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SAFER SYSTEMS BETTER CARE QSA VERIFICATION REPORT

FINDINGS FROM 2011 ON-SITE VERIFICATION PROGRAM OF 2010 SELF-ASSESSMENT

November 2011

© Clinical Excellence Commission 2011

This work is copyright. Apart from any use as permitted under the Copyright Act 1968, no part may be

reproduced without prior written permission from the Clinical Excellence Commission. Requests and enquiries

concerning reproduction and rights should be directed to the Director, Corporate Services, Clinical Excellence

Commission, Locked Bag A4062 Sydney South NSW 1235.

This publication is part of the Clinical Excellence Commission’s Quality Systems Assessment Series. A complete

list of the CEC’s publications is available from the Director, Corporate Services, http://www.cec.health.nsw.gov.au

National Library of Australia Cataloguing-in-Publication entry

Title: Safer systems better care quality systems assessment report

[electronic resource]: findings from 2011 on-site verification,

program of 2010 self-assessment / Wendy Jamieson ... [et al].

ISBN: 9780980554373 (ebook)

Subjects: Medical care--Quality control.

Medical care--Evaluation.

Health planning.

Other Authors/Contributors: Jamieson, Wendy. Clinical Excellence Commission (N.S.W.)

Dewey Number: 362.1068

Author

Wendy Jamieson

Contributors

Bernadette King, Mark Zacka, Dr Peter Kennedy and Dr Charles Pain

Adrian Lacey, Manager Corporate Communications, Policy & Technical Support Unit

Rae Doble, Design and Print Coordinator, Health Support Services

Suggested citation

Clinical Excellence Commission (CEC) 2011. Quality Systems Assessment On-site

Verification Program Report 2011: Verification of the 2010 Self-assessment.

Clinical Excellence Commission

Board Chair: Associate Professor Brian McCaughan AM

Chief Executive Officer: Professor Clifford F Hughes AO

Any enquiries about or comments on this publication should be directed to:

Dr Charles Pain

Director Health Systems Improvement

Clinical Excellence Commission

Locked Bag A4062

Sydney South NSW 1235

Phone: (02) 9269 5500

Email: [email protected]

Printed by CEC. Design by HSS Design, Health Support Services. December 2011

Front cover: Hospitals included in QSA on-site verification visits include Balmain, Bankstown, Concord, Royal Prince Alfred, Fairfield, Campbelltown, Long Jetty, Manning, Gosford, Wilcannia, David Berry, St Vincents. Campbelltown Hospital photo by Alan Farlow, http://www.panoramio.com/user/872106?with_photo_id=35566222St Vincents Hospital photo by Clytemnestra, http://commons.wikimedia.org/wiki/File:StVincentsHospital1.JPG

http://www.cec.health.nsw.gov.au

mailto:[email protected]

http://www.panoramio.com/user/872106?with_photo_id=35566222

http://commons.wikimedia.org/wiki/File:StVincentsHospital1.JPG

Safer Systems Better Care: Report on the 2011 QSA On-Site Verification Program 1

Table of contents

Foreword ........................................................................................................................................ 2

Executive Summary ........................................................................................................................ 3

1. Quality Systems Assessment ...................................................................................................... 4

2. QSA Verification Program ........................................................................................................... 5

2.1 Aims Of QSA On-Site Verification Visits ................................................................................................5

2.2 Methodology........................................................................................................................................5

2.2.1 Quality Systems Site Assessors .................................................................................................................. 5

2.2.1.1 Recruitment and Training .....................................................................................................................................5

2.2.1.2 Consistency of Assessments ...............................................................................................................................5

2.3 On-site Verification Visits ......................................................................................................................6

2.3.1 Selection of Facilities and Clinical Units ....................................................................................................... 6

2.3.2 Showcase Presentation .............................................................................................................................. 7

2.3.3 Unreported Critical Issues ........................................................................................................................... 7

2.3.4 Innovations .................................................................................................................................................. 7

2.3.5 Final Report ................................................................................................................................................ 7

2.3.6 Recommendations ...................................................................................................................................... 7

2.3.7 Appeal Process ........................................................................................................................................... 8

2.3.8 Evaluation of QSA Process ......................................................................................................................... 8

3. Results ....................................................................................................................................... 9

3.1 2011 Verification Themes ................................................................................................................................... 9

3.2 Scope of 2011 Verification Visits........................................................................................................................ 9

3.3 Accuracy of Self-assessment Responses ......................................................................................................... 9

3.4 Recommendations ............................................................................................................................................ 9 Healthcare Associated Infections ...................................................................................................................................... 10

Open Disclosure ............................................................................................................................................................... 10

Teamwork ......................................................................................................................................................................... 10

4. Innovations ................................................................................................................................11

5. Evaluation ..................................................................................................................................12 5.1 LHD Staff Feedback .........................................................................................................................................12

5.2 Assessor Feedback .........................................................................................................................................12

5.3 Verification Report Turnaround Times ..............................................................................................................12

6. Acknowledgements .................................................................................................................. 13

7. Glossary ....................................................................................................................................14

8. List of Assessors ...................................................................................................................... 15

9. CEC programs and projects ......................................................................................................17

2 Safer Systems Better Care: Report on the 2011 QSA On-Site Verification Program

Foreword

The Quality Systems Assessment (QSA) program conducted by the Clinical Excellence Commission (CEC) provides a framework to identify risks to clinical safety and quality in the NSW health system and recommend action for improvement.

The QSA works on a five-year cycle to assess the systems and processes in place to ensure quality and safety for patients. The initial self-assessment in 2007 provided a baseline census which will be reviewed in 2012.

The 2010 self-assessment examined four themes: healthcare associated infections, open disclosure, teamwork and mental health (for the NSW Ambulance Service only). It was completed by more than 1,500 respondents with a participation rate at the unit level of 93% and the results produced some significant findings and recommendations, which have been detailed in the Safer Systems Better Care report.

The CEC takes great care to ensure the integrity, consistency and reliability of the QSA program. In conducting the on-site verification program we recruit and train clinical staff from all local health districts (LHDs) to become Quality Systems Assessors and ensure the verification visit is arranged and conducted in a collaborative manner with LHD senior executives. While the main purpose of the verification program is to verify responses from the self-assessments it also provides a means to increase knowledge of key issues affecting quality and safety in the system

This report provides encouraging feedback on the verification of more than 16,000 responses to the 2010 QSA. The overall accuracy rate was just under 98% - and more than half of those assessed as inaccurate were judged to have under-estimated performance. In other words, the system was safer than indicated in the self-assessment.

In the very small number of cases where more significant issues were revealed, verification teams have worked with those involved to improve understanding for future self-assessments.

I would like to thank all of those who participated in the 2010 QSA and the 2011 verification program. This is a very important part of our efforts to ensure safer, better care for NSW patients.

Professor Clifford Hughes, AOChief Executive OfficerClinical Excellence Commission


Executive Summary

The QSA provides a framework to identify risks to clinical safety and quality in the NSW health system and recommend action for improvement. It is based on self-assessment by people working at all levels of the system. The QSA verification program tests the accuracy of self-assessment responses. The verification program has been developed using best practice methodology from a number of industries. It is not intended to assume the regulatory or compliance role of accreditation.

In 2011 the CEC undertook the third year of the QSA On-site Verification Program across all LHDs, Justice Health and Ambulance Service NSW. The aim was to verify the accuracy of responses to the 2010 self-assessment, which examined three main themes:

• Healthcare associated infections (HAIs)

• Open disclosure, and

• Teamwork.

The on-site verification program also aimed to:

• Identify for wider application innovations related to the assessment themes that had been shown to enhance safety and quality

• Identify areas needing improvement, and

• Evaluate how the verification process was received by the LHDs.

The 2011 on-site verification program involved 36 qualified Quality System Assessors who made on-site visits to:

• 41 LHD hospitals, 43 clinical units, and 21 groups of front-line clinical staff at smaller facilities (eg multi-purpose services)

• One clinical steam and six operational units in Justice Health, and

• Two ambulance divisions and eight ambulance stations.

Overall, 16,095 self-assessment responses were verified. Assessors found inaccuracies in only 392 responses, giving an accuracy rate of 97.8% - consistent with the findings of the 2009 and 2010 verification programs.

QSA Assessors made 142 recommendations for improvement across the visited organisations. The majority related to HAIs (62.7%), with 28.2% directed at open disclosure, 7% at teamwork and 2.1% relating to clinical governance units addressing issues around the QSA process and improvement plans.

The assessors identified and reported 19 innovations – seven regarding HAIs, eight directed at teamwork and four involving open disclosure.

Assessor teams significantly improved the time for returning draft verification reports to LHDs in 2011, reducing the average turnaround time following on-site visits from 15 days in 2010 to 6.8 days.

During each LHD verification visit feedback questionnaires are provided to all staff interviewed by assessors. Completed questionnaires are collated and reviewed at the CEC. Results from the 2011 program indicate that LHD staff found the on-site verification process was conducted professionally and was beneficial and effective.

Foreword


1. Quality Systems Assessment

The QSA program is an important part of ensuring patient safety and clinical quality in NSW public health services. It is a clinical risk management program with a focus on learning and improvement. The QSA provides clinicians and managers with a convenient and accurate means for determining compliance with policy and standards, identifying clinical risks and deficiencies in practice, as well as highlighting and sharing exemplary practice.

The QSA features a multi-level approach to quality systems assessment. This approach allows for responses at different levels of the organisation to be correlated and to assess the effectiveness of governing and reporting structures. The program has four main elements (figure 1):

• Self-assessment: every level of each public health organisation (PHO) in NSW completes an annual self-assessment to assist in identifying areas of risk and vulnerability with regard to patient safety and quality care.

• Feedback and reporting: the CEC provides feedback to all contributing respondents, the health system and the community. Various levels of reports are provided to ensure that PHOs have meaningful information, as the basis for action on their performance, strengths and weaknesses.

• Improvement plan: development of the improvement plan addresses the identified risks and means by which improvement will be achieved through the QSA self-assessment. Each level of the organisation (district, facility, and department) is expected to use the results and respond to the issues identified in the self-assessment.

• Verification: this program verifies the accuracy of a sample of the previous year’s self-assessment responses. Annually 20% of all PHOs are visited, with the aim that all will have participated in the verification process within a five year cycle.

Figure 1: QSA Model

Feedback & Reporting

Improvement Plan

Verification

Self-assessment


In the development of a verification program for the QSA a variety of organisations that already undertake this sort of ‘checking’ process were researched. These included KPMG, the NSW Health numerical profile program, occupational health & safety industry, Australian Council on Healthcare Standards (ACHS EQuIP) accreditation, the Irish Accreditation system, Internal Audit Bureau, Child Care Accreditation, NATA Laboratory Accreditation, UK Healthcare Commission and USA Joint Commission. From this review and in keeping with the improvement philosophy of the QSA the verification program was developed not with a regulatory or compliance focus but to provide a risk identification and improvement framework. Consequently while the verification process confirms the robustness of the self-assessment responses, it has developed into a means to provide an opportunity to review improvement plans as well as provide peer review advice and support to the LHD improvement efforts.

2.1 Aims of QSA On-site Verification Visits The verification program aims to:

Verify Accuracy of Self-assessment Responses

Determine the accuracy of a sample of responses from three high risk/clinical quality topics from the 2010 on-line self-assessment: healthcare associated infections (HAIs), open disclosure and teamwork.

Review Evidence

View documents/resources used to inform the evidence base for the 2010 self-assessment such as policies, guidelines, protocols, minutes, reports and audit results quoted as evidence etc.

Determine Areas for Improvement

Review progress in complying with relevant policies, protocols, guidelines and best practice standards.

Identify gaps and discuss remedial options with staff during the verification interview. Document recommended improvements in the LHD on-site verification visit final report.

Review Use of QSA Results

Determine how the 2010 QSA self-assessment data/results were used at the district/facility level to drive change. Determine if the LHD QSA report was tabled and discussed at the LHD peak quality committee.

LHD QSA Improvement Plan Progress

Ensure the LHD has a QSA improvement plan and is acting on recommendations from previous QSA self-assessments and verification visits.

Share Innovations

Highlight and report on successful innovations designed and implemented by LHD staff to help drive improvements under the three review topics.

2.2. Methodology

2.2.1 Quality Systems Site Assessors

2.2.1.1 Recruitment and Training

Since 2009 the CEC has invited expressions of interest annually for volunteer Quality Systems Site Assessors from all public health organisations. Sixty assessors have been recruited and trained so far, including nine in 2011. All have successfully completed a two-day, competency-based, certified auditor training program conducted by SAI Global and are credentialed quality and management systems auditors.

2.2.1.2 Consistency of Assessments

CEC recognises the importance of ensuring consistency between different verification teams and individual assessors – a concept known as inter-rater reliability.

2. QSA Verification program


The strategies adopted by the CEC to ensure reliability include:

• recruitment of appropriate, experienced, reliable staff;

• extensive initial training and competency tests for all assessors by a skilled and experienced auditing organisation (SAI Global) prior to the initial on-site visit;

• development of simple tools and clear templates by the CEC QSA Verification Program Leader for assessors to record findings and for production of the final report;

• including in the audit tool best practice criteria that assessors must report against, with recommendations for action where criteria are not met satisfactorily;

• pre and post-verification visit teleconferences with assessor teams;

• the assignment of a CEC assessor to each team to ensure consistency in recording findings and report writing, troubleshoot problems and ensure strong communication with the CEC QSA team;

• requiring interviews at all levels of the LHD to be conducted by a pair of assessors to provide a double-check on facts, and to reduce the risk of variability and ambiguity in findings; and

• ensuring assessors review feedback questionnaires from staff interviewed during their verification visit.

A one-day training session was held for 2011 verification program assessors where experts in the assessment topics provided tips on best practice and addressed verification questions.

2.3 On-site Verification VisitsOn-site verification visits are planned in collaboration with the LHD QSA coordinator who is responsible for overseeing the QSA process within the district and ensuring that actions identified in the QSA improvement plan are implemented. A schedule (timetable) is developed for each on-site visit. The schedule, which includes the times/dates for all interviews, provides advance notice to LHDs to allow staff time to prepare

2.3.1 Selection of Facilities and clinical units At the commencement of the Verification Program it was intended that all of the former area health services (now LHDs) would be reviewed annually and within each area, 20% of facilities would be visited. This meant that over a five year cycle all NSW hospitals would be visited by an assessor team.

This approach has since been varied slightly to provide for flexibility between metropolitan and rural LHDs in the selection of/hospitals for review.

In metropolitan LHDs, a group of differing sized/peer group hospitals will be visited each year.

In rural LHDs the selection of facilities/hospitals will be by geographic region.

In the selection of clinical units for verification two units are chosen by the QSA team with a third Dr Charles Pain - CEC Director of Health Services

Improvement discussing Teamwork.


clinical unit selected by the LHD director of clinical governance. In small rural hospitals where there are only one or two clinical units/wards, the LHD selected one or two staff to be interviewed to represent front-line clinicians.

2.3.2 Showcase PresentationEach LHD is invited to provide a 10 minute showcase presentation on a clinical quality/safety topic of its choice at the initial LHD level welcome meeting. The presentation is expected to focus on measurable outcomes.

2.3.3 Unreported Critical IssuesWhere assessors identify a serious incident such as an unreported SAC 1 incident or an instance of unethical or reckless staff behaviour, they are instructed to immediately contact the facility general manager, LHD director of clinical governance and the deputy CEO of CEC. If relevant, the Director General of NSW Health would also be notified.

No incidents of this nature were identified during the 2011 verification program.

2.3.4 Innovations During 2011 verification visits, assessors identified 19 innovations that could be shared across other units/departments/facilities/LHDs (further details Section 4).

2.3.5 Final reportWithin two weeks after each verification visit a draft report is sent to the LHD director of clinical governance and QSA coordinator. They then have two weeks to respond and correct any errors of fact. Following feedback the final report is sent to the LHD chief executive.

2.3.6 RecommendationsOn receipt of the final report, LHDs are required to review any recommendations and include an action response in the LHD QSA Improvement Plan. Implementation of recommendations should be monitored regularly, reported to the LHD peak quality committee and chief executive, and evaluated for effectiveness. The LHD QSA Improvement Plan is reviewed annually by assessors during on-site verification.

Introductory meeting at St Vincent’s Hospital. (L-R): Rosemary Cullen - QSA Assessor, Grainne O’Loughlin - Director Allied Health, Dr Marcel Leroi - QSA Assessor, Dr Peter Kennedy - CEC Deputy CEO, Chris Conn - Manager of Patient Safety & Quality, Dr Brett Gardiner - Director Clinical Governance and Jonathan Anderson - Executive Director.


2.3.7 Appeal ProcessEach LHD can appeal against findings in the final report. Appeals must be lodged with the CEC CEO within 28 days of receipt of the final report. Any appeal must be referred for independent review within four weeks of lodgement.

No appeals have been received on 2011 verification program findings.

2.3.8 Evaluation of QSA processThe on-site verification program is assessed through feedback questionnaires completed by both LHD staff and assessors.

Report writing: Assessors Michelle Cuttler & Dr Chris Lowry


3.1 2011 Verification Themes In 2011 the verification process focused on the three themes surveyed in the 2010 QSA:

• Healthcare associated infections

• Open disclosure

• Teamwork.

3.2 Scope of 2011 Verification Visits In 2011 verification visits were made to:

Local Health Districts:

• 41 facilities

• 43 clinical units

• 21 groups of front-line clinical staff at smaller facilities/hospitals

Justice Health:

• one clinical stream

• 6 operational units in correctional centres

Ambulance Service of NSW:

• two divisions

• eight stations

3.3 Accuracy of Self-assessment ResponsesIn 2011 assessors reviewed 16,095 self-assessment responses from the 2010 on-line QSA self-assessment. Inaccuracies were established in 392 responses, giving an accuracy rate of 97.8%. This compares favourably with the accuracy rate achieved in the 2009 and 2010 verification programs (Table 1).

3.4 RecommendationsQSA Assessors made 142 recommendations for improvement across the visited organisations. Most involved HAIs (62.7%), with 28.2% directed at open disclosure, 7% at teamwork and 2.1% at the need for some clinical governance units to address issues around the QSA process and improvement plan.

LHDs were advised of all relevant recommendations in verification visit final reports and asked to include them in their QSA Improvement plans and implement remedial action. Progress in addressing and evaluating these actions will be reviewed in future verification visits.

3. Results

Year of verification Responses verified Inaccurate responses Accuracy rate

2009 2,795 36 98.6%

2010 20,438 277 98.6%

2011 16,095 392 97.8%

Table 1: Accuracy rate for the QSA Self-assessment 2009-2011

Topic verified Accuracy rate Recommendations

Healthcare associated infections 97.7% 89

Open disclosure 97.7% 40

Teamwork 97.3% 10

Table 2: Summary table of findings in relation to each topic verified


Healthcare Associated Infections HAI recommendations related to:

• Lack of auditing or monitoring of HAI activities.

• Lack of public display of hand hygiene results.

• Non use of chlorhexidine impregnated wipes when inserting IV cannulae (based on best practice NHMRC Australian Guideline standard).

• Lack of indwelling catheter education and training.

Open DisclosureThe assessors generally found that clinical staff were practicing general level open disclosure in all aspects of their everyday activities. Most of the recommendations related to the need for further ongoing education and training for both high and general level open disclosure.

TeamworkMost recommendations regarding teamwork related to the development, strengthening and education of staff around team values, leadership and structures.

“The QSA verification process has helped clinical staff prepare for EQuIP accreditation where they have acted on recommendations from the QSA external assessors to improve processes and outcomes for patients.”

Feedback from verification interviewee.

How verification can support best practice on system level

Area of verification: Healthcare associated infections.

Finding: Across all LHDS some facilities / clinical units were using alcohol impregnated wipes not chlorhexidine impregnated wipes to prepare patients skin when inserting IV cannula.

Best practice: Standard stated in the NH&MRC Australian Guidelines for the Prevention and Control of Infection in Healthcare is to use chlorhexidine impregnated wipes to prepare skin.

Recommendation: That Chlorhexidine (0.5%) impregnated alcohol wipes be sourced, stocked and utilised on all IV Cannula Trolleys in the department / hospital / district.


During the verification visits assessors often see innovations that could be shared to improve care across other departments or facilities.

In 2011, QSA assessors identified 19 innovations worth noting in the LHD final report and reporting back to the CEC – seven regarding HAIs, eight directed at teamwork and four involving open disclosure. These included:

4. Innovations

Topic Innovation

HAI

Introduction of two separate towels for washing patients - blue for the face and white for the rest of the body – greatly reducing the incidence of conjunctivitis

Weighing of pads and urine receptacles to measure urine output, resulting in more accurate fluid balance, reduction in use of urinary catheters and hazards related to spills and splashes

A standardised wound folder that provides information on correct choice of wound dressings and their management

Open disclosure

Introduction of stickers for inclusion in medical records to indicate that open disclosure has been activated in response to an incident

Development of forms for inclusion in the medical record to provide guidance and assurance on all aspects of the open disclosure process, enabling outcomes to be monitored and audited

Inclusion of interns in first year, buddied with an experienced team member, as part of root cause analysis team to gain understanding of incident review and open disclosure

Teamwork

Development and use of the simplified multidisciplinary Clinical Pathways for COPD and CCF which include discharge planning and patient information

Aboriginal cultural awareness information developed by the HSM and Aboriginal staff member as a resource for students and staff unfamiliar with working and caring for Aboriginal people

DVD Having a Baby in Australia produced to provide non-English speaking patients with information in their own language about birth procedures, dramatically reducing the emergency caesarian rate

Dignity at Work program incorporating employee of the month awards, staff lunches and newsletters, developed in consultation with staff to promote agreed values, resulting in improved staff morale and communication

Implementation of Country Career support position for new practitioners working in isolated areas

Measurement and prominent display of weight carrying capacity of equipment, improving safety for patients and staff

The CEC is working with LHDs to ensure successful innovations are spread widely to maximise benefits to NSW patients.

Table 3: Summary table of findings in relation to each topic verified


Each year feedback is sought from assessors and staff interviewed during verification visits to determine the effectiveness of and satisfaction with the on-site verification process and areas of improvement.

5.1 LHD Staff FeedbackWhile some staff expressed concern about the burden of preparing for the on-site visit, the majority of feedback from clinical staff indicate that they find the on-site verification process beneficial, effective and undertaken professionally. Staff reported that assessors were organised and knowledgeable about verification topics.

5.2 Assessor FeedbackThe main highlights / benefits for the assessors included:

• Gaining a broader knowledge of the healthcare system and its processes

• Opportunity to visit another LHD and seeing firsthand how it operates

• Seeing progression and innovations in safety and quality

• A prompt to look at their own units practices and improve, and

• Opportunity to participate in a valuable system review which they felt had the potential to improve patient safety and quality systems.

All assessors stated that they would recommend being a QSA assessor to a colleague. There were several recommendations for improvement, which were noted, and will be reviewed by the CEC QSA Team and acted upon.

5.3 Verification Report Turn Around TimesAssessor teams significantly improved the time for returning draft verification reports to LHDs in 2011, reducing the average turnaround time following on-site visits from 15 days in 2010 (range 3-33 days) to 6.8 days (range 4-13 days).

The 2011 assessor teams also improved the turnaround time of returning the final report to the LHD chief executive after review by the director of clinical governance (standard: < 42 days). The 2011 average turnaround time for the final report was 32 days from the last day of the verification visit (range 19–49 days), compared to 42 days in 2010 and 75 days in 2009. Only one LHD verification report failed to meet the 42-day turnaround standard in 2011.

5. Evaluation

Quality Systems Site Assessors who attended the Verification Topic Training on Wed 2nd March, 2011. L-R: Prof Michael Fulham (SNSWLHD), Dr Brett Courtenay (St Vincent’s Network), Dr Vicky Ting (SNSWLHD), Jan Heiler (SESLHD), Robyn Schubert (ISLHD), Michelle Cuttler (SESLHD), Dr Marcel Leroi (NBMLHD), Liz Harford (MLHD), Andrew Dagg (MLHD), Christine Hughes (HNELHD), Dr Trish Saccasan-Whelan (MLHD), Mick Rowles (SESLHD), Sharon McKay (WNSWLHD), Alan Hall (SWSLHD), Dr Nick Collins (SWSLHD), Alan Morrison (ASNSW), Lee Silk (CCLHD), Pauline Gaetani (ISLHD), Rodney Smith (St Vincent’s Network), Amanda Walker (SWSLHD), Catherine Turner (HNELHD), Jane Walsh (NNSWLHD) and Deborah Elligett (WNSWLHD).


Many CEC staff have contributed to the development and execution of QSA On-site Verification Program, including:

• Wendy Jamieson

• Bernie Harrison

• Dr Peter Kennedy

• Bernadette King

• Mark Zacka

• Professor Cliff Hughes

• Dr Charles Pain

• Alex Warner

Administration support for the 2011 verification program provided by Michelle Geehan.

Others who were instrumental to the success of the program include:

• Volunteer quality systems site assessors

• LHD clinical staff from all levels of the organisation who participate in the verification process

• LHD QSA coordinators

• LHD directors of clinical governance

• QSA Advisory committee

5. Evaluation

Previous reports from the Quality Systems Assessment program Available at http://www.cec.health.nsw.gov.au/programs/qsa

6. Acknowledgements

http://www.cec.health.nsw.gov.au/programs/qsa


AHS Area Health Service

ASNSW Ambulance Service NSW

CCF Congestive Cardiac Failure

CCLHD Central Coast Local Health District

CEC Clinical Excellence Commission

CGU Clinical Governance Unit

COPD Chronic Obstructive Pulmonary disease

CPI Clinical Practice Improvement

CVC Central Venous Catheter

HAIs Healthcare Associated Infections

HNELHD Hunter New England Local Health District

HSM Health Services Manager

IDC Indwelling Catheter

IIMS Incident Information Management System

IP&C Infection prevention & control

ISLHD Illawarra Shoalhaven Local Health District

LHD Local Health District

MLHD Murrumbidgee Local Health District

NBMLHD Nepean Blue Mountains Local Health District

NNSWLHD Northern NSW Local Health District

PHO Public Health Organization

Process audits Assessing clinical practice against a standard, guideline or policy e.g. Central Venous Catheter insertion

QSA Quality Systems Assessment

SESLHD South Eastern Sydney Local Health District

SLHD Sydney Local Health District

SNSWLHD Southern NSW Local Health District

WNSWLHD Western NSW Local Health District

7. Glossary


All assessors certified BSBAUD402B (Participate in a Quality Audit) and RABQSA-AU (Management Systems Auditing).

The QSA Assessors

8. List of Assessors

Trish Alexander Clinical Product Manager, Area Supply, Hunter New England Health - Northern Hunter New England

Suresh Badami (Dr) Staff Specialist in General Practice at Justice Health. Justice Health

David Baker OAM OStJHR consultant. NSW Ambulance Service

Michael BazaleyAllied Health Manager, Forensic Hospital, Malabar, NSW. Justice Health

Steven Bernardi Mental Health Program Manager from St Vincents. St Vincents & Mater Network

Elaine BuggySenior nurse manager working directly for the Executive Director, Nursing & Midwifery. Western Sydney

Cain ByrnesNUM, Dillwynia Correctional centre. Justice Health

Ray Chaseling (Dr) Neurosurgeon. Sydney Childrens Network

Richard CheneyAllied Health Advisor (Dietician). Western NSW

Richard ChristensenArea Allied Health Advisor (Physio). Northern NSW

Nick Collins (Dr)Staff specialist & director, Ambulatory Care, Campbelltown Hospital & GP Leumeah. South Western Sydney

Brett Courtenay (Dr) Orthopaedic surgeon, St Vincents Hospital. St Vincents & Mater Network

Rosemary Cullen Acting Divisional Manager, Div of Surgery & Anaesthetics, Nrth Shore Ryde Health service, RNSH. Northern Sydney

Lyn Currie (Dr) Clinical Leader, Southern NSW Local Health District. Murrumbidgee

Michelle CuttlerOutpatient Therapy & Allied Health Manager. South Eastern Sydney

Andrew DaggNurse Manager Health Service - Deniliquin Hospital. Murrumbidgee

Linda Davidson DON/Nurse Manager, Ryde Hospital. Northern Sydney

Stephen Della-Fiorentina (Dr)Head Macarthur Cancer therapy Centre. South Western Sydney

Debbie Edwards Patient Safety manager, Northern Hospital Network CPIU - SHSEH & POWH. South East Sydney

Deborah ElligettBloomfield Hospital, Nurse Supervisor (mental health). Western NSW

Alan Forrester (Dr) Director ED, Port Macquarie Hospital. Mid North Coast

Michael Fulham (Prof)Clinical Director - Imaging Services; HOD - PET; Snr Staff Specialist - Neurology. Sydney

Mary FullickProgram Manager. Clinical Excellence Commission

Pauline Gaetani Southern Hospitals Network Accreditation Manager for nine network hospitals & community. Illawarra Shoalhaven

Allan Hall Director Clinical Governance, Area Mental Health Services. South Western Sydney

Liz Harford Centre Sector Director Nursing & Midwifery. Murrumbidgee

Jan HeilerNurse Manager/General Manager, Garrawarra Centre, Waterfall. South East Sydney


Christine HughesQuality Coordinator, Inverell District Hospital. Hunter New England

Wendy Jamieson QSA Program Leader, Verification. Clinical Excellence Commission

Bernadette King QSA Program Leader, Program management and Report Development. Clinical Excellence Commission

Vickie Knight CNC, Sydney Sexual Health Clinic at Sydney Hospital. South East Sydney

Marianne Lackner Area co-ordinator Aged and Extended Care. Murrumbidgee

Aileen LawtherManager Division of Women’s, Children’s and Family Services, North Shore Ryde Health Service. Northern Sydney

Chris Lemmer Acting Executive Director (CE) Hutt St Centre, Adelaide. NSW Ambulance Service

Marcel Leroi (Dr) Staff specialist in Clinical Microbiology and Infectious Diseases Nepean hospital. Nepean Blue Mountains

Chris Lowry (Dr) Staff Specialist Anaesthetist, Lismore. Northern NSW

Denise McCallumCNC Broken Hill. Far West

Sharon McKayActing General Manager - Rural Clinical Service Operations, GWAHS. Western NSW

Nicole MoloneySnr Nurse Manager Cowra health service. Murrumbidgee

Alan Morrison Manager, Education. NSW Ambulance Service

Ken Paulsen Ambulance Administration (Retired 2007).NSW Ambulance Service

Michael Peregrina Divisional Manager WCFH Hornsby Ku-ring-gai Hospital. Northern Sydney

Michael RowlesCommunity Services Manager, Sutherland Mental Health Service. South East Sydney

Genevieve RussellDON & M Batemans Bay & Moruya Hospitals. Southern NSW Local Health District

Robyn Schubert Director of Clinical Services: Shellharbour / Bulli / Port Kembla/ Kiama / Coledale Hospitals (NSW). Illawarra Shoalhaven

Lee SilkEducator - Central Coast Mental Health. Central Coast

Jason Simpson Nurse Manager of Peri-operative Services - CHW. Sydney Childrens Network

Rodney SmithRelief Nurse Manager, Heart Lung and Cancer Program, St Vincents Hospital. St Vincents & Mater Network

Tracey Tay (Dr)Deputy Director, Department of Anaesthetics, John Hunter Hospital/ Royal Newcastle Centre, Clinical Lead, Innovation

Support, Hunter New England Health. Hunter New England

Vicky Ting (Dr)Staff Specialist Geriatrician Canterbury / Concord Hospital. Sydney

Catherine TurnerNurse Manager Clinical Practice & Policy. Hunter New England

Antonella Ventura (Dr) Senior Staff Specialist Psychiatry at Forensic Hospital, Malabar (Long Bay).Justice Health

Amanda Walker (Dr)Area Medical Director SSWAHS Palliative care services. South Western Sydney

Jane WalshDirector of Breast Screen for NCAHS, previously the Area Quality Systems Manager (Nurse). Northern NSW

Alex WarnerClinical Excellence Commission

Patricia Saccasan Whelan (Dr) Director of Critical Care; Deputy Health Services Functional Area Coordinator for Disasters - Goulburn, GSAHS. Murrumbidgee and Southern NSW Local Health Districts

Bradley Williams Executive Manager / Director of nursing, War Memorial Hospital, Waverley. South East Sydney

Natasha YuleActing Central Hospital Network Executive Officer for Ministerial and Briefings. South East Sydney

Mark Zacka QSA Program Leader, Self-assessment Development & Data Management. Clinical Excellence Commission


9. CEC programs/projects

Between the Flags - The Clinical Excellence Commission, working closely with expert clinicians, the Agency for Clinical Innovation and the NSW Department of Health has developed and implemented the Between the Flags program. It is designed to establish a 'safety net' in all NSW public hospitals and health care facilities to reduce the risk of patients deteriorating unnoticed and to ensure they receive appropriate care in response if they do.

Patient Safety and Incident Management - The patient safety program utilises Incident Information Management System and root cause analysis reports, along with discussions with key clinical groups and directors of clinical governance, to identify opportunities for improvements in the safety and quality of clinical care.

Hand Hygiene - The CEC is leading the implementation of the National Hand Hygiene Initiative in NSW at the request of NSW Health. It is based on the “5 Moments for Hand Hygiene” promoted by the World Health Organisation – World Alliance for Patient Safety.

Sepsis - This project aims to reduce preventable harm to patients with severe infection and sepsis through early recognition and prompt treatment. This is a two-phase project. Phase 1 which promotes faster recognition and treatment for patients in the emergency department has just started.

Clinical Leadership - The CEC Clinical Leadership program has a focus on improving patient safety and clinical quality by supporting and developing clinical leaders in the workplace.

Medication Safety - The Medication Safety and Quality Use of Medicines program focuses around the provision of tools and resources which enable hospitals to analyse and improve their medication management systems.

Quality Use of Antimicrobials in Intensive Care - This project started mid 2010 and is examining ways to optimise the use of antibiotics and other agents used to treat infections in Intensive Care Units.

BloodWatch - The CEC BloodWatch program, co-ordinates the implementation of improvements in transfusion practice across NSW, based on priority areas identified by the NSW Department of Health Blood Clinical and Scientific Advisory Committee.

Falls prevention - The NSW Falls Prevention program is focused on older people to reduce the incidence and severity of falls and to reduce the social, psychological and economic impact of falls among older people, families and carers. The NSW Falls Prevention Program extends Statewide across hospitals, community and residential aged care.

Collaborating Hospitals’ Audit of Surgical Mortality - This is a systematic peer review audit of deaths of patients who were under the care of a surgeon at some time during their hospital stay in NSW.

Partnering with patients - The CEC has established the Partnering with Patients Program to foster the inclusion of patients and family as care team members to promote safety and quality.

Chartbook - As part of its goal to provide assurance through credible public reporting, the CEC publishes an annual Chartbook of health system indicators.

Any enquiries about or comments on this publication should be directed to:

CLINICAL EXCELLENCE COMMISSION

Locked Bag A4062

Sydney South NSW 1235

Tel. (02) 9269 5500

Email: [email protected] or visit the CEC website: www.cec.health.nsw.gov.au

mailto:[email protected]

http://www.cec.health.nsw.gov.au

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