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.
JUNE 2022
EDITION 15
The new streamlined Comprehensive Care Risk Screening and Assessment Pathway has been developed within the eMR to screen patients for key risks and issues. The pathway then generates recommendations and strategies presented for consideration and actioned according to clinical judgment. In addition to the new Pathway, there are new documentation workflows for Medical / Nurse Practitioners, Allied health staff and Allied health Students; as well as a new Smoking Cessation Management Pathway. These all went live on the 7th June 2022 in all Emergency and Inpatient settings across Northern Sydney and Central Coast Local Health Districts. Community services will soon follow on June 14 with the introduction of the Smoking Cessation Management Pathway. Interactive eLearning modules (Comprehensive Care and Smoking Cessation Learning Pathways) are available for nurses and midwives, doctors and nurse practitioners, and allied health staff on My Health Learning. eMR refresher sessions on Care Compass and iView are available by visiting the eMR enhancements SharePoint site for further information.
IN THIS EDITION:
Comprehensive care risk screening and assessment pathway goes live Release of the 2022 NSW Health Services Aboriginal Cultural Engagement Self- Assessment Audit Tool Clinical procedure safety resources Pressure injury point prevalence audit findings New ACSQHC online Escalation Mapping Template Effectiveness and Appropriateness dimension of healthcare quality
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COMPREHENSIVE CARE RISK SCREENING AND ASSESSMENT PATHWAY GOES LIVE In collaboration with the Australian Commission for Safety and Quality in Healthcare, Clinical Excellence Commission, Agency for Clinical Innovation and Local Health Districts, the eHealth NSW’s eMR Connect Program has developed a Comprehensive Care solution for the eMR that supports clinicians in providing comprehensive care to inpatients which aligns with Version 2 of the National Safety and Quality Health Service Standards (NSQHS). Comprehensive care is the coordinated delivery of the total health care required or requested by a patient. This care is aligned with the patient’s expressed goals of care and healthcare needs, considers the impact of the patient’s health issues on their life and wellbeing, and is clinically appropriate. (NSQHS - Comprehensive Care Standard)
Contact: Zoe.Howard@health.nsw.gov.au (eMR Enhancement Projects Change Manager NSLHD, ICT)
Comprehensive Care Standard
JUNE 2022
EDITION 15
RELEASE OF THE 2022 NSW HEALTH SERVICES ABORIGINAL CULTURAL ENGAGEMENT SELF- ASSESSMENT AUDIT TOOL (ACESAAT)
Clinical Governance Standard
Annette.Penney@health.nsw.gov.au (District Accreditation Manager) or mob: 0450 880 429 (will lead the implementation in consultation with Peter Shine and Paul Weir) for general matters. Aishwarya.Ramesh@health.nsw.gov.au (Clinical Analytics and Information Manager) for completing the self-assessment tool within QARS Peter Shine (Director Aboriginal and Torres Strait Islander Health Service) or Paul Weir (Deputy Director Aboriginal and Torres Strait Islander Health Service) on ph: 9462 9017 for queries regarding the development of appropriate Action Plans or refer to the NSQHS Standards User Guide Aboriginal and Torres Strait Islander Health. For queries or further information please contact; NEW ONLINE ESCALATION MAPPING TEMPLATE (EMT) The Australian Commission on Safety and Quality in Health Care (ACSQHC) has produced a new and improved resource for recognising and responding to deterioration in a person’s mental state. The Escalation Mapping Template (EMT) is a quality improvement tool to assist health service organisations to assess the effectiveness of their systems for recognising and responding to deterioration in a person’s mental state. The EMT supports services to identify existing local processes, map their alignment to the systemic recognition and response model, and evaluate their effectiveness. To enhance the user experience and navigation of the EMT, the Commission has updated the previous Excel version to an online web-based application. The new online EMT provides greater user functionality, including self-generated reports, interactive step-by-step prompts, links to Commission resources, multiple user collaboration, timestamps and more.
Estimating our progress by comparing 2020 and 2022 ACESAAT results Identification of focus areas for action and development of action plans for monitoring and review of ongoing progress While the Centre for Aboriginal Health (CAH) will review the data across LHDs, we are also strongly encouraged to undertake a local analysis of the 2022 ACESAAT results. This will enable; Tier: Local Health District/Districtwide Services & Programs - jumps to Q2 Tier: Facilities (Hospitals) & Districtwide Services & Programs – jumps to Q33 Tier: Services at the Customer Interface – jumps to Q85 In the 2022 ACESAAT , jump logic has been included at a tier level and tiers have been colour coded. The tiered approach is: The audit tool (which is now available in QARS and accessible via QARS is to be completed by close of business (COB) Wednesday 20 July 2022 (NSLHD internal deadline) Action Plans, based on your ACESAAT results, are to be completed in QARS by COB Wednesday 3 August 2022 The Clinical Governance Unit, in partnership with the Aboriginal and Torres Strait Islander Health Unit, will have oversight of the completion of the audit. Action plans are to be completed where areas of improvement are identified. The annual NSW Health Service’s Aboriginal Cultural Engagement Self-Assessment Audit Tool (ACESAAT) for 2022 is now available for completion and is accessible via the Quality Audit Reporting System (QARS). In 2020, NSLHD completed the ACESAAT and this initiative greatly assisted NSLHD’s progression ‘towards a health system where cultural differences and strengths were recognised and responded to in the governance, management and delivery of health services’ . Due to the impact of COVID 19 on resources across the system, the ACESAAT was not completed in 2021. Following the Centre for Aboriginal Health revision of the ACESAAT in 2020 – 2021, the 2022 ACESAAT includes a ‘tiered’ approach to the 60 questions, clarifying which level of LHD operations would be accountable for organisational and local questions. Some questions are duplicated across tiers and all questions are mandatory. This is not dissimilar to NSLHD’s 2020 tiered approach.
The new and improved EMT is available on the Commission’s website .
JUNE 2022
EDITION 15
NSLHD PRESSURE INJURY POINT PREVALENCE AUDIT (PIPPA)
Clinical procedures are performed multiple times across every service setting in NSLHD. Preventing incidents of incorrect patient, incorrect procedure or incorrect site associated with clinical procedures is critical to patient safety and the quality of clinical care we provide. The Clinical Procedure Safety – NSLHD Procedure has recently been made available to provide NSLHD clinicians with practical applications to address clinical care and patient safety risks associated with clinical procedures. The new procedure supports our district in complying with the NSW Health Clinical Procedure Safety policy directive (PD2017 032) and In addition to the Procedure, other resources are now also available on the Clinical Procedure Safety intranet page, including a decision support tool that provides guidance to define the Clinical Procedure level and corresponding necessary safety requirements; and a Clinical Procedure Safety Poster that provides an overview of the four steps (verification, matching information, time-out, post- procedure confirmation and documentation) to be completed to ensure safe clinical procedures are performed. the NSQHS Clinical Governance and Communicating for Safety Standard. CLINICAL PROCEDURE SAFETY
The most common pressure injury stages are stage 1 (non-blanching erythema or intact skin) and stage 2 (partial thickness skin loss). Heels and sacrum remain the most common sites for pressure injury development. There is a mismatch ordering pressure redistribution support surfaces for patients with an active pressure injury. Less than 40 per cent of patient medical records documented pressure injury prevention consumer engagement and education. Throughout our district, staff work tirelessly to prevent and minimise avoidable pressure injuries for our patients. The Pressure Injury Point Prevalence Audit (PIPPA) is the annual snap-shot review of pressure injury prevalence and severity across our sites and services. Findings from this year’s audit indicate that overall, NSLHD has demonstrated a reduction in pressure injury prevalence since 2018. However, while overall pressure injuries prevalence has decreased, hospital acquired point prevalence has increased by 0.44 per cent, indicating that a pressure injury developing is more likely to be acquired in hospital. Additional findings from the audit include: The findings determine opportunities to further enhance the care we provide to reduce the risk to our patients in developing a pressure injury. This includes enhanced staff education and training to reinforce the need to complete pressure injury risk screening within the first eight hours of patient hospital admission, as well as enabling clinicians to inform and partner with patients and their loves ones, so as to prevent the development of pressure injuries while in hospital. In addition, the Skin Integrity Committee will review support surface ordering and management to ensure that patients at risk of pressure injury are provided timely access to the right support surfaces as required. Contact: Lizanne.Dalgleish@health.nsw.gov.au (A/Skin Integrity Improvement Facilitator) for further information.
Click on image to download full poster or access from the CPS Intranet page
Ongoing work to integrate clinical procedure safety requirements into clinical documentation in the eMR continues. The documentation processes for clinical procedure safety requirements as determined and followed by the facility, service, specialty or department will remain current until the release of new integrated and optimised documentation in eMR. The first change to be introduced in eMR will be found in iView - Access Devices, Lines, Tubes and Drains. Contact: Jillian.Moxey@health.nsw.gov.au (Service Development Manager, Surgery and Anaesthesia Network)
Communicating for Safety Standard
Comprehensive Care Standard
JUNE 2022
EDITION 15
Health services monitor population growth and demographics of the local area to deliver appropriate care in the right settings, e.g. maternity services in areas matched with demand. The RNS ICU team introduced interventions to reduce the need for unnecessary Arterial Blood Gas Testing, without demonstrable negative effects on patient outcomes. Patient benefits include the avoidance of anaemia, reduced risk of infections and improved patient experience. Mental Health consumers with physical health vulnerabilities due to long term medication use are provided with the appropriate physical health screening, assessment and interventions to optimise their health. Frailty is known by clinicians to be a significant contributor to poorer health outcomes, extended hospital stays and surgery cancellations. Numerous initiatives across the district have been introduced to improve screening for frailness in patients at highest risk. How effective and appropriate are your everyday processes and interactions? There are many examples of NSLHD initiatives which have been introduced that improves delivery of effective and appropriate care. Here are just some examples. Can you think of more? Foundations of Safety and Quality e-learning pathway on My Health Learning (course code 335318052) The Safety and Quality Essentials Pathway (CEC) NSLHD Quality Improvement Intranet page. Want to learn more? Enrol in the next one-day
EFFECTIVENESS AND APPROPRIATENESS
In this edition, let's dive deeper into another of the six dimensions of healthcare quality .
Effective healthcare focuses on providing services and treatments based on evidence-based practice to all who could benefit. Appropriate care is when the right evidence-based care is provided by the right providers, to the right patient, in the right place, at the right time, resulting in optimal quality care. Our patients, consumers and carers expect that the health care and treatment they receive is based on the best available evidence (including symptoms and any test results), their needs and personal preferences. Effective or appropriate care can also mean not providing tests, medications, treatments or services to those not likely to benefit from them. Over-treatment can cause stress and anxiety in patients, add to their costs and can impact their quality of life e.g. unnecessary blood transfusions. Under treatment can occur when care is inconsistent with best practice. For example, not performing risk screening or acting on the results of routine risk screening or not providing appropriate peri-operative antibiotics when they are indicated. To provide truly appropriate care , we need to reflect on, challenge and reduce unnecessary over treatment and under treatment that can occur in our healthcare system.
Improvement Science workshop . Spaces are limited. Enrol via MHL (course code 42956746). Join in on a monthly Improvement Science Drop in Clinic
Contact: Cathy.Vinters@health.nsw.gov.au or Catherine.Rosario@health.nsw.gov.au (Clinical Reliability Improvement Facilitators, Clinical Governance)
Clinical Governance Standard
JUNE 2022
EDITION 15
IMPROVEMENT SCIENCE DROP-IN CLINICS
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 2022-23 NSLHD Clinical Audit Schedule. Note: The schedule is divided into three categories (NSLHD acute, sub-acute, MHDA and PACH). Visit the clinical audit intranet page for more information. Clinical audits required to be completed this month is listed below.
Monthly "drop-in" clinics are open to anyone undertaking an improvement project or has an interest in resources and tools to run a successful improvement project. Staff can join in virtually via the MS teams meeting (see the link to flyer below). The first 30-40 minutes will be dedicated to a specific topic and the following 20-30 minutes will be open to staff who have any questions or concerns about their projects, the direction the project is heading, or barriers they have come across and how to overcome them. Refer to the Drop-in clinics 2022 flyer to access the link to join the online MS teams meeting and view future scheduled topics. Watch previously recorded drop-in clinic sessions focusing on topics such as writing up your project for an award entry and how do I know if my changes are an improvement? Contact: Cathy.Vinters@health.nsw.gov.au or Catherine.Rosario@health.nsw.gov.au (Clinical Reliability Improvement Facilitators, Clinical Governance)
June 2022 QARS Audit (entry link)
NSLHD_2022 Aboriginal Cultural Engagement Self- Assessment Audit Tool (ACESAAT) PACH Clinical Documentation Record Audit 2022
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NSLHD_03_Aseptic Technique
NSLHD_4_Monthly Accountable Drug (S4D_S8) Register Audit (RNSH | HKH | Ryde | MV | MHDA) NSLHD_05_ Perioperative Patient Positioning (RNSH | HKH | Ryde) NLSHD_08_Monthly inspection for resuscitation trolley/ Resuscitaire equipment checklists NSLHD_8_Standard Adult General Observation chart (BTF Audit) (PACH | HKH | Ryde | MV | MHDA) (RNSH | HKH | Ryde | MV | MHDA | PACH)
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POLICIES, PROCEDURES AND GUIDELINES New, updated and recently published district-wide PPGs.
Clinical Governance Standard
Click on the links below to download documents from the Prompt document system. Refer to the NSLHD weekly bulletin in your inbox to access the most up-to-date list of PPGs
Cleaning Patient Care Equipment Infection Prevention and Control - NSLHD Guideline Management of Hypertension in Pregnancy - NSLHD Guideline Newborn Resuscitation - NSLHD Guideline Oral Hygiene and Denture care (adults) - NSLHD Procedure Post-operative Nausea and Vomiting Management – Adults-NSLHD Guideline Risk Mitigation - Standard and Transmission-Based Precautions - NSLHD Guideline Personal Protective Equipment (PPE) Requirements - NSLHD Guideline Hand Hygiene - NSLHD Guideline
LESSONS LEARNED FROM SERIOUS ADVERSE EVENT REVIEWS
Clinical Governance Standard
Did you know that the Clinical Excellence Commission shares findings from serious incidents that have occurred across NSW to aid in reducing preventable risk of a similar event occurring to another patient? Recent publications include: Lessons from Serious Adverse Event Reviews (SAER) in MHDA services across NSW - April 2022 More publications are available from the lessons learned intranet page. The scenarios depicted in the publications have been drawn from a variety of cases across NSW in order to maintain the confidentiality of consumers and staff. It is acknowledged that the issues identified in these cases represents a small portion of care.
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