Clinical Branches evidence for ACSQHC accreditation

Preventing and Controlling Infections Standard

No.	Actions	Evidence provided by Clinical Branches
3.01	The workforce uses the safety and quality systems from the Clinical Governance Standard when: Implementing policies and procedures for infection prevention and control Identifying and managing risks associated with infections Implementing policies and procedures for antimicrobial stewardship Identifying and managing antimicrobial stewardship risks	Supports implementation of policies and procedures for AMS. Provide surveillance for antimicrobial use and AMS activities. Intuitive design reduces training requirements for AMS approval systems for new users.
3.02	The health service organisation: Establishes multidisciplinary teams to identify and manage risks associated with infections using the hierarchy of controls in conjunction with infection prevention and control systems Identifies requirements for and provides the workforce with access to training to prevent and control infections Has processes to ensure that the workforce has the capacity, skills, and access to equipment to implement systems to prevent and control infections Establishes multidisciplinary teams or processes to promote effective antimicrobial stewardship Identifies requirements for and provides access to training to support the workforce to conduct antimicrobial stewardship activities Has processes to ensure that the workforce has the capacity and skills to implement antimicrobial stewardship Plans for public health and pandemic risks	KPI workbenches provide feedback to the workforce on AMS. KPI workbenches can be reviewed by AMS committee to assess the effectiveness of the processes. Onboarding demonstration ensures all staff have training in how to use the AMS system. KPI information can be used to inform your quality improvement plan. This information includes things such as IV to Oral switch and readmission rates (infective indication).
3.03	The health service organisation applies the quality improvement system from the Clinical Governance Standard when: Monitoring the performance of infection prevention and control systems Implementing strategies to improve infection prevention and control systems Reporting to the governance body, the workforce, patients, and other relevant groups on the performance of infection prevention and control systems Monitoring the effectiveness of the antimicrobial stewardship program Implementing strategies to improve antimicrobial stewardship outcomes Reporting to the governance body, the workforce, patients, and other relevant groups on antimicrobial stewardship outcomes Supporting and monitoring the safe and sustainable use of infection prevention and control resources	Clinical Branches has inbuilt KPI dashboards to allow governance bodies to assess the effectiveness of the AMS program and usage trends over time.
3.04	Clinicians use organisational processes consistent with the Partnering with Consumers Standard when assessing risks and preventing and managing infections and implementing the antimicrobial stewardship program to: Actively involve patients in their own care Meet the patient’s information needs Share decision-making	Clinical Branches provides shared care decision-making guides for clinicians e.g. “Shared decision making in acute bacterial rhinosinusitis” and “Shared decision making for suspected streptococcal pharyngitis or tonsillitis”. Locally developed guides and information leaflets can be added to Clinical Branches for easy access by clinicians.
3.05	The health service organisation has a surveillance strategy for infections, infection risk, and antimicrobial use and prescribing that: Incorporates national and jurisdictional information in a timely manner Collects data on healthcare-associated and other infections relevant to the size and scope of the organisation Monitors, assesses, and uses surveillance data to reduce the risks associated with infections Reports surveillance data on infections to the workforce, the governing body, consumers, and other relevant groups Collects data on the volume and appropriateness of antimicrobial use relevant to the size and scope of the organisation Monitors, assesses, and uses surveillance data to support appropriate antimicrobial prescribing Monitors responsiveness to risks identified through surveillance Reports surveillance data on the volume and appropriateness of antimicrobial use to the workforce, the governing body, consumers, and other relevant groups	Provides constant surveillance of antimicrobial prescribing. Pathways are modifiable to suit your antibiogram and local epidemiology complexity of the care and treatment provided by your organisation. Can benchmark RAPA data with other organisations.

Antimicrobial Stewardship

No.	Actions	Evidence provided by Clinical Branches
3.18	The health service organisation has an antimicrobial stewardship program that: Includes an antimicrobial stewardship policy Provides access to and promotes the use of current evidence-based Australian therapeutic guidelines and resources on antimicrobial prescribing Has an antimicrobial formulary that is informed by current evidence-based Australian therapeutic guidelines and resources and includes restriction rules and approval processes Incorporates core elements, recommendations, and principles from the current Antimicrobial Stewardship Clinical Care Standard Acts on the results of antimicrobial use and appropriateness audits to promote continuous quality improvement	Pathways for all Antibiotic eTG topics are included in Clinical Branches. Pathways are easy to access and quick to follow – average completion time is 48 seconds. Supports your antimicrobial stewardship policy and provides approval for prescribing according to predefined protocols. Provides an easy-to-use workbench for AMS team to identify patients requiring review. Can automate referrals from pathways. Clinical hints help identify patients at risk of medical misadventure. Compliance with recommendations is visible through RAPA. Vanc AUC Calculator provides tailored dosing recommendations.
3.19	The antimicrobial stewardship program will: Review antimicrobial prescribing and use Use surveillance data on antimicrobial resistance and use to support appropriate prescribing Evaluate performance of the program, identify areas for improvement, and take action to improve the appropriateness of antimicrobial prescribing and use Report to clinicians and the governing body regarding: compliance with the antimicrobial stewardship policy and guidance areas of action for antimicrobial resistance areas of action to improve appropriateness of prescribing and compliance with current evidence-based Australian therapeutic guidelines or resources on antimicrobial prescribing the health service organisation’s performance over time for use and appropriateness of use of antimicrobials	Continual auditing with RAPA. Ability to benchmark RAPA data with other hospitals within the health service or nationally. Ongoing evaluation of AMS activities (i.e., clinician uptake of recommendations, change in prescribing practice of teams post-intervention).

Medication Safety Standard

No.	Actions	Evidence provided by Clinical Branches
4.01	Clinicians use the safety and quality systems from the Clinical Governance Standard when: Implementing policies and procedures for medication management Managing risks associated with medication management Identifying training requirements for medication management	Clinical Branches provides an easy platform for building prescribing pathways for clinicians to follow. Onboarding demonstration ensures all staff have training in how to use Clinical Branches.
4.02	The health service organisation applies the quality improvement system from the Clinical Governance Standard when: Monitoring the effectiveness and performance of medication management Implementing strategies to improve medication management outcomes and associated processes Reporting on outcomes for medication management	Clinical Branches has inbuilt KPI dashboards to allow governance bodies to assess the effectiveness of the pathways and usage trends over time.
4.03	Clinicians use organisational processes from the Partnering with Consumers Standard in medication management to: Actively involve patients in their own care Meet the patient’s information needs Share decision-making	Clinical Branches provides shared care decision making guides for clinicians e.g. “Shared decision making in acute bacterial rhinosinusitis” and “Shared decision making for suspected streptococcal pharyngitis or tonsillitis”. Locally developed guides and information leaflets can be added to Clinical Branches for easy access by clinicians.
4.04	The health service organisation has processes to define and verify the scope of clinical practice for prescribing, dispensing, and administering medicines for relevant clinicians.	AMS pathways enforce scope of practice for prescribing antimicrobials. IPU Management. Easy access to formulary including scope of practice information.
4.05	Clinicians take a best possible medication history which is documented in the healthcare record on presentation or as early as possible in the episode of care.	Can track and report on completion of BPMH rates.
4.06	Clinicians review a patient’s current medication orders against their best possible medication history and the documented treatment plan and reconcile any discrepancies on presentation and at transitions of care.	Can track and report on medication reconciliation rates.
4.07	The health service organisation has processes for documenting a patient’s history of medicine allergies and adverse drug reactions in the healthcare record on presentation.	Clinical hints can flag adverse reaction/prescription mismatch.
4.10	The health service organisation has processes: To perform medication reviews for patients in line with evidence and best practice To prioritise medication reviews based on a patient’s clinical needs and minimising the risk of medication-related problems That specify the requirements for documentation of medication reviews including actions taken as a result	Can track and report on medication reviews. Clinical hints assist pharmacists to identify which patients are a higher priority for medication review.
4.11	The health service organisation has processes to support clinicians to provide patients with information about their individual medicines needs and risks.	Formulary page provides links to CMIs. Health services can link their own information to the formulary pages.
4.13	The health service organisation ensures that information and decision support tools for medicines are available to clinicians.	Any required protocols can be built as pathways in Clinical Branches. Pathway for Review list identifies pathways which are due or overdue for review. Every pathway has an assigned owner so it is clear who is responsible for reviewing and making updates. eTG antibiotic are maintained by Kraken Coding team to keep up to date. Pathways are easy to access and quick to follow – average completion time is 48 seconds.
4.15	The health service organisation: Identifies high-risk medicines used within the organisation Has a system to store, prescribe, dispense, and administer high-risk medicines safely	Clinical hints help identify patients who are prescribed a high-risk medicine. Pathways can be built to guide users on appropriate prescribing of high-risk meds. Vanc AUC calculator. Opioid workbench (in development).