Transcript Slide 1

HAVING TROUBLE UNDERSTANDING
NZS 8134.2008 ?
2001–2008
The four previous standards were
reviewed with the aim of:
• Reducing duplication between
standards
• Updating content to reflect current
accepted good practice.
INTERPRETATION
•
•
•
Not all standards or criteria within NZ 8134 are relevant
to your service
A standard or criterion assessed as being not relevant to
a service will be recorded as being ‘not applicable’ on
your audit report
For example, some parts of NZS 8134 will apply only to:
a)
b)
c)
Intellectual disability services
Mental health and addiction services; or
Acute, secondary, or tertiary services.
The notations ‘ID’, ‘MHA’, and ‘S’ identify those parts of the
standard which only apply to those particular services.
KEY TERMINOLOGY
The definition of ‘Good Practice’ is:
“The current accepted range of safe and
reasonable practice that results in efficient and
effective use of available resources to achieve
quality outcomes, and minimise risk for the
consumer.”
DETERMINING WHAT IS
GOOD PRACTICE
• Good practice can be reflected in policies and
procedures or documentation for service delivery,
for example:
a)
b)
c)
d)
e)
f)
Codes of practice
Research, evidence, or experience-based practice
Professional standards
Good practice guidelines
Recognised or approved guidelines
Benchmarking
• The 2008 standards concentrate more on the
outcome to be achieved.
AMENDED 2008 CRITERIA INCLUDE
KEY WORDS
The 2008 criteria have been updated to be more
outcome-focused
2001 HDSS 2.2.2
Relevant standards are identified and implemented to meet current
accepted good practice in the relevant service area or setting.
2008 HDSS 2.3.3
The service develops and implements policies and procedures that
are aligned with current good practice and service delivery, meet
the requirements of legislation, and are reviewed at regular
intervals as defined by policy.
AMENDED 2008 CRITERIA INCLUDE
KEY WORDS
2008 requires more evidence to meet this criterion.
a)
b)
c)
d)
e)
f)
g)
Scope and content of P&Ps are relevant to type and
complexity of service
P&Ps reflect accepted good practice
Legislative requirements are included
Processes in place to develop and approve new P&Ps
Systems for regular review of P&Ps
Processes implemented to educate staff on new
policies
Document control policy to describe implementation
of P&Ps.
NEW CRITERIA
• There are very few criterion that are
“Entirely New”
• There are some criteria that are
‘amended’ and have some different
aspects
• Some criteria appear to be just “updated”
• Some are so closely related to previous
criteria that the new standard has stated
what would have been “evidence” under
the previous.
SOME AMENDED CRITERIA –
TO WATCH OUT FOR?
HDSS 3.12.1
A medicines management system is implemented to manage the safe and
appropriate prescribing, dispensing, administration, review, storage, disposal,
and medicine reconciliation in order to comply with legislation, protocols, and
guidelines.
This criterion has one new requirement that HDSS 5.3.1 did
not include, around ‘medicines reconciliation’.
So what does that mean for updating policies and
processes?
Having systems in place to ensure the medication and
medication instructions were provided to you before
admission.
WHAT EVIDENCE COULD AUDITORS
BE LOOKING FOR?
HDSS 1.8.1
The service provides an environment that encourages good practice,
which should include evidence-based practice.
•
Some examples include:
–
–
–
–
–
–
–
The education programme includes internal and external training
Some education is delivered by external specialists in their field
Access to professional networking opportunities
Clinical pathways
Treatment protocols
Access to professional development (including mentoring and
supervision)
Resources are available and link to P&Ps.
FOUR NEW CRITERIA AND POSSIBLE
EVIDENCE
HDSS 1.7.1
Services have policies and procedures to ensure consumers are not
subjected to discrimination, coercion, harassment, and sexual or other
exploitation.
•
Evidence that may assist to meet this criterion:
–
Policies and procedures include:
•
•
•
–
Human Resource policies include:
•
•
–
Abuse and neglect
Code of rights
Complaints management
House rules
Code of Ethics
Organisational policies include:
•
•
Management of finances
Services provided to clients.
FOUR NEW CRITERIA AND POSSIBLE
EVIDENCE
HDSS 1.7.3
Service providers maintain professional boundaries and refrain from acts
or behaviours which could benefit the provider at the expense or wellbeing of the consumer.
•
Evidence that may assist to meet this criterion:
–
–
–
–
–
–
Policies and procedures around Code of Ethics for staff
Professional boundaries and job descriptions include the above
Clients state that privacy is ensured
Performance appraisals / supervision is implemented
Staff and management interviews reinforce professional boundaries
House rules.
FOUR NEW CRITERIA AND POSSIBLE
EVIDENCE
HDSS 2.4.4
Adverse, unplanned, and untoward events are addressed in an open
manner through an open disclosure policy.
•
Evidence that may assist to meet this criterion:
–
–
–
–
–
•
Open Disclosure Policy links to incident reporting and
responsibilities
Risk/hazard identification is in place and reviewed
I&A policy, investigation and closure of the quality loop
Families are informed, identified in incident reporting process
I&A form demonstrates family involvement
Note: ‘Guidance on Open Disclosure Policies’ can be found at
http://www.hdc.org.nz.
FOUR NEW CRITERIA AND POSSIBLE
EVIDENCE
HDSS 1.9.1
Consumers have a right to full and frank information and
open disclosure from service providers.
•
Evidence that may assist to meet this criterion:
– Client information packs include open disclosure, code of
rights, and open door approach
– Internet sites including information on service
– Easy access to community information, advocacy
– Access to client records
– Implemented informed consent policies
– Resident / family meetings
RESTRAINT MINIMISATION
•
Restraint standard NZS 8134.2 now consists of 3 main
documents:
– 8134.2.1 Restraint Minimisation
– 8134.2.2 Safe Restraint Practice
– 8134.2.3 Seclusion
•
When considering which standards are important for
your service, note that:
– All services must meet 8134.2.1
– All services where restraint (including seclusion) is used shall
meet 8134.2.2
– All services which use seclusion shall meet 8134.2.3
•
Therefore where restraint is not used, 8134.2.2 and .3
will be assessed as being not applicable. Note: You still
need to meet 8134.2.1.
RESTRAINT MINIMISATION 8134.2.1
•
•
NZS 8134.2.1 includes one standard and 6 criteria
These key areas need to be in place and implemented:
1.
2.
3.
4.
5.
6.
You will need a Restraint minimisation policy and procedure
Risk assessment processes and resident care plans support
interventions that avoid use of restraint
Enabler use has clear guidelines for safe and appropriate use
Enabler use shall be voluntary and the least restrictive option
Education provided relevant to service setting – around
Restraint P&Ps, Enabler use P&Ps, alternative interventions,
and de-escalation.
Systems / processes need to be in place for meeting 8134.2.2
if and when a restraint event occurs.