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Table 1 Risk indicators used to determine RAC homes failing accreditation outcomes 1.8 and 2.4

From: The contribution of electronic health records to risk management through accreditation of residential aged care homes in Australia

Indicators used to determine that outcome 1.8 Information Systems was not metIndicators used to determine that outcome 2.4 Clinical Care was not met
 1. Information was not accurate, up-to-date, complete, consistent and sufficient to guide care delivery.
 2. Staff did not have access to the information.
 3. Monitoring mechanisms were not effective in identifying deficiencies in management and staff practice.
 4. Staff did not consistently report clinical incidents.
 5. Key information such as clinical data was not always used to identify and meet the needs of residents and staff.
 6. Communication was not systematic and effective.
 7. Policies and procedures were not evidence-based.
 8. Staff were not familiar with computerised systems.
 9. Management did not regularly review the information system.
 0. Residents and their representatives were not satisfied because the information they provided were not incorporated into care.
1. RAC home was not able to demonstrate residents were receiving appropriate clinical care.
2. Staff did not appropriately assess residents’ clinical care needs on entry to home and on an ongoing basis.
3. Care plan did not always reflect current care needs and preferences of residents.
4. Clinical care was not provided in accordance with directives from qualified staff, care plan and residents’ needs and/or preferences.
5. Changes in care were not consistently documented and doctors were not informed about them.
6. Residents experienced unrelieved pain, their wounds were not always promptly reviewed, and changes in their health conditions were not recognised by staff.
7. Information was not always current, accurate and consistent.
8. Information systems and communication processes were not effective to support the provision of appropriate clinical care.
9. Monitoring mechanisms such as audits, care reviews and incident reporting were not effective in the identification of deficiencies in care delivery.
10. Clinical incidents were not consistently collated and analysed to identify opportunities for improvement.
11. Referrals to other health professionals were not implemented in a timely manner.
12. Staff was not knowledgeable about residents’ care needs.
13. Staff reported not adequate time to complete all required tasks and staffing insufficiency had negative impact on their ability to provide care that meets care recipients’ needs and preferences.
14. Residents and representatives reported dissatisfaction with the adequacy and responsiveness of care.