Better health and ageing for all Australians

Evaluation of the mental health nurse incentive program

Appendix C: comparison of with ATAPS clinical governance framework

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The Access to Allied Psychological Services (ATAPS) Clinical Governance Framework was developed by the Australian Medicare Local Alliance (AMLA) on behalf of DoHA. The Framework is designed to provide a "significant opportunity for Medicare Locals and contracted agencies to rethink their ATAPS programs and to ensure that all population groups identified under ATAPS have access to quality primary mental health care services" 24.

The Clinical Governance Framework comprises of seven pillars of clinical governance that are applicable for the ATAPS program. Each of these pillars contains a number of activities or strategies that are underpinned by a set of core elements. These core elements are supported by a number of suggested key resources, which our outlined in table 8.4 below.

The Clinical Governance Framework provides a useful benchmark for a comparison against evidence collected during MHNIP case study site visits. It should be noted that this framework was developed to be implemented and managed by Medicare Locals, and may not be suitable for all MHNIP eligible organisations. Furthermore, the framework has been applied retrospectively to the information gathered during the case studies. Questions were therefore not specifically targeting each element under this framework.

There are a number of suggested resources in this framework appearing under more than one core element. These key resources are marked with an * and the MHNIP case study observation has not been repeated.

Table 8.4 ATAPS suggested resource from the ATAPS clinical governance framework - comparison with MHNIP case study observation

Table 8.4 is presented as a list in this HTML version for accessibility reasons. It is presented as a table in the PDF version.

The following lists the MHNIP case study observation for an ATAPS suggested resource. Each resource is graded as a minimum requirement (MR) or a desired requirement (DR).

Pillar 1: consumer and community participation

  • ATAPS client consent form (MR) - No specific MHNIP consent forms were observed, although patient agreement should be sought as part of the mental health care plan.
  • ATAPS information brochure (MR) - No evidence of a MHNIP information brochure.
  • Client feedback form (MR) - There was no evidence of a formalised process/form specific to MHNIP. However, some eligible organisations had implemented patient satisfaction forms and or surveys, of all patients not just MHNIP clients.
  • Complaints form (MR) - There was no evidence of a formalised process/form specific to MHNIP. However, some eligible organisations had implemented patient satisfaction forms and or surveys, of all patients not just MHNIP clients.
  • Complaints policy (MR) - There was no evidence of a formalised process/form specific to MHNIP. However, some eligible organisations had implemented patient satisfaction forms and or surveys, of all patients not just MHNIP clients.
  • Complaints procedure (MR) - There was no evidence of a formalised process/form specific to MHNIP. However, some eligible organisations had implemented patient satisfaction forms and or surveys, of all patients not just MHNIP clients.
  • Privacy and confidentiality policy (MR) - Not observed directly, but assumed exists within each eligible organisation‟s policy framework.
  • Quality improvement framework (MR) - No evidence of formal Quality Improvement Framework specific to MHNIP.
  • Statement of clients' rights and responsibilities (MR) - There was little evidence of a formalised process. However, it may fall within the content of the mental health care plan.
  • Consumer participation strategy (DR) - No strategy was observed.
  • Needs assessment framework (DR) No formal needs assessment framework observed.
  • Remuneration policy for consumers and carers (DR) - N/A
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Pillar 2: service delivery and access

  • ATAPS information brochure* (MR) - Repeat, see ATAPS information brochure above.
  • ATAPS triage and referral procedure (MR) - No formalised MHNIP triage and referral procedure.
  • Client feedback form* (MR) - Repeat, see client feedback form above.
  • Clinical pathway for ATAPS clients (MR) - No formal documented pathway was observed.
  • Clinical supervision policy and procedure (MR) - There was little evidence of a formalised policy and process for MHNIP.
  • Needs assessment framework* (DR) - Repeat, see needs assessment framework above.
  • Service access assessment tool (DR) - There was some evidence of triaging occurring, but a formal assessment tool was not observed.
  • Standard contract for private allied health providers (DR) - N/A

Pillar 3: service evaluation, quality improvement and innovation

  • Client feedback form* (MR) - Repeat, see client feedback form above.
  • Clinical pathway for ATAPS clients* (MR) - Repeat, see clinical pathway above.
  • Clinical supervision policy and procedure* (MR) - Repeat, see clinical supervision above.
  • Quality improvement framework* (MR) - Repeat, see quality improvement framework above.
  • Reporting template for the MDS (MR) - There is no formal reporting aspect for MHNIP, other than registration and regular submission of claim forms.
  • Terms of reference for a clinical quality and risk management committee (MR) - Not observed under MHNIP.
  • Clinical record audit summary form (DR) - Not observed under MHNIP.
  • Guidelines for conducting clinical audits (MR) - Not observed under MHNIP.

Pillar 4: risk management

  • Allied health accreditation and continuing professional development register (MR) - Yes. ACMHN credentialing requirement for mental health nurses.
  • ATAPS staff induction checklist and feedback form (MR) - Not observed, but likely to be part of general staff induction process.
  • ATAPS staff induction procedure (MR) - Not observed, but likely to be part of general staff induction process.
  • ATAPS triage and referral procedure* (MR) - Repeat, see ATAPS triage and referral procedure above.
  • Clinical pathway for ATAPS clients* (MR) - Repeat, see clinical pathway above.
  • Clinical risk management procedure (MR) - There was no evidence of a procedure specific to MHNIP.
  • Code of conduct policy (MR) - There was no evidence of a procedure specific to MHNIP.
  • Critical incident policy and procedure (MR) - There was no evidence of a procedure specific to MHNIP.
  • Critical incident report form (MR) - There was no evidence of a procedure specific to MHNIP.
  • Generic role description for private allied health provider (MR) - Generic role description for MHN contained in MHNIP Guidelines.
  • Mandatory reporting obligations (MR) - Not observed.
  • Recruitment and employment policy (MR) - Not observed.
  • Terms of reference for a clinical quality and risk management committee (or equivalent) (MR) - Not observed.
  • Clinical risk register (DR) - Not observed.
  • Guidelines for clinical note taking for allied health professionals (DR) - N/A.
  • Performance development and review form (DR) - ACMHN credentialing requirement.
  • Staff handbook (DR) - N/A
  • Staff support structure (DR) - No.
  • Standard contract for private allied health providers* (DR) - Repeat, see standard contract above.
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Pillar 5: information management systems and technology

Pillar 6: workforce development and credentialing

  • Allied health accreditation and continuing professional development register* (MR) - Repeat, see allied health accrediation above.
  • ATAPS staff induction checklist and feedback form* (MR) - Repeat, see ATAPS staff induction checklist above.
  • ATAPS staff induction procedure* (MR) - Repeat, see ATAPS staff induction procedure above.
  • Clinical pathway for ATAPS clients* (MR) - Repeat, see clinical pathway above.
  • Clinical position description for employed AHPS (MR) - Role description in the MHNIP Guidelines is open to interpretation. There was some evidence that organisations have developed their own position descriptions.
  • Clinical supervision policy and procedure* (MR) - Repeat, see clinical supervision above.
  • Contract review procedure* (MR) - Repeat, see contract review procedure above.
  • Generic Role Description for Private Allied Health Provider* (MR) - Repeat, see generic role description above.
  • Terms of reference for a clinical quality and risk management committee* (MR) - Repeat, see terms of reference above.
  • Continuing professional development log (DR) - This is a requirement of credentialing for ACMHN.
  • Performance development and review form* (DR) - Repeat, see performance development above.
  • Standard contract for private allied health providers* (DR) - Repeat, see standard contract above.
  • Template MOUs and contracts for sub-contractors (DR) -

Pillar 7: clinical accountability

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