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.
FEBRUARY 2023
EDITION 22
Figure 1.
NSW Medicines Formulary update Project Spotlight - Youth Suicide Framework NSLHD Quality and Improvement Awards Human Factors: The Filthy Fifteen Human Experience Week Patient Reported Measures Research Symposium What did you think of this issue? Please give us your feedback. IN THIS EDITION: NSW MEDICINES FORMULARY UPDATE In the April 2022 edition of Foresight, we shared that a state-wide reform to establish an NSW Medicines Formulary had commenced, led by the Clinical Excellence Commission (CEC) on behalf of NSW Ministry of Health (MoH). The transition to the NSW Medicines Formulary will involve some changes for our local Drug and Therapeutics Committees (DTCs), clinicians and pharmacy departments. Implementation of the NSW Medicines Formulary is made in tranches based on therapeutic groups (figure 1). Multidisciplinary stakeholders across the district are working to prepare NSLHD for transitioning to the NSW Medicines Formulary, with tranche 1 and 2 underway.
Will this impact current practice? Clinicians are strongly encouraged to familiarise themselves with the list of medicines approved. A gap analysis was completed to identify any medicines that may have a significant change to clinical practice. Email NSLHD-DTC@health.nsw.gov.au to request a copy of the gap analysis. NSLHD Drug and Therapeutics Committee A district advisory group was convened in July 2022 to oversee NSLHD's implementation of the NSW Medicines Formulary and establish the NSLHD Drug and Therapeutics Committee (DTC). The NSLHD DTC will meet monthly commencing Standardisation of medication practice in NSLHD. Facilitate system-wide medication safety initiatives across NSLHD. Prepare and support the district's transition to the NSW Medicines Formulary. existing facility / service DTCs to provide strategic direction to Medication Governance in NSLHD. The committee's objectives include: February 2023 with multidisciplinary representation from all sites and services. This peak committee will replace
Click on the image to find out more:
download Information for Clinicians fact sheets by therapeutic group, which provide an overview of potential changes that may be required to current clinical prescribing, indications for medication use and restrictions to prescribing. The dedicated NSW Medicines Formulary page may be accessed via a Quick Link on the NSLHD intranet home page. Visit the page to: read about updates of our district's transition to the NSW Medicines Formulary, search the list of approved medicines on the NSW Medicines Formulary, or
Contact NSLHD-DTC@health.nsw.gov.au.
Contact: Rupali.Sarkar@health.nsw.gov.au (Medication Safety Improvement Facilitator)
Medication Safety Standard
FEBRUARY 2023
EDITION 22
Project Spotlight
YOUTH SUICIDE FRAMEWORK
Aligning with the Premier’s Priority to reduce the rate of suicide deaths in NSW, NSLHD's Child and Youth Mental Health Service (CYMHS)'s first-in-state initiative provides an evidence-based, systematic approach to responding to a youth suicide death. Responding to the suicide death of a young person (postvention) requires rapid and considered action to support those who are bereaved and prevent imitative suicides by individuals who may be at risk. While the team has always identified young people at risk following a suicide death, there was no formal framework to guide this work. The Youth Suicide Response Framework was introduced by CYMHS, NSLHD Mental Health Drug and Alcohol in 2020, to ensure an agile response to the situation. It focuses on mapping a “circle of vulnerability” of other vulnerable individuals and groups following a suicide death. The Framework design, with an easy-to-follow guide, checklists and templates, means that anyone leading the response can work through it in the same systematic way. At the time of writing, the service identified 71 vulnerable people who were provided with support to reduce the risk of suicide since the Framework’s inception. Youth suicide death rates decreased in the district in 2021 and 2022, and the Framework has been enacted within 48 hours of each tragic incident. Assessors praised the Framework when the Service underwent 2021 Accreditation to NSQHS Standards, suggesting there was potential for it to be scaled to a state- wide best practice model. Multiple other health districts have requested it for use following local deaths. The team were awarded winners at the 2022 NSLHD Quality and Improvement Awards for Excellence in the Provision of Mental Health Services and finalist in the 2022 NSW Health Awards.
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. There are eight award categories:
1. 2. 3. 4. 5. 6. 7.
Transforming the Patient Experience Patient Safety First Delivering Value-Based Integrated Care Supporting our People and Culture Keeping People Healthy Health Research and Digital Innovation Excellence in the Provision of Mental Health Services Planetary Health
8.
Key dates (2023)
Entries open: 27 Feb - 6 April* Finalists announced: 24 May NSLHD Quality and Improvement Awards Ceremony: 29 June * local sign-off process may require an earlier closing date. Contact your local facility or service Awards coordinator, Clinical Governance or Safety and Quality unit. Further information will be communicated out to all staff from the 27 February 2023. See videos showcasing last year's winning teams and their projects Join an online drop in session on writing up a successful award entry for your team's improvement project or program - 9 March 2023 Contact: NSLHD-Awards@health.nsw.gov.au Catherine Rosario (Clinical Reliability Improvement Facilitator | Quality Awards Coordinator)
How do I start an improvement project? Find out more on the Clinical Governance Quality Improvement Intranet site, Innovation Hub or contact your local quality advisor CYMHS, MHDA team at the 2022 NSW Health Awards Ceremony L to R: Andrea Taylor, Director MHDA; Catherine Rosario, Quality Awards Coordinator; Ayisha Chitakunye Service Director, CYMHS; Lee Gregory, I/CE NSLHD; Di Simes, Safeguards Manager CYMHS; Noel Meredith Service Manager, CYMHS; Elizabeth Penman, Towards Zero Clinical Change Manager
Clinical Governance Standard
FEBRUARY 2023
EDITION 22
HUMAN FACTORS: THE FILTHY FIFTEEN
Human factors refers to the interrelations between the environment, the job and the organisation in which the work is being carried out. Human factors was first identified in aviation and other high-risk industries as being important to consider in order to prevent or mitigate incidents, accidents or near misses. The role of human factors has become important in the healthcare setting as we know that people carrying out their roles can unintentionally contribute to safety incidents occurring, whether it be a medication incident, a patient fall or an incorrect procedure. This is important when we are looking at causes which contribute to incidents happening. Gordon DuPont, a highly respected aircraft engineer, described twelve factors that contributed to accidents or incidents in the airline industry but could equally be applied to the healthcare industry or other high-risk industries. These were referred to as the “Dirty Dozen” (1993) In 2014, Boeing added a further three possible contributing factors and the fifteen are now referred to as the “Filthy Fifteen” . The Filthy Fifteen are outlined below and will be expanded on further over the next few issues of Foresight 1
Complacency
Pressure
Stress
Lack of operational integrity
Distraction
Fatigue
Lack of professionalism
Lack of communication
Lack of assertiveness
Lack of Awareness
Not admitting limitations
Lack of knowledge
Lack of resources
Lack of teamwork
Norms
The expansion to the Dirty Dozen becomes the Filthy Fifteen (Boeing – 2014)
The original Dirty Dozen (Gordon Du Pont, 1993)
The potential precursors to accidents, incidents or elements that can influence people to make mistakes. The aim of the concept is to focus attention and resources towards reducing and capturing human error.
Complacency – So self-satisfied that we lose awareness of dangers. Distraction – Anything that takes your mind off the job at hand even for an instant. Fatigue – Lack of sleep or extended wakefulness. Lack of assertiveness – saying yes to something you should say no to Lack of awareness – One of the safety nets for lack of awareness is to ask more “what ifs” when there is conflicting information or things don’t quite seem right. Lack of communication – Abbreviations, voice, tone, intonation Lack of knowledge – With constantly changing technology, this contributor is more common than we think Lack of operational integrity – Can result in risk taking behaviour Lack of professionalism – When staff choose to do things their way, are rude or behaving badly or simply do not have pride in their work. Lack of resources – Has contributed to many incidents. Lack of teamwork – Team dynamics may vary dependent upon whether team members are well known to one another, or whether they are a transient team which comes together for specific tasks. Norms – Can be unwritten rules that are enforced. Not admitting limitations – Hasn’t received adequate training on something but has so much experience, they can “figure it out.” Pressure – To be on time is ever-present. Most industries are time-sensitive and many decisions centre around that fact. Stress – We all have some stress in our lives, and it is not all bad unless it becomes excessive.
1. 2. 3. 4. 5. 6. 7. 8. 9.
10. 11. 12. 13.
14.
15.
Clinical Governance Standard
Contact: NSLHD-SQEP@health.nsw.gov.au
FEBRUARY 2023
EDITION 22
HUMAN EXPERIENCE WEEK
Call for Abstracts
Save the date ! 1 – 7 May 2023.
Abstract submissions are now accepted and more information can be found on the Human Experience Week Abstract Submission Information Sheet. Healing in a time of COVID and other natural disasters: Challenges and triumphs in providing care during a global pandemic and other natural disasters. Human Experience in Action: How an intentional focus on the experiences of our people will transform the way we deliver and receive care The Evidence for Elevating the Human Experience: What the research shows – what we know and what we need to know. Education and Coaching for Elevating the Human Experience: How can education and coaching build capability in Human Experience The Power of Love and Belonging: Stories of love and belonging Codesign / Co creating for Elevated Human Experiences: Codesign/co creation as a strategy to enhance the human experience. NSW Health staff and consumers are invited to submit an abstract for online presentation, aligned to the theme and sub-themes of Human Experience Week 2023 and one of the following categories:
The theme for the Human Experience Week is: All of Us: The Power of Community , with the sub themes of: Love, Belonging and Healing. Previously known as "Patient Experience Week", this change reflects the strategic importance of human experience and the inextricable link between of patient, carer, family, volunteer and caregiver (staff) experiences.
Expression of Interest to host a local event/s
PATIENT REPORT MEASURES RESEARCH SYMPOSIUM – 2023 CALL FOR ABSTRACTS Metropolitan Local Health District or Speciality Network to host an in-person event, aligned to this year's theme and sub themes The Human Experience Week EOI will provide seed funding of up to $10,000 to one Regional and one As part of this rebranding, MoH are launching an Expression of Interest (EOI) to provide Local Health Districts and Speciality Networks financial support to host local in-person events. Click on the link to view the Human Experience Week Expression of Interest Information Sheet and submit your EOI. The Agency for Clinical Innovation Patient Reported Measures team is hosting the Patient Reported Measures Research Symposium on the 30th of May 2022 at the Kirribilli Club, Kirribilli, NSW. The ACI are seeking expressions of interest for individuals and teams to present patient reported measures research and local quality improvement projects that have been conducted to improve the provision and equity of care for patients and consumers of healthcare in NSW. The Patient Reported Measures (PRMs) Research Symposium is open to medical, nursing, allied health clinicians, health managers and consumers. The expected presentation time will be 10-15 minutes (depending on the number of finalised presenters). Formal instructions and guidance will be provided to all presenters once the program for the event has been finalised.
Partnering with Consumers Standard
Criteria: • Content should relate to the use of Patient Reported Measures in the context of a health service. • Projects must be currently underway or already complete. • Presentations should reflect on outcomes and learnings (including consumer involvement that are relevant across the health sector). • The presenter(s) will be expected to attend the event in person to present the project. • Preference will be given to projects that consider Aboriginal and Torres Strait Islander, culturally and linguistically diverse (CALD) and priority populations. You can register your interest in presenting at the PRMs Research Symposium on the 30th of May 2023, by completing your submission via this online form by 5pm Sunday, 19th February 2023. Successful applicants will be advised by Monday 6th March 2023. Click here to learn more about Patient Reported Program.
Did you know that QIDS can provide you with direct access to a wealth of safety and quality data and tools for the purpose of improving the quality and safety of our health service delivery?
The Improvement module on QIDS is designed for teams to support running a successful improvement project. Teams can document their progress and access a range of 'Improvement Science' tools that easily convert findings to visual diagrams and charts to measure, evaluate and share project success. The system allows for improved collaboration and communication among the teams including quality managers and project sponsors
The 6 steps to starting a Quality Improvement Project: 1.
Identify an area for improvement. Do others think it is a problem? Speak to your team leader or manager Involve a Quality Advisor or Quality Manager to advise you on an appropriate methodology such as Improvement Science (previously known as Clinical Practice Improvement) and consider enrolling in an Improvement Science workshop. Identify if ethics review is required Register your project
2. 3.
4. 5.
a.
with your local facility and service Safety and Quality Unit / Clinical Governance Unit Enter your project into QIDS to start using the inbuilt tools and collaborate with your team
b.
Introduction to QIDS video YouTube 2.26 mins | CEC
See quick reference guide
6. Promote your project
Login to QIDS https://qids.cec.health.nsw.gov.au/ Login with your stafflink ID and password Check out the following resource pages on the NSLHD Intranet
QIDS Resource page Quality Improvement Project Resources
Contacts:
NSLHD-QIDS@health.nsw.gov.au (for QIDS access & trouble shooting) NSLHD-SQEP@health.nsw.gov.au (for Improvement Project queries)
FEBRUARY 2023
EDITION 22
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 are listed below.
February 2023 QARS Audits (entry links)
NSLHD_03_Peripheral Intravenous Cannula (PIVC) Insertion & Management and Care
St 3
St 4
NSLHD_4_Monthly Accountable Drug (S4D_S8) Register Audit (RNSH | HKH | Ryde | MVH | MHDA)
NSLHD_6_ ID Band Specifications Adult / Paediatric Inpatients NSLHD_6_ID Band Specifications for Newborns V2
St 6
NLSHD_08_Monthly inspection for resuscitation trolley/ Resuscitaire equipment checklists (RNSH | HKH | Ryde | MV | MHDA | PACH-HITH)
St 8
POLICIES, PROCEDURES AND GUIDELINES New, updated and recently published district-wide PPGs. 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
End of Life Care Planning and Shared Decision-Making - ADULTS NSLHD Health Care Record Forms - Creation and Revision Geriatric Outreach Service Guideline Use of the GE Panda™ Resuscitaire Warmer for infants in Paediatrics
SAFETY ALERTS New, updated and recently published
Safety Alert (SA) - Requires immediate attention and action Safety Notice (SN) - Requires risk assessment at the district level Safety Information (SI) - Ensuring that lessons learned from state-wide, national or international sources are shared actively across NSW health system SI:003/23 - HIV Post Exposure Prophylaxis in Emergency Departments and Sexual Health Services -issued 10 February 2023 SN:002/23 - Updated: Transvaginal mesh implants for Pelvic Organ (Vaginal) Prolapse - issued 1 February 2023 SI:002/23 - Updated: Potential for error: look-alike fentanyl and suxamethonium Juno® ampoules - issued 31 January 2023 SN:001/23 - Disruption to supply – multiple antibiotic oral liquids - issued 23 January 2023 SA:002/23 - Updated: Defect alert: Computerised Ambulatory Delivery Device (CADD) Infusion pump disposables - issued 12 January 2023 SA:001/23 - Clinician Alert - Invasive group A streptococcal disease - issued 5 January 2023
For more information, contact: NSLHD-SafetyAlert@health.nsw.gov.au
Medication Safety Updates Medication Safety Updates including medication shortages are available on the CEC website.
Clinical Governance Standard
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