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.
MARCH 2024
EDITION 31
CEC Sepsis Pathways: Webinar Series 11 – 22 March 2024
RELEASE OF UPDATED CEC SEPSIS PATHWAYS The Adult, Maternal, Paediatric and Neonatal Sepsis Pathways (paper forms) have been revised to align with evidence-based sepsis clinical guidelines and advice from NSW Health expert groups. They have been approved by the State Forms Management Committee. The NSLHD Sepsis Working Group is coordinating the release of the Sepsis Pathways across the district. In addition, over 500 NSW Health clinicians completed a survey on the use of the current sepsis pathways. The results of this survey are provided within the Clinical Excellence Commission (CEC) Sepsis Pathways Behavioural Survey Report which may inform local implementation. The CEC is working with eHealth to make the pathways accessible in the eMR whilst awaiting a digital sepsis solution in the single digital paper record. IN THIS EDITION: Release of the updated CEC Sepsis Pathways 2024 NSLHD Quality and I mprovement Awards Leading for Safety and Quality Improvement Learning Pathway Human Experience Week 2024 – Save the Date Gathering of Kindness Patient Reported Measures Update What is Teach - back?
The Clinical Excellence Commission (CEC) are hosting a series of webinars in March to support the transition to the new pathways. Five webinars will be held over the fortnight (one webinar for each of the specific pathways and a focused session on all the pathways for those working in Emergency Departments). The webinars will provide a summary of the learnings from the statewide sepsis pathways behavioural survey, the rationale and changes made for each sepsis pathway, as well as provide an opportunity for some Q&As. CEC advises the webinars will be recorded and available for anyone that registers – this means that staff members are encouraged to register even if they are unable to attend any of the below sessions. Webinars will be run via MS Teams. If you are interested in attending any of the webinars, please click on the registration links below. Adult Sepsis Pathway Webinar Monday 11 March 2024, 2pm – 2.45pm Click here to register Neonatal Sepsis Pathway Webinar Thursday 14 March 2024, 2pm – 2.45pm Click here to register Emergency Department Sepsis Pathway Webinar Monday 18 March 2024, 2pm – 3pm Click here to register Paediatric Sepsis Pathway Webinar Tuesday 19 March 2024, 2.30pm – 3.15pm Click here to register Maternal Sepsis Pathway Webinar Thursday 21 March 2024, 2:30pm – 3.15pm Click here to register
Recognising and Responding to Acute Deterioration Standard
Open for entry
Key dates (2024)
The Northern Sydney Local Health District Quality and Improvement Awards celebrate the outstanding achievements of teams across our health district who introduce change to improve patient outcomes and experience, staff experience and the overall quality of our health service.
Entries open: 28 Feb - 3 April* Finalists announced: 23 May NSLHD Quality and Improvement Awards Ceremony: 17 June * please note local sign-off process and deadlines for your facility or service. Visit the QI Awards website or intranet page to download the entry form and submission guide , view local signoff deadlines, key contacts and other resources. Check out previous year’s winners and runners- up and learn about their projects Tips for writing up a successful award entry - updated 2024 resource Contact: NSLHD-Awards@health.nsw.gov.au
The 2024 award categories are:
Planetary Health Award 1. Transforming Patient Experience Award 2. Patient Safety First Award 3. Keeping People Healthy Award 4. People and Culture Award 5. Excellence in the Provision of Mental Health Services Award 6. Excellence in Multicultural Healthcare Award 7.
Health Innovation Award 8. Health Research Award 9.
This year Northern Sydney LHD is introducing a new Readiness to Lead for Safety and Quality workshop to complement the successful long running Improvement Science workshop . These two face-to-face live workshops, delivered over 2 days, forms the Leading for Safety and Quality Improvement Learning Pathway . Participants will benefit from a hands-on, facilitated and social approach to their learning and development in safety and quality. See the flyer on the next page to find out more. New learning and development pathway to support current and future leaders in safety and quality improvement Staff who prefers a more self directed flexible learning style can access equivalent e-learning modules available in MHL
Readiness to Lead for Safety and Quality. Online e-learning. MHL course code: 382398949 Introduction to Improvement Science (6 modules) Online e-learning. MHL course code: 378591148
Contact: NSLHD-SQEP@health.nsw.gov.au
Clinical Governance Standard
Leading for Safety and Quality Improvement Intermediate learning pathway Northern Sydney Local Health District
Program Overview 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 completion of the learning pathway, 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 and is comprised of:
Target Audience: All staff Duration: 2 days, CPD 13 hours Dates
7 and 14 May at HKH 2 and 9 August at RNSH More dates to follow
Time: 8:30am - 4:30pm
Enrolments and enquiries: Open to all staff. Places are limited
Staff interested but unable to attend both dates are to contact NSLHD- SQEP@health.nsw.gov.au and request to be added to the waiting list. Participants who are able to attend one day only will be expected to complete the equivalent online e- learning modules available on MHL. Enter the code 518150533 in the MHL catalogue to view and enrol in available offerings under the learning pathway. Staff must enrol in both days .
Readiness to Lead for Safety and Quality Introduction to Improvement Science
Readiness to Lead for Safety and Quality (Day 1) On completion participants will be able to: Describe the leadership skills and attributes required of a contemporary leader in healthcare. Describe 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 Lead the team in safety and quality Build positive group dynamics within a team Identify a range of opportunities for ongoing development of your leadership capability Improvement Science Workshop (Day 2) On completion participants will be able to: Describe the Model for Improvement Identify a suitable problem to solve through a quality improvement project Create and interpret a flowchart of the current process Demonstrate the importance of baseline diagnostic data Create and interpret driver diagrams List the steps in a Plan-Do-Study-Act (PDSA) cycle Develop outcome, process and balancing measures Identify ways to measure and track progress using run charts, etc Use tools to assist in how to spread, scale up and sustain improvement initiatives.
Pre-requisites
View the Six Dimensions of Healthcare Quality video ( 6 minute) on My Health Learning (Course code: 340129036), OR Participate in a 30min Foundations of Healthcare Safety and Quality guided session to reflect on the 6 dimensions of healthcare quality and how each applies to your own local workplace.
Other preparation activities will be communicated closer to the date.
Following completion of the program you will be welcomed into our district’s Safety and Quality Alumni and learn about opportunities to continue to apply learning.
MARCH 2024
EDITION 31
Consumer and Patient Experience
Partnering with Consumers Standard
HUMAN EXPERIENCE WEEK 2024 – SAVE THE DATE
This year’s Human Experience Week (HEW) “Innovate to Elevate” will take place from 29 April 2024 to 3 May 2024. NSLHD Consumer and Patient Experience Team have partnered with Virtual Care and Hospital in the Home Services and the Ministry of Health to hold a hybrid event on 29 April 2024, between 9 – 11am at Norman Nock Room 1, Level 5, Kolling Building, Royal North Shore Hospital Campus, St Leonards.
29 April - 3 May 2024
The event will showcase the NSLHD Virtual Care and Emergency Ambulance Avoidance Strategy. The strategy illustrates how NSLHD Virtual Care and Hospital in the Home Service have used innovation in virtual care to elevate the experience of staff and consumers. Consumers will tell their story outlining their experience of surviving to thriving. Look out for further details of this event and local events happening during the week. For further information please email NSLHD-ThePatientExperience@health.nsw.gov.au
REACH (RECOGNISE, ENGAGE, ACT, CALL, HELP IS ON ITS WAY) REACH is a Clinical Excellence Commission initiative that enables patients, carers, families to raise their concerns about a worrying change in a patient’s condition while in hospital. To understand how REACH is implemented in your service please refer to the local procedure or guideline for managing the deteriorating patient. Information can also be found on the Clinical Excellence Commission’s website (Between the Flags and REACH). For general inquiries, contact your local facility or service REACH coordinator or the Consumer and Patient Experience Unit on NSLHD- ThePatientExperience@health.nsw.gov.au
Recognising and Responding to Acute Deterioration Standard
MARCH 2024
EDITION 31
The Gathering of Kindness offered an opportunity for NSLHD to promote kindness and compassion. Activities were held at various NSLHD services between 13 – 17 of November 2023.
Kindness Kits (an initiative originating from Ryde Hospital) were promoted at Hornsby Ku-ring-gai Hospital, Royal North Shore Hospital, Primary and Community Care and Mental Health (Macquarie campus). Collaboration and kindness was also shown across Hornsby Ku-ring-gai Hospital with general hospital and on site Mental Health colleagues sharing messages of kindness and chocolates. Ten Ministry of Health Gathering of Kindness virtual sessions were advertised to all staff with topics focusing around the theme 'My KIND of Experience - Reframing quality and safety' and the actions and moments that matter to us all in transforming experiences in healthcare. Click on the link above to watch the recorded sessions on demand. NSLHD submitted three nominations to the Ministry of Health (MoH) Kindness Champion initiative . The nominees were: Cathy Butler, Manager Multicultural Health; Kylie Leach, Whole of Hospital and Service Development Manager, Hornsby Ku-ring-gai Hospital; and Paula Hanlon, Manager Ryde Consumer Services Mental Health Drug and Alcohol. NSLHD staff profiles and stories are being used for MoH Elevating the Human Experience promotional materials, such as the bi-monthly newsletter, video, and presentations.
Catherine Nurse (Manual Handling Co-ordinator) and Michelle Barry (Work Health Safety Consultant) at Hornsby Ku-ring-gai Hospital
Elisabeth Manning (MHDA), Julie Wright (PACH) and Anne Bajuk (MHDA) at Macquarie Hospital
Michael Felicetti (Senior HR Business Partner), Marg Fagan (NSLHD Consumer Advisor), and Thelma De-Lisser Howarth NSLHD Consumer and Patient Experience Manager
Hornsby Ku-ring-gai Hospital staff Gathering of Kindness
MARCH 2024
EDITION 31
NSLHD 160 tales of Kindness
NSLHD Consumer and Patient Experience team and Mental Health Drug and Alcohol set a challenge to capture 160 Tales of Kindness from across the district to celebrate the impact kindness can have on people and places. An initiative that originated in Prince of Wales Hospital, sharing tales of kindness, looks to integrate the power that kindness holds as an enabler for staff well-being, person- centred care, and happy workplaces. ‘Kindness works here’ cards were created in the NSLHD compliment portal for staff to access. NSLHD received 167 over the week from across all services. As a result a Kindness word tree poster is available to download and display.
PATIENT REPORTED MEASURES UPDATE ACI Site Visit – February 2024 The NSLHD Consumer & Patient Experience Team hosted the Agency for Clinical Innovation (ACI) Patient Reported Measures (PRMs) Team in February 2024 to showcase examples of local services using PRMs to improve patient care via the Health Outcomes & Patient Experience (HOPE) IT platform. James Zhang, GP VMO, Long Covid Clinical Lead, Virtual Care Service presented on the Virtual Care Team’s experience of using PRMs in Long Covid. Elline Pamplona, Nurse Practitioner, RNSH Department of Endocrinology, presented on the RNSH Diabetes Assessment Clinic’s experience. The meeting was a great opportunity to share lessons learned and provide feedback to inform the ongoing local and state-wide implementation of PRMs.
HOPE 2.1b Release – March 2024 ACI have advised that the next significant update to the HOPE IT platform is planned for 8 March 2024. The 2.1b release includes the introduction of: Four new clinical cohorts, including paediatrics, maternity, brain injury, and menopause. The NSLHD PRMs Team will be reaching out to these services shortly. Seven new patient reported outcome measures (PROMs). This includes the PROMIS CAT which has the potential advantages of being shorter and more relevant for patients than the PROMIS-29. other platform and performance enhancements. For more information about PRMs please get in touch NSLHD-prms@health.nsw.gov.au.
WHAT IS TEACH BACK? Teach Back is a communication tool which can be used to check patients understanding of verbal information provided to them by staff. The technique involves patients repeating back to staff in their own words what staff have told them. The tool should be used when communicating with patients, families, and carers, particularly when staff are providing important health information that has instructions patients need to follow. Teach back is not a test but rather checking how well the health staff have explained the information delivered. This is not a one size fits all process and should be adapted to the audience at the time. Teach back is recommended in the NSW Health Literacy Framework 2019 – 2024 and the NSLHD Partnering with Consumers framework . There are a number of resources available for staff to access that explain teach back. For more information check the Health Literacy intranet page or log into My Health Learning and search for Learn about teach-back (MHL code 409377612) and Health literacy and Teach-back (MHL code: 241744958). Partnering with Consumers Standard
MARCH 2024
EDITION 31
NSLHD CLINICAL AUDIT SCHEDULE
Clinical Governance Standard 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 2024-2025 NSLHD Clinical Audit Schedule from the Clinical Audit Schedule Intranet page Clinical audits required to be completed this month are listed below.
March QARS Audits ( direct links available from Clinical Audit Intranet page)
NSLHD_03_Aseptic Technique
Standard 3
NSLHD_4_Monthly Accountable Drug (S4D_S8) Register Audit 2024 Vaccine Management and Storage Audit NSLHD_05_ Nutrition Care Audit NSLHD_05_Cognitive Impairment Audit(Delirium) NSLHD_05_Surgical plume and electrosurgical audit 2024
Standard 4
Standard 5
NSLHD_06_ Consent Audit
Standard 6
NLSHD_08_MONTHLY_Resuscitation trolley/backpack & Resuscitaire equipment audit -V2 NSLHD_08_BIANNUAL_Resuscitation trolley/backpack & Resuscitaire equipment Audit
Standard 8
POLICIES, PROCEDURES AND GUIDELINES Refer to the NSLHD weekly bulletin 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
Medication Safety Updates including medication shortages are available on the CEC website.
SAFETY ALERTS New, updated and recently published
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