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.
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IN THIS EDITION :
NSW MEDICINES FORMULARY The NSW Ministry of Health (Ministry) is leading a reform to establish a state-wide medicines formulary. The NSW Medicines Formulary is a list of medicines and other therapeutic agents that have been approved for use within NSW public hospitals and health services. It includes the approved indication, dose formulations and any applicable prescribing restrictions for each medicine. Providing better value health care across the NSW Health system reduce variation in medicine use while maintaining appropriate clinical choice. improve patient care and equity of access to medicines. optimise medication safety through consistency of medicines use. use statewide purchasing to obtain best value. The change from facility or local health district to a standardised state-wide approach to pharmaceutical procurement seeks to: Fostering best practice clinical care to improve patient outcomes supporting clinical governance through streamlined formulary medicine decision making, and reducing duplication of effort. supporting monitoring and feedback of data to clinicians and managers to support the delivery of high-quality care. improving patient outcomes by supporting evidence-based use of medicines. Establishing a statewide formulary is expected to have several additional benefits, including:
NSW Medicines Formulary Opioid Analgesic Stewardship in Acute Pain Clinical Care Standard NSQHS Accreditation update PPG Communique is now in the Weekly Bulletin Partnering with Consumer Framework published Timeliness and accessibility quality dimension April Falls Month Project spotlight - Delivering Paediatric Speech Pathology via Telehealth What did you think of this edition? Give us your feedback. A key change is to manage the shift from our health District's existing governance framework for medicine evaluation and approval to the state-wide model. Transitioning to the NSW Medicines Formulary will involve some changes for local Drug and Therapeutics Committees (DTCs), clinicians and pharmacy departments. Activities in preparing NSLHD facilities for the transition to and implementation of the NSW Medicines Formulary will soon commence with an establishment of an NSLHD DTC and Formulary Implementation Advisory Group. If a prescriber needs to initiate a medicine for a patient that is not on the NSW Medicines Formulary, prescribers can still obtain local approval to prescribe through the usual DTC Individual Patient Use (IPU) application process. Alternatively, there may be another therapeutically equivalent medicine listed on the NSW Medicines Formulary that could be a suitable substitute. Visit the NSW Health Medicines Formulary website for further information. Contact: Daniel.Searle@health.nsw.gov.au (NSLHD Medication Safety Improvement Facilitator)
Medication Safety Standard
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Medication Safety Standard
The ACSQHC Clinical Care Standards Describe the care patients should be offered by health professionals and health services for specific clinical conditions or defined clinical pathways in line with current best evidence. Play a vital role in reducing unwarranted variation. Are developed in collaboration with a topic working group of clinicians, researchers and consumers. Public consultation is also conducted before finalisation. Describe high priority areas for quality improvement. They are based on areas of current variation, information about what we know works in terms of treatments, procedures and processes, and what care should be offered to a patient. Clinical Care Standards in use (ACSQHC)
OPIOID ANALGESIC STEWARDSHIP IN ACUTE PAIN CLINICAL CARE STANDARD Official launch - 27 April 2022 The national Opioid Analgesic Stewardship in Acute Pain Clinical Care Standard will be released on 27 April. This standard will outline the appropriate use and review of opioid analgesics for managing acute pain in acute care settings. The Australian Commission on Safety and Quality in Health Care will host a live webcast and panel discussion to launch the new clinical care standard.
When: Wednesday 27 April, 12 pm - 1 pm Click here to register your attendance.
HORNSBY & ROYAL NORTH SHORE HOSPITALS ACCREDITATION ASSESSMENTS IN MAY 2022
Preparation work is progressing for Hornsby & Royal North Shore Hospitals’ Accreditation Assessments scheduled for the following consecutive weeks in May.
Hornsby Ku-ring-gai Hospital: 16 - 20 May 2022 Royal North Shore Hospital: 23 - 27 May 2022
Both hospitals recently participated in Trial Assessments. The scope of the Trial Assessments was limited to National Standards 1 & 3 due to both hospitals experiencing the pressures of COVID at the time. A Nurses’ Strike also occurred during RNSH’s first day of their Trial Assessment. The Trial Assessors expressed their gratitude to the staff for taking the time to participate in the Trial Assessments, despite the pressures they have endured. LATEST POLICIES PROCEDURES GUIDELINES (PPG) NOW IN THE WEEKLY BULLETIN To reduce email traffic, the NSLHD PPG Communique will now be featured in the NSLHD Weekly Bulletin instead of as a standalone email. The Communique provides information about the latest published NSLHD PPGs; Ministry of Health Policies, Guidelines and Information Bulletins; current PPGs on Draft for Comment; and rescinded PPGs.
Clinical Governance Standard
Contact: Nitisha.bangera@health.nsw.gov.au (NSLHD Policy and Compliance Manager)
PARTNERING WITH CONSUMERS FRAMEWORK The new NSLHD's Partnering with Consumer Framework has recently been published. The Framework outlines our district's commitment to partnering with consumers and the broader community. Northern Sydney Local Health District's vision is to grow and support inclusive, collaborative consumer engagement through valued partnerships to inform health service planning, delivery, development and evaluation from lived experiences.
Visit the Partnering with Consumers intranet site to access the framework, resources and further information
Contact. Kate.Bokenham@health.nsw.gov.au (A/Manager, Consumer and Patient Experience
Partnering with Consumers Standard
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Mona Vale Hospital identified extensive waiting times for OT assessments and to address this issue, specific strategies were introduced to reduce the waiting times for OT appointments Consumers who are discharged from mental health inpatient units receive a follow up contact by the service within 7 days of discharge. The week following discharge is considered to be a high risk time for consumers, as such it is critical this follow- up is timely way. RNSH's discharge collective aimed to improve patient flow by increasing the proportion of early discharges (before midday) to enable improved accessibility to beds (especially for critical care areas). The project was also able to demonstrate reductions in length of stay. Response to the COVID-19 pandemic has escalated the uptake of telehealth and virtual care services. The digital virtual infrastructure supports the use of telehealth services as a sustainable model of care to allow patients convenient access to the clinical care they require. In addition, the infrastructure has enabled families and carers to connect with patients at the bedside during periods of restrictions. How can you play a part in making sure patients receive timely and accessible care in your workplace? There are many examples of initiatives in NSLHD that have led to the prevention of patient harm incidents. Here are some examples. Can you think of more?
TIMELINESS AND ACCESSIBILITY In this edition, we will take a closer look at another of the six dimensions of healthcare quality .
Timely care is how quickly patients receive the care they need. Can you recognise any timeliness issues and areas for improvement where you work? For example, reducing waiting times for patients to be seen by a doctor in the Emergency Department, timely completion of X-rays, reducing the waiting time to be admitted to the ward from the Emergency Department, or to be discharged. Non-clinical examples may include meals not delivered to patients on time, or delays in having rooms or beds ready for new patients. Accessible care is when patients receive the health care or service they need when they need it. Does your area of work consider geographical, financial, medical or social issues that inhibit the patients from receiving the right care at the right time? Is care equally accessible to patients who are Culturally and Linguistically Diverse (CALD); bariatric patients or consumers in Mental Health; or corrective services facilities? At times there may be tensions between the dimensions of care. For example, while providing timely care is often a feature of system performance, pressures to meet these performance targets may lead to ‘work arounds’ or increases in risks e.g. wrongly diagnosing a patient, or re-admissions as a result of pressure to discharge patients early. Additionally, access to healthcare also needs to be efficient and cost-effective.
Want to learn more?
Foundations of Safety and Quality e-learning pathway on My Health Learning (course code 335318052) The Safety and Quality Essentials Pathway NSLHD Quality Improvement Intranet page.
Enrol in the next one-day virtual Improvement Science workshop on 13 May 2022 . Spaces are limited. Enrol via MHL (course code 42956746)
Contact: Cathy.Vinters@health.nsw.gov.au or Catherine.Rosario@health.nsw.gov.au (Clinical Reliability Improvement Facilitators, Clinical Governance)
Clinical Governance Standard
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Did you know in the Community?
The Healthy Active for Life online program is free for staff, family, patients and consumers aged 60 years or over who want to get healthier through physical activity and healthy nutrition. Visit www.activeandhealthy.nsw.gov.au for more information and to register. Contact: Margaret.Armstrong@health.nsw.gov.au (NSLHD Falls Prevention Coordinator) 37% of injury-related deaths are caused by falls 30% of over 65’s fall each year 72% of major trauma patients 65+ years have fallen 55% of all major trauma deaths are related to falls, exceeding road trauma 75% of hospital incidents relate to a fall 30-40% will result in an injury 60-80% of falls are unwitnessed 70% occur at the bedside in relation to toileting Did you know in Hospitals?
April Falls Day® and April Falls Month 2022 is an annual campaign to raise awareness about the impact of falls and to promote the latest best practice fall prevention strategies. The last two years have been difficult with many community fitness groups and social activities unable to continue due to COVID. This has contributed to an increase in inactivity, deconditioning, frailty, and increasing social isolation in many adults regardless of ability or age. This year's campaign Better ‘Balance’ for Fall Prevention aims to promote increased physical activity (improve balance and strength) to reduce people's risk of falling and suffering a fall-related injury. Research has shown that exercise of any type has been shown to reduce the risk of falling by 23 per cent. Additionally, the campaign promotes social ‘balance’ for better mental health and less isolation by encouraging people to exercise in groups or with friends. Visit the NSLHD Falls Prevention Intranet page to access April Falls Month 2022 campaign materials.
Comprehensive Care Standard
Project Spotlight
DELIVERING PAEDIATRIC SPEECH PATHOLOGY VIA TELEHEALTH WITH A COVID PUSH Child, Youth and Family Speech Pathology (Primary and Community Health Service) made a rapid transition to telehealth during COVID-19 restrictions in March 2020, to allow them to continue delivering services. During a four week period of strict restrictions, 82 per cent of sessions were done via telehealth and throughout the year the team provided 30 virtual parent programs servicing 256 families. More than 80 per cent of clients felt virtual services met their needs, 85 per cent identified benefits in the areas of flexibility and convenience and almost 70 per cent would like virtual sessions in the future. The Child, Youth and Family Speech Pathology Service was a winner in the 2021 NSLHD Quality and Improvement Awards
Have you and your team completed a quality improvement project or program in the last 2 years that led to positive outcomes? The 2022 NSLHD Quality and Improvement Awards are accepting entries until 29 April 2022 . Download the submission guide and entry form the NSLHD Quality and Improvement Awards Intranet page. Watch the recorded webinar session on how to write up a competitive award entry for tips to guide your entry. Contact: Catherine Rosario (Clinical Reliability Improvement Facilitator) NSLHD-Awards@health.nsw.gov.au The Innovation Program provides an opportunity to seek funding to further develop and embed your ideas to improve patient outcomes and experience; the health of populations; staff experience or reduce the cost of care. The first Pitch event for 2022 will be held on Tuesday 26th April as a live stream event. For further information or questions about the Innovation Program please contact the team at NSLHD-InnovationProgram@health.nsw.gov.au or check out the Improvement Hub .
Watch short video of this initiative, as well as all the winning projects of the 2021 NSLHD Quality and Improvement Awards.
NSLHD CLINICAL AUDIT SCHEDULE APR I L 2 0 2 2
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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 during April are listed below.
April 2022 QARS Audit (entry link)
April 2022 QARS Audit (entry link)
NSLHD_3_Infection Prevention Control Program compliance NSLHD_03_Transmission Based Precautions NSLHD_4_Monthly Accountable Drug (S4D_S8) Register Audit (RNSH | HKH | Ryde | MV | MHDA) NSW 2022 Vaccine Management and Storage Audit (all locations and QARS links) NSLHD_06_Clinical Handover - all Clinical Disciplines NSLHD_06_Handover Nursing Shift to Shift (RNSH | HKH | Ryde | MV) NLSHD_08_Monthly inspection for resuscitation trolley/ Resuscitaire equipment checklists (RNSH | HKH | Ryde | MV | MHDA)
NSLHD_05_ Falls Audit Documentation and Observation_Inpatient and MHDA
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(RNSH | HKH | Ryde | MV | MHDA)
NSLHD_05_Falls Design and Structure: General Overview and Checklist for Bedrooms & Bathrooms Inpatient and MHDA
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(RNSH | HKH | Ryde | MV | MHDA)
NSLHD_05_Falls Audit Documentation Community and Ambulatory Care Locations NSLHD_05_Falls Design and Structure Community and Ambulatory Care Locations NSLHD_05_Delirium Screening and Management Audit (RNSH | HKH | Ryde | MV ) NSLHD_5_Nutrition Care Audit
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(RNSH | HKH | Ryde | MV )
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 Venous Thromboembolism (VTE) Prophylaxis Guidelines - NSLHD User applied medicine labelling Assessment and Care of Heavy Menstrual Bleeding NSLHD Chest Injury Pathway (ChIP) Guideline Real Time Patient Experience Survey (RTPES) Policy Real Time Patient Experience Survey (RTPES) Procedure Oxygen Therapy & Delivery (Adult Inpatients) Rehabilitation Pathways following COVID-19 related illness - NSLHD Bereavement and Care of the Deceased Patient In A General Inpatient Setting Guideline
Carbapenem Resistant Enterobacteriaceae (CRE) _Guideline HYDROmorphone: Guidelines for Use and Management Uniform and Dress Code for Clinical Staff – NSLHD_Policy 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 - March 2022 How IDEAL was your last discharge - Paediatric Watch Edition 1/2022 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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