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.
MAY 2023
EDITION 25
IN THIS EDITION:
National Palliative Care Week NSLHD Compassionate Hospitals End of Life Care: Education and Training Co-design Policy, Procedure and Guideline (PPG) drop-in sessions Hindsight: Thematic review of SAER incidents Human Factors: Situational Awareness
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NATIONAL PALLIATIVE CARE WEEK 21 – 27 May 2023
The theme for National Palliative Care Week this year is: ‘ Matters of Life and Death’. It aims to highlight the need for a person- centred approach to care. Palliative care week is recognised across Australia to promote the awareness of the scope and benefits for palliative care. As a society, we need to acknowledge death as a normal part of life. Therefore, as healthcare workers, it is important we prepare for and talk to patients and loved ones about dying. The scope of palliative care extends beyond end of life care. In fact, the most rewarding developments and impact we can make is earlier on in someone’s disease progression. Palliative care may be offered to anyone with a life-limiting illness (last 12 months of life) who require help with distressing symptoms, whether they be physical, emotional, or spiritual. The approach to care is patient and family centred and requires the expertise of many disciplines including medical, nursing and allied health. In this time of living with an advanced illness, the aim of palliative care is to ensure the focus is on living well and making a plan for end of life care when the time comes. This year's campaign includes the launch of an inspirational documentary film about living and dying in Australia. ' Live the life you please' powerfully makes the case for the impact accessible services can make as we approach the end-of-life. It also supports the concepts of cultural safety, healthy conservations about death and dying amongst family members, and the importance of advance care planning. 'Live the life you please' is screening United Cinemas, Warriewood on 24 May (click on flyer to register for free tickets) and in other participating cinemas in NSW during May.
Palliative Care Special Interest Group
Pall care SIG is an initiative led by the Supportive and Palliative Care team. The group convenes monthly to share information and education on end of life and palliative care. It is a space to come together, network and get to know other clinicians from across the District. All are welcome! Contact Jacqueline Endicott (Palliative Care, CNC) if you would like to join this supportive & collaborative team.
Partnering with Consumers Standard
MAY 2023 COMPASSIONATE HOSPITALS NSLHD’s palliative approach to end of life care
EDITION 25
Partnering with Consumers Standard
Dying is often recognised late and may lead to people receiving unwanted, futile or burdensome interventions and can extend to missed opportunities for the person and their loved ones to have important conversations, conclude life/legacy work or be in their preferred place when they die. To support clinicians to recognise and care for people and their loved ones, at end of life, NSHLD has developed the Compassionate Hospitals bundle. The aim of the program is to improve recognition of the dying person and to provide tools to support holistic and safe end-of-life care. The bundle includes the Care of the Dying observation chart (NS12126), guidelines on anticipatory prescribing, and information for carers and loved ones. The program is supported by local policies, procedure and guidelines. NSLHD have a locally developed resource ‘Sorry Business’ to support and care for Aboriginal and Torres Strait Islander people and their families as well as information on cultural consideration when providing end of life care through iPEPA (Indigenous Program of Experience in the Palliative Approach).
END OF LIFE CARE: EDUCATION AND TRAINING
A network of clinicians in Northern Sydney, who are passionate about education and who believe that all healthcare workers across the district should be able to provide a palliative approach when caring for people at the end of their lives. The provision of quality end of life care is not solely the domain of palliative care but spans all specialties and disciplines. End of life care will touch everyone at some point whether in our professional or personal lives. To demystify death and provide clinicians with the skills to provide quality care for people with a life limiting illness or those at the end of their life, the palliative care team offer education and training supported by the PEPA program. This year PEPA events will be hosted at RNSH in November and December. Heath Education and Training Institute (HETI) have developed online education modules (learning pathways) specifically designed to support end of life care including: End of life Symptom Assessment and Management; End of Life Screening and Planning Enabling person centred end of life care for people living with dementia, mental illness or intellectual disability; Enabling culturally sensitive end of life care for Aboriginal people; and Culturally responsive end of life care for people from culturally and linguistically diverse (CALD) communities. The end of life essentials program provides online learning opportunities and practice resources for doctors, nurses and allied health professionals to improve the quality and safety of end-of-life care in hospitals. The 15 modules that contain information on understanding the context of death and dying, clinical skills in end of life care and patient states of mind ELLC is supported through the Palliative Care Education & Training Collaborative and has 12 education and training modules available for all healthcare professionals that focuses on the law relating to end of life decision-making.
Online modules on My Health Learning
NSLHD Library have a dedicated Supportive, Palliative and End of Life Care page
More information can be located on the Clinical Governance End of Life: Education and Training intranet page
MAY 2023
EDITION 25
CO-DESIGN
Partnering with Consumers Standard
Co-design enables consumers to become equal partners in the improvement process for health services. It is a way of bringing consumers, carers and families together to improve health services. Planning, designing and producing services with people that have lived experience of the problem or service means the final solution is more likely to meet their healthcare needs and that of our community. Co-design is about shared decision-making with multiple people, including healthcare staff, patients and consumers. It creates an equal and reciprocal relationship between all stakeholders, enabling them to design and deliver services in partnership with each other.
Introduction to co-design The principles and practices of co-designing healthcare with consumers. Agency for Clinical Innovation | 6:14 minutes
Resources The Agency for Clinical Innovation (ACI)'s Co-design toolkit is a practical resource for teams to adopt a co- design approach in improving systems and processes of health services. Recruit a Consumer Advisor. It can take up to 6 weeks to recruit a Consumer Advisor, so it is best to start early. Currently Consumer Advisors give their time freely and are not remunerated for their contributions. Therefore please consider how you will value their input and involvement and provide respect for their viewpoints and contributions. Contact the Consumer and Patient Experience Team to express interest to request a consumer to be involved in your improvement project. The Consumer Tick process is to be followed when designing and refining patient facing information, documents, etc 7 Habits of Highly Engaged committees (Habit 1: Co-design thinking) on My Health Learning (course code 305574382) This way of working demonstrates a shift from seeking involvement or participation after an agenda has already been set to seeking consumer and clinician leadership from the outset so that consumers and clinicians are involved in defining the problem and designing the solution. Committees with Consumer Advisor involvement should ensure a prompt is added to meeting Agendas to acknowledge consumer participation and their lived experience.
DROP IN SESSIONS - POLICY, PROCEDURE AND GUIDELINE DEVELOPMENT
Clinical Governance Standard
These "drop in" sessions are open to anyone involved in developing Policies, Procedures or Guidelines (PPGs). PPG Authors and Document Owners, who are involved in writing PPGs or who coordinate consultation and approvals, are encouraged to join. Held fortnightly via MS Teams, the sessions begin with a 20 minute presentation on a specific PPG development topic. The remainder of the session is open to any PPG development related questions. The first session " Update on the Current PPG Process ", was held on the 28 April, and has been positively received by the attendees, who rated the usefulness of the session 5 stars.
“Thanks so much for the PPG session today, it was really helpful.”
Visit the PPG Drop in Sessions page on the NSLHD PPG Intranet site for a schedule of future drop in sessions, the list of topics being presented and video recordings.
Please contact NSLHD-Policies@health.nsw.gov.au for inquiries or to recommend topics for future sessions.
THEMES FROM NSLHD SERIOUS ADVERSE EVENTS
A serious adverse event review (SAER) is required for clinical Harm Score 1 incidents or clinical incidents that the Chief Executive determines may be due to a serious systemic problem. The focus of a SAER investigation is on learning from error and strengthening our systems and processes. It is not about individual staff performance. What are the main findings from SAERs for adults receiving general care in the last 5 years?
Top principal incident types
Top 3 clinical risk factors
Inadequate treatment Missed diagnosis Healthcare associated infection Delayed treatment Uncommon complication Death following a fall
Physical co-morbidities
Deteriorating patient*
Confusion and Delirium
0 25 50 75
*Failure to recognise the deteriorating patient
0
5
10
15
The presence of multiple diseases and medical conditions, chronic or acute, in the one person increases the risk the patient will experience serious preventable harm and is associated with more complex clinical management, poor treatment outcomes, longer hospital stays and increased risk of readmission. Adding to the risk of physical co-morbidities is the fact that as age increases the number of co-morbidities also tends to increase, adding to the complexity of the treatment plan and requiring management by multiple care providers.
Top 5 principal incident type
Strategies to mitigate this risk include:
Involve patients, their families and carers in care planning Prioritise continuity of care between multiple care providers and services Provide tools to improve communication between care providers and documentation Ensure that the patient’s medical history is complete, assess medication safety, including undertaking and documenting medication reconciliation
Top human factors
Human factors were identified in many NSLHD SAERs to have contributed to poor patient outcome. The most frequent human factors were ‘Loss of situational awareness’ and ‘Cognitive bias errors’. These have significant impact on decision making, diagnostics and care planning. Situational awareness is about being aware of all the elements in your immediate environment and how they relate to patient and personal safety. It is the careful observation of what’s around us (perception), understanding its significance (reflection) and predicting how it might influence what we are doing (forecast). Read more on page 6. Cognitive bias is defined as ‘failure to understand, synthesize or act appropriately on available information despite adequate education and knowledge levels’. Examples include following the wrong clinical pathway, incorrect pattern matching and/or false hypothesis.
Loss of situational awareness
Cognitive bias errors
Clinical Governance Standard
Knowledge based errors
0
5
10 15
20
Top 3 system factors
The system issue of ‘Care Planning’ was identified as a significant factor impacting on the risk of a patient experiencing a serious adverse event. It relates to where there may have been gaps or failures in collaborative planning for patients receiving care from more than one team. This includes care co-ordination and high-risk system issues within a facility or between health care facilities. Care Planning also includes where a patient's risk factors (‘High Risk not considered’) have not been adequately assessed or managed.
Poor communication and inadequate assessment of risk were also identified as top contributory system factors from serious incident investigations over the last 5 years. The most recently publish report from the CEC (Biannual Incident Report January -June 2021), indicates that care planning and communication are the top system factors identified contributing to adverse events occurring across the state.
Care planning
Poor communication
Inadequate assessment of risk
0 50 100 150 200
Communication
Timing and Access 18.1%
It is interesting to note that communication was also seen as key finding from complaints received from our patients and consumers.
Communication 31.7%
Top 5 principal incident type The system issue of ‘Care Planning’ was identified as a significant factor impacting on the risk of a patient experiencing a serious adverse event. It relates to where there may have been gaps or failures in collaborative planning for patients receiving care from more than one team. This includes care co-ordination and high-risk system issues within a facility or between health care facilities. Care Planning also includes where a patient's risk factors (‘High Risk not considered’) have not been adequately assessed or managed. Poor communication and inadequate assessment of risk were also identified as top contributory system factors from serious incident investigations over the last 5 years. The most recently publish report from the CEC (Biannual Incident Report January -June 2021), indicates that care planning and communication are the top system factors identified contributing to adverse events occurring across the state. Top 3 system factors Clinical care, treatment and safety 38.1% Management of facilities 6.8% Improvement opportunities to strengthen communication 31.7% of patients and consumers have provided feedback that their experience of care has been affected by miscommunication between staff from departments, or lack of or poor communication received by patients regarding their care plan and their discharge instructions. Source: Thematic review of compliments and complaints reported on ims+ (1 June 2021 - 31 May 2022). The role of the Consumer Peer Worker employed across MHDA services. These Peer workers provide lived expertise to service decision making, the development initiatives through committee representation, consultation, co-designing and co-producing projects, and co-facilitate training and education. Elevating the Human Experience Program which involve working with patients, their families and carers to improve the performance of health systems and most importantly, delivering better health outcomes for patients. The Best Care Together Program at RNSH Safety Huddles - A multidisciplinary process ensuring that the entire team is mindful of the tasks that need to be completed by each team member Intentional Patient Rounding is purposeful hourly communication by a healthcare team member with each patient and/or their carer or family. The aim of this: Keeps patients and/or their carer or family informed about and involved in their care Supports the delivery of safe, quality care Regularly evaluates the quality of care delivered Creates trust and reduces patient and/or carer or family anxiety by providing clear expectations for each interaction by a known care giver Speaking up for Safety Across NSLHD there continues to be several strategies which have been implemented to improve communication between clinical teams and between clinicians and patients/family/carers. These include:
HUMAN FACTORS: SITUATIONAL AWARENESS The human factors topic highlighted in this month's edition is Situational Awareness, as this was identified as a major contributing human factor from the latest thematic analysis of Serious Adverse Event Reviews in NSLHD.
People often ignore warning signs as they lose situational awareness and don’t look at the bigger picture.
According to experts in human factors in healthcare, Global Air Training , Situational Awareness can be described in simple terms as knowing what is going on around you, or having a ‘helicopter view’ of the situation in front of you, as well as what other factors could impact the current situation. It is clear to see how this would be beneficial to the delivery of safe and effective healthcare. What is Situational Awareness? The short video Just a Routine Operation is a compelling example where a loss of situational awareness was seen as one of the predominant causes that led to serious harm. In this case, the clinical team were so focused on dealing with the emergency in front of them that they lost sight of the fact that the patient has been deprived of oxygen for a significant period of time. The film is a reenactment of an actual event, where the patient's husband talks about his experience of losing his wife during an apparently routine procedure and his hopes for making a change to practice in healthcare.
Picture Ref: Daily Mail Australia, 12 June 2018
Endangering colleagues working around you Endangering yourself Forgetting information (due to distraction or interruption) Misinterpreting information (assumption!) Missing information Not passing on all information Not requesting information Hazards associated with lack of situational awareness: Avoid confirmation bias Be assertive, don’t keep concerns inside... Speak Up for Safety Communicate openly & ensure everybody is in the loop If you feel your situational awareness is being lost, say something Interpret the facts, not what you want to see Take time, don’t be rushed Think ahead, plan ahead, review a course of action Try to remain alert and vigilant Recovering or maintaining situational awareness You can practice being more situationally aware using this short model (Endsley, 2005) 1.
Just a Routine Operation Human Factors in Patient Safety YouTube | 13min 55sec
Increasingly “a loss of situational awareness” is identified when reviewing safety incidents internationally. Investigators should first begin to understand why situational awareness may have been lost or not maintained, before considering appropriate measures to reduce the risk of recurrence in the future.
Perception of elements within the environment around you (picking up cues, noticing) Comprehension - understanding the current situation, and Projecting what might happen next (planning ahead
2.
3.
Distractions Execution of improper procedure Fatigue High workload Lack of communication Lack of experience Conditions that contribute to loss of situational awareness:
MAY 2023
EDITION 25
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.
May 2023 QARS Audits (entry links)
NSLHD_1_Maternity_Safe Sleeping for Babies (HKH Maternity | RNS Maternity) NSW MRN 01.16 Maternity Continuum Documentation (HKH Maternity | RNS Maternity)
St 1
NSLHD_03_Peripheral Intravenous Cannula (PIVC) Insertion and Management
St 3
NSLHD_4_Monthly Accountable Drug (S4D_S8) Register Audit (RNSH | HKH | Ryde | MVH | MHDA) NSLHD_06_Clinical Handover -all Clinical Disciplines NSLHD_06_Handover Nursing Shift to Shift (RNSH | HKH | Ryde | MVH)
St 4
St 6
NSLHD Patient Blood Management Audits (Perioperative)
St 7
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
Central Venous Access Device (CVAD)_Guideline (updated) Management of Health Care Records- NSLHD_Policy (updated)
Cognitive Impairment – Care of Adults in Hospital – NSLHD_Guideline (updated) Management of Infection Risk to Patients from Animal Visitations_Procedure (updated)
Complaints - Management of Patient/Consumer/Carer/Family Complaints NSLHD_Procedure (updated) Acute Respiratory Infection (ARI) Infection Prevention and Control Management - NSLHD_Guideline (updated)
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 Updated: Cannabis (THC) lollies and risk to children - issued 4 May 2023 ( available on NSW Health intranet only) Updated: Illicit cocaine containing high levels of lidocaine (lignocaine) - issued 4 May 2023 Updated: Disruption to supply: Heparin sodium (Pfizer®) 5000 units/5 mL injection ampoule - re-issued 29 April 2023
Medication Safety Updates including medication shortages are available on the CEC website.
For more information, contact: NSLHD-SafetyAlert@health.nsw.gov.au
LESSONS FOR LEARNING Did you know that the Clinical Excellence Commission(CEC) shares findings from serious incidents that have occurred across NSW to aid in reducing preventable risk of a similar event occurring to another patient? Click below for the latest lessons for learning from the CEC COVID-19 IPAC Fundamentals - April 2023 Access past lessons from the lessons learned intranet page. Clinical Governance Standard
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