A salute to ten years of Australian Clinical Care Standards: celebrations and challenges

The Australian Commission on Safety and Quality in Health Care (hereafter, the Commission) published the first national Clinical Care Standard on antimicrobial stewardship ten years ago. In the decade since, 19 Clinical Care Standards have been developed and maintained by the Commission in line with the latest evidence (https://www.safetyandquality.gov.au/standards/clinical‐care‐standards/10th‐anniversary‐clinical‐care‐standards/timeline‐clinical‐care‐standards). Clinical Care Standards have become an integral part of the Australian health care quality improvement landscape with substantial impact on processes of care and patient outcomes (https://www.safetyandquality.gov.au/standards/clinical‐care‐standards). At this ten‐year anniversary, it is timely to reflect on what has been achieved by the standards, as well as future challenges and opportunities.

What are Clinical Care Standards?

Clinical Care Standards comprise up to ten quality statements that focus on specific areas of care where there is significant potential to improve clinical outcomes by increasing use of evidence‐based guidelines or models of care. The Clinical Care Standards also describe, for consumers, the care they can expect to be offered or receive. Measurable quality indicators aligned with the quality statements are included, which can be used by health care services and clinicians to assess, monitor and improve the quality of care they provide.

Importantly, the Clinical Care Standards are developed with advice from multidisciplinary working groups comprising expert clinicians, research leaders and consumers with lived experience. Draft documents are further refined through public consultation to ensure their relevance to key stakeholders including health services and agencies, and consumer and professional organisations.

By defining what high quality care looks like for health care services, clinicians and consumers and carers, the Clinical Care Standards support translation of knowledge into action at several levels of the health care system. This is vital given the complex interaction of individual patient factors, care processes and system factors that underpin the delivery of high quality care.

How do Clinical Care Standards work to effect change?

Various factors have facilitated the implementation and impact of the Clinical Care Standards, which cover a diverse range of clinical fields with different enablers and challenges. Firstly, specific requirements within the National safety and quality health service standards, to which all acute services must be accredited, provide a regulatory lever for implementation. Services implementing the Clinical Care Standards should ensure that systems, policies and processes are in place to enable clinicians to provide the level of care described.1 Although some of the Clinical Care Standards are mandatory for accreditation of hospitals providing relevant services, others are implemented according to local priorities.1 This means that the standards also rely on awareness and relevance to influence changes in care — including in primary care where the regulatory requirements differ.

An evaluation of the hip fracture, delirium and antimicrobial stewardship Clinical Care Standards by the Commission in 2023 found a high degree of awareness (90%) among health services surveyed, with 96% believing that the standards were relevant. Among the health services implementing these Clinical Care Standards, 92% reported an improvement in the quality of care. Although 60–85% of the surveyed health services stated that organisational changes were required, the type of change varied. Changes in policies, service delivery or procedures were the most common, with setting up data collection or monitoring processes less common.2

The ability to measure processes and outcomes is a key enabler and is the reason for including quality indicators within the standards. A number of national clinical quality registries (CQRs), including the Australian and New Zealand Hip Fracture Registry (ANZHFR, https://anzhfr.org/registry‐reports/), the Australian Stroke Clinical Registry (https://auscr.com.au/about/annual‐reports/) and the National Cardiac Registry (https://nationalcardiacregistry.org.au/) collect, analyse and report data against quality indicators defined in the related Clinical Care Standards. Such registries serve as fundamental drivers of quality improvement, as they use facility‐ and patient‐level data to provide regular feedback to participating hospitals, which enables the tailoring of quality improvement activities so these hospitals can foster and sustain practice change. Where there is no registry or broader data collection in place, the indicators support local quality efforts.

Evidence of impact

Tangible evidence of how Clinical Care Standards lead to improved outcomes when integrated into national CQRs was demonstrated by a recent study. Researchers showed that adherence to the Hip Fracture Clinical Care Standard was associated with improved survival after surgery for hip fracture in New South Wales hospitals participating in the ANZHFR.3 Strikingly, the study demonstrated a 60% reduction in 30‐day mortality risk in people who received care that was more closely aligned with the Clinical Care Standard, compared with individuals who received care that was only partially aligned (that is, meeting five or six versus three or fewer of the quality indicators assessed). This survival benefit was evident for up to one year after surgery, with a 40% reduction in mortality risk demonstrated for close versus partial alignment of care with the quality indicators. Importantly, although adherence to selected quality indicators led to better outcomes for hip fracture, about one‐third of people were receiving suboptimal care, suggesting potential to realise further improvements.3 This reflects the difficulty of achieving practice change in complex systems and the need for ongoing tailored implementation strategies.4

It is important to realise that the impact of Clinical Care Standards is often enhanced by other Commission activities related to its national role for safety and quality in health care, where the standards are one component of a multifaceted approach. Examples include national requirements for antimicrobial stewardship (AMS) programs in hospitals dovetailing with the AMS Clinical Care Standard, and the monitoring of hospital‐acquired complications related to the Clinical Care Standard for delirium.5,6

Several Clinical Care Standards have been developed by the Commission in response to findings of health care variation from the Australian Atlas of Healthcare Variation Series (hereafter, Atlas), including Clinical Care Standards for cataract surgery, colonoscopy, hip fracture, osteoarthritis of the knee, low back pain, heavy menstrual bleeding, third and fourth perineal tears, and most recently, chronic obstructive pulmonary disease.7 The Atlas has been central in identifying variation in the provision of health care services across Australia based on geographic location, funding, socio‐economic status and, where possible, Aboriginal and Torres Strait Islander status. When such potentially unwarranted variations in care have been identified, a Clinical Care Standard can enable system change by guiding health services and clinicians in how to implement change and address variation.7

For example, in 2015, the Atlas identified considerable geographical variation in the rates of hysterectomy for women with benign conditions such as heavy menstrual bleeding, suggesting that women were not being offered access to less invasive options. In response, the Commission published the first Heavy Menstrual Bleeding Clinical Care Standard in 2017, supporting evidence‐based management and shared decision making. A subsequent Atlas report demonstrated a 20% decrease in hysterectomy rates nationally between 2014–15 and 2021–22, suggesting that this decrease was related to system‐wide awareness of the variation data and the Heavy Menstrual Bleeding Clinical Care Standard, although it is not possible to draw a direct link.7

There is other evidence of Clinical Care Standards being used to evaluate the quality of care and experiences of care in various settings.8,9,10,11 This is a significant development as it will help to generate a body of evidence for the quality of care in Australia based on nationally consistent criteria. For example, recent surveys evaluated self‐reported adherence to two Clinical Care Standards in emergency departments for peripheral intravenous catheters (PIVCs) and management of low back pain.8,9 In each case, a substantial number of respondents (40–50%) reported clinical practice behaviour that was not in line with several (at least three) best practice recommendations. Moreover, with respect to PIVC use, about half of the survey respondents reported that they were unaware of the PIVC Clinical Care Standard, and some disagreed with its recommendations, suggesting that more education and exploration of barriers to adherence around the standard is needed.8 These findings are also valuable to ensure ongoing relevance. As the Commission reviews each standard, it can respond to issues that emerge relating to implementation difficulties, changes in evidence or quality improvement priorities.

Future directions

Although much has been achieved, there is more to be done. Over the next ten years, the Clinical Care Standards will need to be responsive to the considerable challenges facing health care systems, including workforce and financial constraints, rapidly changing technology, artificial intelligence (AI), climate change, increasing patient complexity and social inequity in health care outcomes. Some challenges present opportunities too, for example, to improve the use of quality data by harnessing digital systems and AI, reducing the time burden for data collection in resource‐stretched services.

There remains a need to close the gap in health outcomes for First Nations peoples and to bring their cultural wisdom into mainstream health care. To address disparities in care, since 2023 the Clinical Care Standards have had an increased focus on cultural safety and equity. Services are encouraged to consider models of care and referral pathways to support First Nations peoples and to provide culturally safe and appropriate care.

Aligned with the National Health and Climate Strategy,12 inappropriate health care practices consume resources, fail to provide valuable outcomes for consumers or services and impact negatively on climate change. In the future, we can expect the impact of low value care on the sustainability of health care to come to the fore. This focus is highlighted in the Joint Statement on Climate Change and Health, signed in October 2024 by specialist medical colleges, which represents a shared vision to work together to address the health impacts of climate change.13 From 2024, new Clinical Care Standards include a section on environmental sustainability and climate resilience in health care outlining how to minimise the impact of disease management on the environment. By embedding evidence‐based care that is also patient‐centred, the Clinical Care Standards can help health care providers increase the value and impact of care provided. An example of this is the use of primary care‐based interventions for musculoskeletal conditions that enable patients to avoid or delay surgery.14,15

Although the Clinical Care Standards set the expected standards of care, it is the voices of consumers and the actions of clinicians, health services and those in health care governance and clinical leadership roles who bring the Clinical Care Standards to life. Indeed, many peak bodies, including consumer and professional organisations and specialist medical colleges have contributed to and endorsed the Clinical Care Standards. Clinical Care Standards are important tools that will continue to evolve and support clinicians, health care services and consumers to realise better outcomes and ensure appropriate and effective, cost‐efficient and environmentally sustainable care into the next decade.