Rehabilitation service delivery: audit tool for best practice

1. Leadership and governance

This is one of eight audit templates that form the Rehabilitation service delivery: audit tool for best practice.

This tool enables rehabilitation services to plan and review their practice to identify areas that will improve service delivery and patient outcomes. It can also be useful for teams involved in planning and establishing new rehabilitation services.

This template focuses on organisational responsibilities. It is to be completed by the local health district, specialty health network, affiliated health organisation or the private health provider of rehabilitation services. For the best result, involve a range of staff in the discussions.

Core element rating scale

N/A	0	1	2	3	4
Not applicable	Not achieved	Rarely achieved	Sometimes achieved	Often achieved	Always achieved

Instructions

After discussing each core element with members of the working group, agree on the rating, and note the evidence to support this rating.

Use the action plans to note areas for improvement, key actions and who is responsible.

For more information about the audit tool, visit: https://aci.health.nsw.gov.au/networks/rehabilitation/resources/audit-tool

1. Leadership and governance

Organisation/health service: Date:

Team/s:

No.	Core elements	Organisational rating N/A 0 1 2 3 4	Supporting evidence
1.1	The organisation has a clearly defined organisational structure with a representative of rehabilitation services included within the executive team.
1.2	The organisation’s strategic plan includes rehabilitation as a priority area.
1.3	The organisation provides executive sponsorship and support to rehabilitation leaders when advocating for service changes or enhancements.
1.4	The organisation has clearly defined expectations for the rehabilitation service to meet deliverables and outcomes in the relevant strategic and operational plans.
1.5	The organisation has an accessible organisational chart with clear reporting lines of responsibility and accountability and a designated leader who is responsible for rehabilitation service delivery.
1.6	The organisation ensures the rehabilitation service maintains ongoing records of the National Safety and Quality Health Service and Australian Council on Healthcare Standards indicators between accreditation cycles.
1.7	Rehabilitation health professionals are involved in organisational strategic planning.
1.8	Consumers are involved in organisational strategic planning.
1.9	For statewide specialty/networked services The organisation supports the rehabilitation service to work collaboratively with other statewide services and deliver on statewide goals and strategies. This includes: funding and time to participate in meetings time to work on statewide quality improvement projects provision of rehabilitation clinicians to provide support to networked services. Note: Rate each sub-question separately.
1.10	Strategic planning includes consideration of the broader context in which rehabilitation in NSW operates, including affiliated health organisations, private providers, NDIS and icare.
1.11	Rehabilitation health professionals are involved in organisational service planning.
1.12	Rehabilitation health professionals are involved in the development and maintenance of rehabilitation care settings and programs.
1.13	Recruitment of rehabilitation staff is undertaken by clinicians with experience in the rehabilitation setting as well as discipline-specific knowledge.
1.14	The organisation, in collaboration with the rehabilitation service, has a defined process for the regular review of the following measures: patient reported experience measures and patient reported experience measures bed and resource efficiency. Note: Rate each sub-question separately.

Leadership and governance action plan

Date:

Core element #	Area for improvement	Action/s	Person responsible	Due date

Published November 2023. Next review 2028. ACI/D23/3804 (ACI) SHPN (ACI) 230798-1 [ACI_4923]

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