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.
OCTOBER 2024
EDITION 35
IN THIS EDITION: Medication Safety Week
Patient Feedback NSLHD Thematic Analysis 2023/2024 RNSH Menopause Hub and Greenwich Ambulatory
2025 Applied Safety and Quality Program Statewide Health Literacy Hub launch Celebrating 25 years of youth action in health Gathering Of Kindness Week 2024
Rehabilitation Service go live with PRM NSLHD Disability Care Plans Procedure Communication and Care Cues (CCC) form
Medication Safety Week 28 October – 1 November 2024
NSLHD will celebrate Medication Safety Week from 28 October to 1 November 2024. During Medication Safety Week, NSLHD will highlight key medication safety practices that help keep our patients safe. These practices include taking and reconciling medication histories, regularly reviewing Venous Thromboembolism (VTE) risk assessments, accurately documenting patient weight and allergy status, and ensuring the optimal use of high-risk medications.
NSLHD Medication Safety Week schedule of events and activities
Mon 28 Oct
Tues 29 Oct
Wed 30 Oct
Thurs 31 Oct
Fri 1 Nov
Daily email / virtual quiz
Ryde Hospital Medication Safety Stall main entrance foyer (9:30am - 12pm)
RNSH Medication Safety Stall ASB foyer (9:30am - 12pm)
HKH Medication Safety Stall Lvl1, Bld 60 (10 am - 12 pm)
Escalating Medication Safety Related Concerns Discussion Panel MS teams (1:30 - 2:30pm)
Wednesday Weigh Day - Recording Patient Weight Discussion Panel MS Teams (1:30 - 2:30pm)
Ward competition all week on measuring and documenting accurate patient weight
Daily prizes up for grabs! Visit our stalls, participate in online quizzes, panel discussions AND MORE!
OCTOBER 2024
EDITION 35
Medication Safety Week 28 October – 1 November 2024
Accurately recording a patient’s weight is essential for calculating medication dosages, assessing the appropriateness of high-risk medications, and monitoring fluid balance and nutritional status. To highlight the importance, all inpatient wards across NSLHD are invited to participate in a competition during Medication Safety Week that involves measuring and documenting accurate patient weight. The ward with the highest rate of accurate patient weight documentation from each hospital will win a morning tea or equipment sponsored by the NSLHD Clinical Governance Unit. Winners will be announced in early November. To participate, ward teams should: Discuss the importance of documenting accurate weights in team meetings or huddles Ensure an accurate and updated weight is documented for each patient, where possible Escalate any issues related to obtaining an accurate weight, along with their clinical implications, to the clinical team, team leader, or manager Patient weight documentation - ward competition
Learn to win Complete any of these medication safety specific e-learning modules on My Health Learning before 15 November to win a prize. Complete all to increase your chances! Safe Use of High-Risk Medicines Safe Use of Hydromorphone Safe Use of Anticoagulants Safe Use of Opioids Safe Use of Insulin: Challenge Safe Use of Benzodiazepines in the Older Person Vaccine Storage and Cold Chain Management More prizes up for grabs during Medication Safety Week! Visit the medication safety stalls Participate in online quizzes Join in the panel discussions on MS teams
Australia's response to WHO Global Patient Safety Challenge – Medication without harm
Since 2020 Australia has made significant progress towards reducing medication errors and adverse drug events. Key findings according to the Australian Commission on Safety and Quality in Health Care include: 11 per cent reduction in dispensing rates of antipsychotic medications for people aged 65 years and over between 2016–17 and 2020–21. 10 per cent decrease in the rate of hospitalisations for insulin-related adverse events and poisonings since the peak in 2021-22, even as diabetes continues to rise. 37 per cent decrease in unintentional drug-induced deaths involving opioids since 2018, due to regulation of access and the implementation of real-time prescription monitoring. As an Organisation, we can continue to work together to improve patient safety and mitigate medication- related harm. Visit the Australian Commission on Safety and Quality in Health Care website to learn more.
OCTOBER 2024
EDITION 35
APPLIED SAFETY AND QUALITY PROGRAM
Would you like to make a difference in your workplace to improve the quality of care delivered to patients and consumers, as well as develop your skills and knowledge to apply patient safety and quality improvement in everyday practice? Delivered in partnership with the Clinical Excellence Commission, the program is currently the highest- level learning offering under the Safety and Quality Essentials Pathway, building staff capability in healthcare safety and quality to an adept level (see page 4) Delivered over 12 months, the Applied Safety and Quality Program will enable participants to: Apply safety and quality tools and methods to influence workplace culture and improve patient outcomes. Lead an improvement project that aligns with strategic goals, ensuring tangible contributions to local priorities. Complete practical workplace activities and reflections to reinforce their learning and role- modelling behaviours. Participants will gain vital skills that are needed for current and future leaders. These include: Systems thinking for understanding complex healthcare environments. Facilitation skills, including navigating change and transitions. The ability to identify and manage clinical risks and gaps. Data analysis skills to assess local safety and quality. Enhanced stakeholder engagement and team effectiveness to foster high-reliability care. Mindfulness and wellbeing techniques for sustained professional resilience. More on page 4 Notably, upon successful completion of the program, graduates will earn credits towards relevant postgraduate courses with partner universities.
“Participating in the Applied Safety and Quality Program has been an immensely rewarding experience, both personally and professionally. I greatly appreciated the program’s structured and insightful approach to patient safety, risk management, mindfulness training and continuous quality improvement. The course was not only engaging but also highly practical, providing me with tools that I can apply in my daily work. On a personal level, it has sharpened my attention to detail, strengthened my sense of accountability, and made me more proactive in identifying potential risks before they escalate. I now feel more confident making critical decisions that prioritise patient safety and healthcare quality. Professionally, the program not only deepened my understanding of improvement science but also significantly enhanced my facilitation skills, enabling me to lead more effective meetings and training sessions. Additionally, the program has bolstered my leadership abilities, helping me promote a culture of safety and teamwork within my organisation. I’ve gained valuable skills in communication, problem-solving, and implementing evidence-based practices, all of which have improved my ability to work efficiently in high-pressure environments like IPAC. The knowledge and confidence I’ve gained from this program will undoubtedly have a lasting impact on my career and the quality of care I deliver." Testimonial by Biny Mathews, CNC Infection Prevention and Control (Applied Safety and Quality Program Graduate 2023 cohort).
Download the application form and FAQ to find out more.
Applications close 8 November 2024
For inquiries, contact: NSLHD-SQEP@health.nsw.gov.au
OCTOBER 2024
EDITION 35
The NSW Healthcare Safety and Quality Capabilities set describes the key knowledge, skills, and behaviours expected of NSW Health employees to engage in safety and quality improvement. Below are some examples demonstrating the adept level capability that participants of the Applied Safety and Quality Program look to develop and gain. What does having an adept level safety and quality capability look like?
Manage clinical incidents and risk Be able to explain the legislation and regulatory processes and policies relevant to incident reviews and clinical risk management to the team Lead unit or service-level incident reviews Monitor and meet requirements regarding the organisation’s safety and quality accreditation process and other safety assurance activities Track unit or service-level clinical risk and environmental hazard analyses and recommendations
Contribute to high reliability
Understand the concepts:
The elements of a safety culture Safety I and Safety II Hierarchy of the effectiveness of interventions Build teams with effective communication, psychological safety and demonstration of respectful behaviour. Discuss the interaction of safety and efficiency with team members to identify risks and to ensure reliability of service delivery Use of Safety Fundamentals, or local equivalent in your unit or service Monitor and use safety and quality data over time to ensure reliable service delivery in your unit or service
Uphold a safety culture
Manage individual factors that influence performance at work Lead open discussions on how to support each other when involved in incidents and where to access organisational physical and psychological wellbeing resources Follow up with staff who have been involved in incidents regardingongoing need for support Practise self-reflection and emotional regulation, and understand the impact of own and other’s emotions and physical feelings on safety Critical reflection of own cognitive biases and how they influence decisions, behaviours and actions at work Role-model reflective practice by facilitating discussions about learning for improvement Lead open discussions about how team members’ emotions and physical feelings impact safety Recognise and reward staff for speaking up for safety and supporting others to do the same Lead reviews following incidents and near- misses in a calm, logical and reflective manner so that others feel psychologically safe to contribute Ensure there is authentic and appropriate support provided to patients, families, carers, or other staff after an incident Ensure staff in your unit or service understand and participate in the Open Disclosure process Set the expectation in the unit or service that understanding consumer or customer needs and complaints is essential for high- quality, reliable service delivery
Utilise system thinking
Anticipate the impacts of interactions between staff, teams, consumers and customers in your unit or service Cultivate and maintain a network of relationships outside your unit, within the service or District/Network, which you can use to achieve safety and quality improvement outcomes Connect patients, families, carers, or other staff and leaders with the support they need from other units or services where you work Follow up to see if they received the support they needed from other units or services where you work
Utilise improvement methodologies
Apply quality improvement methods and tools to suit the context of the improvement need Understand the need for appropriate diversity in quality improvement teams Guide others on quality improvement in your unit or service Understand the importance of a measurement for improvement initiatives Read and interpret data presented in quality improvement tools/systems Understand benchmarking, common cause variation and special cause variation as it applies to quality improvement Understand and apply the principles of Human- Centred Design Understand and apply evidence-based change management methods for service delivery improvement Support challenging conversations about change with teams and help remove barriers to change for improvement Support spread of quality improvement initiatives
OCTOBER 2024
EDITION 35
Consumer and Patient Experience Statewide Health Literacy Hub launch
Partnering with Consumers Standard
The Statewide Health Literacy Hub is a NSW Health initiative that builds and advances health literacy leadership and capacity locally to build awareness, foster partnerships and knowledge sharing in health literacy, enhance system-wide processes through resource implementation, develop and grow health literacy research, and empower consumer/community to achieve outcomes that matter to them. The hub was launched on 2 October 2024 with NSLHD staff presenting at the launch on two local initiatives. Melanie Perry (NSLHD Consumer and Patient Experience Coordinator) presented on the NSLHD Consumer Tick initiative to enhance health literacy. Using the NSLHD Consumer Tick initiative improves the clarity and usability of health information provided to consumers. Using this process is a practical way to ensure all health documents undergo thorough checks for layout, pictures, formatting, language, and accuracy. The process has been streamlined in the last year and there has been a 107 per cent increase in health information gaining the consumer tick. Joey Chan (Senior Pharmacist) represented the Adolescent and Young Adult Hospice (AYAH) and presented her joint project with Dr Abigail Franklin (AYAH palliative care staff specialist). Attendees gained insight into the critical need for age-appropriate Consumer Medicines Information (CMI) for adolescents and young adults in palliative care to enhance communication, support informed decision making and improve quality of care in palliative settings. The presentation Three of our NSLHD Consumer Advisors (Yvonne Parsons, Sonia Dixon and Julie Toma) also co-facilitated sessions on the day. Please register to access the Health Literacy Hub . highlighted how existing resources fall short for this demographic and demonstrate how tailored CMIs can enhance understanding and engagement with medication management.
Joey Chan Senior Pharmacist AYAH)
Sonia Dixon (NSLHD Consumer Advisor)
Celebrating 25 years of youth action in health
For 25 years, the first-of-its-kind Youth Health Consultant initiative has amplified the voice and action of local young people to enhance Northern Sydney Local Health District (NSLHD) services and initiatives that support the health and well-being of adolescents and young adults. Integral to this program is the team of 12 diverse Youth Consultants aged 15-24 whom NSLHD Population Health Promotion employs, trains and empowers to share their unique perspectives and expertise as local young people. The Youth Consultants play a vital role in conducting two types of free consultations for services. Firstly, they conduct walk-through audits for those who work with young people, thoroughly assessing factors such as environment, engagement strategies, accessibility, and confidentiality. Their insights lead to highlighting strengths and actionable recommendations for improvement.
Youth Consultants offer guidance and advice on various youth-targeted health initiatives and resources, including input on local council youth plans. In fact, the team has even left their mark further afield after providing input in the ‘Finding a general practitioner and getting a referral’ resources by the Agency for Clinical Innovation. In 2023-2024, twelve consultations were conducted. Join us in celebrating 25 years of our youth consultant’s work on empowerment, innovation, and collaboration! For more information email NSLHD-YouthHealthPromotion@health.nsw.gov.au
EDITION 35
OCTOBER 2024
Patient Feedback - NSLHD Thematic Analysis 2023/2024
The thematic analysis is a yearly report that presents themes identified from the qualitative compliments and complaints data captured in ims+, the Real Time Patient Experience Survey (RTPES) feedback captured in the Quality Improvement Data System (QIDS), and the Patient Reported Measures Program data captured in the
Health Outcomes and Patient Experience (HOPE) Platform. Most patients reported high-quality care , evidenced by:
A Net Promoter Score of 8.83 out of 10 for adult admitted patients, (RTPES data). 93 per cent of respondents rated their Outpatient care as “very good” (HOPE data).
55 % increase in compliments received from patients/family/carers (1000 compliments received and captured in ims+) and a 3 per cent decrease in complaints received from patients/family/carers since the last reporting period (ims+). From the ims+ data, the main themes found in complaints are related to Communication; Clinical care, Treatment and Safety (focusing on examination and treatment, and coordination of patient care); Patient Rights and Humaneness; and Management of Facilities. Teach-back Several recommendations in the thematic analysis have been made to improve the patient experience. One of these recommendations relates to increasing the use of teach-back when communicating with patients and consumers. The teach-back method is a way to check understanding by asking patients to state in their own words what they need to know or do about their health. My Health Learning has an easy online module explaining this method. Staff are encouraged to complete the training to familiarise themselves and increase their understanding of this useful method ( Learn about teach-back - MHL code 409377612). New services successfully ‘go-live’ with patient reported measures (PRMs) The RNSH Menopause Hub and Greenwich Ambulatory Rehabilitation Service went live in July and Aug 2024 to use the Health Outcomes and Patient Experience (HOPE) IT platform and begin embedding patient- reported outcome measures (PROMs) in clinical care. The Menopause service is now using the Menopause- Specific Quality of Life measure (MENQoL) and Greenwich Ambulatory Care is now using the Assessment of Quality of Life – 6D measure (AQoL-6D) . These measures were selected based on the recommendation of state-wide clinical networks and consumer groups to help teams identify and measure what matters to patients. We look forward to supporting the teams as they continue to progress toward business as usual. For more information about using PRMs please contact the NSLHD PRMs Team via nslhd- prms@health.nsw.gov.au. Gathering Of Kindness Week 2024
Across NSLHD Gathering of Kindness Week will be held between 11 - 15 November 2024 to continue conversations about kindness and compassion in healthcare. This year’s theme is ‘Kindness is my Superpower’ .
Following the success of last year, NSLHD is again setting a challenge to capture 160 Tales of Kindness from across the district during Gathering of Kindness week, to celebrate the impact kindness can have on people and places. More information to come. In 2023, 167 tales were captured through the NSLHD compliment portal. Staff are encouraged to reflect on the act of kindness and how it can potentially make someone’s day. In-person events are also being planned. More information will be out soon on events happening locally. Posters, banners and cards are now available to download for departments from the Gathering of Kindness Ministry of Health intranet page. If you have any questions, please don’t hesitate to contact us at NSLHD- ThePatientExperience@health.nsw.gov.au. Online events are happening every day during the Gathering of Kindness week hosted by the Ministry of Health in partnership with the Hush Foundation. Register to join online events and be immersed in new ideas and innovation, reinforcing best practices and introducing new information. View the full MoH Gathering of Kindness 2024 program to find out more.
OCTOBER 2024 NSLHD Disability Care Plans Procedure
EDITION 35
The new NSLHD Disability Care Plans Procedure supports all clinicians involved in providing care to a person with a disability who cannot self-communicate their needs. The newly endorsed procedure explains how clinicians can access existing Disability Care Plan documents created by private community clinicians to enhance continuity of care. This procedure addresses recommendations made by the Royal Commission into Violence, Abuse, Neglect and Exploitation of People with Disability and aligns with National Safety and Quality Health Service (NSQHS) standards particularly partnering with consumers, comprehensive care and communicating for safety standards.
Disability Care Plans document a person’s preferences, support requirements, communication, behavioural support needs, and contact details of organisations providing care. Disability Care Plans can be in any format endorsed by the Agency for Clinical Innovation and used across the state including the Top 5 form, Admission2Discharge (A2D) folder, Hospital Support Plan, My Health Matters, and My Health Passport. Clinicians can now request, upload, access, and use existing electronic documents. This helps to facilitate improved continuity of care and reduce workload and paper use.
Behaviour support/Disability Care Plans are routinely used for people with established behavioural support needs funded by the National Disability Insurance Scheme (NDIS) and are mandatory for people living in a Residential Aged Care Facility (RACF) who need that type of care. If documents don’t exist Mental Health Drug and Alcohol ( MHDA) and Disability Support Workers can use the Top 5 form. The Communication and Care Cues form can be used for unpaid carers.
Communication and Care Cues form The Communication and Care Cues (CCC) form is an NSLHD- endorsed tool designed to be used to improve the communication and understanding of the needs of patients who have a cognitive impairment. It provides quick access to essential information provided by the patient's carer.
The CCC form is to be completed by the carer with nursing staff ensuring it is then reviewed, shared with colleagues at handover, and loaded onto the patient’s record, making it accessible in eMR or Clinical Notes View. The form provides insights from carers - those who know how to communicate with and calm the patient best - helping staff better understand how to engage and support patients. By integrating the CCC into daily practice, nursing and clinical teams can offer more tailored care and an improved hospital experience for patients with cognitive challenges, aligning directly with the goal of quality, person-centred care (Quality Statement 1). For more information on the CCC, see the CCC Toolkit page, which also provides access to corresponding NSLHD Policies and Procedures.
OCTOBER 2024
EDITION 35
NSLHD Clinical Audit Schedule
The NSLHD Clinical Audit Schedule supports all sites and services within NSLHD to monitor and evaluate clinical care processes and informs clinical quality improvement activities across NSLHD. Download the complete 2024-2025 NSLHD Clinical Audit Schedule from the Clinical Audit Schedule Intranet page Clinical audits required to be completed this month are listed below.
October QARS Audits ( direct links available from Clinical Audit Intranet page)
NSLHD_01_Clinical Documentation Audit (Nursing and Midwifery | Allied Health | HIS ) NSLHD_01_Clinical Documentation Audit - Medical Officers (MVH | HKH | Ryde | RNSH) NSLHD_01_Clinical Documentation - Emergency Department & Urgent Care (MVH | HKH | Ryde | RNSH) NSLHD_1_Maternity_Safe Sleeping for Babies (HKH Maternity | RNSH Maternity)
Standard 1
NSLHD_3_Infection Prevention Control Program compliance NSLHD_03_Transmission Based Precautions NSLHD_04_Prescription Pad: Quality of Prescribing NSLHD_04_ Prescription Pad: Storage and handling NSLHD_4_VTE Prevention for admitted patients
Standard 3
Standard 4
NSLHD_05_Nutrition Care Audit V2 - Adults and Paediatric patients NSLHD_05_Post Partum Haemorrhage (PPH) Audit Version 3 ( RNSH | HKH Maternity | HKH Birthing)
Standard 5
NSLHD_07_ Blood Product Transfusion Documentation
Standard 7
NSLHD_08_MONTHLY_Resuscitation trolley/backpack and Resuscitaire equipment audit (RNSH | HKH MVH | RYDE | MHDA | HITH)
Standard 8
NSLHD – Recently Published Policies, Procedures, Guidelines and Standing Order
For any queries relating to policy, procedure and guideline development contact NSLHD-Policies@health.nsw.gov.au Basic hand, foot and nail care for adult inpatients – NSLHD Nurses/Midwives Procedure Suppression of Lactation in Maternity Services - NSLHD Guideline Model of Care Development, Approval and Review Process - MHDA Procedure Blood & Blood Products Administration - NSLHD Procedure Care Zoning Clinical Practice Guidelines Community MHDA Guideline Fixed Assets Guideline - NSLHD Guideline Oral Health Service - Time Out Procedure - NSLHD Perinatal Loss – Investigation and Bereavement Care of Registered Babies ≥20 Weeks Gestation - Procedure
Refer to the NSLHD weekly bulletin to access the most up-to-date list of PPGs
Safety Alerts -
New, updated and recently published
Medication Safety Updates including medication shortages are available on the CEC website.
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