the mortuary at Bamaga are fit-for-purpose. d) Include the lot number, batch number and expiry of testing kits for as part of water testing records for renal dialysis. e) Ensure there is a replacement satellite phone for the Bamaga mental health team. 2. Arrangements for an alternative fuel supply to the TI generator diesel fuel storage tank need to be formalised and contingency plans are in place for interruptions to supply caused by natural weather events and disasters. 3. Ensure there are no communication devices [hand held radios] between the chief fire warden and the various other wardens. 4. Review ageing equipment regarding potential for uninterrupted power supply (UPS) and generator failure to ensure the potential for cold chain breeches is minimised. 5. Undertake an environmental risk assessment of the storage of propane gas cylinders at Bamaga Hospital. Management Interview: Management identified the need for more accommodation for permanent and relief staff across the Torres and Cape Regions to attract and retain staff due to limited and expensive accommodation options. TCHHS staff report restrictions to ‘Breast Screen’





mammography services due to unsealed roads compromising sensitive screening equipment. CQI Recommendation: 1. Consider in master planning and regionalisation a potential ratio/formula for assessing the adequacy of accommodation options. 2. Develop a ‘Treatment Action Plan’ to address insufficiencies in ‘Breast Screen’ service provision across the NPA. Safety and Quality Documents/Records: The surveyors identified several safety items which require review. CQI Recommendation: 1. It is recommended that: a) the organisation risk assess the location of the propane gas cylinders at Bamaga Hospital. b) The mental health team at Bamaga be provided with replacement satellite phones. c) there be a review of all power sources to ensure that site satisfactory power back-up is available d) the main diesel storage supply on Thursday Island is returned to operation as soon as possible and that arrangements for other fuel supplies or generating capacity are reviewed and revised. e) the organisation review the communication systems for the fire wardens and ensure that they are adequate. f) the organisation develop an action plan for transport logistics in consideration of environmental risks (mitigation) due to the remoteness of the health clinics.

1.5 Financial Management Financial Documents/Records: The financial delegations require review in relation to the remote context and necessity for expediency in decision making. CQI Recommendation: 1. It is recommended that the organisation: a) review financial delegations to ensure that they are reasonable for each circumstance. b) review financial delegations for organisational governance verses project governance.

1.6 Knowledge Management IM/IT and Knowledge Management Documents/Records: Staff interview suggests that 'SharePoint' software is underutilised across the organisation. This may be due in part to the preferential use of email or limited access to ongoing training. The use of ‘SharePoint’ should be encouraged and supported by ongoing training opportunities. CQI Recommendation:





1. Encourage the use of ‘SharePoint’ across the organisation. TCHHS staff may require additional education to maximise the potential of the software. The MMEx clinical information system is currently in the design phase. This provides an important opportunity to customise the software. CQI Recommendation: 1. Consider including Research Governance in the design phase of MMEx, specifically the data dictionary, to enable good research practice. Management Interview: The Torres and Cape Tuberculosis Control Unit is tasked with the diagnosis, treatment and case management of active tuberculosis in accordance with the Queensland Government Health Service Directive for Tuberculosis (TB) Control. It is a requirement that clinical information is entered into Tuberculosis and Related Diseases Information System (TARDIS). Staff interview suggests that surveillance data is currently managed on a Microsoft Excel spreadsheet. CQI Recommendation: 1. Enter all relevant clinical information directly into TARDIS to ensure full compliance with the Health Service Directive for TB Control. Staff interview suggests that data management across a range of programs could be strengthened in terms of data collection and organisation (e.g. spreadsheets, databases), data security (e.g. reduce the risk of data breach) and data preservation and sharing with others (e.g. data policies and dissemination approaches). CQI Recommendation: 1. Ensure the data management plan is periodically reviewed and revised according to the needs of the health service and any changes in protocol. It is further recommended that the organisation seek input from the Director of Aboriginal and Torres Strait Islander Health and the Chief Information Officer. Service Development, Delivery and Management Documents/Records: The Torres and Cape TB Control Unit and the Cairns TB Control Unit are required to share data in order to fulfil surveillance objectives. Staff interview suggests that the time to first consultation, diagnosis and treatment in the Torres and Cape could be shortened through data linkage i.e.





screening cannot occur in the Torres and Cape until data is requested and provided by the Cairns TB Control Unit. CQI Recommendation: 1. Explore opportunities for data linkage between the Torres and Cape Tuberculosis Control Unit and the Cairns TB Control Unit in order to meet surveillance objectives in the timeliest manner. Staff interview suggests that the Torres Strait Island Regional Council and Australian Border Force are not informed when a Papua New Guinea resident with a diagnosis of infectious TB is commenced on treatment. CQI Recommendation: 1. Consider sharing information with Torres Strait Island Regional Council and Australian Border Force (subject to information privacy and confidentiality) with the aim of supporting an effective and coordinated response to TB control. There is growing international consensus that oral health is a key determinant of overall health and quality of life. A relationship has been suggested between poor oral health and a number of medical conditions. It may be beneficial to support sharing of relevant information between the patient’s dental record and their medical record. CQI Recommendation: 1. Explore the potential for information sharing between the patient’s dental record and medical record where relevant i.e. rheumatic heart disease. For example, Oral Health clinical records could be incorporated into MMeX. Evaluation and Feedback Documents/Records: Staff interviewed demonstrated a commitment to continually improving services and programs through the collection, analysis and use of consumer feedback. The quality and safety of these services and programs could be further improved by seeking specific feedback about each service and program, by examining their performance along the patient journey and by comparing results over time. For example, mental health services have been increased from 5 days to 7 days per week at some sites but consumer and carer feedback is lacking. CQI Recommendation: 1. Consider the use of tailored surveys to enable specific areas of care to be examined in greater depth, examine performance along the patient journey and compare the





results over time. Staff Interview: Staff interview found double documentation of patient clinical records is occurring across a number of sites. For example, staff are documenting patient information in the paper record and then manually entering data into the clinical management software ‘Best Practice’. This may result in inconsistencies between patient medical records. CQI Recommendation: 1. It is the understanding of the Accreditation Team that the Primary Health Care paper record is considered ‘the source of truth’ by TCHHS. Paper records should be scanned and entered into ‘Best Practice’ where possible.

1.9 Safety and Quality Integration HRM Documents/Records: Management interview suggests that TCHHS is committed to fostering workplaces free from occupational violence towards or between staff, consumers/carers and other visitors. Online training for the prevention and management of occupational violence is currently in place. This training should be used to support and reinforce face-to-face training programs. CQI Recommendation: 1. Progress with the development of face-to-face training for the prevention and management of occupational violence where reasonably practicable and reflective of local need.

2.1 Assessment and Planning Service Development, Delivery and Management Documents/Records: Although patient feedback is routinely collected and analysed to understand service need and performance, this process requires further development. CQI Recommendation: 1. Patient feedback should be actively encouraged at all steps of the patient journey. For example, feedback should be sought from patients regarding their hospital stay at Cairns Hospital. Clinical Documents/Records: The community and relevant individuals are not always consulted on special health promotion projects. CQI Recommendation: 1.Ensure there is consultation with the communities and relevant individuals on their expectations for any special health promotion projects. Evaluation and Feedback Documents/Records:





There are opportunities to strengthen consumer and community engagement. CQI Recommendation: 1. Include consumers and the community in: a) training staff b) facility refurbishment and design c) artwork

2.2 Focusing on Positive Outcomes Staff Interview: The development of the Nurse Navigator and Indigenous Nurse Navigator Support Officer role has resulted in measurable improvements in patient outcomes (i.e. hospital avoidance) and a significant reduction in costs associated with patient travel and accommodation. Although patient feedback is routinely collected and analysed to understand service need and performance, this process requires further development. CQI Recommendation: 1. Consider encouraging patient feedback along all steps of the patient journey. For example, feedback could be sought from patients regarding their hospital stay at Cairns Hospital. TCHHS encourages the involvement of consumers/carers in shift-to-shift handover by undertaking bedside handover where possible. This allows for a more accurate and complete information exchange while respecting the right of consumers/carers to be involved in making decisions about their health care. Staff interview suggests there are variable handover practices across the organisation with regards to consumer/carer involvement particularly in the Southern Sector. The involvement of consumers/carers in clinical handover should be consistent across the organisation. CQI Recommendation: 1. Consider a review of current handover practices and improve them as required. Evaluation and Feedback Documents/Records: The Torres and Cape TB Control Unit should be commended for their commitment to optimising patient outcomes, program resources and public health surveillance. Improvements in data management will help to ensure that services and programs are provided in an effective safe and responsive way. CQI Recommendation: 1. As per the Queensland Health Service Directive for TB control all data should be entered into the electronic case management database TARDIS.





2.3 Ensuring Cultural Safety and Appropriateness

Management Interview: Interview with Management Staff in the Southern Sector highlighted the need to ensure that the physical environment and facilities of the health service are adequate to meet the cultural needs of Aboriginal and Torres Strait Islander people. There were suggestions that culturally appropriate artwork and signage across the health service would add to the cultural appropriateness of the service. In addition, patient care areas should be designed to protect patient privacy/confidentiality with separate areas for men and women where appropriate. CQI Recommendation: 1. Seek further input from local communities on the cultural appropriateness of health care facilities as part of a broader approach to facilitating a culturally respectful association between the TCHHS and Aboriginal and Torres Strait Islander people.

2.4 Confirming Consumer Rights Clinical Documents/Records: Generally, brochures for TCHHS are written in English. CQI Recommendation: 1. Review brochures with community members for consideration of putting in the local language (i.e. rights and responsibilities). Consumer Documents/Records: One of the biggest challenges faced by the TCHHS is the high percentage of people who speak a language other than English including Aboriginal languages and a variety of Creole dialects. This may impact upon the ability of consumers and/or carers to understand their healthcare rights and responsibilities and make appropriate decisions about the services and programs offered. Site inspection finds that there is limited written information regarding patient’s rights and responsibilities and other healthcare information in local languages. CQI Recommendation: 1. Consider the development of health care information including the ‘Australian Charter of Healthcare Rights’ and other health information brochures in local languages.

2.5 Coordinating Services and Programs Service Development, Delivery and Management Documents/Records: There is not a calendar of visiting services on the islands for the community members to refer to for planning their time and as a reminder of appointments. CQI Recommendation: 1. Implement a calendar of visiting services to the islands for





community information. Staff interviews found that information sharing between TCHHS and Queensland Corrective Services regarding previous episodes of care is limited. At the very least, this compromises the ability of the health service to provide continuity of care. However, document review finds that a Memorandum of Understanding (MOU) exists between Queensland Health and Queensland Corrective Services which supports clinicians in sharing of information while safeguarding the patient’s right to confidentiality. CQI Recommendation: 1. Liaise with Queensland Corrective Service to ensure that routine procedures are in place to facilitate the transfer of health information (including mental health) and continuity of care when the patient is released from prison. This information could be captured in MMEx. External information pathways are not always effective and/or consistently followed by staff on both sides. CQI Recommendation: 1. Improve information pathways with external services, including the Queensland Offender Health services and Cairns Hospital. There is a low awareness of support services available to support ATSIHW’s staff. CQI Recommendation: 1. All staff should be made aware of resources available to support well-being.

3.2 Collaboration and Strategic Positioning Service Development, Delivery and Management Documents/Records: The sharing of patient information is an important component of the transfer to community controlled health centres. CQI Recommendation: 1. It is recommended that, with the planned transfer to community controlled health centres, the organisation ensures that the information sharing and service agreements are robust enough to ensure that: a) the sharing of patient information continues both now and in the future. b) Essential services continue such as TB clinics.

3.3 Incorporation and Contribution to Good Practice

Governance Documents/Records: A review of the 'TCHHS Research Strategy 2017 - 2020' finds that the Board is committed to a research agenda that





provides translational benefits to the communities it serves. However, the methods by which TCHHS will engage local communities in the dissemination and implementation of the research agenda remains unclear. CQI Recommendation: 1. Consider the implementation a community-identified research agenda that is pro-active and reviewed periodically with the communities to ensure that it remains relevant to their needs as well as broader organisational objectives.




1 Building Quality Organisations Standard: 1.1 Governance

The organisation’s governance structure builds a collective sense of purpose and direction that enable the organisation’s mission, values, goals and service priorities to be identified and met.

Rating: Met

Evidence Questions

Description Assessment Rating

Assessment Comments Final Rating

1.1 A The powers and responsibilities of the governance structure and its members are documented and understood, delegations are defined and accountabilities for the organisation are communicated.

Met Board Interview: Interview with the Board confirmed there is an appropriate mix of skills and significant expertise within the Board and sub committee structure to meet the governance requirements of the Torres and Cape Hospital and Health Service (TCHHS). Several members have an extensive background in Public Health Administration, Rural and Remote Health, Finance and Law. The Board invites experts in their field to be included in the sub committee structure as required. CEO Interview: At interview the Chief Executive Officer (CEO) could describe the powers and responsibilities of the governance structure, the various sub committees (Finance Risk and Audit; Clinical Governance) and the delegations and accountabilities of their position. Governance Documents/Records: Review of governance documents shows a clearly documented governance structure with well defined delegations and accountabilities in place. The CEO reports directly to the Board of TCHHS. Governance responsibilities are supported by the system of sub committees which cover areas including Finance Risk and Audit. These sub committees have up to date terms of reference, meet regularly, receive reports regarding key performance indicators, project outcomes, finance and risk, and report through to the CEO and Board. Improvement Opportunities Governance Documents/Records: There has not been a consistent plan for, and participation in Board Training specific to the context of the TCHHS. CQI Recommendation:

Met




Evidence Questions



1. Review Board Training requirements and areas where whole of Board participation is required verses selected members who would benefit from education and training to support them in their role.

1.1 B The interests of consumers and stakeholders are represented, they are able to participate through formal and informal structures and processes and there is evidence that their views influence decisions.

Met CEO Interview: Interview with the CEO confirmed that the community and other stakeholders have a voice in the organisation's direction and development. Consumer Interview: TCHHS effectively engages with their consumers through a range of forums in each of the regions and communities the organisation operates in throughout the Torres and Cape Region. These forums include Consumer Advisory Networks (CANs) and Health Action Networks Teams (HATs) which include consumer and community representatives with insight into community health needs and the opportunity to influence service practices. Community members across the regions sighted examples of their participation in health care planning, use of facility buildings, artwork, and facilitation of health promotion events. Evaluation and Feedback Documents/Records: Review of evaluation and feedback documents shows consumers and stakeholders are represented and participate through surveys and informal structures and processes. Governance Documents/Records: Review of the strategic planning documentation shows that consumers and stakeholders participate in strategic planning through formal and informal structures and their views influence decisions. TCHHS is engaged with consumers and stakeholders across a wide spectrum of networks, in local communities, planning and action committees and various levels of government in exchanging ideas and information which informs planning and organisational development. Improvement Opportunities Consumer Interview: Community engagement in the development and review of the health services could be strengthened in some of the communities visited.

Met




Evidence Questions



CQI Recommendation: 1. Invite community members to assist in developing a rights and responsibilities poster. 2. Invite the community members to suggest artwork and colours for the outside and reception/consulting areas. 3. Ensure that appropriate consultation occurs with communities when preparing new facilities. Evaluation and Feedback Documents/Records: CQI Recommendation: 1. Consider ways in which the community and stakeholders can be included in formal evaluation of strategic goals and performance. Governance Documents/Records: The organisation does not have a comprehensive "map" of partnerships and collaborations for each region. CQI Recommendation: 1. It is recommended that the organisation develops a "map" of partnerships and collaborations for each region across the health service to facilitate better strategic planning.

1.1 C The strategic directions of the organisation are identified, documented, communicated, used for decision-making and resource allocation, and routinely reviewed.

Met Board Interview: Interview with the Board which has responsibility for governance demonstrated they have a strong commitment to planning the strategic direction of the organisation in alignment with the Strategic Plan which was developed through extensive consultation with stakeholders. The Board has members represented across the regions covering the Torres and Cape and works to meet and be 'present' across the area. Board visits to regions include a day of meetings with the community and sharing health service data, strategic direction, and community investment decisions/issues. CEO Interview: Interview with the CEO confirmed a strategic planning process has been in place for the

Met




Evidence Questions



organisation aligned to the Queensland Health Department Strategic Directives and regular review of key performance indicators and progress against objectives has occurred. The strategic objectives are clearly identified, documented, communicated and used for decision-making and resource allocation. Under the amalgamation of the Torres and Cape Regions, the first priority has been to set in motion a process for developing consistent policy and practice going forward. Senior management reflected positively on the achievements over the past three years in bringing the two entities together into the one organisation. Governance Documents/Records: The strategic focus of the Board and Senior Management reflects the commitment to ensuring TCHHS meets its strategic goals, is sustainable and financially viable in the long–term. The current strategic plan is sufficient and aligned with State and Commonwealth strategic priorities. Management Interview: Management staff interviewed confirmed the Strategic Plan is based on consultation with all stakeholders which included extensive consultation with staff and community members across the regions. Improvement Opportunities Board Interview: While there is good evidence that all Board Members are offered governance and Board training, the target for minimum participation expected for each Board Member remains unclear. CQI Recommendation: 1. The program of Board development should include a target for minimum participation expected for each Board Member. This information could be included in the annual review of Board performance Governance Documents/Records:




Evidence Questions



Workforce planning has to date involved mainly senior management. The organisation is currently in the process of workforce master planning. CQI Recommendation: 1. It is recommended that the Board and senior management ensure that workforce strategy and planning be more transparent so that all levels of the organisation have an opportunity to participate in planning. 2. Develop a strategic plan for building and infrastructure replacement / refurbishment – presently reactive and “filling the gaps”. Management Interview: The organisation is starting the process of developing a plan for regionalisation to place key staff and functions into regions and communities. CQI Recommendation: 1.The Board are encouraged to conduct a feasibility study on the cost and projected benefits of regionalisation, and possible risks and impact on the workforce and communities.

1.1 D Reporting arrangements are in place to ensure the governance structure is well informed for monitoring, planning and decision-making.

Met Board Interview: Interview with the Board which has responsibility for governance confirmed they receive reports from the various sub committees and CEO which inform their decision-making. The Board have a standardised process for informing meetings including action registers, papers for information noting decisions and dash board reporting of KPI's. CEO Interview: The CEO interviewed could describe the reporting arrangements in place and the reports received that allow monitoring of the operations of the organisation. Governance Documents/Records: Governance is informed by a system of sub committees which meet regularly to review reports, key performance indicators, projects, finance and risk. The sub committees include Audit and Risk, Executive, Safety and Quality and Finance. For clinical governance, the regional clinical governance committees report through to the Safety and Quality

Met




Evidence Questions



Committee, which in turn report through to the Chief Executive Officer and Board. Individual governance responsibility and accountability is clearly defined in terms of reference and role descriptions. These are communicated within board member induction and orientation.

1.1 E The organisation’s mission, values, goals and service priorities are articulated and the organisation’s actions reflect them.

Met Governance Documents/Records: Review of the mission, vision and values documentation shows they are articulated and the organisation's actions reflect them. The leadership demonstrated by the Board and Executive management team supports and fosters the consistent understanding and implementation of the organisation’s values and mission. HRM Documents/Records: Review of the orientation/induction documents shows the mission, vision and values are included. Management Interview: Management staff interviewed could describe how they measure staff performance against the mission, vision, values and service priorities. Positive feedback was received from staff on their understanding of the vision, mission, and values for TCHHS. Staff interviewed were able to describe the organisations mission, vision and values.

Met

1.1 F Governance structure performance is routinely reviewed.

Met Board Interview: Interview with the Board confirmed they have a performance review process in place which is part of an annual planning process as a group. Overall reviews of sub committee roles and membership occurs to ensure optimal committee function. Opportunities for improvements in committee function are identified through this process. The Terms of Reference are changed as required and updated. Governance Documents/Records: Review of governance documents shows the performance of the governance structure is routinely reviewed.

Met




Evidence Questions



1.1 G The performance of the chief executive (or equivalent) is routinely monitored and reviewed.

Met Board Interview: There are clearly defined processes for monitoring the performance of the CEO as part of their Performance Agreement. This is reviewed on an annual basis or before as required. Governance Documents/Records: There are clearly defined processes for monitoring the performance of the CEO as part of their Performance Agreement. This is reviewed on an annual basis or before as required.

Met

Standard: 1.2 Management Systems The organisation has effective and responsive management systems to enable and coordinate achievement of the organisation’s mission, values, goals and service priorities.

Rating: Met

Evidence Questions



1.2 A There is a clear, integrated and effective management and reporting structure, with roles, responsibilities and accountability of management and staff mandated, documented and known.

Met CEO Interview: The CEO receives a range of reports to keep them informed including the operational report, Queensland Government benchmarking report, OHS reports, People and Culture and Risk Management reports. Governance Documents/Records: The Organisational Chart outlines the hierarchy of management systems within TCHHS. HRM Documents/Records: Review of position descriptions shows lines of accountability, delegations and performance indicators. Staff Interview: Staff interviewed were able to describe their roles and responsibilities and who they report to. Volunteer Interview: TCHHS does not have any volunteers currently.

Met




Evidence Questions



1.2 B Powers for key actions are formally delegated.

Met Governance Documents/Records: A review of documentation relating to the Board demonstrated there is an effective management system with clearly identified and documented delegations of responsibility. Delegations of authority and responsibility are clearly defined in policy and regularly reviewed. These are understood by management and staff. Delegations documents define the extent of authority for various roles. Policies and procedures are well written, comprehensive and readily accessible to staff on the intranet. HRM Documents/Records: Review of position descriptions found lines of delegations.

Met

1.2 C Decision-making and planning structures and processes are established, maintained and followed.

Met CEO Interview: The CEO interviewed could describe the organisations decision-making and planning structures and the processes in place to ensure these are followed. Governance Documents/Records: Review of governance documents shows decision-making and planning structures and processes are in place. Improvement Opportunities Governance Documents/Records: The organisation has undergone and is continuing to experience significant periods of change and growth. CQI Recommendation: 1. It is recommended that the organisation consider the development of a Growth Management plan to align with the operational plan for each community.

Met

1.2 D Operational and service planning is linked to strategic planning and informs service and program implementation.

Met CEO Interview: The CEO interviewed could describe the organisations operational and servicing planning process and how they are linked to the strategic plan. Governance Documents/Records: A review of operational plans showed they effectively support development of the strategic and business plans. Planning occurs within a 12 month cycle and is linked to budget planning and resource allocation.

Met




Evidence Questions



Management Interview: Interview with management staff confirmed operational and service planning is linked to strategic planning. Service Development, Delivery and Management Documents/Records: Review of service and program plans shows planning is linked to the strategic plan. Improvement Opportunities Governance Documents/Records: Regionalisation of the workforce may re-enforce regionalised thinking. CQI Recommendation: 1. All health clinics are different and consideration needs to be given to the feasibility of the types of services, training and local policies. 2. Consideration of strategies for maintaining connection to broader workforce and disciplines in other regions such as communities of practice. Service Development, Delivery and Management Documents/Records: The organisation faces an ongoing challenge of retaining staff in the remote communities and filling specific positions. Apart from nursing, indigenous health care workers, administration, and specialist clinical are harder to maintain permanent personnel, particularly for the most remote community health clinics. This has obvious strategic consequences for the organisation. The development and trial of Health Action Teams (HAT's) has shown promise in driving change and enhancing clinical practice. CQI Recommendation: 1. Strengthen strategic planning around workforce planning. This may include: a) the set up of an 'Alumini' association of ex-staff who the organisation can keep in touch with and invite back to fill positions. b) providing more graduate places for various disciplines. c) working with other services and businesses in each community to share a casual pool of administration staff to provide enough hours and variety for a feasible relief or




Evidence Questions



permanent role. d) promoting the potential career pathway, training and work opportunities for indigenous health care workers. 2. Evaluate what are the 'success factors' for the HAT'S to ensure the projected roll out across the Torres and Cape is effective.

1.2 E Staff, consumers and other stakeholders actively participate in and influence decision-making.

Met Governance Documents/Records: The organisation seeks input from all stakeholders in strategic planning processes. Communications by consumers and community members with staff are open and positive, supported by regular meetings and newsletters. Input and feedback is regularly sought from consumers and community members to inform service development. Stakeholder Interview: Interview with stakeholders confirmed the organisation seeks input from all stakeholders in strategic planning processes.

Met

1.2 F There is a system for developing, mandating, implementing and reviewing policies and procedures.

Met Financial Interview: Interview with finance staff confirmed the system for developing, mandating, implementing and reviewing policies and procedures. Management Interview: Management staff interviewed could describe the system for developing, mandating, implementing and reviewing policies and procedures in the organisation. Policies are reviewed, distributed for consultation and then put through the relevant Committee or the Board for ratification. Policies follow a review schedule and are subject to audit processes. Safety and Quality Documents/Records: Policies and procedures are well written, comprehensive and readily accessible to staff on the intranet. Policies, procedures, guidelines, work instructions and other intranet content support staff understanding of various functions and processes.

Met

1.2 G Communication systems are open and positive.

Met Financial Interview: Interview with finance staff confirmed communication systems are open and positive. Governance Documents/Records:

Met




Evidence Questions



Managers ensure strategies and work actions are implemented via regular monitoring, discussion, feedback and reporting at meetings, as well as through direct communication via email and face to face. Examples include reporting for consumer statistics, complaints, incidents, business and portfolio plan monitoring, strategy implementation and progress reporting. Staff Interview: Interview with staff confirmed the organisation has a open and positive communication system. Stakeholder Interview: Interview with stakeholders confirmed communication systems within the organisation are open and positive. Volunteer Interview: The organisation does not currently have volunteers.

1.2 H Management decisions are recorded, implemented, communicated to staff and evaluated.

Met CEO Interview: Management decisions are clearly communicated directly through meetings, and meeting minutes/correspondence. Position descriptions establish responsibilities, accountabilities and reporting requirements for all positions. Management Interview: Management staff interviewed could explain how management decisions are recorded and communicated to staff. Service Development, Delivery and Management Documents/Records: Review of management meeting records/documents shows decisions are recorded, implemented and communicated to staff.

Met

1.2 I Systems and strategies embed CQI, foster innovation and manage change at all levels within the organisation.

Met Safety and Quality Documents/Records: All management systems have embedded continuous improvement mechanisms that facilitate innovation. Staff share a common commitment to quality improvement and the organisation has a robust quality system in place. Continuous Quality Improvement (CQI) is supported by policy and in practice which encourages improvements in service practice

Met




Evidence Questions



and outcomes for consumers of the service. Service Development, Delivery and Management Documents/Records: Continuous Quality Improvement (CQI) is supported by policy and in practice which encourages improvements in service practice and outcomes for consumers of the service.

1.2 J Performance of the management system is routinely monitored and reviewed.

Met HRM Documents/Records: Review of human resource management documents found the performance of the management system is monitored and reviewed. Management Interview: Interview with management staff confirmed a process is in place for the monitoring of the management system performance.

Met

Standard: 1.3 Human Resources Human resources are managed to create an effective and competent service.

Rating: Met

Evidence Questions



1.3 A All staff are professionally qualified and experienced, able to work with consumers and willing to engage with CQI.

Met Volunteer Interview: There were no volunteers available to interview at the time of the Accreditation Survey. Improvement Opportunities HRM Documents/Records: Aboriginal and Torres Strait Islander Health Workers (ATSIHW’s) with isolated practice authorisation have an important role within the TCHHS. However, at the time of the Accreditation Survey there were only 8 ATSIHW’s with isolated practice authorisation employed by the organisation. The Accreditation Team were informed that this has resulted in deficiencies in staffing in specified isolated locations in the Northern Sector. CQI Recommendation: 1. Review workforce practice, strategies and plans to ensure that the organisation contributes to the attraction, retention and development of ATSIHW’s with isolated

Met




Evidence Questions



practice authorisation. Management Interview: TCHHS recognises that ATSIHW’s play a vital role in improving the health outcomes of Aboriginal and Torres Strait Islander people. A number of strategies are in place to achieve sustainable employment outcomes for ATSIHW’s including specific recruitment and training initiatives. This process could be further improved by including ATSIHW’s workforce vacancies as a standing agenda item at Workforce Planning meetings. CQI Recommendation: 1. Consider including ATSIHW’s workforce vacancies as a standing agenda item at Workforce Planning meetings in order to actively manage the workforce and identify any gaps between workforce projections and the available supply of staff. This information could be reported to the Board.

TCHHS recognises that young people are at higher risk of developing sexually transmitted infections (STI's) and that STI screening in young people presents a number of additional challenges for the health professional that are not usually encountered when screening adults for the same infections. In response, the organisation has implemented a ‘Guide to Offering STI Testing to People Aged < 16 years Attending Clinical Services’. However, interview with health professionals across the TCHHS suggests ambiguities in the current interpretation of this document. These include the required qualifications of the health professional able to perform a 'Gillick Competency' assessment, training in issues related to capacity and consent for people aged less than 16 years and information sharing with other agencies including the Department of Community, Child Safety and Disability Services. CQI Recommendation: 1. Review the program for staff support and training to ensure that ‘STI screening for people aged < 16 years’ is delivered according to the ‘Guide to Offering STI Testing to People Aged < 16 years Attending Clinical Services.’

Interview with staff across the Northern and Southern sectors suggests that few clinicians




Evidence Questions



have received training in forensic examination and collection of forensic specimens outside of the Cairns-based hub. This has the potential to compromise the forensic investigation process, justice system outcomes and the mental and physical well-being of the patient. CQI Recommendation: 1. While it is noted that TCHHS currently do not have the ‘sustainable expertise to deliver forensic investigation services’ the alternative of sending patients to Cairns for this service would appear likely to potentially increase the trauma to victims of sexual assault. It is suggested that TCHHS take this into account when prioritising the areas for staff education. Staff Interview: A number of TCHHS management staff reported a delay in receiving clinical audit results conducted outside of the Cairns-based hub. This was perceived to be a result of low computer literacy levels among some staff members rather than difficulties with physical access or connectivity. CQI Recommendation: 1. A computer literacy course that considers important cultural factors that may influence motivation for acquiring computer skills would help to ensure the timely submission of clinical audit results.

1.3 B The organisation’s structure and environment encourage staff responsibility, initiative and cooperative work practices.

Met HRM Documents/Records: Review of human resource management documents found the organisation's structure and environment encourage staff responsibility, initiative and cooperative work practices. Staff Interview: Staff interviewed were able to describe how they are supervised and the support they receive in their role. Improvement Opportunities

Met




Evidence Questions



Management Interview: A common concern of staff and community members on the outer islands of the Northern Sector was the limited information provided about locum staff. One staff member stated "we don’t know who we’re getting and it makes us worry if they haven’t been here before.” Some community members reported feeling anxious when a regular staff member left the island for leave or training purposes. CQI Recommendation: 1. Consider providing regular staff with further information on the experience and skill set of locum staff prior to their arrival. This information could then be communicated to the local community.

1.3 C Administration and personnel systems operate efficiently to support the work of staff and the organisation’s effective functioning.

Met HRM Documents/Records: Review of human resource management documents found administrative and personnel systems in place to support staff. Improvement Opportunities Staff Interview: A common concern outside of the Cairns-based hub was lack of administrative support for key positions. One staff member reported feeling “swamped” by paperwork which compromised her ability to perform in her assigned role. The Accreditation Team would like to highlight the lack of administrative support for the Nursing Director at Bamaga Hospital as a particular area of need. CQI Recommendation: 1. Review administrative support for key positions across the organisation. The ATSIHW’s interviewed described a number of factors that increased the difficulty of their day to day work. These included managing requests for support outside of working hours, dealing with grief and loss, setting boundaries and working with family members. These difficulties were more prominent for ATSIHW’s living in remote locations with most relying on their co-workers or family for support. Of the employees interviewed, both ATSIHW’s and non-ATSIHW’s, none were able to identify ATSIHW’s employee support services outside of the Employee Assistance Program (EAP). ATSIHW’s are likely to

Met




Evidence Questions



experience additional difficulties within the workforce, particularly those individuals who are living and working in remote communities. CQI Recommendation: 1. A range of resources are available to support ATSIHW’s well-being and all staff should be made aware of these resources.

1.3 D Orientation, support and development needs of staff are systematically identified and met in a way that supports the organisation’s goals.

Met HRM Documents/Records: Review of human resource management documents found orientation, support and development needs of staff are systematically identified and met. Volunteer Interview: There were no volunteers available to interview at the time of the Accreditation Survey. Improvement Opportunities Staff Interview: Staff interview suggests that additional support is required for staff members who are returning to a role after extended leave, secondment or other absence. This is also likely to apply to existing staff members who are relocated to a new position or role. CQI Recommendation: 1. Review the current time frames for a refresher induction for staff members returning to work after a long absence. Existing staff members who are changing roles may need further induction training in order to understand their new duties, processes and occupational health and safety requirements. TCHHS supports ATSIHW’s to achieve Certificate III and IV in Aboriginal and/or Torres Strait Islander Primary Health Care. Staff interviewed at one site in the Northern Sector stated that these qualifications “are all about Aboriginal people” with little consideration of the great diversity between Aboriginal and Torres Strait Islander cultural groups. CQI Recommendation: 1. Liaise with the course provider to ensure that the syllabus is culturally appropriate and

Met




Evidence Questions



inclusive of both Aboriginal and Torres Strait Islander People.

1.3 E A system exists to remedy situations where staff have acted inappropriately, or provided poor or unacceptable services.

Met HRM Documents/Records: Review of human resource management documents found processes in place to manage inappropriate staff behaviour or service. Management Interview: Interview with management staff confirmed a process is in place for dealing with inappropriate, poor or unacceptable services.

Met

Standard: 1.4 Physical Resources The organisation’s physical resources are managed to ensure an effective safe and efficient service.

Rating: Met

Evidence Questions



1.4 A The organisation’s assets are adequate to meet its goals.

Met Financial Documents/Records: The systems and processes for managing the organisation’s physical resources, overseen by the CEO, Executive, and the Finance Committee are effective to ensure the resources are adequate for the organisation’s and consumers needs. Improvement Opportunities Financial Documents/Records: The evidence provided failed to demonstrate that a robust system is in place for the scheduling of preventative maintenance. CQI Recommendation: 1. A robust system be developed for the scheduling of preventative maintenance.

Met

1.4 B The organisation’s needs for physical resources are regularly reviewed?

Met Financial Documents/Records: Inventories are reviewed annually and asset registers maintained, while maintenance and repair of assets is performed as scheduled or as needed. Effective stewardship of physical resources is demonstrated through systemic monitoring.

Met




Evidence Questions



1.4 C Equipment and facilities are organised, recorded and regularly maintained to ensure a safe, effective, accessible and comfortable service?

Met Facilities and Equipment: There are effective preventative and reactive maintenance systems and processes for building and equipment. Work site inspections are regularly undertaken. Electrical tagging has been completed and is up to date. Fire suppression equipment is regularly checked and is up to date. The BEMS system effectively monitors equipment on sites including fridges, generators and power supply. Management Interview: Interview with management staff confirmed a process is in place to ensure safe and effective service. Safety and Quality Documents/Records: Review of OHS audits and maintenance schedules shows equipment and facilities are regularly maintained and reviewed. Improvement Opportunities Facilities and Equipment: The surveyors identified items which require attention under preventative maintenance. The TI generator diesel fuel storage tank has been isolated for 6 months; only an informal agreement with other fuel supply source. There is a guarantee for second back-up generator [if required] with the mains supplier but only if the supplier interrupts the supply, not if there is a storm. There are no communication devices at Thursday Island Hospital [hand held radios] between the chief fire warden and the various other wardens. Ageing equipment – UPS and generator failure identified as responsible factors for spike in cold chain breech.

Met




Evidence Questions



A site inspection of Bamaga hospital found that the storage shed for propane gas cylinders is located next to the helicopter landing zone. CQI Recommendations: 1. It is recommended that the organisation: a) Reviews the sound proofing of the interview room of the mental health service at Bamaga or moves interviews to another room. b) Review PPE signage across the sites to ensure that it is specific, uniform and appropriately sited and that all staff and VMO's receive education on the appropriate selection of PPE. c) Ensure the equipment and drainage at the mortuary at Bamaga are fit-for-purpose. d) Include the lot number, batch number and expiry of testing kits for as part of water testing records for renal dialysis. e) Ensure there is a replacement satellite phone for the Bamaga mental health team. 2. Arrangements for an alternative fuel supply to the TI generator diesel fuel storage tank need to be formalised and contingency plans are in place for interruptions to supply caused by natural weather events and disasters. 3. Ensure there are no communication devices [hand held radios] between the chief fire warden and the various other wardens. 4. Review ageing equipment regarding potential for uninterrupted power supply (UPS) and generator failure to ensure the potential for cold chain breeches is minimised. 5. Undertake a risk assessment associated with storage of propane gas cylinders at Bamaga Hospital. Management Interview: Management identified the need for more accommodation for permanent and relief staff across the Torres and Cape Regions to attract and retain staff due to limited and expensive accommodation options. TCHHS staff report restrictions to ‘Breast Screen’ mammography services due to unsealed roads compromising sensitive screening equipment. CQI Recommendation:




Evidence Questions



1. Consider in master planning and regionalism a potential ratio/formula for assessing the adequacy of accommodation options. 2. Develop a ‘Treatment Action Plan’ to address insufficiencies in ‘Breast Screen’ service provision. Safety and Quality Documents/Records: The surveyors identified several safety items which require review. CQI Recommendation: 1. It is recommended that: a) the organisation risk assess the location of the propane gas cylinders at Bamaga Hospital. b) The mental health team at Bamaga be provided with replacement satellite phones. c) there be a review of all power sources to ensure that site satisfactory power back-up is available d) the main diesel storage supply on Thursday Island is returned to operation as soon as possible and that arrangements for other fuel supplies or generating capacity are reviewed and revised. e) the organisation review the communication systems for the fire wardens and ensure that they are adequate. f) the organisation develop an action plan for transport logistics in consideration of environmental risks (mitigation) due to the remoteness of the health clinics.

1.4 D The organisation plans and implements responsible environmental practices and reviews those practices.

Met Safety and Quality Documents/Records: Ten community health clinics currently use solar power. Procurement decisions for vehicles include consideration of carbon emissions. There are recycling programs onsite for reducing paper usage, ink cartridges and packaging.

Met

Standard: 1.5 Financial Management The organisation’s financial management reflects its goals and supports an efficient and sustainable service.

Rating: Met

Evidence Questions






Evidence Questions



1.5 A Systems are in place to ensure all financial reporting requirements are met.

Met Board Interview: Board members interviewed could describe the organisation's financial position. Financial Documents/Records: There are clear delegations of authority set for expenditure, which are adhered to, monitored, and updated as changes occur in the organisation. The financial delegations documents and financial management framework clearly defines financial approval levels for positions within each position and the detailed authorisations applicable to those levels. Financial Interview: Finance reports are discussed with managers and strategies for managing variances. Governance Documents/Records: Review of board reports shows financial performance is reported to the governance structure.

Met

1.5 B Accounting methods meet industry standards and legislative requirements.

Met Financial Documents/Records: Comprehensive financial reporting and monitoring processes are in place. Accounting methods match industry standards and are adhered to, monitored, and updated as changes occur in the organisation and legislation. The Financial Delegations clearly define financial approval levels for positions within each area and the detailed authorisations applicable to those levels. Financial Interview: Interview with finance staff confirmed financial practices meets industry and legislative standards.

Met

1.5 C Financial management is transparent and resource decisions are justifiable to appropriate stakeholders.

Met Board Interview: Interview with the Board confirmed they monitor the organisation's financial performance. CEO Interview: The CEO interviewed could describe the organisations financial performance.

Met




Evidence Questions



Financial Documents/Records: Management and staff participate in the budget planning processes and receive regular updates on income and expenditure. Auditing of accounts and acquittals occur as regulated. Financial Interview: Interview with finance staff confirmed financial management processes are transparent and resource decisions are justifiable to appropriate stakeholders. Improvement Opportunities Financial Documents/Records: The financial delegations require review in relation to the remote context and necessity for expediency in decision making. CQI Recommendation: 1. It is recommended that the organisation: a) review financial delegations to ensure that they are reasonable for each circumstance. b) review financial delegations for organisational governance verses project governance.

1.5 D Sufficient forward planning is undertaken for the organisation to provide an effective and sustained service and meet its financial obligations.

Met Financial Documents/Records: Annual and quarterly budget process ensures reviews of financial requirements from risk perspective to ensure effective expenditure and linked to planning documents to enable achievement of objectives. Financial Interview: Interview with finance staff confirmed planning is undertaken for the organisation to provide an effective and sustained service.

Met

1.5 E Financial goals support the organisation’s goals.

Met Financial Documents/Records: The Strategic Plan is linked to budget planning. New initiatives are required to have a business case which forms part of the project proposal. Managers sighted several examples of new projects which were required to have a business case developed, together with a risk management plan. Financial Interview: Interview with finance staff confirmed budgeting is undertaken to ensure the

Met




Evidence Questions



organisations goals.

Standard: 1.6 Knowledge Management Knowledge (including research and the collection storage and sharing of information) is managed in a systematic ethical and secure way and the organisation uses it to inform service review and development.

Rating: Met

Evidence Questions



1.6 A The organisation keeps up to date with current trends in its field and uses demographic and research data to improve outcomes for its consumers.

Met Facilities and Equipment: Inspection of the organisations equipment and facilities shows resources including practice manuals, research reports, articles are available to staff. HRM Documents/Records: Review of memberships and participation records shows that the organisation is involved in professional/industry associations and networks and participates in networks. Management Interview: Management staff interviewed described how the organisation uses demographic and research data to improve outcomes for consumers. Service Development, Delivery and Management Documents/Records: Review of service management documents shows the organisation keeps up to date with current trends and uses demographic and research data to improve outcomes.

Met

1.6 B Cooperative work practices exist to share knowledge within the organisation.

Met IM/IT and Knowledge Management Documents/Records: Review of knowledge management policy found a system in place for knowledge to be shared within the organisation.

Met

1.6 C Information is stored in an organised way that is easily accessible to approved staff and consumers and, when necessary, is secure and legally compliant.

Met Facilities and Equipment: Inspection of the organisations equipment and facilities shows information is stored securely. Improvement Opportunities

Met




Evidence Questions



IM/IT and Knowledge Management Documents/Records: Staff interview suggests that 'SharePoint' software is underutilised across the organisation. This may be due in part to the preferential use of email or limited access to ongoing training. The use of ‘SharePoint’ should be encouraged and supported by ongoing training opportunities. CQI Recommendation: 1. Encourage the use of ‘SharePoint’ across the organisation. TCHHS staff may require additional training to maximise the potential of the software. The MMEx clinical information system is currently in the design phase. This provides an important opportunity to customise the software. CQI Recommendation: 1. Consider including Research Governance in the design phase of MMEx, specifically the data dictionary, to enable good research practice.

Management Interview: The Torres and Cape Tuberculosis Control Unit is tasked with the diagnosis, treatment and case management of active tuberculosis in accordance with the Queensland Government Health Service Directive for Tuberculosis (TB) Control. It is a requirement that clinical information is entered into Tuberculosis and Related Diseases Information System (TARDIS). Staff interview suggests that surveillance data is currently managed on a Microsoft Excel spreadsheet. CQI Recommendation: 1. Enter all clinically relevant data directly into TARDIS to ensure full compliance with the Health Service Directive for TB Control.

Staff interview suggests that data management across a range of programs could be strengthened in terms of data collection and organisation (e.g. spreadsheets, databases), data security (e.g. reduce the risk of data breach) and data preservation and sharing with others (e.g. data policies and dissemination approaches).




Evidence Questions



CQI Recommendation: 1. Ensure the data management plan is periodically reviewed and revised according to the needs of the health service and any changes in protocol. It is further recommended that the organisation seek input from the Director of Aboriginal and Torres Strait Islander Health and the Chief Information Officer.

1.6 D Protocols on the sharing of information about consumers exist and are used.

Met Service Development, Delivery and Management Documents/Records: Review of policies shows processes for sharing of information about consumers is in place. Improvement Opportunities Service Development, Delivery and Management Documents/Records: The Torres and Cape TB Control Unit and the Cairns TB Control Unit are required to share data in order to fulfil surveillance objectives. Staff interview suggests that the time to first consultation, diagnosis and treatment in the Torres and Cape could be shortened through data linkage i.e. screening cannot occur in the Torres and Cape until data is requested and provided by the Cairns TB Control Unit. CQI Recommendation: 1. Explore opportunities for data linkage between the Torres and Cape Tuberculosis Control Unit and the Cairns TB Control Unit in order to meet surveillance objectives in the timeliest manner. Staff interview suggests that the Torres Strait Island Regional Council and Australian Border Force are not informed when a Papua New Guinea resident with a diagnosis of infectious TB is commenced on treatment. CQI Recommendation: 1. Consider sharing information with Torres Strait Island Regional Council and Australian Border Force (subject to information privacy and confidentiality) with the aim of supporting an effective and coordinated response to TB control.

Met




Evidence Questions



There is growing international consensus that oral health is a key determinant of overall health and quality of life. A relationship has been suggested between poor oral health and a number of medical conditions. It may be beneficial to support sharing of relevant information between the patient’s dental record and their medical record. CQI Recommendation: 1. Explore the potential for information sharing between the patient’s dental record and medical record where relevant i.e. rheumatic heart disease. For example, Oral Health clinical records could be incorporated into MMeX.

1.6 E Data on the use of services and advances in the field are collected and used in planning, evaluation and quality improvement.

Met Evaluation and Feedback Documents/Records: Review of consumer/stakeholder feedback reports shows data is collected and used for planning, evaluation and quality improvement. Improvement Opportunities Evaluation and Feedback Documents/Records: Staff interviewed demonstrated a commitment to continually improving services and programs through the collection, analysis and use of consumer feedback. The quality and safety of these services and programs could be further improved by seeking specific feedback about each service and program, by examining their performance along the patient journey and by comparing results over time. For example, mental health services have been increased from 5 days to 7 days per week at some sites but consumer and carer feedback is lacking. CQI Recommendation: 1. Consider the use of tailored surveys to enable specific areas of care to be examined in greater depth, examine performance along the patient journey and compare the results over time.

Met

1.6 F Staff are involved in the collection, analysis and use of data to improve services and programs and time is allocated for these activities.

Met Service Development, Delivery and Management Documents/Records: Staff interview suggests that data management across a range of programs could be strengthened in terms of data collection and organisation (e.g. spreadsheets, databases), data security (e.g. reduce the risk of data breach) and data preservation and sharing with others (e.g. data policies and dissemination approaches).

Met




Evidence Questions



CQI Recommendation: 1. Ensure the data management plan is periodically reviewed and revised according to the needs of the health service and any changes in protocol. It is further recommended that the organisation seek input from the Director of Aboriginal and Torres Strait Islander Health and the Chief Information Officer.

1.6 G The organisation maintains a comprehensive, confidential, secure and accurate record system for each consumer.

Met IM/IT and Knowledge Management Documents/Records: Review of the records/file management policy found a system in place to ensure each consumer has a comprehensive, confidential, secure and accurate record. Improvement Opportunities Staff Interview: Staff interview found double documentation of patient clinical records is occurring across a number of sites. For example, staff are documenting patient information in the paper record and then manually entering data into the clinical management software ‘Best Practice’. This may result in inconsistencies between patient medical records. CQI Recommendation: 1. It is the understanding of the Accreditation Team that the Primary Health Care paper record is considered ‘the source of truth’ by TCHHS. Paper records should be scanned and entered into ‘Best Practice’ where possible.

Met

Standard: 1.7 Risk Assessment and Management The organisation identifies, assesses and manages risks to ensure continuous safe, responsive and efficient services.

Rating: Met

Evidence Questions



1.7 A The organisation understands that risk has dimensions that include strategic, governance, operational, property, financial and clinical risks.

Met Board Interview: The Quality and Safety Committee oversees the effective implementation of the risk management and business continuity systems. Risks are analysed and discussed and compliance with regulations is assured. New risks are identified and added to the risk register. Risk assessments are facilitated where required, to enable project success

Met




Evidence Questions



through risk mitigation, where possible. CEO Interview: The CEO interviewed could describe how organisational risk is identified and managed across the organisation. Clinical Governance Documents/Records: Review of the Clinical Risk Management Framework shows the organisation has processes in place to manage clinical risks. Financial Interview: Interview with finance staff confirmed financial risk is considered as part of organisation wide risk management. Risk Management Documents/Records: Risks are considered per the Risk Management Policy across the various dimensions of risk including clinical risk, OHS, human resources, organisational, reputation and image and financial. These risks are considered as well during any planning activity.

1.7 B The organisation complies with the legislative context in which it operates and which defines relevant risks.

Met Board Interview: Board interviewed could describe the legislative context in which it operates and how it complies with each requirement. CEO Interview: The CEO interviewed could describe how the organisation complies with legislative requirements. Legislative Compliance Documents/Records: Review of legislative/regulatory compliance schedule identifies relevant laws and regulations in relation to managing organisational risk. Risk Management Documents/Records: Risk management is integrated into the routine business of the organisation with

Met




Evidence Questions



effective recording, timely risk mitigation responses and ongoing performance monitoring at all levels of the organisation. There is an effective reporting system to record and report patient/client and staff incidents, hazards and consumer feedback to strengthen incident reporting processes.

1.7 C There are planned and systematic ways of collecting and analysing data that address potential and actual risks to the organisation as a whole and to the services it provides.

Met Management Interview: Interview with management staff confirmed they are involved in identifying and managing risk across the organisation. Risk Management Documents/Records: Review of risk management documents shows the organisation has a system in place for collecting and analysing data. Staff Interview: Staff interviewed were able to describe what they would do if they identified a risk or issue.

Met

1.7 D Procedures are implemented to manage and respond to risks in a timely way.

Met Risk Management Documents/Records: Review of risk management documents shows processes are in place to manage risks.

Met

Standard: 1.8 Legal and Regulatory Compliance The organisation ensures compliance with all relevant laws and regulations.

Rating: Met

Evidence Questions



1.8 A Is aware of the legislative framework that applies to its operations.

Met Legislative Compliance Documents/Records: Review of policies and procedures show relevant legislation/regulations that applies to the organisation and its operations.

Met

1.8 B Maintains internal processes to monitor compliance regularly

Met CEO Interview: The CEO interviewed could describe the process in place that monitors compliance. Legislative Compliance Documents/Records: Compliance obligations are documented and accessible to all relevant staff through the policy and procedure system. Policy/procedure custodians ensure these documents

Met




Evidence Questions



accurately reflect legislative/regulatory requirements. Financial compliance is assessed and audits occurs annually to review legal and financial compliance. Legislative alerts provide regular updates on changes to legislation and related information, as well as updates on other key State and national compliance requirements and best practice matters in the health sector.

1.8 C Has and uses protocols to remedy the situation whenever non-compliance occurs.

Met Safety and Quality Documents/Records: Internal audits effectively assess and report on compliance to OHS legislation. Risks are analysed and discussed and compliance with regulations is assured. Risk assessments are facilitated where required.

Met

1.8 D Fulfils all reporting requirements regarding legal compliance.

Met Legislative Compliance Documents/Records: Review of legislative compliance records shows the organisation fulfils all legal reporting requirements.

Met

Standard: 1.9 Safety and Quality Integration Safety and quality systems are integrated and are managed systematically with clear lines of accountability to ensure continuously improving performance.

Rating: Met

Evidence Questions



1.9 A The organisation has specified safety and quality performance requirements.

Met CEO Interview: The Health Service Chief Executive (HSCE) together with the other members of the Executive Leadership Team guide the ongoing development of an organisational culture that is dedicated to continuous safety and quality improvement. This provides a solid foundation for the 2015 ‘TCHHS Clinical Governance Safety and Quality Framework’ which clearly outlines organisational and individual accountabilities and key principles and practices necessary for the planning, implementation and monitoring of health services. Interview with ‘front line’ staff across the organisation provides additional evidence that the HSCE makes a significant contribution to safety and quality improvement activities.

Met




Evidence Questions



Management Interview: Management staff interviewed could describe processes in place that ensure services being provided are safe for the client and of high quality. Safety and Quality Documents/Records: Review of safety and quality documents shows the organisation has specified safety and quality performance requirements.

1.9 B There are cross organisational forums, processes and procedures for ensuring communication, planning and learning about safety and quality.

Met Management Interview: Interview with management staff confirmed they have undertaken education and training on safety and quality. Safety and Quality Documents/Records: Review of safety and quality documents shows communication, planning and learning about safety and quality across the organisation. Improvement Opportunities HRM Documents/Records: Management interview suggests that TCHHS is committed to fostering workplaces free from occupational violence towards or between staff, consumers/carers and other visitors. Online training for the prevention and management of occupational violence is currently in place. This training should be used to support and reinforce face-to-face training programs. CQI Recommendation: 1. Progress with the development of face-to-face training for the prevention and management of occupational violence where reasonably practicable and reflective of local need.

Met

1.9 C Responsibility for managing and leading safety and quality improvement is assigned, those responsible are accountable, and routine reporting of safety and quality performance to senior

Met Governance Documents/Records: Review of Board reports shows safety and quality performance of the organisation is reported to the governance structure. HRM Documents/Records:

Met




Evidence Questions



management and the governance structure occurs.

Review of position descriptions found safety and quality roles are assigned.

1.9 D Service and program evaluation is routinely conducted and findings are used to for future planning and decision-making.

Met Evaluation and Feedback Documents/Records: Review of service/program reports shows evaluation is conducted and findings are used for future planning and decision making. Management Interview: Management staff interviewed could describe how service and program evaluation is routinely conducted and how the findings are used.

Met

1.9 E The organisation has an integrated complaints mechanism and complaints are addressed in a fair and timely way.

Met Consumer Interview: Interview with the consumer representatives confirmed the service has a complaints process in place. Evaluation and Feedback Documents/Records: Review of complaints policy and register shows a complaints process is in place and complaints are addressed in a fair and timely way. Management Interview: Management staff interviewed could describe the process for complaint management.

Met

1.9 F Safety incidents are managed and reported, and future planning is informed by data and analysis arising from such incidents.

Met Management Interview: Management staff interviewed could describe the process for safety incident management. Safety and Quality Documents/Records: Review of safety incident documents, registers and reports shows safety is managed and reported and future planning undertaken. Staff interviewed were able to describe the process that occurs when a safety incident occurs.

Met




2 Providing Quality Services and Programs Standard: 2.1 Assessment and Planning

Assessment and planning are undertaken at individual and community levels to ensure services and programs are responsive to identified needs.

Rating: Met

Evidence Questions



2.1 A Data collection, needs assessment and analysis are routine and systematic.

Met Governance Documents/Records: Review of needs analysis shows collection and assessment of community needs is undertaken. Service Development, Delivery and Management Documents/Records: Review of service documents shows data collection, needs assessment and analysis are undertaken routinely. Staff Interview: Staff interviewed were consistent across programs and disciplines in their responses on how they conduct assessments and health care planning. Clinical review meetings help with input and assists with the ongoing treatment. Data is collected and used to plan and develop future consumer/patient treatment approaches. Improvement Opportunities Service Development, Delivery and Management Documents/Records: Although patient feedback is routinely collected and analysed to understand service need and performance, this process requires further development. CQI Recommendation: 1. Patient feedback should be actively encouraged at all steps of the patient journey. For example, feedback should be sought from patients regarding their hospital stay at Cairns Hospital.

Met

2.1 B Communities, consumers and stakeholders are engaged in planning.

Met Clinical Documents/Records: Documents showed a wide range of activities engaging communities, consumers and stakeholders in planning. These include Memorandum of Understanding (MOUs) with stakeholders, partnering with other organisations (Apunapima), providing community education (i.e. diabetes, sexually transmitted diseases), sending newsletters,

Met




Evidence Questions



presentations at schools, consumer representatives, partnering with services, and participation on Advisory Committees (CAN's). Consumer Interview: Interview with the consumer/community representatives confirmed they were engaged in the planning of their care. Evaluation and Feedback Documents/Records: The move towards Regionalisation/Transition to Community Control has involved the development of a number of working groups with the community to bring about the transformation. This includes the CEO Group, Service Redesign and Innovation Group, Information Sharing Group and Health Intelligence Group. Part of the aim is for staff to relocate into areas to live and provide services at the local level. This initiative involves a range of partnering and collaborative arrangements with groups such as the Primary Health Network (PHN’s), Allied Health and local communities. Staff Interview: Staff interviewed were able to explain how community, consumers/patients/clients and stakeholders are engaged in service and program planning. Improvement Opportunities Clinical Documents/Records: The community and relevant individuals are not always consulted on special health promotion projects. CQI Recommendation: 1.Ensure there is consultation with the communities and relevant individuals on their expectations for any special health promotion projects. Evaluation and Feedback Documents/Records: There are opportunities to strengthen consumer and community engagement. CQI Recommendation: 1. Include consumers and the community in: a) training staff




Evidence Questions



b) facility refurbishment and design c) artwork

2.1 C Services and programs are developed to respond to identified needs.

Met Management Interview: Management staff interviewed could describe how services and programs are developed to respond to identified needs of the community. Service Development, Delivery and Management Documents/Records: Review of proposals and implementation plans for new programs and services shows these are developed to respond to identified needs.

Met

2.1 D Plans with measurable outcomes are developed and used.

Met Clinical Documents/Records: Review of case/care plans confirm measurable outcomes are developed and used. Service Development, Delivery and Management Documents/Records: Review of service/program plans shows measurable outcomes are in place. Stakeholder Interview: Interview with stakeholders confirmed plans with measurable outcomes are developed and used.

Met

2.1 E Assessments and plans are documented. Met Clinical Documents/Records: Files reviewed confirm that consumer/client/patient assessments and plans are documented. The clinical handbooks provide guidance for staff in assessment and case review, particularly for chronic disease management.

Met

2.1 F Assessment and planning processes and structures are evaluated.

Met Clinical Documents/Records: Evaluations of assessments and planning occurs in weekly clinical reviews, supervision and file audits. Clinical policies and procedures are reviewed according to a schedule and updated as required. Service Development, Delivery and Management Documents/Records: Review of service/program reports shows assessment and planning processes are evaluated.

Met

2.1 G Service and program planning is linked to the organisation’s strategic priorities.

Met Service Development, Delivery and Management Documents/Records: Review of service/program plans shows planning is linked to strategic priorities.

Met




Standard: 2.2 Focusing on Positive Outcomes Services and programs are provided in an effective, safe and responsive way to ensure positive outcomes for consumers and communities.

Rating: Met

Evidence Questions



2.2 A Interventions and actions are based on assessment and planning.

Met Clinical Documents/Records: Interventions and actions are based on assessment and planning. Service Development, Delivery and Management Documents/Records: Review of service/program manuals shows interventions and actions are based on assessment and planning.

Met

2.2 B Services and programs are managed to ensure positive outcomes for consumers and communities.

Met Consumer Interview: Interview with the consumer representatives confirmed services and programs ensure positive outcomes for consumers and communities. Evaluation and Feedback Documents/Records: Review of evaluation and feedback documents shows services and programs have positive outcomes for consumers and communities. Service Development, Delivery and Management Documents/Records: Review of service management documents shows services and programs are managed to ensure positive outcomes.

Met

2.2 C Information about the rationale, risks and effect of services and programs is routinely provided to consumers and communities.

Met Clinical Documents/Records: Information about the rationale, risk and effect of services and programs is routinely provided to consumers and communities. Consumer Documents/Records: Review of documentation provided to consumers shows information about the rationale, risks and effect of services and programs. Staff Interview: Staff interviewed were able to explain how information the service and programs is provided to consumers and communities.

Met




Evidence Questions



2.2 D Consumers and communities participate in decision-making about services and programs they receive.

Met Clinical Documents/Records: Review of case/care plans shows agreed goals of care and strategies to achieve these goals. Evaluation and Feedback Documents/Records: Review of evaluation and feedback documents shows consumers and communities participate in decision-making about services and programs they receive. Improvement Opportunities Staff Interview: The development of the Nurse Navigator and Indigenous Nurse Navigator Support Officer role has resulted in measurable improvements in patient outcomes (i.e. hospital avoidance) and a significant reduction in costs associated with patient travel and accommodation. Although patient feedback is routinely collected and analysed to understand service need and performance, this process requires further development. CQI Recommendation: 1. Consider encouraging patient feedback along all steps of the patient journey. For example, feedback could be sought from patients regarding their hospital stay at Cairns Hospital.

Met

2.2 E Services and programs are safe and risks are identified and addressed.

Met Clinical Governance Documents/Records: Review of consumer files showed risks are considered in the assessment of each consumer. Risk Management Documents/Records: Review of risk management documents shows risks are identified and addressed for services and programs.

Met

2.2 F This indicator relates to organisations providing direct services to individuals and families only. Service and clinical governance systems are in place.

Met CEO Interview: The Health Service Chief Executive interviewed demonstrated an expert understanding of the TCHHS Clinical Governance Safety and Quality Framework and how clinical risks are managed. Interview with 'front line' staff across the organisation suggests that the HSCE and the Executive Leadership Team promote a sound risk culture that helps to ensure all significant risks are identified and appropriately managed.

Met




Evidence Questions



Clinical Governance Documents/Records: Review of the Clinical Governance Framework, policy and procedures shows clinical governance systems are in place. Clinical Interview: Interview with clinical staff confirmed there is a clinical governance framework in place. Management Interview: Management staff interviewed could describe the clinical governance systems in place. Service Development, Delivery and Management Documents/Records: Review of service governance framework/policy shows a service and clinical governance system is in place.

2.2 G This indicator relates to organisations providing direct services to individuals and families only. Intake is integrated and priority-based.

Met Management Interview: Management staff interviewed could describe the intake process and what priority-based systems are in place. Service Development, Delivery and Management Documents/Records: Review of entry/intake policy and procedures shows a system in place to ensure intake is integrated and priority based. Staff interviewed could explain how the organisation manages waiting lists.

Met

2.2 H This indicator relates to organisations providing direct services to individuals and families only. Effective referral practices are in operation.

Met Service Development, Delivery and Management Documents/Records: Review of referral policy and procedures shows effective referral processes in place. Staff Interview: Staff interviewed could describe the referral processes in place.

Met

2.2 I This indicator relates to organisations providing direct services to individuals and families only.

Met Management Interview: Management staff interviewed could describe how the services and programs provided by the organisation are evidence based.

Met




Evidence Questions



Services and programs are evidence based.

Service Development, Delivery and Management Documents/Records: Review of service/program manuals shows evidence based guidelines are included.

2.2 J This indicator relates to organisations providing direct services to individuals and families only. Services and programs follow case/care plans developed with consumers.

Met Clinical Documents/Records: Review of case/care plans shows consumer involvement. Consumer Interview: Interview with the consumer representatives confirms they were involved in developing their case/care plans. Service Development, Delivery and Management Documents/Records: Review of case/care planning policy and procedures shows processes are in place to ensure case/care plans are developed with consumers. Improvement Opportunities Staff Interview: TCHHS encourages the involvement of consumers/carers in shift-to-shift handover by undertaking bedside handover where possible. This allows for a more accurate and complete information exchange while respecting the right of consumers/carers to be involved in making decisions about their health care. Staff interview suggests there are variable handover practices across the organisation with regards to consumer/carer involvement particularly in the Southern Sector. The involvement of consumers/carers in clinical handover should be consistent across the organisation. CQI Recommendation: 1. Consider a review of current handover practices and improve them as required.

Met

2.2 K This indicator relates to organisations providing direct services to individuals and families only. Re-assessment occurs after services and/or program is provided to check effectiveness.

Met Clinical Documents/Records: Review of case/care plans shows review dates and effectiveness measures. Clinical Interview: Interview with clinical staff confirmed that service provisions outcomes are monitored to check effectiveness.

Met




Evidence Questions



Service Development, Delivery and Management Documents/Records: Review of case/care plans shows re-assessment occurs after the service/program is provided.

2.2 L This indicator relates to organisations providing direct services to individuals and families only. Processes are in place for managing demand when it exceeds capacity to provide services and programs.

Met Clinical Interview: Interview with clinical staff confirmed that processes are in place for managing demand when it exceeds capacity to provide services and programs. Service Development, Delivery and Management Documents/Records: Review of service management documents shows processes are in place for managing demand when it exceeds capacity to provide services and programs.

Met

2.2 M This indicator relates to organisations providing direct services to individuals and families only. Client and community outcomes are documented and clear, accurate and secure client and program records are kept.

Met Clinical Documents/Records: Client and community outcomes are documented and clear, accurate and secure client and program records are kept. Management Interview: Management staff interviewed could describe how consumer records and outcomes are clearly recorded, accurate, remain confidential and secure. Staff interviewed could describe how consumer records remain confidential and secure.

Met

2.2 N This indicator relates to organisations providing direct services to individuals and families only. Service and program provision are routinely evaluated and the findings used for improvement.

Met Clinical Interview: Interview with clinical staff confirmed processes are in place to evaluate service outcomes. Improvement Opportunities Evaluation and Feedback Documents/Records: The Torres and Cape TB Control Unit should be commended for their commitment to optimising patient outcomes, program resources and public health surveillance. Improvements in data management will help to ensure that services and programs are provided in an effective safe and responsive way. CQI Recommendation: 1. As per the Queensland Health Service Directive for TB control, all data should be entered into the electronic case management database.

Met




Evidence Questions



2.2 O This indicator relates to organisations providing direct services to individuals and families only. Incidents, adverse events and near misses are reported, and reports are used to inform improvements.

Met Clinical Interview: Interview with clinical staff confirmed that processes are in place for reporting incidents, accidents and near misses in services. Safety and Quality Documents/Records: Review of safety incident documents, registers and reports shows incidents, adverse events and near misses are reported and improvements implemented.

Met

2.2 P This indicator relates to organisations providing direct services to individuals and families only. Where appropriate, case closure is planned with the consumer.

Met Clinical Documents/Records: Where appropriate, case closure is planned with the consumer. Management Interview: Management staff interviewed could describe how case closure is planned with the consumer. Service Development, Delivery and Management Documents/Records: Review of exit planning documents shows case closure is planned with the consumer. Staff interviewed could explain how case closure is planned with the consumer.

Met

Standard: 2.3 Ensuring Cultural Safety and Appropriateness Services and programs are provided in a culturally safe and appropriate manner.

Rating: Met

Evidence Questions



2.3 A Processes and practices ensure respect and responsiveness to consumer diversity by being inclusive and flexible.

Met Consumer Interview: Interview with the consumer representatives confirmed they were respected at all times. Facilities and Equipment: Inspection of the organisations facilities shows consumer resources available in a limited range of other languages. The Australian Translating and Interpreting Service is available 24 hours per day 7 days per week as required.

Met




Evidence Questions



Governance Documents/Records: Review of cultural diversity policy, procedures and plans shows processes are in place to ensure respect and responsiveness to consumer diversity.

2.3 B The changing profile of consumers is monitored.

Met Evaluation and Feedback Documents/Records: Review of consumer data reports shows the changing profile of consumers is monitored. Governance Documents/Records: Review of a community profiling document shows the consumer changing profile is monitored. Management Interview: Management staff interviewed could describe how the changing profile of consumers is monitored.

Met

2.3 C Appropriate links with indigenous and other community groups are established to ensure that services and programs remain responsive and respectful.

Met Service Development, Delivery and Management Documents/Records: Review of meeting records shows links with indigenous and other community groups are established. Staff Interview: Staff interviewed could describe initiatives undertaken by the organisation to develop relationships with indigenous and community groups. Stakeholder Interview: Interview with stakeholders confirmed initiatives have been taken by the organisation to develop relationships with indigenous and community groups.

Met

2.3 D Professional development regarding consumer diversity is available to staff.

Met HRM Documents/Records: Review of training records found consumer diversity training is conducted.

Met

2.3 E Cultural safety is addressed in service and program plans.

Met Management Interview: Management staff interviewed could describe how services are delivered in a way which provides a safe environment for people from different community groups. Service Development, Delivery and Management Documents/Records: Review of service management documents shows cultural safety is addressed in service

Met




Evidence Questions



and program plans. Improvement Opportunities Management Interview: Interview with Management Staff in the Southern Sector highlighted the need to ensure that the physical environment and facilities of the health service are adequate to meet the cultural needs of Aboriginal and Torres Strait Islander people. There were suggestions that culturally appropriate artwork and signage across the health service would add to the cultural appropriateness of the service. In addition, patient care areas should be designed to protect patient privacy/confidentiality with separate areas for men and women where appropriate. CQI Recommendation: 1. Seek further input from local communities on the cultural appropriateness of health care facilities as part of a broader approach to facilitating a culturally respectful association between the TCHHS and Aboriginal and Torres Strait Islander people.

Standard: 2.4 Confirming Consumer Rights Services and programs are provided in a way that strengthens the rights of consumers, empowers them and is ethical.

Rating: Met

Evidence Questions



2.4 A Services are delivered in a respectful way that recognises each consumer’s personal worth and individuality.

Met Consumer Documents/Records: Review of consumer/client/patient documentation shows the service has a charter/statement of consumer rights and responsibilities available. Staff Interview: Staff interviewed could explain how services are delivered respectfully. Staff reported that at the consumer/client/patient's commencement of involvement with the service that staff take time to explain their rights and responsibilities and are provided with a brochure outlining these. The consumer/client/patients are also provided with information of the services available. The consumer/client/patients interviewed

Met




Evidence Questions



confirmed that this occurs and in their interviews they reported that staff treated them respectfully.

2.4 B Consumers’ privacy is ensured, information is confidential and the organisation meets legislative requirements.

Met Facilities and Equipment: Inspection of the organisations equipment and facilities shows privacy is ensured. HRM Documents/Records: Review of human resource management records found confidentiality agreements are in place. Legislative Compliance Documents/Records: Review of the privacy policy shows a process is in place to ensure the organisation meets legislative requirements. Staff Interview: Staff interviewed could explain how consumers/clients/patient privacy is ensured and the legislative requirements for privacy.

Met

2.4 C Eligibility requirements for service and program participation are fair, ethical and transparent.

Met Consumer Documents/Records: Consumer information brochures outline service eligibility requirements which are helpful for referral source including self referrals. Upon commencement of the service, the consumers are provided with privacy statements, rights and responsibilities, information on missed appointments and the evaluation process. These are discussed with consumer and case-noted in consumer files. If needed, an interpreter service is used to ensure that the consumer understands. Service Development, Delivery and Management Documents/Records: Review of service management documents shows fair, ethical and transparent eligibility requirements are in place.

Met

2.4 D Informed consent processes are implemented for service and program provision, and when personal information is gathered, stored, shared and used.

Met Clinical Documents/Records: Review of consumer/client/patient files showed informed consent is documented. Informed consent processes are implemented for service and program provision, and when personal information is gathered, stored, shared and used.

Met




Evidence Questions



Service Development, Delivery and Management Documents/Records: Review of informed consent policy and procedures shows processes are in place. Improvement Opportunities Clinical Documents/Records: Generally, brochures for TCHHS are written in English. CQI Recommendation: 1. Review brochures with community members for consideration of putting in the local language (i.e. rights and responsibilities).

2.4 E Consumers are aware of their rights and responsibilities including complaint, grievance, appeal and conflict resolution procedures, and these procedures are implemented promptly, judiciously and fairly.

Met Consumer Documents/Records: Review of consumer/client/patient documentation shows the service provides them with information on their rights and responsibilities covering complaint, grievance, appeal and conflict resolution procedures. Consumer Interview: Interview with the consumer/client/patient representatives confirmed they are aware of their rights and responsibilities. Staff Interview: All staff interviewed confirmed that consumers/clients/patients are provided with hard copies of their rights and responsibilities at their first treatment session. The information is then discussed and clarified, and if needed an interpreter is used to ensure that the consumers/clients/patients fully understand. Improvement Opportunities Consumer Documents/Records: One of the biggest challenges faced by the TCHHS is the high percentage of people who speak a language other than English including Aboriginal languages and a variety of Creole dialects. This may impact upon the ability of consumers and/or carers to understand their healthcare rights and responsibilities and make appropriate decisions about the services and programs offered. Site inspection finds that there is limited written information regarding patient’s rights and responsibilities and other healthcare

Met




Evidence Questions



information in local languages. CQI Recommendation: 1. Consider the development of health care information including the ‘Australian Charter of Healthcare Rights’ and other health information brochures in local languages.

2.4 F Barriers to service access are identified and addressed, and consumers are supported to access services.

Met Consumer Interview: Interview with the consumer/client/patient representatives confirmed they did not have any difficulties accessing the service. Evaluation and Feedback Documents/Records: Review of consumer/client/patient feedback reports/surveys shows barriers to service access are identified and addressed. Service Development, Delivery and Management Documents/Records: Review of service management documents shows consumers/clients/patients are supported to access services.

Met

2.4 G There are formal and informal mechanisms for consumers to participate in the review, planning and design of services.

Met Consumer Interview: Interview with the consumer/client/patient representatives confirmed they are able to participate in the review, planning and design of services. Evaluation and Feedback Documents/Records: Review of evaluation and feedback documents shows there are formal and informal mechanisms for consumers/clients/patients to participate in the review, planning and design of services.

Met

2.4 H The organisation advocates on behalf of individual consumers at their request and at community and political levels as appropriate.

Met Service Development, Delivery and Management Documents/Records: Review of service management documents shows the organisation advocates on behalf of consumers/clients/patients. For example, coordination of travel for medical procedures and appointments with the passenger transport services to reduce multiple trips, and the introduction of the Nurse Navigator role to assist with continuity of treatment. Staff Interview: Staff interviewed could explain how the organisation advocates for

Met




Evidence Questions



consumers/clients/patients.

2.4 I The organisation specifies the ethical standards expected of personnel in service and program provision and in research, and ensures these standards are met.

Met HRM Documents/Records: Review of the staff/volunteer code of conduct found the organisation specifies the ethical standards expected of personnel.

Met

Standard: 2.5 Coordinating Services and Programs Services and programs within the organisations are coordinated.

Rating: Met

Evidence Questions



2.5 A Coordinates services and programs to meet the needs of consumers.

Met Consumer Interview: The consumers/clients/patients interviewed related that their experience in assessment led to appropriate treatment. Service Development, Delivery and Management Documents/Records: Review of service management documents shows the organisation coordinates services and programs to meet the needs of consumers/clients/patients. TCHHS has a multi-disciplinary workforce which responds to the diverse needs of consumers. The clinical review with such a multi-disciplinary team has positive outcomes for the consumer/client/patient providing a more holistic approach to their health care needs. Staff interviewed related case management across disciplines ensured that the consumer/client/patient was central in the planning of their care in the service. Improvement Opportunities Service Development, Delivery and Management Documents/Records: There is not a calendar of visiting services on the islands for the community members to refer to for planning their time and as a reminder of appointments. CQI Recommendation:

Met




Evidence Questions



1. Implement a calendar of visiting services to the islands for community information. Staff interviews found that information sharing between TCHHS and Queensland Corrective Services regarding previous episodes of care is limited. At the very least, this compromises the ability of the health service to provide continuity of care. However, document review finds that a Memorandum of Understanding (MOU) exists between Queensland Health and Queensland Corrective Services which supports clinicians in sharing of information while safeguarding the patient’s right to confidentiality. CQI Recommendation: 1. Liaise with Queensland Corrective Service to ensure that routine procedures are in place to facilitate the transfer of health information (including mental health) and continuity of care when the patient is released from prison. This information could be captured in MMEx. External information pathways are not always effective and/or consistently followed by staff on both sides. CQI Recommendation: 1. Improve information pathways with external services, including the Queensland Offender Health services and Cairns Hospital. There is a low awareness of support services available to support ATSIHW’s staff. CQI Recommendation: 1. All staff should be made aware of resources available to support well-being.

2.5 B Delivers cross-discipline services seamlessly.

Met Service Development, Delivery and Management Documents/Records: Review of service management documents shows delivery of cross discipline services. The multi-disciplinary approach to consumer/client/patient care results in a more streamlined service for clients. Consumers/clients/patients reported that having access to the different treatment providers in the same location was helpful, especially when they were able to have back to back appointments. Staff interviewed reported on the benefits of Clinical review and handover meetings.

Met




Evidence Questions



2.5 C Supports staff working across different disciplines to coordinate services.

Met HRM Documents/Records: Review of staff/team meeting agenda and minutes shows staff are supported working across different disciplines to coordinate services.

Met

2.5 D Works with consumers to review the effectiveness of coordinated services.

Met Evaluation and Feedback Documents/Records: Review of consumer/client/patient feedback reports shows the organisation involves consumers with service coordination.

Met




3 Sustaining Quality External Relationships Standard: 3.1 Service Agreements and Partnerships

The organisation enters into formal service agreements and other less formal partnerships to ensure a continuous and sustainable service.

Rating: Met

Evidence Questions



3.1 A The organisation works to negotiate service agreements so they are legal, fair and result in quality outcomes for consumers.

Met Service Development, Delivery and Management Documents/Records: A review of documentation confirmed TCHHS has a range of formalised Memoranda of Understanding (MOU), Contracts and Service Agreements in place to ensure equitable and effective service contract and delivery for consumers. Documentation reviewed confirmed the proactive approach of TCHHS in working with other organisations to provide services to all consumer groups in a legal, fair and culturally secure way. Stakeholder Interview: Interviews with a wide range of stakeholders confirmed all have a service agreement with the organisation. Service agreements are in the form of Contracts, Memoranda of Understanding or formal Agreements. Stakeholders stated the agreements meet legislative requirements. Stakeholders commented on TCHHS ability to provide an effective service with limited resources in remote locations. Stakeholders provided information showing the outcomes for their consumers are positive with referrals responded to in a timely manner.

Met

3.1 B The organisation is accountable through its service agreements and partnerships.

Met Service Development, Delivery and Management Documents/Records: Review of service agreements shows a line of accountability.

Met

3.1 C Service agreements and partnerships are reviewed regularly against the values and goals of the organisation and their impact on consumers.

Met Service Development, Delivery and Management Documents/Records: Review of service agreements shows they are aligned with relevant values and goals of organisation as well as the strategic plan.

Met

3.1 D Mechanisms are in place to resolve contractual disputes if they arise.

Met Service Development, Delivery and Management Documents/Records: Review of service management documents shows dispute resolution clauses in service agreements and contracts.

Met

3.1 E Contracted services to consumers are reviewed regularly.

Met Evaluation and Feedback Documents/Records: A review of documentation confirmed management monitor the effectiveness of MOUs, Agreements and Contracts. All staff activities and partnership arrangements are conducted in accordance with the policies and procedures.

Met




Standard: 3.2 Collaboration and Strategic Positioning The organisation collaborates with other organisations and positions itself strategically within the wider service system.

Rating: Met

Evidence Questions



3.2 A Collaborates with other organisations. Met Service Development, Delivery and Management Documents/Records: A review of documentation confirmed TCHHS proactive approach in developing a variety of relationships across the board to ensure the effective provision of services to consumers/clients/patients to meet their needs. A review of meeting minutes confirmed that staff are in constant contact with external services to ensure a shared understanding of the needs of consumers/clients/patients and how barriers to access can be overcome. Stakeholder Interview: Interviews with stakeholders confirmed the organisation works collaboratively across the sector for the benefit of consumers/clients/patients. Stakeholders commented on the proactiveness of TCHHS in arranging localised meetings and providing training that benefits all staff.

Met

3.2 B Collaborations contribute to a more effective use of resources.

Met Financial Documents/Records: A review of documentation confirmed TCHHS works toward effective use of resources.

Met

3.2 C Avoids unnecessary and inefficient duplication of services.

Met Service Development, Delivery and Management Documents/Records: A review of documentation confirmed a wide range of partnerships are in place to avoid unnecessary duplication of services. Improvement Opportunities Service Development, Delivery and Management Documents/Records: The sharing of patient information is an important component of the transfer to community controlled health centres. CQI Recommendation: 1. It is recommended that, with the planned transfer to community controlled health centres, the organisation ensures that the information sharing and service agreements being developed are robust enough to ensure that: a) the sharing of patient information continues both now and in the future. b) Essential services continue such as TB clinics.

Met




Evidence Questions



3.2 D Reviews the effectiveness of any collaboration in terms of consumer outcomes, available resources and the strategic placement of the organisation.

Met CEO Interview: The Health Service Chief Executive interviewed could describe how partnerships with the organisation are reviewed and evaluated. These partnerships include Apunipima Cape York Health Council, Royal Flying Doctor Service (Queensland), Northern Peninsula Area Family and Community Services Aboriginal and Torres Strait Islander Corporation and Cairns and Hinterland Hospital and Health Service. Management Interview: Management interviewed described the system being used to review and evaluate partnerships. They described a process whereby partnerships are reviewed with a view to ensuring consumers/clients/patients are receiving the best available service to met their needs. Management described new services that have been set up as a result of partnerships in the various regions and communities. Service Development, Delivery and Management Documents/Records: Review of service management documents shows evaluation of collaboration with other organisations. Stakeholder Interview: Stakeholders interviewed all confirmed that their individual partnerships are reviewed and evaluated on an ongoing basis. Stakeholders commented that TCHHS works collaboratively across the region and communities for the benefit of consumers/clients/patients.

Met

Standard: 3.3 Incorporation and Contribution to Good Practice The organisation demonstrates that it has incorporated and contributes to currently accepted good practice in its field.

Rating: Met

Evidence Questions



3.3 A Has systems of information collection, research and analysis to keep abreast of developments in its field.

Met CEO Interview: The Health Service Chief Executive interviewed could describe the organisations system for information collection, research and analysis that contributes to the development of

Met




Evidence Questions



best practice. This information was consistent with the 'TCHHS Research Strategy 2017 - 2020'. Service Development, Delivery and Management Documents/Records: Review of service management documents shows there is a system for information collection, research and analysis in place. Improvement Opportunities Governance Documents/Records: A review of the 'TCHHS Research Strategy 2017 - 2020' finds that the Board is committed to a research agenda that provides translational benefits to the communities it serves. However, the methods by which TCHHS will engage local communities in the dissemination and implementation of the research agenda remains unclear. CQI Recommendation: 1. Consider the implementation a community-identified research agenda that is pro-active and reviewed periodically with the communities to ensure that it remains relevant to their needs as well as broader organisational objectives.

3.3 B Uses industry benchmarks to review services and programs.

Met Service Development, Delivery and Management Documents/Records: Review of service management documents shows industry benchmarks are used to review services and programs. Staff Interview: Staff interviewed could describe how industry benchmarks are used to review services and programs.

Met

3.3 C Uses research literature to inform the review and development of its services.

Met Service Development, Delivery and Management Documents/Records: Review of service management documents shows the use of research literature to inform the review and development of its services.

Met

3.3 D Acts on review recommendations in a timely way.

Met Service Development, Delivery and Management Documents/Records: Review of service management documents shows recommendations are acted on in a timely manner.

Met




Evidence Questions



3.3 E Employs a range of internal practices such as mentoring or supervision to share and enhance the skills of staff.

Met HRM Documents/Records: Review of human resource management records found mentoring or supervisions is undertaken. Management Interview: Management staff interviewed could describe how supervision or mentoring of staff occurs in the organisation.

Met

Standard: 3.4 Community and professional capacity building The organisation works to build the capacity of the community it serves and the professional community to which it belongs.

Rating: Met

Evidence Questions



3.4 A Works with its community to address the determinants of wellbeing, to identify needs and to plan and implement appropriate services.

Met CEO Interview: The Health Service Chief Executive (HSCE) interviewed could describe how the organisation is accountable to the community, how it identified the community needs and implements appropriate services. Evaluation and Feedback Documents/Records: Review of consumer/community/stakeholder engagement framework, policy and procedures shows that the organisation has processes in place to work with the community to identify needs and plan services. Service Development, Delivery and Management Documents/Records: Review of service management documents shows the organisation works with the community to identify needs and plan services.

Met

3.4 B Shares information with its community. Met Consumer Documents/Records: Review of consumer documentation shows the service shares information with the community. Governance Documents/Records: Review of the annual report shows the organisation shares information with the

Met




Evidence Questions



community.

3.4 C Participates in professional associations and other forums in its field.

Met Governance Documents/Records: Review of staff development documents shows participation in professional associations and other forums. Staff Interview: Staff interviewed confirmed they participate in professional associations and other forums.

Met

3.4 D Works with other organisations and special needs groups to improve their capacity to meet consumer needs.

Met Service Development, Delivery and Management Documents/Records: Review of service development and management records shows the organisation works with other groups to improve their capacity to meet consumers needs. Stakeholder Interview: Interview with stakeholders confirmed the organisation works with special needs groups.

Met

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