Published November 2023
This tool enables multidisciplinary rehabilitation services to plan and review their practice. It guides the delivery of evidence-based, best-practice rehabilitation.
The Principles to Support Rehabilitation Care underpins the audit process. The audit tool is for specialist and generalist rehabilitation services and organisations planning new services.
The audit process:
- enables a deeper understanding of rehabilitation as a health service
- supports service review, gap analysis and quality improvement initiatives
- informs service planning, design and delivery for new services
- supports expanding existing facilities and services or investing in new equipment and technology.
Who needs to be involved?
A steering committee and nominated executive sponsor provide sponsorship and governance for the audit process. A working group completes the audit. To ensure a diversity of views, the group could include:
- Rehabilitation head of department
- Rehabilitation physician(s)
- Senior allied health clinicians and rehabilitation nurse(s)
- Clinical nurse educator and/or consultant – rehabilitation
- District (or facility) service manager – rehabilitation
- Consumer representative(s)
- Executive team member with responsibility for recruitment and professional development
- Executive team member with ongoing involvement in organisational strategic planning
- Patient flow/whole-of-health lead
- Representative from finance
The pilot process for this tool revealed how valuable the conversations can be between staff; especially when they share a variety of opinions and perspectives. As a result of the audit, pilot sites developed local quality improvement initiatives based on areas identified by the discussions.
Core elements of rehabilitation
The Principles to Support Rehabilitation Care outlines the essential elements to deliver best-practice care. These are divided into eight categories, which are used in this audit tool.
Core elements are the responsibility of either:
- organisations (such as local health districts)
- individual rehabilitation services; OR
- both the organisation and rehabilitation service.
The organisation will usually be the local health district or specialty health network, affiliated health organisation or the private provider of rehabilitation services.
Organisational activities refer to activities and inputs that should be facilitated, supported, or provided by the organisation to:
- optimise patient outcomes
- promote patient flow
- contribute to the health and wellbeing of the community.
These refer to the activities and inputs that the individual service is required to provide. The person, people or team may vary depending on the service model and setting, for example:
- a day rehabilitation program
- in-reach rehabilitation
- rehabilitation in the home.
How to complete the audit tool
The audit tool includes a template for each of the eight categories. These templates guide the working group through the audit process.
As identified above, core elements are either an organisational or individual service responsibility, or a mix of the two. Each template details who needs to complete it. For best results, convene meetings with working group members to complete the audit templates.
A note on multiple settings of care
If a rehabilitation service has multiple settings of care, apply the rating scale to each setting, if appropriate. The decision to score settings individually is at the discretion of the working group.
Rating scale
The rating scale leads the process.
- 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.
| Download leaderhip and governance self-assessment template | |
|---|---|
| No. | Core element |
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:
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:
Note: Rate each sub-question separately. |
| Download infrastructure self-assessment template | |
|---|---|
| No. | Core element |
2.1 | Rehabilitation services and infrastructure are available across a range of settings to optimise patient flow and access based on client acuity and clinical need (e.g. in-patient, in-reach, day rehabilitation program, transitional living units, community rehabilitation, rehabilitation in the home, etc). |
2.2 | Rehabilitation infrastructure is designed in accordance with the Australasian Health Facility Guidelines and Australasian Faculty of Rehabilitation Medicine Standards for the provision of inpatient adult rehabilitation medicine services in public and private hospitals (2019). |
2.3 | Appropriate workspaces are available to support rehabilitation staff working in a flexible and multidisciplinary way. |
2.4 | Technology gaps are identified and assessed, with rehabilitation services provided with the opportunity to engage in planning of solutions. |
2.5 | The organisation invests in, and implements technology systems and solutions to enhance the provision of best-practice rehabilitation care. |
2.6 | The infrastructure and IT support is provided to enable the use of virtual care for telerehabilitation. |
2.7 | Appropriate equipment and technology are available for use across both organisation-based and community-based rehabilitation settings. |
2.8 | Single rooms are available in the inpatient settings where clinically indicated. |
2.9 | Transitional living units (TLU) and/or independent living units are available in the inpatient setting for the purposes of training independent living skills, self-management, carer training, discharge planning and facilitating efficiency in sub-acute bed management. |
2.10 | Dedicated private spaces are available for family and carer meetings. |
2.11 | An adequate number of dedicated office spaces are available for rehabilitation staff. |
2.12 | Access to pool cars and other forms of transport is provided to facilitate community access and facilitate safe and timely transition to home. |
2.13 | The physical rehabilitation environment is designed to facilitate individual rehabilitation programs and is tailored to meet physical, cognitive, emotional, social and spiritual needs and ensure safety. (Consider each care setting.) |
2.14 | The social aspects of the rehabilitation environment are designed to facilitate the client’s rehabilitation needs and ensure safety. (Consider each care setting.) |
2.15 | Cultural safety and inclusiveness are considered in the design of the rehabilitation environment. Refer to My rehab, my journey for suggestions. |
2.16 | Processes are in place to review the environment in which rehabilitation occurs as a client’s status changes. This may involve transition from one care setting to another. |
2.17 | In the inpatient and TLU settings, patients’ rooms are set up to encourage activities of daily living as part of rehabilitation. |
2.18 | In the inpatient and TLU settings, patients’ rooms simulate a home environment where possible. |
2.19 | Both clinical and recreational areas are used for the purposes of individual and group therapy, e.g. physiotherapy gym, bathroom areas, patient kitchen, outdoor gardens, etc. |
2.20 | In the inpatient setting, where possible, most of the therapy is undertaken/co-located in the general ward area (as distinct from standalone therapy areas located elsewhere). |
2.21 | In the inpatient and TLU settings, shared-living arrangements and small-group programs are used to promote peer interactions, learning, transfer of skills to everyday living and reinforcement of positive social behaviours. |
2.22 | Practice spaces that facilitate skill development (such as negotiating challenging physical environments) are available and used to support the client reaching their goals. |
2.23 | The community is accessed for the development of skills in everyday environments and situations, e.g. shopping and recreation. |
| Download funding self-assessment template | |
|---|---|
| No. | Core element |
3.1 | The organisation’s budget for rehabilitation is developed with a strong understanding of the way in which the rehabilitation service operates in inpatient, outpatient and community settings. |
3.2 | The scope of services is planned and funded in accordance with the NSW Health Guide to the Role Delineation of Clinical Services (2021) and Australasian Health Facility Guidelines. |
3.3 | The rationale for the annual budget is provided to the rehabilitation service. |
3.4 | Rehabilitation services understand the implications of activity-based funding and work with local costing and coding teams to improve documentation to support appropriate coding. |
3.5 | Processes are in place to manage underspend and overspend variations in the budget. |
3.6 | Yearly budgets are reviewed and adjusted based on the prior year’s activity and performance and anticipated future service needs. Consideration of future service needs may include a review of:
|
3.7 | Rehabilitation services are provided with adequate funding to ensure an appropriate number of trained rehabilitation staff are available for all shifts, including weekends. |
3.8 | Rehabilitation services are provided with adequate funding to ensure an appropriate skill mix and experience of staff to meet the needs and complexities of rehabilitation clients. Recommended skill mix for the inpatient setting is outlined in the Australasian Faculty of Rehabilitation Medicine standards for the provision of inpatient adult rehabilitation medicine services in public and private hospitals (2019). |
3.9 | Systems and processes are in place to ensure appropriate care of non-Medicare eligible patients. |
3.10 | There is a documented and executed process for identifying and accessing external funding sources for patients while in hospital and transitioning to the community, e.g. National Disability Insurance Agency, Lifetime Care and private health insurance. |
3.11 | The organisation provides rehabilitation services with the opportunity to make internal and external funding bids to meet identified service delivery gaps. |
| Download rehabilitation outcomes self-assessment template | |
|---|---|
| No. | Core element |
Communication | |
4.1 | All client documentation and medical records are readily available to all members of the care team. |
4.2 | The client and their carers are informed of the optimal and predicted length of stay within 24-48 hours of admission to the rehabilitation care setting. Any change to this length of stay is immediately communicated to the patient and carers. |
4.3 | There is a documented process to facilitate easy access to the clinical team for carers – this may include the use of a key person role (see below under Care coordination). |
Goal-directed care plans | |
4.4 | Each client has a documented goal-directed care plan that includes medical, nursing and allied healthcare. |
4.5 | The care plan includes client-centred goals, realistic time frames and strategies for goal attainment. |
4.6 | Care plans are regularly reviewed and updated with input by all members of the care team (including medical, allied health and nursing). |
4.7 | Care plans are reviewed and updated in collaboration with the client and their carers. |
4.8 | In the inpatient setting, each client contributes to the development of their daily timetable of therapy and activities and is provided with a copy. |
Self-management | |
4.9 | Self-management is facilitated by the clinical team, e.g. patient education, peer support programs, coaching, etc. |
4.10 | Individualised approaches are used with each patient based on an assessment of the client’s: a) readiness to participate b) current self-management knowledge, skills and priorities c) health literacy, ability to learn and engage in self-management. Note: Rate each sub-question separately. |
4.11 | Self-directed activities are routinely included as part of the rehabilitation care plan. |
4.12 | The client is provided with daily opportunities for semi-supervised or independent practice as part of their rehabilitation care. |
4.13 | Where appropriate, day, evening, overnight and weekend leave is used to facilitate the development of self-management skills. |
4.14 | Clients are encouraged to take an active role in identifying and selecting external providers for use on discharge, e.g. community programs (where applicable). |
4.15 | Clients are encouraged to review their rehabilitation program against their goals and make decisions in relation to future needs. |
Person-centred care, treatment and shared decision making | |
4.16 | The rehabilitation service delivers care in an inclusive, non-judgmental manner that ensures all people feel safe and supported in their rehabilitation program. |
4.17 | The client is encouraged to articulate their valued activities, people, places, cultural background and beliefs as part of their assessment, treatment and ongoing education. |
4.18 | The client and their carers develop person-centred rehabilitation goals with the clinical team upon admission using a shared decision-making framework. |
4.19 | Evidence-based treatment approaches to meet identified goals are discussed and the program agreed with the client and their carers. |
4.20 | Clients are provided therapy by the most appropriate members of the allied health team required to meet their identified goals. This includes physiotherapy, occupational therapy, dietetics, speech pathology, clinical psychology and neuropsychology, social work, prosthetics and orthoptics. |
4.21 | Regular review of a client’s rehabilitation program is undertaken to ensure that rehabilitation is being provided in the most appropriate setting and intensity for their needs and circumstances. |
4.22 | Rehabilitation goals are regularly reviewed and updated throughout a client’s rehabilitation program. |
4.23 | Rehabilitation is conducted at an intensity and level of complexity suitable to the client and their goals. |
4.24 | Vocational rehabilitation and support to return to work is provided in accordance with the person’s goals, as required. |
4.25 | In the in-reach and inpatient settings, experienced rehabilitation nurses are available on all shifts. |
4.26 | Rehabilitation nurses work with clients to increase the intensity of rehabilitation activity by using and reinforcing on-the-spot goals negotiated with the client. |
4.27 | Within the inpatient setting, staff facilitate an environment where peer interaction, support and mentoring are encouraged, and clients provide support to each other, e.g. the use of shared living arrangements and small group programs. |
4.28 | Potential barriers to client communication are identified and alternative methods of communication used, as required. |
4.29 | The clinical team provides support to those who have communication challenges, as required. This may include speech pathology, the use of interpreters and alternative technology. |
Client education | |
4.30 | An orientation package is provided to all clients when they are accepted into a rehabilitation program. |
4.31 | Clients are educated about the need to be proactively engaged in the rehabilitation process prior to admission. This is reinforced over the course of admission. |
4.32 | Clients and carers are provided with education on the benefits and risks (where applicable) of different interventions. |
4.33 | Clients and carers are provided with education on the different settings of care and empowered to make their own decisions on the most appropriate setting of care (where clinically appropriate). |
4.34 | Staff have a shared understanding of the need for all clients to have time to process information, cognitively reframe and build resilience as a part of their rehabilitation program. |
4.35 | Education is tailored to the client to ensure different cultural and learning styles are considered. This may include the use of different mediums of information and different time intervals for delivering information. |
4.36 | Feedback is sought from the client and carer about the education provided and the level of information that is understood. |
Care coordination | |
4.37 | The clinical team includes a dedicated case management, care coordination or key person role to ensure coordinated continuity of care across the service settings and communication with the client and their carers. |
4.38 | Where required, case management is flexible, reinforcing and fostering the development of a client’s self-management skills. |
Outcome measurements
For the purposes of this section, the following definitions are used:
Standardised functional measures: clinician obtained measures that quantify a client’s performance of particular tasks and activities, e.g. the Berg balance scale, timed up and go test
Patient Reported Outcome Measures (PROMs): measures that capture the patient’s perspective about how illness or care impacts on their health and wellbeing
Patient Reported Experience Measures (PREMs): measures that capture the patient’s perception of their experience with the healthcare provided by services.
Continue to use the rating scale N/A 0 1 2 3 4 5.
| No. | Core element |
|---|---|
4.39 | The rehabilitation service uses a range of standardised functional measures in alignment with all components of the World Health Organization International Classification on Functioning, Disability and Health. |
4.40 | Standardised functional measures are used to monitor the client’s progress. At a minimum, measures are recorded at admission and discharge, with documented procedures for intermittent measures set by the service. |
4.41 | Services have a documented process detailing which outcome and experience measures are to be used for specific patient cohorts, conditions and treatments. |
4.42 | Services have a documented process detailing how outcome and experience measures are to be documented and followed up. |
4.43 | Results of functional measures are communicated to the client after each measurement. |
4.44 | Patient report outcome measures (PROMs) and patient reported experience measures (PREMs) are routinely captured and used by the clinical team for care planning. |
4.45 | Individual and collective results of patient/service outcomes and PREMs/PROMs are reviewed by the treating team and opportunities for improvement identified (e.g. participation in Australian Rehabilitation Outcomes Centre benchmarking). |
Culturally appropriate care | |
4.46 | Rehabilitation care is designed and delivered in a culturally appropriate manner for those clients who identify as Aboriginal and Torres Strait Islander. Refer to My rehab, my journey. |
4.47 | Aboriginal liaison officers are involved in the care of people who identify as Aboriginal and/or Torres Strait Islander. |
4.48 | Rehabilitation care is designed and delivered in a culturally appropriate manner for those clients from culturally and linguistically diverse backgrounds, including the use of multicultural health services and interpreters where required. |
Behaviour support | |
4.49 | A process is in place to identify clients in need of a structured behaviour support framework to enable positive change for those clients who exhibit behaviours of concern. |
4.50 | Rehabilitation services have access to a clinician trained in positive behaviour support to complete functional assessments, develop behaviour support plans and train and support staff. |
4.51 | Where a behaviour support plan is required, this plan includes least restrictive practices, the use of positive reinforcement and fosters the development of self-regulation skills. |
| Download access and equity self-assessment template | |
|---|---|
| No. | Core element |
| Access and equity | |
5.1 | The organisation provides access and referral pathways to a continuum of care that includes all rehabilitation settings, e.g. in-reach, inpatient, day programs and community-based ambulatory rehabilitation ensuring optimal efficiency, patient outcomes and experience. |
5.2 | Local processes ensure patients are referred to rehabilitation as early as possible in their hospital admission. |
5.3 | Once a person is accepted into a rehabilitation program, minimal delays are experienced in admitting them into that program. |
5.4 | Admission criteria for each rehabilitation setting or program are clearly documented. |
5.5 | These documented admission criteria and referral processes are communicated to: a) acute care teams b) local primary health providers. Note: rate each sub-question separately. |
5.6 | Information on types of rehabilitation and documented admission criteria is publicly available in a variety of common languages for consumers. |
5.7 | A clear and transparent process is in place to review non-accepted referrals and provide alternative options for ongoing care. |
| Patient flow | |
5.8 | The rehabilitation service has a system for determining a person’s optimal length of stay, e.g. Australian Rehabilitation Outcomes Centre (AROC) benchmarks. |
5.9 | The optimal length of stay is informed by input from all members of a person’s care team. |
5.10 | Length of stay is benchmarked with other rehabilitation programs via AROC. |
5.11 | Memorandums of understanding, statements of commitment, interagency agreements and employment contracts are in place for the purposes of formalising relationships with key stakeholders. This may include local National Disability Insurance Scheme (NDIS) providers, icare, private rehabilitation facilities and aged health providers. |
5.12 | Processes are in place for prompt liaison with icare once eligible patients are admitted into a rehabilitation program. |
5.13 | Processes are in place to ensure NDIS eligible patients are identified as early as possible in the patient journey and funding is applied for. |
5.14 | A clearly documented process for guardianship is in place, including appropriate consideration of a person’s capacity. |
| 5.15 | Data relating to discharge delays is captured and regularly reported, e.g NDIS, aged care delays. |
| 5.16 | Data on discharge delays is reviewed and used to identify and resolve systemic barriers to timely discharge. |
| Download responsiveness self-assessment template | |
|---|---|
| No. | Core element |
6.1 | Rehabilitation service review is scheduled to take place every three to five years, at a minimum. |
6.2 | The following groups are involved in rehabilitation service review: a) rehabilitation clinicians b) hospital executives c) consumers d) external stakeholders, e.g. affiliated health organisations, external providers, icare. Note: Rate each sub-question separately. |
6.3 | Consumers are involved in the design, planning and development of new rehabilitation services. |
6.4 | Patient Reported Experience Measures (PREMs) are routinely collected by the rehabilitation service. |
6.5 | The organisation and rehabilitation service have a documented process to follow up on results of PREMs and any other feedback received from clients and carers. |
6.6 | Client and carer feedback is used by the organisation and rehabilitation service to inform local quality improvement, processes, and care delivery. |
6.7 | The organisation conducts staff surveys on a regular basis, ideally every one to two years. |
6.8 | Staff survey results are used to inform staff wellbeing and retention programs, quality improvement, processes and care delivery. |
6.9 | Organisation and hospital executives undertake leadership rounding on a regular basis. |
| Download education and training self-assessment template | |
|---|---|
| No. | Core element |
7.1 | At any organisational level, there is a documented process for: a) professional development b) performance review c) monitoring registration with the Australian Health Practitioner Regulation Agency. Note: Rate each sub-question separately. |
7.2 | The professional development of rehabilitation health professionals is supported in the form of access to study leave and educational opportunities. |
7.3 | Rehabilitation staff are provided with opportunities for career progression. |
7.4 | Staff are provided with regular in-services, including training in the use of new equipment and technology. |
7.5 | The rehabilitation service provides opportunities for coaching and mentoring for staff. |
7.6 | The organisation supports rehabilitation staff to be involved in statewide networks (e.g. the Agency for Clinical Innovation, the Australasian Rehabilitation Nurses Association) to facilitate evidence-based care delivery. |
7.7 | The rehabilitation service is staffed to include clinicians with a broad range of skills and training, in addition to discipline-specific knowledge. Examples include training in a variety of relevant approaches such as resilience, change, motivation therapy, grief and loss. |
7.8 | The rehabilitation service identifies gaps in skill mix and supports staff to undertake education and training to meet these gaps. |
| Download research quality improvement self-assessment template | |
|---|---|
| No. | Core element |
8.1 | The organisation supports the engagement of rehabilitation staff in research activities. |
8.2 | The organisation supports the engagement of rehabilitation staff in quality improvement initiatives. |
8.3 | The rehabilitation service has a documented research and quality improvement plan based on current priorities. |
8.4 | The organisation has a process for collating and reporting on current research activity. |
8.5 | The organisation has a process for collating and reporting on current quality improvement initiatives. |
8.6 | Processes are in place for the transparent distribution of information about research grants and scholarships to rehabilitation clinicians. |
8.7 | Resources and opportunities are available and promoted for rehabilitation clinicians to be involved in the conduct of research. |
8.8 | Processes are in place to evaluate the translation of research into practice. |
8.9 | Processes are in place for rehabilitation services to report on the impact of discipline-specific and team education sessions on service activities and outcomes. |
More information about the tool
The Principles to Support Rehabilitation Care was published in 2019, leading to the need for the audit tool.