edel murray - st vincent's hospital sydney - using auditing to meet many needs ‘wift’ what...

St. Vincent’s Private Hospital, Sydney

12/1/2015 Edel [email protected]

Edel Murray Quality Manager SVPHS

• National Safety and Quality Health Service Standards (ACSQH, 2011)

endorsed by Health Ministers to protect consumers from harm &

improve health service provision

12/1/2015 Edel Murray Quality Manager ext:6460

Standards to be met: 10 National standards & 11-15 EQuIP National

ACHS Accreditation

29th,30th Sept & 1st Oct 2015

Edel Murray

Quality Manager

Auditing to meet NSQHSS & EQuIP

• 2012 Gap analysis

• 2013 Queensland audit

tools

• 2013 Periodic review

• 2014 drowning in data• SVPHS audit data

• SVHA Internal audit

• paper audits

• some survey monkey


Review our auditing plan


Justification for Research

Edel Murray Student Id:116458

• National Safety and Quality Health Service Standards (ACSQH, 2011)

endorsed by Health Ministers to protect consumers from harm &

improve health service provision

NSQHS Standard 1: Establish & maintaining governance

for safety & quality

• Accreditation: Healthcare services must provide documentation &

validation (from executive management to bedside clinician) of a clinical

governance principles

• Outcome: Multiple definitions, principles, approaches of clinical

governance resulting in divergence in outcomes & continuing adverse

events

Justification for Research


Literature review

Searched research literature -1998 to present

Keyword search

clinical governance

principles, themes, concepts, components, context, elements,

pillars, framework, models

Major data bases: CINAHL, Medline

Grey Literature – OECD countries

Citations in papers identified in above searches

From Quality Assurance to Clinical Governance


Clinical Governance definition

Clinical Governance: A system through which

organisations are accountable for continuously improving

the Quality of their services and safeguarding high

standards of care/ This is achieved by creating an

environment in which there is transparent responsibility

and accountability for maintaining standards and by

allowing excellence in clinical care to flourish (Scally & Donaldson, 1998)


NHS Pillars of Clinical Governance


Audit

What, Who and Why?

What:• questions do we need

answered/evaluated?

• audit tools are we using?

Who:• else is auditing?

• else can we use?

Why:

• rational


Gap analysis

Gap analysis to answer

• What questions do we need answered/evaluated?

• Why?

• Timelines?

• What audit tools are we using?

• Why?

• Medium?

• What are others using?

• Who else is auditing?

• ?????????


Who else can we use?

• Internal audit

• Health Information Teams

• ITSC teams

• Research teams

• Students • Undergraduate

• Post graduate

• PHD & PD

• Executives

• University partners


WIFT model


Why???

• Fundamental to safe care• Risks occur when there is a mismatch between patient &

care• Patient identification is routine ‘can be seen as unimportant’• Systems ensuring patients are correctly matched to their

care means that more attention can be paid to more complex tasks


19

Structure of Standard 5

5.1.1, 5.1.2 Organisation-wide

patient identification system

5.3.1 Patient

identification

bands

5.2.1, 5.2.2

Mismatching

events

5.4.1 Handover,

transfer and

discharge

5.5.1, 5.5.2, 5.5.3

Matching patients to

their intended care

Put the system

in place

Audit / review performance

of or compliance with the

system

Make improvements

based on the results of

the audit


Who is this?


What would we call her?

• Elizabeth Alexandra

Mary Windsor

• 1973 – : Her Majesty

Elizabeth the

Second, by the

Grace of God, Queen

of Australia and Her

other Realms and

Territories, Head of

the Commonwealth


Auditing requirements

• 5.1.1, 5.1.2, 5.3.1, 5.3.1 ID band and national identifiers

• Minutes and action plans tell the story


Frequency Audit Reported to

Yearly PI/AMS/AT/Blood/Chart audit Units, NQSC,QSC

Monthly Surgical Services Handover

WHO

Time out

Deteriorating Patient

Units, SSSC,NQSC,QSC

Bimonthly Clinical Handover

Uspace PI Audit

Units, NQSC,QSC

Quarterly Chart Audit/Medication Audits Units, PCS, QSC

Daily SS/ICU Time out SSSC,NQSC,QSC

Aseptic technique

Pre and post implementation audits

Team• Infection control/Associates

• Work Health and Safety/Associates

• Clinical Educators

• Quality

Audit• Patient identification

• Consent

• Aseptic technique competency/policy

• PPE


Legalisation compliance

Pre and post compliance audits

Team• Legal team

• RiskMan

• Quality and Safety Committee

Audit• Compliance with legalisation

Outcome

• Legalisation compliance module now electronic in

RiskMan


Population health

Pre and post implementation audits

Team• Preadmission staff

• Patients and families

• Research team

• Heart Foundation

Audit• Patient identification

• Consent

• Health promotion

• Health literacy

• Research process


Preventing & Managing Pressure Injury

Audits

Team• Wound CNC

• ACU & Griffith University

• INTACT researchersAudit

• Consent

• Pressure risk assessments

• Acquired pressure injuries

• Patient involvement

• Patient identification


SVHA Internal Audit

Compliance audits

Team• SVHA Internal Audit team

• Clinical Risk manager

Audit• Medication Compliance with legalisation

• Meeting NSQHS


HDR Students

Collaboratively developing a pre-operative checklist: an

e-Delphi study Kim Walker Funded Murphy, K

Duff J, Walker K,

Engaging patients in communication at transitions of careEdel Murray Funded ACSQHC Edel Murray Prof Anne McMurray

INTACTEdel Murray Funded NHMRC

David Bayliss, Kelly Edwards

Edel Murray, Maria Ocampo

Prof Wendy Chaboyer, A/Prof Liz McInnes

Factors affecting discharge effectiveness in PACUKerry-Anne Cobbe Unfunded Kerry-Anne Cobbe

Effectiveness of pre op Lyrica and Celebrex achieving

enhanced recovery

Susan Djukanovic Unfunded Susan Djukanovic

Healthy bowel project Jackie Johnston Unfunded Jackie Johnston

Quality of Life of Persons post Trans-Oral Robotic

Surgery Pauline Dooley Dooley P,

National Antimicrobial Prescribing Survey (NAPS) 2014 Belinda Johnson FundedJohnson B, Aguilera J, Crawford B

DVT prevalence study in ankle/foot surgery patients (non

weight bearing) Martin Sullivan Omari, , Walker, Duff Panti, Walton

Prospective Audit of Preoperative Iron Therapy using

Ferric Carboxymaltose (Ferinject) for Patients with Iron

Deficiency Anaemia undergoing Joint Arthroplasty at

SVPHS Yoon Ooi

Jenny Stevens, Kim

Walker

Katherine Lee

Perioperative intravenous lignocaine infusion Matthew Ho

ICU discharge criteria for post-operative cardiothoracic

patients Louise Sellars

Development and pilot of a real time patient experience

measurement tool Funded Kelly Edwards Kim Walker, Jed Duff

What factors influence how men with prostate cancer

make treatment decisions Funded David Bayliss Kim Walker, Jed Duff

Cardiac failure patient's understanding of and adherence

to fluid restriction guidelines Leeana Woods Kim Walker, Jed Duff


We are all


Make sure they all know they are


Responsible

Patient involvement


Report monthly

• Quality plans

• Projects from gap

analysis

• Evidence

• Audits

• Education

• Cultural shift

• Responsibilities


2016 and beyond

• Gap analysis for the organisation against version 2 of the NSQHS

standards

• Development of SVHA Private Division auditing tools

• Electronic auditing tools

• Personal Bias

• ‘No matter how smart, people usually see what they're already

looking for’ Veronica Roth (Author)


Acknowledgements

• Supervisors: Prof Kim Walker, Dr Jed Duff and Dr Danielle Williams

• SVPHS: A/Prof Jose Aguilera

• UTAS

• & fellow students


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