Patient safety

Directive number: QH-HSD-032

Effective date: 9 October 2024

Review date: 9 October 2027

Supersedes: Version 5.0

On this page:

Purpose

The purpose of this Directive is to contribute to fulfilling the requirements for monitoring the quality of health services delivered by Hospital and Health Services, as identified in the Hospital and Health Boards Act 2011. This Health Service Directive specifies the monitoring, reporting and response requirements of Hospital and Health Services for:

  • Clinical Incident Management, including coronial management
  • Congenital syphilis analysis and management
  • Variable Life Adjusted Displays (VLADs) and other National Patient Safety Indicators (PSIs) e.g. Hospital Standardised Mortality Ratios
  • Patient Safety Alerts and Notifications
  • Gastrointestinal Endoscopic Services Quality Framework
  • Clinical Services Capability Framework
  • Accreditation
  • Obtaining informed consent for health care procedures or treatment

Scope

This Directive applies to all Hospital and Health Services.

Principles

  • Patient safety—the collection, monitoring and analysis of clinical incidents and patient outcome data as well as the development of patient safety notifications supports Hospital and Health Services reduce preventable patient harm.
  • Continuous quality improvement—the collection and monitoring of patient outcome data supports Hospital and Health Services identify areas for improvement.
  • System improvement focus—state-wide analysis of clinical incidents and patient outcome data supports Hospital and Health Services to identify and address underlying system issues.
  • Informed care decision-making – enabling patients to make informed decisions about their health care.

Outcomes

Hospital and Health Services included in the scope of this directive shall achieve the following outcomes:

Clinical incident management

  • All severity assessment code (SAC) 1 clinical incidents and analysis reports are submitted to Patient Safety and Quality (PSQ), Clinical Excellence Queensland (CEQ), Department of Health
  • All responses to coronial recommendations are submitted to PSQ, to meet whole-of-government reporting requirements.

Congenital syphilis analysis and reporting

  • All congenital syphilis analysis reports are submitted to PSQ.

VLAD and other national patient safety indicators

  • All VLAD lower level 3 flags and statistically significant national patient safety indicator review responses will be submitted to the PSQ.

Patient safety notifications

  • Where Hospital and Health Services identify a patient safety issue and identify the issue may impact on the safety of patients in other Hospital and Health Services, this will be reported to the PSQ.

Gastrointestinal Endoscopy Services Quality Framework

  • Where Hospital and Health Services identify key performance indicator benchmarks of the Gastrointestinal Endoscopic Quality Framework that are not met for services or individual endoscopists, the reasons are to be explored and where appropriate, corrective action implemented.

Clinical Services Capability Framework

  • Hospital and Health Services must self-assess in line with Queensland’s Clinical Services Capability Framework.

Accreditation

  • Hospital and Health Services must maintain accreditation under the Australian Health Service Safety and Quality Accreditation Scheme.
  • General practices owned or managed by the HHS must maintain accreditation under the National General Practice Accreditation Scheme.
  • Residential aged care facilities must maintain accreditation against the Aged Care Quality Standards in accordance with the Aged Care Quality and Safety Commission.
  • BreastScreen Queensland Services managed by the Hospital and Health Services must maintain accreditation under the BreastScreen Australia National Accreditation Standards.
  • Hospital and Health Services hospitals providing specialist medical training must maintain accreditation against the College Standards.

Obtaining informed consent for health care procedures or treatment

  • Hospital and Health Services must obtain informed consent from patients for health care procedures or treatment. Informed consent must be obtained by an experienced health professional.
  • Contemporaneous records documenting discussions with patients in relation to their health care (including when obtaining informed consent) must be kept by Hospital and Health Services.

Mandatory requirements

Clinical incident management

  • Hospital and Health Services will report all SAC1 clinical incidents to the PSQ, CEQ through Queensland Health’s RiskMan information system within one (1) business day of becoming aware of the SAC1 event.
  • Hospital and Health Services will conduct an analysis of all SAC1 clinical incidents and submit a report to the PSQ, CEQ within 90 calendar days of the clinical incident being reported as a SAC1.
  • Each analysis report must contain:
    • a factual description of the event
    • the factors identified as having contributed to the event
    • recommendations to prevent or reduce the likelihood of a similar event happening again.
  • Where a coroner makes a recommendation to a Hospital and Health Service following an inquest, the Hospital and Health Service will provide an initial response to the recommendation to the PSQ, CEQ within 90 days of the inquest findings, and provide six monthly updates until the implementation of the recommendations is complete.

Congenital Syphilis

  • Hospital and Health Services must comply with and report to the Department in accordance with the Protocol for Reporting Congenital Syphilis.

Variable life adjusted display and other National patient safety indicators

  • Hospital and Health Services will conduct a review of all lower level 3 VLAD flags and statistically significant national patient safety indicators (for example, hospital standardised mortality ratios) and provide a review response to the PSQ within 30 calendar days.

Patient safety alerts and notifications

  • Hospital and Health Services will report to the PSQ, all locally identified patient safety issues or risks with the potential for state-wide adverse impacts.

Gastrointestinal Endoscopy Services Quality Framework

  • Hospital and Health Services providing gastrointestinal endoscopic services will comply with the Gastrointestinal Endoscopic Services Quality Framework.

Clinical Services Capability Framework

  • Hospital and Health Services must comply with and report to the Department in accordance with the Guideline for Clinical Services Capability Framework.

Accreditation

  • Hospital and Health Services must comply with and report to the Department in accordance with the Guideline for Accreditation.

Accreditation of Specialist Training against Medical College Standards

  • All Hospital and Health Services hospitals providing specialist medical training must be accredited against the College Standards.
  • Following assessment against the College Standards, the Hospital and Health Services must provide immediate advice to the Executive Director, PSQ, CEQ at PSQ_ED@health.qld.gov.au if accreditation by one of the Australian Medical Colleges has been suspended or ceased.

Obtaining Informed Consent for health care procedures or treatment

  • Hospital and Health Services must comply with the Protocol for Obtaining Informed Consent for health care procedures or treatment.
  • Enterprise Architecture Health Service Directive
  • National Safety and Quality Health Service Standards Second Edition 2017. (Australian Commission on Safety and Quality in Health Care)
  • Coroners Act 2003
  • Health Ombudsman Act 2013
  • Hospital and Health Boards Act 2011
  • Hospital and Health Boards Regulation 2023

Supporting documents

Business area contact

Review

This Health Service Directive will be reviewed at least every three years.

Date of last review:      09/10/2024

Supersedes:                  Version 5.0

Approval and implementation

Directive Custodian

Executive Director, PSQ, CEQ, Department of Health

Approval by Chief Executive

Director General, Queensland Health

Approval date:

09/10/2024

Issued under section 47 of the Hospital and Health Boards Act 2011

Definitions of terms used in this directive

Term Definition / explanation / detailsSource
Clinical Incident Any event or circumstance which has actually or could potentially lead to unintended and/or unnecessary mental or physical harm to a patient. Clinical Incident Management Guideline
Flag A point on the VLAD, identifying a predetermined level of variation has been reached i.e. more (or less) patients have experienced an outcome than expected over a period of time. VLAD Guideline
Patient safety issue An event or circumstance that has led to patient harm or could potentially lead to patient harm.  
Hospital standardised mortality ratio The hospital standardised mortality ratio compares the observed number of deaths in a hospital with the expected number of deaths based on jurisdictional (state or national) data, using a logistic regression model that adjusts for factors that affect the risk for in-hospital death such as age, principal diagnoses, co-morbidities, length of hospital stay and route of admission. The Medical Journal of Australia Volume 194 Number 12 20 June 2011
Lower level 3 flag A level 3 flag indicates a hospital’s result is highly statistically significantly different from the State average. VLAD Guideline
Patient Safety and Quality Improvement Service The Patient Safety and Quality Improvement Service, Clinical Excellence Queensland, Department of Health  
Severity assessment code 1
(SAC1) 		Death or likely permanent harm which is not reasonably expected as an outcome of healthcare. Clinical Incident Management Guideline
Variable Life Adjusted Display also referred to as VLAD A statistical methodology used to monitor patient outcomes to assist in identifying possible areas of concern or strength for safety and quality of care. It is to be interpreted and viewed with the intention to understand causation and to determine whether corrective action is necessary. VLAD Guideline
VLAD review response Feedback from a Hospital and Health Service detailing what was considered in the review, review findings and actions. VLAD Guideline

Version control

VersionDate Prepared byComments
1.0 01/07/2013 PSQIS First issued.
2.0 17/04/2014 PSQIS Second version issued
3.0 05/05/2020 PSQIS Removal of the requirement to submit lower level 2 VLAD to PSQIS.
Modified requirement of coronial reporting from quarterly to six monthly.
Updated email addresses, phone numbers and the name Patient Safety Unit, to PSQIS.
Minor clerical amendments in line with the Queensland Health Editorial style guide 2019.
4.0 25/05/2021 PSQIS HHSs to comply with the Gastrointestinal Endoscopic Services Quality Framework
5.021/12/2022PSQ, CEQ

HHSs to comply with the Clinical Services Capability Framework

HHSs to comply with the Australian Health Service Safety and Quality Accreditation Scheme, National General Practice Accreditation Scheme, Aged Care Quality Standards and Breast Screen National Accreditation Standards.

6.009/10/2024PSQ, CEQ

HHSs to comply with the Protocol for Obtaining Informed Consent for health care procedures or treatment.

HHSs to comply with the Protocol for Reporting Congenital Syphilis.

Hospital and Health Services hospitals providing specialist medical training must be accredited against the College Standards and provide immediate advice to PSQ, CEQ if accreditation by one of the Australian Medical Colleges has been suspended or ceased.

Last updated: 20 December 2022