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.
AUGUST 2025
EDITION 39
IN THIS EDITION: Worried they are getting worse? New proactive escalation tool eMR enhancements Survey Implementation Checklist for Patient Reported Experience Measures (PREMs) Welcome to our new Youth Consultants Risky Business - Quality Improvement Project Leading for Safety and Quality Improvement Workshops What Matters to You Day recording Medication Safety Week Launch of NSLHD Formulary App
WORRIED THEY ARE GETTING WORSE?
NEW PROACTIVE ESCALATION TOOL
T he CEC has launched a suite of resources to support the implementation of the ‘Worried they are getting worse?’ proactive escalation tool across NSW Health. You can click through the link below to access the CEC Intranet where you will find a webinar recording and additional internal implementation materials. 👥 Join the Community of Practice (COP) To further support clinicians and facility leads, the CEC is hosting a fortnightly Community of Practice. This is a casual, drop-in space designed to: Share experiences and insights Collaborate on implementation strategies Discuss challenges and successes Whether you're just starting or already implementing the tool, this is a great opportunity to connect and learn from others.
📣 Who Should Be Involved? It’s vital that:
All paediatric and Emergency Department staff engage with the resources and COP sessions Managers actively support their teams in applying the changes This tool is a key step in improving proactive escalation and patient safety—your involvement matters. Family, carer and clinician resources are available at the link: We are here for you
Click here to access posters and resources
Thank you for your participation and commitment to improving patient safety.
Partnering with Consumers Standard
Clinical Governance Standard
Communicating for Safety Standard
AUGUST 2025
EDITION 39
eMR BTF enhancement Implementation of “Worried they are getting worse?”
A number of changes have been made to Between the Flags (BTF) observation charts, including:
1. Revision of temperature ranges on the Standard Paediatric Observation Chart 2. Inclusion of ‘C’ for confusion to assess and record changes in charts such as the Standard Paediatric Observation Chart 3. Alteration to Calling Criteria timeframes within which patients and consumers are reviewed 4. New Family/Carer Concern documentation field 5. New lactate documentation feature with alerts when unexpected results are recorded 6.Updated Assessment of Respiratory Distress guide
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If you have any questions about these updates, contact Shiromee Gasperson (shiromee.gasperson@health.nsw.gov.au) or Rusayl Bentiroso (rusayl.bentiroso@health.nsw.gov.au).
Comprehensive information about the changes, along with supporting resources, is available here
Your paragraph text Person-Centred Care Showcase 2025 On Thursday, 23 October 2025 , the Nursing and Midwifery Directorate will host the annual Person-Centred Care (PCC) Showcase at the Kolling Auditorium, Royal North Shore Hospital. This year’s theme is Elevating Outcomes Through Person-Centred Care. The day will be a celebration of innovative and compassionate care across our services. A collection of oral, video and poster presentations will highlight: Innovations, quality improvements and activities in clinical practice and services that demonstrate true partnership with patients, consumers and carers. Projects that focus on enhancing workplace culture, staff empowerment and wellbeing. Stories that amplify the voice of the patient, consumer, carer and staff. Attendance is open for all staff as an opportunity for knowledge sharing, supporting colleagues, networking and celebrating the work that our clinical teams contribute to person-centred care.
You can Register at My Health Learning (Course Code 267534053). For more information, contact 9463 2284. We look forward to seeing you there.
AUGUST 2025
EDITION 39
Patient Reported Measures Updates New Patient Experience Survey Implementation Checklist
What Matters to You Day Recording - 5 June 2025 Meet the NSLHD Patient Reported Measures (PRM) team and hear how Patient Reported Outcome Measures (PROMs) are being used to help identify what matters to patients. Early findings and consumer perspectives are shared, from an NHMRC funded research study 'PROM-PATH'. Click here to view the recording Event Speakers: Dr Thelma De Lisser-Howarth, Manager Consumer & Patient Experience, NSLHD Jessica Nikolovski, Research Associate, NHMRC Clinical Trials Centre, Susan Wakil School of Nursing and Midwifery, The University of Sydney Marg Fagan, Consumer Advisor New Videos for Culturally and Linguistically Diverse Consumers Five new translated videos have been released and are available from the PRM Resources page in Italian, Korean, Macedonian, Serbian, and Spanish. The videos explain what Patient Reported Measures are, how they support shared decision-making, and why they matter to both patients and clinicians. They complement existing versions in English, Cantonese, Mandarin, Arabic, Greek, and Vietnamese. Videos are now available for all 11 languages supported on the HOPE platform. Patient Reported Measures Symposium - 29 August The Agency for Clinical Innovation (ACI) will host the third Patient Reported Measures (PRMs) Symposium on 29 August 2025. The event will be held at the Kolling Institute, RNSH, and online via Microsoft Teams. he The NSLHD Patient Reported Measures team has created a Survey Implementation Checklist to support staff developing new or reviewing existing patient experience surveys, also known as patient reported experience measures (PREMs). All staff developing or reviewing PREMs, excluding surveys for research, should use the checklist. The checklist is available from the Consumer and Patient Experience intranet page , and from your local Quality Manager. The checklist and related consultations help to ensure that additional surveys that are developed are suitable and valuable for improving patient care. Development of the checklist was informed by the Introductory Guide to Collecting Self Reported Information through Surveys (NSW Ministry of Health, December 2024), and by targeted consultation with staff developing PREMs, Quality Managers, and consumers.
The symposium will bring together clinicians, consumers, researchers, academics and PRMs experts to learn about current advances and best practice in the field of PRMs.
Please visit ACI's PRMs page or contact aci-prm@health.nsw.gov.au for more information about the event, including how to register and the event program.
More information about using PRMs in NSLHD Please visit NSLHD's PRMs intranet page or contact the NSLHD PRMs Team nslhd-prms@health.nsw.gov.au .
Partnering with Consumers Standard
AUGUST 2025
EDITION 39
We’re thrilled to welcome ten young people into the Population Health Promotion Service’s Youth Consultant team. Now a group of 12, aged between 15 and 24, the Youth Consultants live, study, and/or work across Northern Sydney, bringing their passion for youth friendliness and accessibility to the district’s health services. A Big Welcome to our District’s Newest Youth Consultants
We’re thrilled to welcome ten young people into the Population Health Promotion Service’s Youth Consultant team. Now a group of 12, aged between 15 and 24, the Youth Consultants live, study, and/or work across Northern Sydney, bringing their passion for youth friendliness and accessibility to the district’s health services.
As an example of the work they do, just last year the Youth Consultants reviewed the Hornsby Early Psychosis Intervention Service (EPIS) and an impressive 70% of their recommendations were put into action within just three months. EPIS staff praised their work, saying “why haven’t I heard of you guys before?” and calling the report “very impressive.” Booking a youth-friendly consultation is a simple and effective way to open a two-way conversation between your service and the young people you aim to support. Youth Consultants offer valuable, real-world insights to help you recognise and enhance the youth-friendliness of your services, spaces, and resources. Get in touch by emailing NSLHD-youthhealthpromotion@health.nsw.gov.au.
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Risky Business – Eating and Drinking with Acknowledged Risk A quality improvement project transforming the patient experience This project has revolutionised care for patients with dysphagia—swallowing difficulties that can lead to serious health risks. Many patients now choose to eat and drink despite the risks to preserve their quality of life. This project introduced a pioneering approach to improve the process called Eating and Drinking with Acknowledged Risk (EDAR), empowering patients to make informed choices. A multidisciplinary team led by Speech Pathology at Ryde Hospital partnered with consumers to co-design an EDAR protocol, including patient education resources, bedside signage, staff training, and documentation templates, enabling informed shared decision-making with patients. This project improved patient experience, staff knowledge, and health service efficiency while delivering cost efficiencies and reducing waste. The time spent nil by mouth (NBM) has reduced from an average of 4 days to 0 days. The length of stay (LOS) in hospital dropped from 20 days to 13 days, improving patient flow and experience. Hospital re-presentations have declined from 33% to 17%, reflecting well-managed care in the community. Palliative care referrals have increased from 19% to 58%, enhancing symptom management and dignity. EDAR decisions honoured has increased from 61% to 100%, showing full respect for patient autonomy. Hospital-acquired respiratory complications have dropped by 71%, improving safety and outcomes. Overall, patients feel more respected and heard: “I understand my swallowing problems… I’m 80, I’m old, I just want to enjoy the time I have left and eat and drink whatever I like!” In recognition of its impact, Risky Business won at the 2025 NSLHD Quality and Improvement Awards for Transforming Patient Experience. A video showcasing the project can be viewed here .
Are you considering doing a Quality Improvement Project?
Resources can be found here
Contact your local Quality Manager or NSLHD-SQEP@health.nsw.gov.au
Partnering with Consumers Standard
Leading for Safety and Quality Improvement Learning Pathway Northern Sydney Local Health District
Places still available for the next 2-day workshops in September and November!
Remaining 2025 dates
Program Overview
5 and 12 September @ HKH 3 and 10 November @ RNSH
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 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. 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: Improvement Science Workshop (Day 1) Readiness to Lead for Safety and Quality (Day 2)
Time: 8:30am - 4:30pm Duration: 2 days, CPD 14 hours
View the Six Dimensions of Healthcare Quality video ( 6 minute) on My Health Learning (Course code: 340129036), Read the Safety Culture Framework and watch the short video on the CEC website . (10 mins). Pre-requisites Enrol on MHL Course code 518150533 Ensure you enrol in Day 1 and Day 2 to avoid missing out. Preference will be given to participants who can attend both days. Equivalent online e-learning modules are available on MHL. Target Audience The Intermediate level offerings is designed for emerging local leaders of safety and quality and aims to build understanding of the tools and skills needed to lead continuous improvement.
Other preparation activities will be communicated closer to the date.
Build positive group dynamics within a team Identify a range of opportunities for ongoing development of your leadership capability
Contact: NSLHD-SQEP@health.nsw.gov.au
AUGUST 2025
EDITION 39
Medication Safety Week - 22-26 September 2025
Your paragraph text Please join the NSLHD Medication Safety Week Discussion Panel Series via MS teams-further details to follow. Prizes are available for staff who visit the medication safety stalls/roaming trolley at the facility, participate in online quizzes and/or attend the panel discussions via MS teams throughout the week. See the table below for the awareness-raising activities will take place across the district during Medication Safety Week: Medication Safety Is everyone’s business. Medication safety plays a vital role in healthcare, supporting the safe use of medicines and ensuring that hospital staff are consistently trained in best practices. During Medication Safety Week, NSLHD will highlight challenging medication safety scenarios, and important practices that keep our patients and staff safe. These practices include safe handling of cytotoxic or hazardous medications, speaking up for medication safety, involving consumers in Medication Safety Checks and optimal use of high-risk medications.
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Lauch of NSLHD Formulary App
The NSLHD Formulary App was developed to combine all medicines on the NSW Medicines Formulary and additional, out-of-scope medicines approved by the NSLHD Drug and Therapeutics Committee for inpatient initiation and/or outpatient supply from NSLHD Pharmacy Departments. Who can use the NSLHD Medicines Formulary App? The app can be used by all clinicians who prescribe, administer and supply medicines but will provide the most benefit to authorised prescribers and pharmacy staff. Once accessed, it’s as easy as searching for a medicine name in the search field and clicking on the relevant listing to view restrictions. Where to access the NSLHD Medicines Formulary App? The NSLHD Formulary App can be accessed from your computer via a direct link ( NSLHD Formulary App ) or from the ‘Intranet Apps’ quick link.
The NSLHD Formulary App can also be accessed on all mobile devices via the ‘Power Apps’ mobile app which is available for download from the Apple App Store, Google Play Store or equivalent. Note: Login to the app will require a Stafflink ID. For more information, refer to NSLHD Formulary App-FAQs or scan the QR code To arrange additional support/education please contact your corresponding hospital Pharmacy Department or email NSLHD-DTC@health.nsw.gov.au.
Medication Safety Standard
AUGUST 2025
EDITION 39
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 2025 - 2026 NSLHD Clinical Audit Schedule from the Clinical Audit Schedule Intranet page Clinical audits required to be completed this month are listed below.
August/September QARS Audits (direct links available from Clinical Audit Intranet page)
NSLHD_01_Clinical Documentation – Health Information Services (HIS) V2
Standard 1
NSLHD_03_Perioperative Sharps Management NSLHD_03_Aseptic Technique NSLHD_Peripheral Intravenous Cannula (PIVC) Insertion & Management and Care
Standard 3
NSLHD_4_Monthly Accountable Drug (S4D_S8) Register Audit NSLHD_4_User applied labelling audit 2025 Vaccine Management and Storage Audit in QARS
Standard 4
NSLHD_05_Cognitive Impairment Audit (Delirium)
Standard 5
NSLHD_06_Clinical Procedure Safety Checklist (level 3 procedures) NSLHD_06_Clinical Handover – Nursing and Midwifery BEDSIDE Shift-to-Shift NSLHD_06_Clinical Handover-all disciplines NSLHD_06_Consent Audit
Standard 6
NSLHD Patient Blood Management (medical)
Standard 7
NSLHD_08_MONTHLY_Resuscitation trolley/backpack & Resuscitaire equipment audit -V2 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
Clinical Governance in NSW (PD2025_032) - Ministry of Health Policy Inpatient Medication Handling Procedure - NSLHD Nasogastric and Orogastric Tube Insertion and Management in Neonates, Infants and Children (GL2025_012) - Ministry of Health Guideline
SAFETY ALERTS New, updated and recently published
Medication Safety Updates including medication shortages are available on the CEC website.
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