NSLHD’s Safety and Quality Newsletter provides information on new and upcoming activities, programs and initiatives within the district that aim to improve the safety of our patients and the quality of our care.
DECEMBER 2025
EDITION 41
2025 SAFETY AND QUALITY ACCOUNT This year's NSLHD Safety and Quality Account is now available to view. This annual publication reflects our district’s ongoing commitment to delivering safe, high-quality care. It provides an overview of achievements realised during the 2024–25 financial year, including improvements in patient outcomes, staff wellbeing, and community health. Inside, you’ll find highlights from the past year—big improvements in patient outcomes, staff wellbeing, and community health—as well as a look ahead at our priorities for 2025–26. The Account also reports NSLHD’s strong performance against several safety and quality indicators, including measures such as Hospital Acquired Complication (HAC) rates. This publication has been shaped through meaningful collaboration with consumers, ensuring it reflects the voices and perspectives of those at the heart of our services. The Account reflects not just achievements but NSLHD’s culture of continuous improvement. It is a testament to the dedication of our staff, who work every day to ensure that patients receive the safest and highest-quality care possible.
IN THIS EDITION: 2025 NSLHD Safety and Quality Account Webpage - Connecting with Consumers
2025 NSLHD Consumer Forum Gathering of Kindness & Kindlab NSLHD Patient Reported Measures Antimicrobial Stewardship Week Person-Centered Care Showcase Quality Improvement Resources
Read the full Account here: NSLHD Safety and Quality Account 2025
Click on the image above
Clinical Governance Standard
Partnering with Consumers Standard
DECEMBER 2025
EDITION 41
Clinical Governance Standard
District Wide Accreditation from January 2027
he Instead of separate assessments at different times, accreditation to the National Safety and Quality Health Service (NSQHS) Standards , the National Clinical Trials Governance Framework , and the National Safety and Quality Primary and Community Healthcare Standards will happen concurrently across the district during one dedicated week. Why are we making this change? This is about working smarter, creating consistency and efficiency while maintaining our commitment to excellence in patient care. The benefits of adopting a district-wide approach include: From 1 January 2027, Northern Sydney Local Health District (NSLHD) will take a major step forward in how we approach accreditation. We’re moving from facility or service-based Short Notice Assessments to a district-wide Short Notice Assessment model. What does this mean?
Y our paragraph text Much of the accreditation process will feel the same-assessors will still visit sites and conduct short notice accreditation assessments. There will be big changes behind the scenes: some coordination activities will happen at a district level, supported by teams across the district carefully preparing to manage multiple assessors across NSLHD simultaneously. Next steps Facility/service-based assessments continue until 31 December 2026, so staying ‘always ready’ remains essential More information will be shared over the coming months about any process changes A District-Wide Accreditation Transition Working Group with representation from facilities and services across the district, is already driving this transition Want to know more? Contact your Clinical Governance Unit OR Victoria (Tori) Pacey, National Standards Accreditation and Project Manager: Victoria.Pacey@health.nsw.gov.au What is included? Accreditation assessments to the NSQHS Standards , the National Clinical Trials Governance Framework , and the National Safety and Quality Primary and Community Healthcare Standards . There will be no changes to assessments for other accreditation schemes. Other accreditation schemes remain unchanged. Royal North Shore, Hornsby Ku-ring-gai, Ryde, and Mona Vale Hospitals, Mental Health, Drug and Alcohol Services, and Primary and Community Health. Services not previously assessed individually, including Virtual Care, Hospital in the Home, PARVAN, and Voluntary Assisted Dying. What does this mean for you?
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DECEMBER 2025
EDITION 41
Consumer and Patient Experience
Partnering with Consumers Standard
Launch of Connecting with Consumers webpage
Northern Sydney Local Health District (NSLHD) is excited to announce the launch of a dedicated webpage for staff, packed with tools and guidance to strengthen partnerships with health consumers. Here you’ll find: Consumer Engagement Toolkit–Practical templates and step-by-step guides. Training & Education–Workshops and e-learning to build confidence in consumer collaboration. Advisory Opportunities–Connect with Consumer Advisors for committees and projects. Policies & Frameworks–Easy access to NSLHD and NSW Health standards.
he The site is now live at https://nswhealth.sharepoint.com/sites/NSLHD- CAPE/SitePages/Connecting-with-Consumers.aspx
2025 NSLHD Consumer Forum
The NSLHD Consumer & Patient Experience (CAPE) Team facilitated the Consumer Forum at the Kolling Building on Friday 14 November 2025 in collaboration with Consumer Advisors. 34 Consumer Advisors and staff from RNSH, Ryde, HKH, MV, Research and Aboriginal Health were included. The forum was a day of engaging discussions and a valuable opportunity for Consumer Advisors to connect from across the district. th The afternoon session was a workshop designed to capture insights, feedback, and ideas from our Consumer Advisors on key projects that shaped the district, relating to Artificial Intelligence Governance Framework Surgical Services Plan Health Literacy initiatives Partnering with Consumers Framework 2021–2026
Partnering with Consumers Standard
EDITION 41
DECEMBER 2025
Consumer and Patient Experience
Partnering with Consumers Standard
Gathering of Kindness & Kindlab 2025
he The theme for Gathering of Kindness in 2025 is One care, many voices–because kindness lives here. As part of our Consumer Forum, Consumer Advisors and Consumer Peer Workers participated in an activity reflecting on moments when they had experienced or witnessed acts of kindness in NSLHD. The acts of kindness expressed were themed and captured in the Kindness Tree featured on the right — a visual reminder that small acts of kindness truly make a big difference. Consumer Advisors and Consumer Peer Workers also shared their hopes for how kindness can continue to be spread across the fabric of our work culture.
Kindlab is a way to gather innovative ideas from NSW Health staff and patients to foster a culture of kindness across NSW Health. NSW Health staff, patients, consumers, and carers are invited to pitch small-scale ideas that enhance kindness and compassion in healthcare. Selected projects receive funding support ranging from $5,000 to $25,000. Whether it’s strengthening relationships, improving wellbeing, or redesigning experiences-Kindlab helps bring great ideas to life. If you have an idea, head to the Kindlab website to get inspired and get guidance to submit your pitch.
NSLHD Patient Reported Measures Welcome Maaike and Annabel Maaike Allard and Annabel Kingsford recently commenced in the Patient Reported Measures (PRMs) Program Officer roles. 2025 Patient Reported Measures Symposium On the 29th August 2025, the Agency for Clinical Innovation hosted the event at the Kolling Institute. Elline Pamplona (Nurse Practitioner, RNSH) and Brad Lloyd (Program Officer, Patient Reported Measures) presented "Delivering Person-Centred Care in a Nurse Practitioner-Led Diabetes Assessment & Management Clinic" describing the positive impact of implementing PRMs. Over 300 attendees were online and in person, providing an opportunity for consumers, clinicians, service managers, and researchers to connect, share insights, and explore innovative approaches to person-centred care using PRMs. Services Adopting HOPE PRMs in January to June 2026 Services onboarding to the statewide PRMs Program using the Health Outcomes and Patient Experience (HOPE) platform will be: • Royal Rehab Outpatients • Royal Rehab Brain Injury Inpatients and Community • Hornsby Healthy Kids Clinic For more information, contact the NSLHD PRMs Team via <NSLHD-PRMs@health.nsw.gov.au>
Fo r more information please contact the NSLHD PRMs Team via nslhd-prms@health.nsw.gov.au.
DECEMBER 2025
EDITION 41
Antimicrobial Stewardship Week 2025 - Northern Sydney Celebrates
Your paragraph text Our District Initiatives AMS Committees at every facility: dedicated AMS teams working with clinicians to optimise prescribing. Audit and Feedback: Regular reviews of prescribing patterns help identify opportunities for improvement and celebrate best practice. Consumer Education: Patient information leaflets and bedside conversations reinforce why antibiotics aren’t always the answer. Infection Prevention Collaboration: AMS is integrated with infection prevention strategies, including hand hygiene campaigns. Your paragraph text During 18–24 November, NSLHD joined the global effort to mark World Antimicrobial Awareness Week (WAAW). This year’s theme, “Act Now: Protect Our Present, Secure Our Future,” reminded us that antimicrobial resistance (AMR) is one of the greatest threats to modern healthcare. AMR impacts every aspect of patient care—from routine surgery to cancer treatments. Inappropriate or unnecessary use of antibiotics accelerates resistance, making infections harder to treat. NSLHD is committed to reducing this risk through strong antimicrobial stewardship (AMS) programs across our hospitals and services. Special Event at RNSH On Tuesday, 18 November, there was an Antimicrobial Stewardship Awareness Stand in the Royal North Shore Hospital foyer. The stand featured Y our paragraph text
AMS experts available to answer questions Educational resources for staff and consumers Interactive activities, including an Escape Room
The RNSH Antimicrobial Stewardship team at the display in RNSH Foyer.
Medication Safety Standard
Preventing and Controlling Infections Standard
DECEMBER 2025
EDITION 41
Person-Centred Care Showcase 2025
On Thursday, 23 October 2025 , the Nursing and Midwifery Directorate held the Person-Centred Care (PCC) Showcase. This year’s theme was Elevating Outcomes Through Person-Centred Care.
The day was a celebration of innovative and compassionate care across our services, with an inspiring collection of oral, video and poster presentations. The winners of the Oral presentation were Erin Mewton and Hayley Young - Enhancing clinical practice and patient outcomes through a Nurse-Led dermatology model. The poster presentation winner was the team implementing Sip Til Send - Dr Leoni Watterson, Stephanie Besley, Caitlin Wardrop, Natasha Wong and Katie Bongiolatti. Julie Moxham from the Springboard to Success program was the winner of the Novice Poster Presentation for her quality improvement initiative on ‘Skill Up’-Transforming Nursing Education in Clinic 16.
NSLHD Libraries Launch: The Quality Improvement Guide
NSLHD Libraries have just launched a new Quality Improvement subject guide , designed specifically to support NSLHD staff undertaking QI projects.
This guide showcases how NSLHD Libraries can actively assist staff throughout the entire improvement science process, from project initiation to publication. It provides curated, stage-specific resources and highlights the library’s role in helping staff access evidence, navigate publishing, and align with healthcare safety and quality standards.
Key sections include:
Starting a QI Project Defining Aims Measuring Success Finding Evidence & Best Practice (journals, guidelines, past QI projects) Publishing & Sharing Your Work Resources aligned with the Tenets of Healthcare Safety and Quality
You can access the guide here: Overview - Quality Improvement - Subject Guides at Northern Sydney Local Health District Libraries.
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DECEMBER 2025
EDITION 41
Environmental Sustainability in QI Resources Now Available
Your paragraph text Many staff members are involved in or embarking on QI projects or activities, but few resources exist to support them in understanding and monitoring environmental impacts in NSW Health. Of those involved in QI, many think about environmental impacts at the end of their project—or not at all. Many staff are interested in environmental sustainability but don’t know where to start. Purpose of these resources: Develop publicly available tools to support staff in designing, managing, and evaluating environmental sustainability in QI. Embed sustainability concepts into existing quality improvement frameworks. Your paragraph text The Clinical Excellence Commission (CEC) has launched Australia’s first environmental sustainability resources for the public health system, designed to help healthcare teams embed sustainability into quality improvement (QI) initiatives. Why is this important? These resources have been developed in partnership with the CEC, Ministry of Health – Climate Risk & Net Zero Unit, Northern Sydney Local Health District (NSLHD), and other Local Health Districts. This collaborative effort ensures sustainability becomes a core part of improving patient care while reducing environmental impact. Explore the resources today: Environmental Sustainability in Quality Improvement – CEC Academy website Download the Guide (PDF) Let’s work together to make healthcare safer, more efficient, and environmentally responsible. Y our paragraph text
Northern Sydney Local Health District
Leading for Safety and Quality Improvement 2-day course
Course Overview
Describe the leadership skills and attributes required of a contemporary leader in healthcare. Examine the relationship between leadership and advocacy (sponsorship) for local patient safety and quality improvement initiatives. Demonstrate the links between safety and quality in healthcare and the role of Clinical Governance to drive the safety and quality agenda Describe the role of the team in safety and quality Explore ways to foster positive group dynamics and enhance motivation within a team Readiness to Lead for Safety and Quality * Participants will be introduced to the essential leadership practices required to be an effective safety and quality leader and gain the knowledge, tools and skills to apply the Improvement Science methodology in projects that improve the safety, quality and patient/consumer experience of their service. On course completion, participants will attain ‘intermediate level’ capability under the NSW Healthcare Safety and Quality Capabilities . This set of capabilities complements the NSW Public Sector Framework . The Learning Pathway has been developed in partnership with the Clinical Excellence Commission under the Safety and Quality Essentials Pathway . The course is comprised of the following sessions and learning objectives on completion:
Next offering in 2026 23 and 24 April @ RNSH 8:30 am - 4:30 pm More dates to follow
Duration: 2 days, CPD 14 hours
Target Audience: Open to all staff. Staff from across the district are welcome to attend any of the available locations Enrolments: Enrol on My Health Learning (MHL) Code: 630735018
Contact for inquiries:
Identify a range of opportunities for ongoing development of your leadership capability
NSLHD-SQEP@health.nsw.gov.au
Pre-requisites
Introduction to Improvement Science*
View the Six Dimensions of Healthcare Quality video ( 6
Describe the Model for Improvement Identify a problem or opportunity that is suitable for a quality improvement project Develop an effective aim statement Create and interpret a flowchart of the current process Create and interpret driver diagrams Describe the importance of data collection and measuring impact. Identify ways to measure and track progress using run charts List the steps in a Plan-Do-Study-Act (PDSA) cycle Use tools to assist in how to spread, scale up and sustain improvement initiatives.
minutes) on My Health Learning (Course code: 340129036)
Other preparation activities will be communicated closer to the course dates *Comparable self-paced e-learning modules are available on MHL
DECEMBER 2025
EDITION 41
NSLHD CLINICAL AUDIT SCHEDULE
The NSLHD Clinical Audit Schedule has been developed for all sites and services within NSLHD to support the monitoring and evaluation of clinical care processes and to provide support for clinical quality improvement activities across NSLHD. Download the complete 2025 - 2026 NSLHD Clinical Audit Schedule from the Clinical Audit Schedule Intranet page
Clinical Governance Standard
Clinical audits required to be completed in December/January are listed below.
December/January QARS Audits (direct links available from Clinical Audit Intranet page)
NSLHD_03_Infection Prevention Control Program compliance NSLHD_03_Transmission Based Precautions NSLHD_03_Aseptic Technique
Standard 3
NSLHD_05_Post Partum Haemorrhage (PPH) Audit
Standard 5
NSLHD_08_MONTHLY_Resuscitation trolley/backpack & Resuscitaire equipment audit NSLHD_08_BIANNUAL_Resuscitation trolley / Resuscitaire check audit
Standard 8
POLICIES, PROCEDURES AND GUIDELINES Refer to the PPG Weekly updates (PPG Resource hub) to access the most up-to-date list of PPGs For any queries relating to policy, procedure and guideline development contact NSLHD-Policies@health.nsw.gov.au
NSLHD – Recently Published Policies, Procedures, Guidelines and Standing Orders
SAFETY ALERTS New, updated and recently published
Medication Safety Updates including medication shortages are available on the CEC website.
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