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SAFER SYSTEMS BETTER CARE QUALITY SYSTEMS ASSESSMENT NSW STATEWIDE REPORT 2010 October 2011

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Page 1: SAFER SYSTEMS BETTER CARE - Ministry of Health · 2 Safer Systems Better Care: QSA Self Assessment Statewide Report October 2011 Foreword In NSW there are around 2.5 million emergency

SAFER SYSTEMS BETTER CAREQUALITY SYSTEMS ASSESSMENT

NSW STATEWIDE REPORT 2010October 2011

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© 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, GPO Box 1614, Sydney NSW 2001.

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

ISBN 978-1-74187-575-1

SHPN (CEC) 110181

Authors

Bernadette King, Mark Zacka, Wendy Jamieson and Dr Charles Pain

Contributors

Professor Clifford Hughes

Dr Peter Kennedy

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

Rae Doble, Design and Print Coordinator, Health Support Services

QSA Advisory Committee

Suggested citation

Clinical Excellence Commission (CEC) 2011. Safer Systems Better Care –

Quality Systems Assessment Statewide Report 2011. Sydney: CEC.

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.

Front cover photograph: Wilcannia Multi-Purpose Service (MPS), Far West District, NSW

October 2011

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Safer Systems Better Care: QSA Self Assessment Statewide Report October 2011 1

Table of contents

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

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

2. The Clinical Excellence Commission ............................................................................ 6

3. Quality Systems Assessment ....................................................................................... 7

4. How it Works ............................................................................................................... 8

5. Assessment Themes ................................................................................................... 9

6. Participation ...............................................................................................................10

7. Results of the 2010 Self-assessment ..........................................................................11

7.1 Quality and Safety Culture .................................................................................................11

7.2 Statewide Programs ..........................................................................................................12

7.2.1 Essentials of Care ..................................................................................................................12

7.2.2 Between the Flags ................................................................................................................12

7.2.3 Clinical Handover ..................................................................................................................13

7.3 Healthcare Associate Infections ........................................................................................ 15

7.4 Open Disclosure ............................................................................................................... 21

7.5 Teamwork ........................................................................................................................ 24

7.6 Evaluation of Self-assessment .......................................................................................... 28

8. On-site Verification ..................................................................................................... 30

9. Next Steps ................................................................................................................ 32

10. Glossary .................................................................................................................... 33

11. Acknowledgements ................................................................................................... 34

12. The QSA Team ......................................................................................................... 35

13. References ............................................................................................................... 36

14. CEC programs/projects .............................................................................................37

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2 Safer Systems Better Care: QSA Self Assessment Statewide Report October 2011

Foreword

In NSW there are around 2.5 million emergency department attendances, 1.6 million admissions to hospital, 250,000 operations and 70,000 births each year.

When things go wrong it is rarely because of a single mistake or a single individual. Therefore we must ensure our health care systems are as safe, efficient and effective as possible.

The Quality Systems Assessment (QSA) is a key component of the NSW Patient Safety and Clinical Quality Program. It is performed on an annual basis and involves all NSW public health organisations (PHOs). It is designed to enable services, facilities and clinicians to critically assess their processes and identify strengths and weaknesses.

This report reflects the results of the 2010 QSA, which focussed on three areas essential for public confidence in a safe, effective health care system; healthcare associated infections (HAIs), open disclosure, and teamwork.

The program involved more than 1,500 clinical staff across NSW and at all levels of the public health care system, with independent verification of more than 20,000 assessments confirming an accuracy rate of almost 99%.

The results show the need for follow-up action at several levels: by local health districts (LHDs) on infection prevention and control; by the Department of Health on policy; and by Clinical Excellence Commission (CEC) on clinical leadership and teamwork.

This is a good example of how self-assessment by experienced professionals on the front line can make a real difference to the safety and quality of care.

I would like to thank all of those who participated in the 2010 QSA for their contribution to this very important part of our efforts to ensure continuous improvement in the safety, quality, efficiency and effectiveness of the care provided to NSW patients.

Professor Clifford Hughes, AOChief Executive OfficerClinical Excellence Commission

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1. Executive Summary

The CEC has a mandate to promote and support clinical quality and safety across the NSW public health system. This requires collaboration, partnerships and teamwork and strong clinical leadership.

The QSA is an example of system-wide collaboration with clinicians, managers and health service executives to improve quality and safety.

This report is a summary of quantitative and qualitative data from the QSA for all PHOs undertaken from September 2010 to November 2010. The 2010 QSA included questions relating to safety culture and three statewide programs. It also focused on three key themes:

• Healthcare associated infection (HAIs)• Open disclosure• Teamwork.

The self-assessment was undertaken by over 1,500 respondents across, and at various levels of, the health system. At the unit level (which includes the Justice Health operational unit, and the Ambulance Service district and station levels) the overall participation rate was 93%.

Ambulance Service and Justice HealthSelf-assessment data from both Ambulance Service and Justice Health has been included in this report, though not all recommendations will relate to their services. The CEC recommends these organisations assess applicability of each recommendation in relation to their clinical environment.

Quality and Safety CultureThe 2010 findings are consistent with previous years and show that patient safety culture within public healthcare organisations across NSW is very positive. However, the results also imply a need for vigilance as there has been a decline in the proportion of respondents who strongly agree with the proposition, there is a positive patient safety culture.

Statewide Program Evaluation The results revealed that all programs have been well received. The Essentials of Care (EOC) program is seen as worthwhile and there is strong support from the 33% (n=384) of units who are engaged in the program. Efforts to extend the current level of engagement would be strengthened by broader inter-disciplinary involvement.

The Between the Flags (BTF) program is seen to be effective and beneficial for patient safety. Executive support is seen as an important part of its success in particular, and endorses the approach taken by the CEC and Department of Health to establish governance as a partnership between executives and clinicians. This is an important lesson that should inform the conduct of future statewide programs.

The statewide Safe Clinical Handover Program has also been well received, and responses indicate an opportunity exists to develop it further in partnership with clinicians at the unit level.

Healthcare Associated InfectionsApproximately half of all clinical units (n=789) and facilities (n=47) indicated HAIs are one of their top three clinical risks. Most reported having effective infection prevention and control (IP&C) governance structures in place. For example, two thirds of facilities have an IP&C committee, three quarters have an infection control risk management plan and two thirds of clinical units have IP&C as a standing agenda item at their regular staff meeting.

Recommendation 1Local health districts must review their infection prevention and control governance arrangements, to ensure they are consistent with relevant NSW Health infection control policy directives and National Health and Medical Research Council Australian Guidelines for Prevention and Control of Infection in Healthcare (page 20).

Foreword

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4 Safer Systems Better Care: QSA Self Assessment Statewide Report October 2011

Given the important leadership roles of the medical workforce and senior management, it is a concern that 19% (n=211) of clinical units disagreed or strongly disagreed that senior medical staff provide leadership in relation to infection prevention and control and that, in only two facilities, the IP&C committee is chaired by the facility’s most senior staff member, the General Manager.

Recommendation 2Local health districts should engage their medical workforce in the development of effective strategies to strengthen medical leadership of infection prevention and control (page 20).

Most clinical areas have in place protocols for the insertion and management of indwelling devices (IDDs) and train staff in their use. However, only 26% are conducting routine audits to assess staff competency and even fewer (18%) have evidence-based care bundles in place to assure a best-practice approach to the use of IDDs.

Recommendation 3Local health districts must ensure that all clinical environments that insert or manage indwelling devices:

• have clear protocols in place and that staff are trained in their use

• undertake routine audits of staff competency with inserting and managing indwelling devices

• have evidence-based care bundles to assure a best-practice approach to the use of these devices (page 20).

The achievement and maintenance of satisfactory cleaning standards is a fundamental component of effective management of HAIs yet significant

gaps have been identified in the auditing of cleaning standards. One third of clinical units (296 units) indicated there were gaps in cleaning audits and just 53 facilities (68%) report environmental cleaning audit results to their IP&C committee.

In contrast, two thirds of clinical units (661 units) agreed or strongly agreed that environmental cleanliness met necessary standards.

Encouragingly, over 90% of respondents (1188) indicated that all or most staff had been trained in basic IP&C measures. However, roughly a third indicated there were gaps in IP&C education and training.

Recommendation 4• Local health districts must ensure that cleaning

audits are conducted at a frequency consistent with that recommended by the relevant NSW Health environmental cleaning policy.

• NSW Health should introduce a standardised cleaning audit tool to support local health districts and ensure consistency in audit methods.

• Cleaning audit data should be routinely reported to facility and/or local health district infection prevention and control committees (page 20).

Open DisclosureOverall the responses at both the facility and clinical unit level indicate a good level of penetration of policy and preparedness to undertake open disclosure. However when asked whether all clinicians can access education, training and other resources specifically designed for open disclosure, only 50% of respondents at the clinical unit level agreed or strongly agreed.

These results demonstrate that there is a need to ensure that education and training in general and high level open disclosure is appropriate to staff needs, is readily available and can be accessed by all levels of staff.

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Safer Systems Better Care: QSA Self Assessment Statewide Report October 2011 5

Recommendation 5Local health districts must ensure that all staff who may be involved in open disclosure have access to the e-learning education package and, where appropriate, have attended an open disclosure training program (page 23).

Teamwork A stable workforce and effective leadership are fundamental to successful teamwork. It is appropriate to direct further effort to these areas. The CEC should extend its efforts in leadership training for clinicians and the Department of Health should continue its efforts to maintain and grow a stable workforce.

Teamwork is overwhelmingly seen as being important to the delivery of good care and generally it appears that teams work well. Ninety six per cent of respondents reported that they deliver patient care as part of a team (or teams), and 94% reported that effective teamwork was either the most important or in the top three most important issues affecting the delivery of quality care. However, there is little formal effort directed towards ensuring teamwork is universally effective.

Recommendation 6Local health districts should strengthen support for participation in clinical leadership training and ensure the opportunity to participate is available to all emerging clinical leaders (page 27).

Recommendation 7A framework and tools should be developed to assist local health districts to develop effective clinical teams with the patient at their centre. The CEC should lead this project in partnership with the Clinical Education and Training Institute, the Agency for Clinical Innovation and other relevant agencies (page 27).

Recommendation 8• Local health districts must be able to demonstrate

they have multidisciplinary membership of clinical councils.

• Where appropriate, clinical units must be able to demonstrate there is multidisciplinary involvement in clinical hand over programs (page 27).

Self-assessment Evaluation The QSA is seen by almost two thirds of respondents as valuable and assists them to improve quality and safety systems. However, two thirds of respondents thought the self-assessment took too long to complete. The results also underscore the importance of maintaining the focus of the self-assessment process on the most important quality and safety issues to ensure that without jeopardising its comprehensive nature, the process is kept to a length that is manageable for busy clinicians and managers.

Continued effort is required at all levels of the health system to increase the percentage of respondents who take action on the issues that are raised during the self-assessment process. Most particularly, on-site verification is a key opportunity to encourage commitment to action and to monitor improvement progress.

On-site Verification In 2010, this program verified over 20,400 responses from the 2009 self-assessment with an accuracy rate of 98.6%. This is comparable with the previous year’s rate.

Feedback indicated the majority of health service staff found the on-site verification process beneficial, effective and undertaken professionally. The assessors indicated that it was a valuable exercise for them and that they were well trained to undertake the verification process.

The CEC will continue to refine and improve the verification process.

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6 Safer Systems Better Care: QSA Self Assessment Statewide Report October 2011

The CEC was established in 2004. Included in its mandate was responsibility to undertake a quality systems assessment of all public health organisations in NSW. The QSA program is now well established and the response has been positive.

The CEC works closely with its key stakeholders, including the Health Minister, the NSW Department of Health, consumers, clinical leaders, network chief executives and clinical governance units. It relies on collaboration, partnerships and teamwork, linked by strong clinical leadership, to achieve change.

CEC Mission StatementTo build confidence in health care in NSW, by making

it demonstrably better and safer for patients and a

more rewarding workplace

2. The Clinical Excellence Commission

Balranald Health Service, Far West NSW. (left to right) Annette Vaarzon Morel (NUM), Lyn Flanagan (A/HSM), Beth Harrison (HSM)

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3. Quality Systems Assessment

The QSA is firstly a clinical risk management program with a focus on learning and improvement. It has been developed to provide clinicians and managers with a convenient and accurate means for determining compliance with policy and standards, identifying clinical risks and deficiencies in practice and highlighting and sharing exemplary practice relating to clinical quality and patient safety.

The QSA is based on the principles of clinical risk management, including the systematic identification, assessment, mitigation and reporting of risks and the ongoing evaluation of risk management activities, including external review.

QSA is not Accreditation There is a clear distinction between the QSA and

accreditation. The QSA has been designed to

complement the broad range of activities including

accreditation which are already in place to assess,

improve or provide assurance on the safety and

quality of patient care in NSW. Participation in the

QSA can help an organisation achieve accreditation.

Sitheni Kapimaupfu, dialysis nurse, Orange Health Service, Western LHD

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8 Safer Systems Better Care: QSA Self Assessment Statewide Report October 2011

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.

4. How it Works

Figure 1: QSA Model

Feedback & Reporting

Improvement Plan

Verification

Self-assessment

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Safer Systems Better Care: QSA Self Assessment Statewide Report October 2011 9

The QSA works on a five year cycle to assess improvement in quality and safety systems.

The initial survey in 2007 provided a baseline census which will be reviewed in 2012.

Specific areas are targeted for assessment in the intervening years (Table 1).

In 2010, themes assessed were:

• Healthcare associated infections

• Open disclosure

• Teamwork

• Mental health (NSW Ambulance Service only).

Why these themes?Themes for assessment are selected based on many factors which include:

• They are important areas that affect a large group of patients

• A specific risk or concern has been identified through previous QSAs or from the statewide Incident Information Management System (IIMS)

• The review may stimulate the potential for improvement.

5. Assessment Themes

Table 1: QSA Cycle of Themes

2007 2009 2010 2011 2012

Baseline assessment

Clinical handover Open disclosure Sepsis

Repeat baseline assessment

Communication Teamwork Paediatrics

Deteriorating patient HAIs Mental health

Medication safety Delirium

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

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10 Safer Systems Better Care: QSA Self Assessment Statewide Report October 2011

All clinical units and facilities are required to participate in the QSA.

The participation rate has improved over the last three years. In 2007 the overall response rate was 82% and in 2009, 90%. The 2010 QSA Self-assessment achieved an overall response rate of 93% and involved over 1100 clinical departments and 93 facilities.

At the clinical unit level (which includes the Justice Health operational unit, and the Ambulance Service district and station levels) the overall response rate was 93% (Table 2).

There is also an expectation that as many members as possible of the management or clinical team will be involved in the formation of self-assessment responses, to provide a comprehensive and balanced risk assessment.

In 2010, at the facility level, all self-assessments were completed by between two and seven people while at the clinical unit level 51% of respondent units involved more than one person in completing the self-assessment.

6. Participation

Table 2: 2010 QSA Self-assessment Response Rate

OrganisationResponse

rate %

AHS* & CHW 94%

Justice Health 100%

Ambulance Service NSW 90%

Total 93%

*Area health services at the time of the survey have now been replaced with local health districts.

Ms Vanessa Fellows, HSM Dungog & District Hospital and Mr Ian Nicholas, Quality Manager - Lower Hunter Cluster, HNELHD

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Safer Systems Better Care: QSA Self Assessment Statewide Report October 2011 11

7. Results of the 2010 Self-assessment

7.1 Quality and Safety Culture An organisation’s healthcare culture can influence the behaviour of staff and therefore affect their performance and that of the organisation. There is good evidence from the literature that safety culture is enormously important in underpinning safe systems for delivering care. Importantly, senior management commitment is crucial to the development and maintenance of a positive patient safety culture.

The 2010 self-assessment asked a series of questions relating to healthcare culture. Figure 2 shows results from the clinical unit/cluster/station levels of all participating organisations to some of those questions.

The results show 94% agreement with the statement there is a positive patient safety and quality culture within our department. This statement has been included in all self-assessments to date and the response is consistently highly positive, with between 94% and 97% either agreeing or strongly agreeing. Of some concern is the observation that in 2010 only 35% strongly agreed with the statement whereas in earlier years 41% (2009) and 56% (2007) strongly agreed with

the statement. The exact meaning of this finding is uncertain and therefore requires further analysis and research. As such, in 2011 further questions will be asked to try to better understand this result.

It is encouraging that over 97% of respondents strongly agree or agree that individuals within the system are willing to report safety violations, unsafe behaviours or hazardous conditions. Some credit is almost certainly due to the NSW Patient Safety and Clinical Quality Program and the Incident Information Management System (IIMS) for this very positive result. A central principle of the program is openness about failure and this has been strongly supported by the establishment of the IIMS system, to which all staff have access. The willingness of staff to report is a sign of a healthy patient safety culture as a good reporting culture is essential to safety and quality improvement1.

Key Finding There continues to be agreement that quality and safety are part of the culture of the workplace.

1 Harper M.L. and R.L. Helmreich. (2005). ‘Identifying Barriers to the Success of a Reporting System.’ Advances in Patient Safety: From Research to Implementation 3: 167-79.

Figure 2: Quality and Safety Culture (Clinical units, Justice Health and Ambulance Service NSW)

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

There is a positive patient safety and quality culture (n=1421)

Individuals are willing to report safetyviolations, unsafe behaviours or hazardous conditions (n=1425)

Our care processes are focussed on achieving the best outcomes and experiences for patients (n=1425)

n Strongly Agree n Agree n Neutral n Disagree n Strongly Disagree

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12 Safer Systems Better Care: QSA Self Assessment Statewide Report October 2011

7.2 Statewide Programs

7.2.1 Essentials of CareThe Essentials of Care program is sponsored by the Chief Nursing and Midwifery Officer of NSW and is being implemented across all local health districts within NSW. To date 440 units/wards have engaged in the program. EOC is a framework that uses a facilitated process to engage staff and enable health care teams to evaluate their workplace and explore how they can improve care.

The program looks at cultural change within wards/units, to develop organisational cultures of critical enquiry, evidence-based practice and improved patient safety. It has six phases over a two-year cycle and involves all people who access the health service including patients, carers, relatives, staff members and management.

Thirty four per cent (384) of respondents at the clinical unit / cluster level are undertaking a project (or projects) related to the EOC program. Of those, 70% (260) are linked to the department/unit’s key patient safety and quality risks or issues. In response to the question what prevents your department / unit from engaging in the EOC program a number of respondents are planning to commence a project within the next 12 months. As well, a number of issues that prevented involvement in the program were identified, which include:

• High turnover of staff / number of casual staff on roster

• Lack of administrative support

• Involvement with other quality and safety projects, ie competing priority issues.

Eighty per cent of respondents at the unit level who were undertaking an EOC project agreed or strongly agreed that “the EOC program is a valuable process that assists our department/unit to improve the quality and safety of care”. Therefore, while only

a third of units were currently undertaking EOC projects, it has high perceived value.

“There are changes in practice and clinical outcomes in units that are engaging in EOC. Staff report increased participation in clinical change and there is anecdotal evidence of cultural change as a result of the processes and methods used within the framework.”

Facility level respondent.

Key Findings The EOC program is worthwhile and there is strong support for it among those who are engaged. While some barriers to engagement exist, the success to date is very encouraging.

7.2.2 Between the FlagsThe Between the Flags program is designed to establish a ‘safety net’ in all NSW public hospitals and healthcare facilities that improves identification of and response to deteriorating patients. The program uses the analogy of Surf Life Saving Australia’s lifeguards and life savers who keep swimmers safe between beach flags by ensuring they are under close observation and rapidly rescuing them, should something go wrong.

“BTF has not only raised awareness but also allowed clinical staff to reflect on practice and implement the principles underlying early assessment and escalation of treatment for deteriorating patients. Timely transfer of patients to acute hospitals is ongoing with continuous review of clinical guidelines and processes.”

Department level respondent.

There was 70% agreement (689 respondents) at the clinical unit / operational unit / station levels that implementation of the BTF program had benefited patient safety.

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Safer Systems Better Care: QSA Self Assessment Statewide Report October 2011 13

There was also agreement that the role of a clinical

leader was important in the uptake and acceptance

of the program by clinicians (61% strongly agree or

agree) and even stronger agreement that executive

support is an important part of the success of BTF.

At the facility level 81% of respondents agreed or

strongly agreed that ‘The statewide Between the

Flags program has assisted departments/units

in our facility to implement and/or improve of the

deteriorating patient’.

“BTF program has enabled a consistent basic

approach for the detection and identification

of the deteriorating patient. It has provided

the opportunity to review practices within an

organisation and the tools to assist clinical

staff with prompting and reinforcing what are

acceptable parameters. This is especially so

for junior, less experienced nursing staff.”

Facility level respondent

Key Findings The BTF program is seen to be effective and beneficial for patient safety. Executive support is an important part of the program’s success and this supports the approach taken by the CEC and Department of Health to establish governance of the program as a partnership between executives and clinicians.

7.2.3 Clinical Handover

Improving clinical handover is a high priority nationally. The NSW Department of Health has implemented the Safe Clinical Handover program including standard key principles that apply to all handovers of clinical care. These are being implemented by all local health districts, Sydney Children’s and St Vincent’s Networks, Justice Health and the Ambulance Service of NSW with flexible standardisation to meet local needs.

Figure 3: Between the Flags (Clinical units, Justice Health and Ambulance Service NSW)

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Strong executive support is an important part of the success of BTF in our department/unit (n=1114)

Our BTF clinical lead (champion) has been critical to the uptake and acceptance of the program by clinicians in our department/unit (n=970)

n Strongly Agree n Agree n Neutral n Disagree n Strongly Disagree

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14 Safer Systems Better Care: QSA Self Assessment Statewide Report October 2011

At the unit / station level 58% (723 respondents) and at the facility level 85% (80 facilities) agreed or strongly agreed that the statewide Safe Clinical Handover program had assisted implementation or improvement of the clinical handover process.

“Safe Clinical Handover has led to a return to bedside handover for nursing staff and has enabled the implementation of dedicated handover time for medical staff across all shifts. It has also strengthened the process of multidisciplinary handover.”

Department level respondent

This may suggest that those with facility level responsibilities have a more positive view of the success of the program than do the clinical unit directors. However, review of qualitative data and feedback from the 2010 self-assessment and verification program confirms that the vast majority of clinical units had already implemented or updated handover processes prior to the handover project.

These results indicate an opportunity for facilities to further support clinical handover by their clinical units.

“The clinical handover at change of shift has always been rather good but the program has highlighted other ways to improve, such as handover between departments, at break times, and to patient transport staff. It has also enabled a consistent basic approach for the detection and identification of the deteriorating patient.”

Facility level respondent

Key Findings Safe Clinical Handover has been positively received, particularly by those at the facility level. An opportunity exists for facilities to support and further develop the clinical handover program in partnership with clinicians at the unit level.

Figure 4: Summary of Statewide Programs: EOC, Safe Clinical Handover and BTF (Clinical units, Justice Health and Ambulance Service NSW)

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

The EOC program is a valuable process andassists us to improve the quality and safety ofcare (Clinical Units only n=411)

The statewide Safe Clinical Handover program has assisted us to implement and/or improve our clinical handover processes (n=1423)

Overall the BTF has benefitted patient safety (n=1013)

n Strongly Agree n Agree n Neutral n Disagree n Strongly Disagree

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7.3 Healthcare Associated Infections

Healthcare associated infections are the most common complication affecting patients in hospital. They complicate illness, can increase the length and cost of a stay in hospital and can contribute to some deaths. Many HAIs can be prevented or the impact minimised through effective, evidence-based infection control practices.

In response to the question asking respondents to rank their top three clinical risks, 58% of clinical units (789 units) and 50% of facilities (47 facilities) nominated HAIs. While many HAIs are preventable or can be minimised through effective, evidence-based infection control, a variety of operational and cultural challenges or constraints hinder control efforts. The top challenges or constraints identified by clinical units, the NSW Ambulance Service and Justice Health in managing HAIs are detailed in table 3.

Though sympathetic to the problems, infectious diseases experts caution that inadequate physical infrastructure should not prevent good infection control. Effective contact precautions can be implemented for patients in shared rooms, by defining a patient zone (and, if necessary, marking

it on the floor with tape) and making sure that precautions are observed within the zone. Infection control is integral to patient care and safety and must not be compromised by workload. Failure to practise appropriate infection control will ultimately increase workload overall. Workload should not be an excuse for failure to comply with hygiene, relevant isolation procedures and appropriate procedures for insertion and management of invasive devices etc.

Infection Prevention and Control GovernanceFor infection prevention and control (IP&C) to be most effective, health organisations need IP&C governance structures – such as appropriate committees – at all levels of the organisation2. Across NSW 64% of facilities who responded indicated they have an IP&C committee in place and that they have processes for evaluating the committee’s performance. Eighty five per cent of facilities with an IP&C committee indicated there were formal links between this committee and the organisation’s audit and risk committee (or similar). Most facilities without an IP&C committee were smaller facilities that address infection control issues through a similar committee at a higher organisational level (e.g. health district level) or had established IP&C as a

2 Cruickshank M, Murphy C, editors (2009). Reducing Harm to Patients from Health-care Associated Infection: An Australian infection prevention and control model for acute hospitals. Australian Commission on Safety and Quality in Health Care, 2009

Table 3: Main Challenges or Constraints confronted in Managing HAIs

IssuesClinical

unitsJustice Health

Ambulance

Bed management 31% – –

Limitations of the physical environment (e.g. lack of single bed accommodation; insufficient ambulance washing facilities)

28% 12% 34%

Staff compliance with policy and/or procedures 22% – 31%

Dept/unit / district / station workload 22% 12% 25%

Achieving or maintaining cleaning standards 18% 20% 35%

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16 Safer Systems Better Care: QSA Self Assessment Statewide Report October 2011

standing agenda item at another committee such as their Occupational Health and Safety Committee.

At the clinical unit level 63% (696 units) have IP&C as a standing agenda item at their regular staff meeting whereas only 26% of ambulance stations (44 stations) and 33% of Justice Health clinical units (16 units) had this arrangement in place.

“KPIs for infection control are reviewed and a process is currently being put into place to develop and set performance targets for the Infection Control Committee.”

Facility level respondent.

Hand hygiene is an essential element of infection prevention and control

An organisational risk management process that systematically identifies infection control issues and feeds into an infection control risk management plan is another important component of a comprehensive IP&C program.3 Seventy seven per cent of facilities (72 facilities) have an infection control risk management plan in place and indicate

3 NHMRC (2010) Australian Guidelines for the Prevention and Control of Infection in Healthcare. Commonwealth of Australia.

that this plan links to the organisation’s corporate risk management plan. Of interest, 10 large facilities (peer group categories A or B) have no such plan. Given the importance of a robust governance structure for successful infection control, Local health districts should review their arrangements to ensure these are optimal for their circumstances.

Staffing and Leadership for IP&C Successful infection control also requires suitably qualified specialist staff and committed leadership from clinicians and management. In facilities that have an IP&C committee the Director of Nursing (or similar role) most frequently acts as chair (20% of instances). In 18% of facilities it is the Director of Medical Services and in 13% of facilities this role is filled by an infection control Clinical Nurse Consultant (CNC) or similar. The IP&C committee of just two facilities is chaired by the facility’s most senior staff member, the General Manager.

Most facilities (83%) employ one or more dedicated infection control professionals (ICPs) and of those 82% of facilities in hospital peer group category A or B (i.e. large metropolitan and regional facilities) have IP&C as the sole responsibility of this position. Of those facilities in other peer groups (representing smaller facilities) that have ICPs, only 38% have IP&C as the sole responsibility and typically share this role as part of a nurse manager’s functions or across multiple sites. Eighty seven per cent of respondents agreed or strongly agreed that when needed, expert advice and/or consultancy from an IPC was readily available.

Forty five per cent of facilities who responded indicated ICPs provided principal leadership in relation to infection control. Only 15% indicated senior management (e.g. General Manager, Director of Nursing) and 2% senior medical staff (e.g. infectious diseases/microbiology consultants) provided principal leadership in relation to infection control. Sixty per cent (616 units) indicated there was a designated champion or role model for HAI

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Safer Systems Better Care: QSA Self Assessment Statewide Report October 2011 17

reduction and IP&C (such as a link nurse) in their clinical unit but a number indicated that these positions were not specifically funded and therefore had little time to devote to IP&C activities.

“First rule of the ward round: Chocolate bar (of their choosing) given to RMO / Registrar / Medical Student who observes me not practising appropriate IP&C. This puts hand hygiene on agenda, sets an expected standard, and gives junior staff permission (and expectation) that they will hold Consultant to this standard... it also makes it fun!”

Senior Consultant response

Given the important clinical leadership role of the medical workforce it is of concern that a significant number of clinical units (211) and facilities (16) disagreed or strongly disagreed that senior medical staff demonstrate clinical leadership and positive role modelling by adhering to IP&C precautions (clinical unit 19%, facility 19%) and by leading or participating in HAI reduction and IP&C programs and improvement projects (clinical unit 29%, facility 25%). Reasons cited include disinterest and disengagement by a proportion of senior medical staff, variable knowledge by medical

staff of IP&C projects or procedures and a lack of role modelling for junior medical staff.

Therapeutic Indwelling DevicesTherapeutic indwelling devices (IDDs) – such as intravascular catheters, urinary catheters and intubation tubes - provide a potential route for infectious agents to enter the body and are a common source of HAIs. This is especially the case in intensive care units where catheter-related bloodstream infections are more common, costly, and more frequently lethal.4

With 90% of clinical units (905 units), 21% of Justice Health units (10 units) and 94% of ambulance stations (236 stations) indicating that they insert or manage at least one kind of IDD, a stringent, evidence-based approach to the insertion and maintenance of these devices is required to minimise the infection risk posed by their use.

Respondents were asked about their use of protocols, training, and auditing and care bundles in relation to four common IDDs. The results (see table 4) indicate

4 Pronovost P, Needham D, Berenholtz S, Sinopoli D, Chu H, Cosgrove S, Sexton B, Hyzy R, Welsh R, Roth G, Bander J, Kepros J, Goeschel C. ‘An intervention to decrease catheter-related bloodstream infections in the ICU.’ N Engl J Med. 2006 Dec 28;355(26):2725-32.

Table 4: Indwelling Devices

QuestionCentral Venous

Catheter

Peripheral Cannula Peripherally Inserted Central

Catheter

Urinary CatheterClinical

unitsAmbulance

Service

Written protocols and/or checklists for insertion, care and management?

81% 75% 95% 80% 77%

Specific training and education required for clinical staff required to insert, care and manage?

71% 75% 95% 71% 68%

Process audits periodically undertaken to assess staff competency with the insertion, care and management?

26% 32% 70% 29% 19%

Care bundles for the insertion, care and management introduced?

22% 16% NOT ASKED 18% 15%

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18 Safer Systems Better Care: QSA Self Assessment Statewide Report October 2011

most are utilising written protocols and/or checklists

(range 77% - 95%) as well as specific training and

education (68% to 95%). However, few respondents

(18% to 32%) - except the ambulance service (70%)

- are undertaking process audits to assess staff

competency and even fewer (15% to 22%) have

introduced evidence-based care bundles.

Care bundles and well designed, local audit

processes with adequate management and

executive support5 are known to be effective quality

improvement and assurance strategies. Relevant

facilities and clinical units should therefore consider

introducing their routine use to assure optimally

efficient and safe insertion and management

of IDDs.

HAI Surveillance To effectively monitor the incidence of HAIs and

evaluate IP&C strategies healthcare facilities require

comprehensive surveillance systems.6 Seventy

three per cent of clinical units indicated that they

receive regular reports, feedback, or have access

to information from surveillance activities such as

hand hygiene audits (54%), MRSA rates (42%) and

Alcohol-Based hand rub usage (36%).

Eighteen per cent of respondents identified problems

or deficiencies with the HAI data they received,

including its timeliness, non-standardised HAI

definitions and the level of administrative support

for data collection and surveillance. Effective HAI

surveillance is also dependent on high levels of

accurate reporting. Clinical unit respondents indicated

that HAIs are reported in a variety of ways including

to IP&C staff, recorded in patient notes, electronic

medical records and patient administration systems.

5 National Institute for Clinical Excellence (2002). Principles for Best Practice in Clinical Audit. Radcliffe Medical Press Ltd

6 Cruickshank M, Ferguson J, editors. Reducing Harm to Patients from Health Care Associated Infection: The Role of Surveillance. Australian Commission on Safety and Quality in Health Care, 2008.

However, only 51% of clinical units who responded indicated that new HAIs are reported in the IIMS. This finding may suggest that HAIs are still perceived by a large proportion of staff as an unavoidable complication of healthcare rather than a potentially preventable incident.

Environmental CleanlinessThere is good evidence demonstrating an association between poor environmental cleanliness and the transmission of infectious agents in healthcare settings.7 Therefore the maintenance of satisfactory cleaning standards is fundamental in the effective management of HAIs. Ninety two per cent of facilities indicated that:

• they have a process in place for monitoring cleaning standards

• they typically conducted monthly to six monthly environmental audits

• audits were conducted by either IP&C staff, hotel staff (domestic, cleaning) or external services.

Just 68% of facilities who responded report environmental audit results to their IP&C committee.

“Bed management and environment issues heavily impact the management of infection control issues. Limited cleaning staff also impacts on this issue.”

Department level respondent

Thirty per cent of clinical units (296 units) indicated that cleaning audits were rarely or never conducted at a frequency that was consistent with that recommended by NSW Health for the level of patient risk in their unit. Additionally, 42% of units indicated that when a cleaning audit was conducted they rarely or never received a report on the outcome (figure 5).

7 Stephanie J Dancer, Liza F White, Jim Lamb, E Kirsty Girvan and Chris Robertson (2009).’Measuring the effect of enhanced cleaning in a UK hospital: a prospective cross-over study’ BMC Medicine 2009, 7:28

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Safer Systems Better Care: QSA Self Assessment Statewide Report October 2011 19

Figure 5: Environmental Cleanliness Responses from Clinical Unit level (excludes Ambulance Service NSW)

100% -

90% -

80% -

70% -

60% -

50% -

40% -

30% -

20% -

10% -

0% -

Are cleaning audits conducted at a

frequency consistent with NSW Health

recommendations? (n=1020)

When a cleaning audit is conducted do you receive a report regarding the outcome?

(n=1003)

n Always (100%) n Often (67-99%) n Sometimes (34-66%) n Rarely (1-33%) n Never (0%)

100% -

90% -

80% -

70% -

60% -

50% -

40% -

30% -

20% -

10% -

0% -

Always(100%)

Often(67-99%)

Sometimes(34-66%)

Rarely(1-33%)

Never(0%)

n Strongly Agree n Agree n Neutral n Disagree n Strongly Disagree

Audits conducted at a frequency with NSW Health recommendation (LHD)

The

Cle

anlin

ess

of o

ur D

epar

tmen

t/Uni

t m

eets

Nec

essa

ry S

tand

ards

(n=

972)

Figure 6: Relationship between Audit Frequency and Staff Perception of Cleanliness

Despite obvious gaps in relation to cleaning

audits, 63% of clinical unit, 71% of ambulance

station and Justice Health unit respondents

agreed or strongly agreed that the environmental

cleanliness met necessary standards.

Further analysis reveals that, of those clinical

units who indicated that cleaning audits were

always conducted at a frequency consistent

with that recommended by NSW Health, 82%

strongly agreed or agreed that the cleanliness

of their unit met necessary standards.

Whereas, those units that indicated that

audits were never conducted at a frequency

consistent with that recommended by NSW

Health, only 43% strongly agreed or agreed

that the cleanliness of their unit met necessary

standards (figure 6).

These findings strongly support the need for

cleaning audits to assure satisfactory cleaning

standards within clinical units.

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20 Safer Systems Better Care: QSA Self Assessment Statewide Report October 2011

Recommendation 1Local health districts must review their infection prevention and control governance arrangements, to ensure they are consistent with relevant NSW Health infection control policy directives and National Health and Medical Research Council Australian Guidelines for Prevention and Control of Infection in Healthcare.

Recommendation 2Local health districts should engage their medical workforce in the development of effective strategies to strengthen medical leadership of infection prevention and control.

Recommendation 3Local health districts must ensure that all clinical environments that insert or manage indwelling devices:

• have clear protocols in place and that staff are trained in their use

• undertake routine audits of staff competency with inserting and managing indwelling devices

• have evidence-based care bundles to assure a best-practice approach to the use of these devices.

Recommendation 4• Local health districts must ensure that cleaning

audits are conducted at a frequency consistent with that recommended by the relevant NSW Health Environmental Cleaning Policy.

• NSW Health should introduce a standardised cleaning audit tool to support Local health districts and ensure consistency in audit methods.

• Cleaning audit data should be routinely reported to facility and/or Local health district infection prevention and control committees.

IP&C Education and TrainingEssential education for all healthcare workers should cover infection prevention and control work practices as part of staff orientation, and continuing professional development. Encouragingly, respondents indicated that all or most staff in clinical units (91%), Justice Health units (93%) and ambulance stations (96%) had been trained (at a minimum) in basic IP&C measures.

However, a significant proportion of clinical units (37%), Justice Health units (23%) and ambulance stations (45%) indicated there were gaps in IP&C education and training for their staff. Examples cited include the lack of annual refresher training, inadequate education and training for medical, allied health and casual pool staff and insufficient education staff.

Key Findings • The threat posed by HAIs to safe, high

quality patient care is widely recognised - most respondents place them in their top three clinical risks.

• A significant proportion of respondents believe that senior medical staff may not be providing satisfactory leadership in relation to IP&C.

• Most clinical areas have in place protocols for the insertion and management of indwelling devices and train their staff in the use of these devices.

• Despite the known risks of IDDs as a means for transmission of infection, a number of the clinical areas that use them still have not adopted a best practice approach.

• A third of clinical units indicate that cleaning audits have not been completed as per NSW Health recommendations.

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Safer Systems Better Care: QSA Self Assessment Statewide Report October 2011 21

7.4 Open DisclosureOpen disclosure means communicating

openly with a patient and his or her support

person when something goes wrong. The focus

is on ensuring that a patient who is affected

by an incident knows and understands what

has happened, and that actions will be taken

to prevent it from happening again. While open

disclosure is already happening in many parts

of our health service, the NSW Government

wants to ensure that it is routinely and

appropriately practised by all staff.

Using NSW Health policy and guideline documents,

the Australian Commission on Safety and Quality

in Health Care and the Australian Open Disclosure

Standard, the 2010 QSA examined:

• Challenges / barriers

• Guidelines / protocols

• Education and training (extent, quality, gaps)

• Organisational support for open disclosure.

Two levels of response are described within the

policy documents. These are general level response

and high level response. The definitions in relation to

these, provided in the self-assessment were:

• A general level response is usually undertaken

for SAC 3 or SAC 4 incidents, where harm to

the patient was minimal. The general response

involves: a meeting with the patient and his/her

support person, where practicable; an explanation

of what happened, the immediate effects, and

prognosis; an apology; the contact names and

phone numbers of people in the health facility

who are available to address concerns and

complaints, including psychological and social

support contacts.

• The high level response involves the full open disclosure process, and is usually undertaken in response to SAC 1 and SAC 2 incidents

The objectives of the NSW Health open disclosure policy are to:

• establish a framework for communicating with patients and their support person, and other stakeholders after an incident

• ensure that communication with, and support for, affected patients and their support person, occurs in an empathetic and timely manner, and

• ensure that the Health Service has established consistent open disclosure processes.

Dr Angus Mackenzie examines Basil Saittaat at the Mona Vale hospital emergency department

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22 Safer Systems Better Care: QSA Self Assessment Statewide Report October 2011

Results

All facilities responded that they had guidelines/policy in place regarding open disclosure. All facilities indicated that the policy provides clear direction for initiating high-level open disclosure and the steps that must be followed in the first 24 hours following an incident, that it identifies the person(s) with authority to initiate high-level open disclosure within the facility, and that it provides guidance to coordinate the open disclosure process with investigative aspects of incident management.

“Open disclosure is a concept that needs cultural change and therefore time to adopt the change. A systematic process to aid support, education and information would be extremely beneficial”.

Facility level respondent

Eighty three per cent (77 facilities) responded that all or most of their departments had implemented open disclosure guidelines/protocols. Eighty six per cent (1183 units and stations) of all respondents reported that policy or guidelines were available and used in open disclosure. The overwhelming majority of all respondents (90%, including Ambulance Service and Justice Health) indicated

they perform general level open disclosure always/often when the need arises.

In response to a series of questions in relation to processes undertaken when general level open disclosure is indicated, responses from the clinical unit level are shown in Figure 7.

At the clinical unit level in response to the question: What do you see as the barriers to conducting open disclosure in your Unit? three main barriers were highlighted:

• fear, embarrassment or discomfort in dealing with a patient’s or family’s reaction

• inadequate training

• legal or malpractice ramifications.

“Open disclosure is quite an uncomfortable and emotional experience actually, but the relatives are so grateful for the honesty”.

Department level respondent

Communicating with the patient and their support person during the emotionally intense period immediately following an incident is important for maintaining a relationship of compassion and trust. All clinical staff should be able to access education, training and other resources specifically designed to prepare them to undertake the process.

Figure 7: Open Disclosure Conduct and Preparedness (Clinical units, Justice Health and Ambulance Service NSW)

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

General-level open disclosure occurs when the need arises (n=1346)

If we need to undertake high-level open disclosure we are prepared (n=1325)

n Always (100%) n Often (67-99%) n Sometimes (34-66%) n Rarely (1-33%) n Never (0%)

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Safer Systems Better Care: QSA Self Assessment Statewide Report October 2011 23

Asked whether all clinicians can access education, training and other resources specifically designed for open disclosure, 50% of respondents at the clinical unit level agreed or strongly agreed. Those respondents who disagreed/strongly disagreed (18%) cited reasons such as they had no experience with open disclosure or had not received training.

While 82% of respondents at clinical unit level

agreed / strongly agreed that they were prepared

to undertake high level open disclosure only 42%

agreed / strongly agreed that education and training

had adequately prepared staff to undertake general

level open disclosure (figure 8). The respondents

note that while there is an e-learning package

available, there are issues such as availability of

time to complete the package as well as access

to computers. Clinical governance and the conduct

and training of staff in relation to open disclosure

is a local responsibility and is actively supported

by the CEC.

In response to the NSW Ombudsman’s report

into concerns raised about the handling of open

disclosure in NSW a committee was convened by

the CEC to review the implementation of the NSW

Health Open Disclosure Policy. The Committee

made several recommendations in relation to the

educational needs of clinical staff as well as the

development of a framework for implementation.

The findings from the QSA support this proposed

way forward. The report is due for release by the

NSW Health Department.

Key Findings NSW public health organisations are aware of the need for open disclosure when something goes wrong. However, there is a need to ensure that education and training in general and high level open disclosure is appropriate to staff needs, is readily available and can be accessed by all levels of staff.

Recommendation 5 Local health districts must ensure that all staff who may be involved in open disclosure have access to the e-learning education package and, where appropriate, have attended an open disclosure training program.

Figure 8: Open Disclosure Education and Training (Clinical units, Justice Health and Ambulance Service NSW)

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Education and training to conduct general- level open disclosure has been provided to staff (n=1319)

Education and training to conduct high-level open disclosure has been provided to staff (n=1292)

n All (100%) n Most (67-99%) n Some (34-66%) n Few (1-33%) n None (0%)

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24 Safer Systems Better Care: QSA Self Assessment Statewide Report October 2011

7.5 Teamwork Effective health care depends on teamwork between the patient, clinicians, the patient’s family and all of the other staff who contribute to this endeavour.

Peter Garling SC recognised the importance of teamwork for the delivery of good care. He wrote of the need to establish ‘a new model of teamwork… to replace the old individual and independent ‘silos’ of professional care.’ He also wrote: ‘The evidence shows that a team-approach to treatment is likely to produce the best results. One proven technique is the multi-disciplinary ward round which includes the consultant and registrar, junior doctors, nursing staff, pharmacists and, where relevant, allied health professionals such as speech therapist or physiotherapist.’ [Overview, para 1.110].

The literature supports the emphasis Garling placed on teamwork. Effective teamwork has been shown to be associated with:

• Fewer unexpected deaths

• Reduced patient length of stay

• More satisfied staff

• Reduced overall costs of care.

There are no NSW Health policy documents available which establish standards for best practice. So, in developing the focus for the 2010 QSA self-assessment on teamwork, questions were based on a variety of national and international best practice guidelines and the literature. For the purpose of the self-assessment a health care team was defined as “an organised group of health care workers who have roles related to meeting the health care needs of a patient or group of patients”.

Questions focused on:

• Challenges and barriers to teamwork

• Teamwork culture

• Existence of guidelines or protocols

• Processes supporting teams e.g. terms of reference, meetings, set agenda items

• Tools and strategies facilitating team communication e.g. briefings, ISBAR

• Organisational support e.g. team recognition/awards

• Teamwork education and training

• Patients as team members.

Professor Michael Fulham (QSA Assessor) in discussion with David Berry Rehabilitation Unit staff during onsite verification visit April 2011

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Safer Systems Better Care: QSA Self Assessment Statewide Report October 2011 25

Figure 9: Barriers to Effective Teamwork

0% 10% 20% 30% 40% 50% 60%

Staffing levels and/or skill mix

Lack of time/workload

None

Professional barriers and scopes of practice

Hierarchical nature of healthcare

Inconsistent team membership

Seperate lines of management control of teams

Inadequate cooperation between teams

In your department/unit what are the main barriers that make achieving effective teamwork more difficult? (Select up to a maximum of three options) n=1133

Results

Importance

At the clinical unit level, 96% of respondents reported that they deliver patient care as part of a team (or teams), and 94% reported that effective teamwork was either the most important or in the top three most important issues affecting the delivery of quality healthcare. At the facility level, 93% responded in the same way. Effective teamwork is clearly rated highly as a contributor to quality healthcare. One respondent wrote:

“Delivery of health care in an Emergency Department is the product of teamwork, never the efforts of only one individual; effective teamwork will always be one of the top three most important issues.”

Department level respondent

Barriers

At the unit level the main barriers to effective teamwork reported by respondents related to staffing levels (especially allied health) and workload. Further barriers included professional barriers and scope of practice, separate lines of management control, inconsistent team membership, the hierarchical nature of healthcare, the involvement of multiple clinical teams, and inadequate cooperation between team members (figure 9).

Forty five per cent of facilities reported they have established a policy, guidelines or protocols specifically aimed at facilitating health professional collaboration and teamwork. Sample policies include codes of conduct and nursing guidelines. At clinical unit level only 42% of respondents felt that development of guidelines would assist team interactions while only 35% had undertaken a form of teamwork training and education.

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26 Safer Systems Better Care: QSA Self Assessment Statewide Report October 2011

Structures in place to support teamwork

Responses to the question: “can you identify any specific support requirements or resources that would assist health professional collaborations or teamwork in your department/unit?” included:

• having a dedicated team leader on shift

• training for teams

• more staff, especially allied health professionals, and

• more space and computers to do work and attend meetings and handovers.

Seventy eight per cent of facilities have a process for recognition of achievement or celebration of team success. This is commonly an employee of the month or year award. However only 44% of respondents at clinical unit level were aware of such a program.

“Team work takes time and the greatest threat to achieving an integrated and functional team is the erosion of time for interacting, talking, planning and working together. This has been a consequence of increasing clinical and bureaucratic demands while not enhancing workforce to manage the increases.”

Department level respondent.

“Frequency of management changes, inadequate induction / orientation programs, recent restructuring of committee structures and reporting lines and requirements to be on multiple committees / working parties are adversely influencing the effectiveness of our teams and their work.”

Department level respondent

Patient-based TeamworkGarling recommended that “the workforce at large

of NSW Health be re-aligned so as to recognise the

principle that each member of the clinical workforce

should be prepared to work within a multidisciplinary

environment as a member of, or as a contributor to

an interdisciplinary team responsible for the delivery of

patient-centred care”. These sentiments are echoed

in the Minister for Health’s letter to health staff which

explains the CORE values (Collaboration, Openness,

Respect and Empowerment) she intends should

become part of the code of conduct of all staff.

Despite the accepted importance of multidisciplinary

working between nurses, doctors and allied

health staff as a means of improving the quality of

decision-making and patient care, it is clear that

there are still significant gaps (see Figure 10). For

example, over 30% of those responding report

that they do not have multidisciplinary patient

reviews (eg ward rounds). Even more do not have

multidisciplinary handover. These gaps point to an

important opportunity for improvement.

“Patients have a very short hospital experience in day surgery so the best care needs to be provided within a very small timeframe. This can only work well when all members of staff have the same aim and goal for the patient.”

Department level respondent

Good information is essential to good decisions.

Eighty six per cent of units stated that they always

/ often help patients obtain information about their

condition. In addition, 84% of units stated that

they always / often provide information to patients

regarding their healthcare rights. It was recognised

that due to the patient’s condition or critical time

constraints it was not always possible to fully

discuss with patients their rights. This is often the

case in emergency cases and in ICU.

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Safer Systems Better Care: QSA Self Assessment Statewide Report October 2011 27

Recommendation 6 Local health districts should strengthen support for participation in clinical leadership training and ensure the opportunity to participate is available to all emerging clinical leaders.

Recommendation 7 A framework and tools should be developed to assist local health districts to develop effective clinical teams with the patient at their centre. The CEC should lead this project in partnership with the Clinical Education and Training Institute, the Agency for Clinical Innovation and other relevant agencies.

Recommendation 8 • Local health districts must be able to

demonstrate they have multidisciplinary membership of Clinical Councils

• Where appropriated clinical units must be able to demonstrate there is multidisciplinary involvement in clinical hand over programs.

Figure 10: Processes Utilised To Support Professional Interactions and Communication - Clinical Unit Level Responses (Excludes Ambulance Service)

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Multidisciplinary patient reviews (ward rounds) n=1257

Multidisciplinary clinical team meetings (ie to discuss patients) n=1318

Multidisciplinary clinical handover n=977

Multidisciplinary administrative team meetings (ie non-patient issues) n=1021

Multidisciplinary morbidity and mortality/peer review meetings (or similar) n=948

n Yes n Planned/in progress n No

Key Findings

A stable workforce and effective leadership are fundamental to successful teamwork. It is appropriate to direct further effort to these areas. The CEC should extend its efforts in leadership training for clinicians and the Department of Health should continue its efforts to maintain and grow a stable workforce.

Teamwork is overwhelmingly seen as being important to the delivery of good care and generally it appears that teams work well. However, there is little formal effort directed towards ensuring teamwork is universally effective. Given its importance, concerted formal effort must be directed towards ensuring the foundations of good teams are laid in every clinical unit, in every department, in every facility across NSW, and that clinical teams and their leaders are empowered to perform their essential functions and have access to the support that they need to be effective teams.

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28 Safer Systems Better Care: QSA Self Assessment Statewide Report October 2011

7.6 Evaluation of Self-assessment

Each year all respondents are asked a series of questions to evaluate the self-assessment process. This information is utilised to improve the process and helps future development of the program.

As in previous years, a large percentage (68%) of all respondents felt the self-assessment took too long to complete. This is important as it has been found to have a significant influence on the respondents’ perception of the value of the self-assessment process, whether they feel the process has raised issues that need action, and whether they are aware of improvements resulting from previous self-assessments (figure 11).

For example, 56% of respondents agreed or strongly agreed that the self-assessment process was valuable and assisted them to improve quality and safety systems. However, for respondents who indicated the self-assessment was too long, this figure fell to 48% while for those who indicated it was not too long, this rose to 73%.

Similarly, 60% of all respondents indicated that the self-assessment had raised issues that needed action. However, for those who indicated the self-assessment was too long, this figure fell to 54% while for those who indicated it was not too long, this figure rose to 74%. At the facility level 88% agreed that the self-assessment raised issues that required action.

Compared to 2009 where only 31% of respondents had completed the 2007 QSA, in 2010 60% of respondents had completed the 2009 self-assessment. However, when asked if any action had been taken to address issues identified in the previous year’s self-assessment, the majority of all respondents (79%) indicated no or don’t know.

Again, for respondents who indicated the self-assessment was too long, those who indicated no or don’t know rose to 82% while for those who indicated the self-assessment was not too long, the figure fell to 73%. The reasons cited for the inaction included a lack of timely feedback, inability to analyse the data, not knowing how to prioritize issues, or a lack of meaningful/applicable recommendations (figure 12).

Figure 11: Perception of the self-assessment’s value*

0% 20% 40% 60% 80% 100%

Clinicalunit

JusticeHealth

Ambulance NSW

State (NSW)

n Strongly Agree n Agree n Neutral

n Disagree n Strongly Disagree

*for Clinical Unit, Justice Health and Ambulance Service

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Safer Systems Better Care: QSA Self Assessment Statewide Report October 2011 29

Figure 12: Self-assessment evaluation*

0% 20% 40% 60% 80% 100%

Has any action been taken to address the

issues identified in the 2009 QSA

self-assessment?

Has the self-assessment raised

issues you need to act on?

n Yes n Don’t Know n No

*for Clinical Unit, Justice Health and Ambulance Service

Key Findings These results underscore the importance of maintaining the focus of the self-assessment process on the most important quality and safety issues and to ensure that without jeopardising the comprehensive nature of the process, it is kept to a length that is manageable for busy clinicians and managers.

Continued effort is required at all levels of the health system to improve the percentage of respondents who take action on the issues that are raised during the self-assessment process. Most particularly, on-site verification is a key opportunity to encourage commitment to action and to monitor improvement progress.

Alexa McKenzie 1 day old, Maternity Unit Orange Health Service, Western NSW

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30 Safer Systems Better Care: QSA Self Assessment Statewide Report October 2011

“The on-site verification visit makes us focus on and review in detail the major issues and risks for the organisation at the facility and department level, which other forms of review do not.”

Facility level respondent

In 2010 the CEC undertook its second year of on-site verification across NSW health services, including Justice Health and the Ambulance Service. This program verifies the accuracy of a sample of the previous year’s self-assessment responses, in this case 2009.

The aim of the on-site verification program is to:

• verify self-assessment responses from the previous year

• review evidence such as policies and guidelines cited in self-assessment responses

• determine areas for improvement

• review use of QSA data/results from previous self-assessment

• review improvement plan progress

• share best practice by encouraging staff to share information on any innovations they have successfully designed and adopted.

A sample of questions were verified from each of the three themes assessed:

• Management of the deteriorating patient

• Clinical handover

• Medication management.

Method The verification process is led by the CEC QSA

Verification coordinator. Each year all public health

organisations are visited for a week by a team

of five qualified quality systems site assessors.

Approximately 20% of the facilities are subject to

an on-site visit each year, which will see all facilities

in NSW having participated in the QSA verification

program over a five year cycle.

During the on-site visit staff are asked to provide

evidence to support their responses to the self-as-

sessment. From this the assessors determine if the

rating was accurate. At the end of the visit a verbal

debrief is given to the organisation’s senior executive

and a report is completed with recommendations.

These recommendations are incorporated into the

QSA improvement plan and are reviewed at the next

verification visit.

The on-site verification visit is not a pass or fail

process. It is well recognised that inaccurate

responses are often not intentional, rather, they

may result from misinterpretation of a question or a

belief that a certain process, system or policy is in

place. These are however important opportunities

for each organisation to work cooperatively and with

renewed insights of each levels of the organisation’s

relevant quality and safety improvement projects.

They also provide an important next step in bringing

clinicians, management and indeed, all parts of

each complex health care organisation together.

8. On-site Verification

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Safer Systems Better Care: QSA Self Assessment Statewide Report October 2011 31

Results from the 2010 Verification Program of 2009 Self-AssessmentFrom April to September 2010 the on-site teams visited:

• All PHO executive/state level offices

• 47 hospitals/facilities

• 50 clinical units and 22 staff groups in small hospitals

• 8 Justice Health clusters/streams

• 6 Ambulance Service divisions/districts

• 493 staff were interviewed.

Over 20,438 self-assessment responses were verified, with an accuracy rate of 98.6%. This is comparable with the previous year’s rate. Other findings included that all PHOs had reported the 2009 QSA results to their peak Quality Committee, acted on their QSA Improvement Plan, and assigned a staff member to oversee the annual QSA process.

Feedback received from clinical staff visited

indicated that the majority of PHO staff found the

on-site verification process beneficial, effective and

undertaken professionally. The assessors indicated

that it was a valuable exercise for them and that

they were well trained to undertake the verification

process. The CEC undertakes an evaluation of the

on-site verification program each year and uses the

information to refine and improve the program.

“I think the on-site verification visits and feedback sessions are very valuable.”

Department level respondent

8. On-site Verification

QSA Assessors – training day March 2011. (L-R) Prof Michael Fulham (SLHD), Dr Brett Courtenay (St Vincent’s Network), Dr Vicky Ting (SLHD), Jan Heiler (SESLHD), Robyn Schubert (ISLHD), Michelle Cuttler (SESLHD), Dr Marcel Leroi (NBM), 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).

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32 Safer Systems Better Care: QSA Self Assessment Statewide Report October 2011

9. Next steps

The QSA will continue to be undertaken on an annual basis, focusing on specific themes which relate to:

• Findings from the previous year’s QSA in relation to extent and degree of deficiencies in practice

• An assessment of the degree of clinical risk presented by the potential target area (prospective and retrospective)

• Advice from a body of experts accessible to the CEC.

The questions posed within the self-assessment will vary from year to year, as systems are improved and standards are embedded.

Data Return While the QSA was undertaken based on area health service (AHS) boundaries, the analysis and report development has been based on local health district boundaries to reflect current service arrangements.

In 2010 the CEC returned the data in four ways:

• Immediately following submission of self-assessment a copy of responses was emailed to each respondent

• Two weeks following assessment closure the raw data (labelled and coded by the online company) was returned to each AHS

• 1-2 months following assessment (March 2011) and to facilitate follow-up and action at facility level a results report for each facility-level respondent (~190) was generated. This report contained aggregated/comparative data based on LHDs

• Statewide report.

It is expected that these four resources will be used by the individual district/facility/clinical unit to identify areas with greatest risk and vulnerability and develop improvement plans to address them.

Improvement Plans Following the yearly QSA self-assessment each LHD/organisation will develop an improvement plan. The development of the improvement plan, which addresses the identified risks and means by which improvement will be achieved, provides an integrated approach between the self-assessment and recommendations. Each plan requires:

• Involvement of the LHD senior executive, clinicians and department heads in the improvement plan development

• The plan to address the key themes that specifically relate to the LHD/organisation

• Regular monitoring and reporting on the progress of the development and implementation of the improvement plan to the organisation’s peak health care quality committee

• Individual facilities and clinical units review their own responses to the QSA and develop a plan that puts into place actions to minimise risks

• Review and sign-off by the PHO Chief Executive

• A formal progress report submitted to the CEC each year.

The improvement plans are reviewed as part of the on-site verification program.

2011 QSA The topics for the 2011 QSA are:

• Sepsis

• Mental health

• Delirium

• Paediatrics.

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Safer Systems Better Care: QSA Self Assessment Statewide Report October 2011 33

BTF - Between the Flags

Care Bundle - a group of evidence-based

practice points that, when combined, define best

care and significantly improve patient outcomes.

CEC - Clinical Excellence Commission

CGU - Clinical Governance Unit

CHW - Children’s Hospital Westmead

CPI - Clinical Practice Improvement

CVC - Central venous catheter

DCG - Director of Clinical Governance

DG - Director General

DMS - Director Medical Services

EOC - Essentials of Care

ED - Emergency Department

GSAHS - Greater Southern AHS

GWAHS - Greater Western AHS

HAIs - Healthcare Associated Infections

HDU - High Dependency Unit

HNEAHS - Hunter New England AHS

ICP - Infection Control Professional

ICU - Intensive Care Unit

IDD - Indwelling Device

IIMS - Incident Information Management System

IP&C - Infection prevention & control

IT - Information Technology

ISBAR - Identification / Situation / Background /

Assessment / Request/recommendation

JMO - Junior Medical Officer

KPI - Key performance indicator

Link nurse - A nurse that is, or is moving towards

being, an expert and resource person for an identified

topic of specialty practice, in which he or she has an

interest and passion. For example an infection

control link nurse

LHD - Local Health District

MPS - Multi Purpose Service

MRSA - Multi Resistant Staphylococcus Aureus

N/A - Not Applicable

NSW DOH - New South Wales Department of Health

OD - Open Disclosure

OT - Operating Theatre

PHO - Public Health Organisation

PICC - Peripherally inserted central catheter

Process audits - assessing clinical practice against a

certain standard, guideline or policy e.g. Central Venous

Cather insertion

PSCQP - Patient Safety and Clinical Quality Program

QSA - Quality Systems Assessment

RCA - Root Cause Analysis

RMO - Resident Medical Officer

SAC - Severity Assessment Code

VMO - Visiting Medical Officer

10. Glossary

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34 Safer Systems Better Care: QSA Self Assessment Statewide Report October 2011

The QSA Assessors

11. Acknowledgements

The CEC acknowledges the significant contribution of clinicians and managers who support the QSA program and who are essential to the program’s success:

• The Directors of Clinical Governance and their staff

• The busy clinicians and managers who appreciate the value of the QSA and take the time to engage in the risk assessment process

• The QSA coordinators who managed the QSA at the local level:

PHO QSA coordinator

Northern Sydney Central Coast

Lorraine Dorrington

South Eastern Sydney Illawarra

Vicki Biro

Sydney South West Brenda Gillard

Sydney West Rosio Cordova

Ambulance Catherine Klarenaar

Justice Health Rhonda Halpin

PHO QSA coordinator

Children’s Hospital Chrissy Ceely

Greater Southern Nicole Smith

Greater Western Di Wykes

Hunter New England

Di Dolan & Gary Martin

North Coast Pam Mitchell

• The staff who volunteer to be Assessors in the verification program.

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 OStJ

HR consultant. NSW Ambulance Service

Michael Bazaley

Allied Health Manager, Forensic Hospital, Malabar, NSW. Justice Health

Steven Bernardi

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

Elaine Buggy

Senior 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

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Safer Systems Better Care: QSA Self-assessment Statewide Report October 2011 35

Ms Wendy Jamieson Program Leader, Verification

Ms Bernadette King Program Leader, Program Management and Report Development

Mr Mark Zacka Program Leader, Self-assessment Development and Data Analysis

Dr Peter Kennedy Deputy Chief Executive Officer

Dr Charles Pain Director Health System Improvement

Christine Hughes

Quality 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 Lawther

Manager 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 McCallum

CNC Broken Hill. Far West

Sharon McKay

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

Nicole Moloney

Snr 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 Rowles

Community Services Manager, Sutherland Mental Health Service. South East Sydney

Genevieve Russell

DON & 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 Silk

Educator - Central Coast Mental Health. Central Coast

Jason Simpson

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

Rodney Smith

Relief 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 Turner

Nurse 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

12. The CEC QSA Team

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36 Safer Systems Better Care: QSA Self Assessment Statewide Report October 2011

13. References

Cruickshank M, Ferguson J, editors (2008). Reducing Harm to Patients from Health Care Associated Infection: The Role of Surveillance. Australian Commission on Safety and Quality in Health Care.

Cruickshank M, Murphy C, editors (2009). Reducing Harm to Patients from Healthcare Associated Infection: An Australian infection prevention and control model for acute hospitals. Australian Commission on Safety and Quality in Health Care.

Harper M.L. and R.L. Helmreich. (2005). ‘Identifying Barriers to the Success of a Reporting System.’ Advances in Patient Safety: From Research to Implementation 3: 167-79. Retrieved 11 November, 2010. <http://www.ahrq.gov/qual/advances/>

National Institute for Clinical Excellence (2002). Principles for Best Practice in Clinical Audit. Radcliffe Medical Press Ltd.

NHMRC (2010) Australian Guidelines for the Prevention and Control of Infection in Healthcare. Commonwealth of Australia.

Pronovost P, Needham D, Berenholtz S, Sinopoli D, Chu H, Cosgrove S, Sexton B, Hyzy R, Welsh R, Roth G, Bander J, Kepros J, Goeschel C (2006). ‘An intervention to decrease catheter-related bloodstream infections in the ICU’. N Engl J Med. 2006 Dec 28; 355(26):2725-32.

Stephanie J Dancer, Liza F White, Jim Lamb, E Kirsty Girvan and Chris Robertson (2009). ‘Measuring the effect of enhanced cleaning in a UK hospital: a prospective cross-over study’. BMC Medicine, 2009 7:28.

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14. 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.

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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