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.
APRIL 2023
EDITION 24
IN THIS EDITION:
Human factors in health - Distraction Virtual Care in Safety and Quality Upcoming free workshops
NSLHD PREPARES TO CELEBRATE HUMAN EXPERIENCE WEEK 1 – 7 May 2023 The theme for the Human Experience Week is: All of Us: The Power of Community , with the sub themes of: Love, Belonging and Healing. Human Experience Week April Falls Month How to recruit a Consumer Advisor Australian Charter of Healthcare Rights Real Time Patient Experience Survey (RTPES) Management of CVAD in NSLHD Embedding Virtual Care in Safety and Quality Frameworks
NSLHD Improvement Science Workshop - 12 May National Clinical Governance Framework (ACSQHC) Healthcare and climate change (ACHS masterclass)
What did you think of this issue? Please give us your feedback.
2023: Better Balance for Fall Prevention
37% of injury-related deaths are caused by falls 30% of 65's fall each year 23% reduction in falls with regular exercise Did you know? The overall Better ‘Balance’ for Fall Prevention campaign goal for 2023 is to promote increasing physical activity for fall prevention, and improvement of life and social balance for better mental health. It’s well known that poor balance and strength will affect a person’s mobility and put them at an increased risk of a fall. Research has shown that exercise of any type has been shown to reduce the risk of falling by 23%. The last two years have been difficult with many community fitness groups and social activities unable to continue due to COVID-19. This has contributed to an increase in inactivity, deconditioning, frailty, and increasing social isolation in many adults regardless of ability. April Falls Day® 2023 is an opportunity to promote 'better balance for fall prevention' across your hospital, community setting or residential aged care facility. Health staff can help reduce the incidence of falls in our health facilities and the community, keep our patients safe and communicating patient's fall safety risks to all staff involved in the patient's care. Visit the April Falls resource page on the intranet to find out more.
NSW Health has a long and proud history of celebrating Patient Experience Week, hosting events annually since 2013. In 2021, NSW Health launched Elevating the Human Experience - A Guide to Action.
This year there are a number of events being held across NSW Health. The program is now available. Co-designed by NSW Health staff and consumers, Human Experience Week promises to immerse attendees in new ideas, innovation, with best practice The change to Human Experience week is a response to NSW Health staff and consumer feedback; and reflects the strategic importance of human experience and the inextricable link between of patient, carer, family, volunteer and caregiver (staff) experiences.
reinforced and new information introduced. At NSLHD, the week will begin with the launch of the NSLHD Partnering with Consumers Framework 2021 - 2026 at RNSH and continue throughout the week with events planned to take place at each facility.
Comprehensive Care Standard
Partnering with Consumers Standard
APRIL 2023
EDITION 24
Partnering with Consumers Standard
Consumer And Patient Experience
HOW TO RECRUIT A CONSUMER ADVISOR
For inquiries, contact the Consumer and Patient Experience (CAPE) team NSLHD-ThePatientExperience@health.nsw.gov.au involvement and provide respect for their viewpoints and contributions. Are you looking recruit a consumer adviser? Follow the 3 easy steps to recruit a consumer advisor on the intranet. Consumers bring unique and different perspectives to all parts of service development, delivery and governance. They work with NSLHD to improve how we deliver care and how we can create a positive experience when patients, carers and families receive care. Consumer Advisors give their time freely and are not remunerated for their contributions. Please consider how you will value their input and
AUSTRALIAN CHARTER OF HEALTHCARE RIGHTS
The Australian Commission on Safety & Quality in Healthcare (the Commission) launched the 2nd edition of the Australian Charter of Healthcare Rights (the Charter) in 2019. The Charter supports Standard 2: Partnering with Consumers as it describes what consumers, or someone they care for, can expect when receiving health care and is an important component of health literacy understanding. The charter must be accessible for consumers and staff in your clinical area. Many other additional resources including translated copies of the Charter, audio files, a consumer guide and top tips for safe healthcare are available on the ACSQHC website at this link Charter Resources. The Charter is displayed in all NSLHD facilities and is available for download from the ACSQHC website and for ordering from Design and Print services on these codes - NS08887K and NS08887P A Braille version of the Charter is available from the Safety and Quality unit in each NSLHD facility and service. NSLHD REAL TIME PATIENT EXPERIENCE SURVEY (RTPES) The RTPES provides a platform to receive timely patient feedback and has been available in all NSLHD adult inpatient wards since 2021. Each unit/ward can pro-actively view and respond to their own patient feedback allowing for patient safety and quality issues to be addressed timely to improve the patient experience. Contact your manager for more information on your RTPES results. To gather real-time feedback, two questions will be asked of inpatients who have been discharged on the previous day. The information collected from the surveys is reported on the the Patient Experience Survey dashboard on the Quality Improvement Data System (QIDS) . A number of reports on the dashboard is available including the Net Promoter Scores (a scale to represent the likelihood a person recommends a service). The dashboard provides real- time patient experience feedback and updated hourly. Posters are now available to raise awareness of the program. Print versions can be ordered through design and print catalogue NS12815 or available to download an e-version pdf. Contact the CAPE team for more information NSLHD-ThePatientExperience@health.nsw.gov.au
APRIL 2023
EDITION 24
EMBEDDING VIRTUAL CARE IN SAFETY AND QUALITY FRAMEWORKS In December 2022, the CEC released Embedding Virtual Care in Safety and Quality Frameworks to support and enable health services to ensure patient safety and clinical quality is maintained when delivering health care via a virtual modality. This resource has been designed to assist in planning, implementing and reviewing virtual care health services. The Management of Central Venous Access Device (CVAD) Procedure ADULT- NSLHD has recently been updated following district-wide consultation with subject matter experts, including, the Acute and Critical Care Network, the Infection Prevention and Control and the Vascular Access Team at Royal North Shore Hospital. The procedure addresses post-insertion management, troubleshooting and removal of CVAD for adult inpatients. The procedure is the most viewed document in NSLHD, with approximately 250 downloads per month. It has been updated to ensure all patients with a CVAD receive safe and high-quality care. The update has been guided by recommendations made by the Agency for Clinical Innovation (ACI) and the Cancer Institute NSW, and is to be used in conjunction with Intravascular Access Devices (IVAD) - Infection Prevention & Control Policy Directive PD2019_040. Preventing and Controlling Healthcare-Associated Infection Standard MANAGEMENT OF CENTRAL VENOUS ACCESS DEVICES (CVAD) IN NSLHD
Key considerations include:
Delivering services via virtual care does not require specific additional clinical governance frameworks to be developed. Rather, the overarching clinical governance framework should encompass and be responsive to virtual care services. This may require some updates to the framework, such as including any virtual care specific committees or metrics, or ensuring patient safety and clinical quality committees have oversight of virtual care safety and quality information. Virtual care incidents are identified, escalated and managed as all incidents are under NSW Health Incident Management Policy Directive. Data should be collected, analysed and reported to inform ongoing improvements to health services – safety metrics for virtual care may include adverse events, aggression events, patient deterioration, missed appointments and patient feedback. The roles, responsibilities, supervision, communication, risk management, and education and training needs of staff may need to be updated when delivering virtual care.
LESSONS LEARNED FROM SERIOUS ADVERSE EVENT REVIEWS 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? The latest Paediatric Watch bulletins include case studies involving a near miss 10 times adrenaline (epinephrine) dose error in anaphylaxis and red flags for non-accidental injuries in children. Access these and other lessons from the lessons learned intranet page. Developed with NSW Health clinicians and virtual care experts, the Framework promotes a consistent, state-wide approach to virtual care education that supports the delivery of safe, quality, patient-centred virtual care. Underpinned by global thinking in education, training and health workforce learning approaches, the Framework presents seven domains, providing evidence-based principles for virtual care best practice in education programs. There are significant infrastructure considerations when planning a virtual care service. This includes the physical space for clinicians, as well as the virtual environment including access, stability, security and privacy. Careful consideration should be given to determining whether an individual patient is suitable for virtual care. This must include consideration of the risk of clinical deterioration and the ability to identify, escalate and manage deterioration as well as patient acceptance of and capabilities to access and participate in virtual care. NSW Health Virtual Care Education Framework 2022-2026 The NSW Health Virtual Care Taskforce and Health Education and Training Institute (HETI) has released NSW Virtual Care Education Framework 2022-2026.
APRIL 2023
EDITION 24
HUMAN FACTORS IN HEALTH
Clinical processes at the point of care e.g., assessment and examination of the patient; investigations ordered, reviewed and acted upon; observations and monitoring undertaken, reviewed and acted upon. Teams and communication e.g., interrelationships between team members, clinical handover of information among team members and between teams, working in multi-disciplinary teams, involving patients in their own care. Environmental e.g., the physical setting in which health workers perform their tasks which includes noise, design, clutter; access to senior clinicians, shift patterns, skills mix. Task, technology and equipment e.g., availability of procedures that are practical and workable; access to functioning equipment and technology; decision making aids. Organisational and management e.g., strategic planning, safety culture, models of care, workforce planning, formalising procedures, training and orientation. External e.g., NSW legislation, policy directives set at the state level, national accreditation standards, codes of conduct for health practitioners. Human factors in health is about looking at people and how they interact with each other and the healthcare system. Health workers are human beings, and like all human beings are fallible. We all make mistakes at work. Usually there is no impact, or the impact is minor. In rare cases the impact is catastrophic. Human factors involves developing ways to minimise or eliminate the potential for mistakes by looking at each of the components of the healthcare system and how they can support health workers do the right thing. The healthcare system is complex and is made up of the following interrelated components. Human factors in health encompasses all of these components that can influence health workers and their performance in the workplace.
Adapted from: Human factors and health workers, Lessons for learning, CEC July 2022
Distraction
This month we will take a more detailed look at the human factor of Distraction. Distraction can occur when our workload becomes unmanageable and we become overloaded and can make errors. What we may not always expect is during periods of low activity, we may not be as vigilant as our defenses are down and we can therefore be more prone to making errors.
Example: In healthcare, this could happen towards the end of a shift when the workload is of high intensity and then followed by a lull in activity. An important routine check of the emergency trolley was not carried out or overlooked. A patient suffered from a cardiac arrest and the required equipment was missing from the emergency trolley, and it took longer for someone to find a replacement. Resulting in a delay in treatment for the patient. This example correlates with the fact that errors often occur in routine, low workload, undemanding situations. Be aware and do not let your vigilance be reduced because the job is simple or routine.
The Filthy Fifteen
Complacency
Pressure
Stress
Distraction
Fatigue
Lack of communication
Lack of assertiveness
Lack of Awareness
Lack of knowledge
Lack of resources
Lack of teamwork
Not admitting limitations
Norms
What you can do:
Lack of professionalism
Lack of operational integrity
Plan ahead and anticipate what might come up Control distractions Talk out loud (risk triggered commentary)
Anticipate issues associated with the environment Ensure you keep well hydrated and nourished. Adopt lifestyle habits conducive to reducing fatigue and remaining alert.
Ref: Global Air Training 2022
Contact: NSLHD-SQEP@health.nsw.gov.au
Clinical Governance Standard
APRIL 2023 UPCOMING FREE WORKSHOPS NSLHD Improvement Science Workshop
EDITION 24
The Australian Commission on Safety and Quality in Health Care invites you to join a free online workshop on the National Clinical Trials Governance Framework, ahead of assessments as part of the National Safety and Quality Health Service Standards starting from 30 May 2023. National Clinical Trials Governance Framework Workshop Wednesday, 19 April, 12:00 - 1:30pm Wednesday, 3 May, 10:00 - 11:30am Register for the free online webinars workshops Reporting on your clinical trial operations Sampling clinical trial services Conducting a self-assessmen Understanding the maturity scale Hosted by Dr Bernadette Aliprandi-Costa, Manager, Safety and Quality Improvement Systems and Intergovernmental Relation s, these workshops will provide valuable insights and advice on:
This one-day workshop aims to develop your capability to influence safety and quality improvement in your local workplace. It will equip you with the knowledge, tools and skills to apply the Improvement Science methodology in projects that improve the safety, quality and patient/consumer experience of your service
The NSLHD Improvement Science workshop is one of the intermediate-level training offerings within the Safety and Quality Essentials Pathway (SQEP). Click on the image below to see view other training offerings available. 2023 Dates > Friday 12 May @ HKH - Only a few places left > Wednesday 6 September @RNSH > Thursday 19 October @ HKH Enrol via My Health Learning. Course code: 42956746
Contact: NSLHD-SQEP@health.nsw.gov.au
Project Spotlight
Healthcare and Climate Change The Australian Council on Healthcare Standards (ACHS) are hosting a free masterclass on one of the most pressing issues of our time: climate change. Currently healthcare accounts for 7% of carbon emissions in Australia. There have been increasing calls for the healthcare sector to take action against climate change. Hear from guest speaker Dr Nick Watts, Chief Sustainability Officer of the NHS UK , responsible for its commitment to deliver a world-class net zero emission health service. Based in London, he leads the Greener NHS team across the country, which focuses on improving the health of patients and the public through a robust and accelerated response to climate change and the broader sustainability agenda. Nick is a medical doctor licensed in Australia and the UK, and a Fellow of the Royal College of Physicians’ Faculty of Public Health.
The benefits of sustainability in healthcare Royal North Shore Hospital's Department of Anesthesia, Pain, and Perioperative Medicine, 2022 NSLHD Quality and Improvement Planetary Health Award winners and 2022 ACHS QI Award Highly Commended finalist shares their initiative in the management of anaesthetic gasses within their hospital's perioperative space. Authors of the " Anaesthetic Greenhouse Gas Reductions " paper, Dr Arpit Srivastava, Dr Maximillian Benness, Dr Matthew Doane, and Dr Adam Rehak outlined their desire to deliver care while minimising the secondary harm from unnecessary carbon impacts. The results were >900 tonne reduction in CO equivalent emissions as well as >$94,000 reduction in expenditure on volatile anaesthetic gases over 12 months. To read the full report, check out pages 95 and 96 in the 2022 Quality Initiatives Publication: the 25th ACHS Quality Improvement Awards or check out their video here 2
Online webinar: 26 Apr 2023, 5:00pm - 6:30pm Register to attend
To get involved in a sustainability initiative at NSLHD or submit an idea, reach out to your local sustainability/planetary health committee to find out about initiatives taking place. To find out who is the most appropriate contact person at your hospital or service, please contact NSLHD-PlanetaryHealth@health.nsw.gov.au or visit the Planetary Health intranet site.
APRIL 2023
EDITION 24
Clinical Governance Standard
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.
April 2023 QARS Audits (entry links)
NSLHD_3_Infection Prevention Control Program compliance NSLHD_03_Transmission Based Precautions NSLHD_4_Monthly Accountable Drug (S4D_S8) Register Audit (RNSH | HKH | Ryde | MVH | MHDA)
St 3
St 4
NSLHD_05_ Falls Audit Documentation and Observation_Inpatient and MHDA NSLHD_05_Falls Design and Structure_Inpatient and MHDA NSLHD_05_Falls Audit Documentation_Community and Ambulatory Care Locations NSLHD_05_Falls Design and Structure_Community and Ambulatory Care Locations NSLHD_05_Post Partum Haemorrhage (PPH) Audit (RNSH | HKH Birthing | HKH Maternity) NSLHD_06_Perioperative Specimen Collection (RNSH Ambulatory Care | RNSH OT | Ryde OT | HKH OT ) NSLHD_06_Clinical Procedure Safety Checklist Audit - Level 3 procedures HKH OT | HKH Medical Imaging | RNSH ASB OT / Anaesthetics | RNSH Maternity Theatre | RNSH Burns Theatre | RNSH Medical Imaging | RNSH Endoscopy | RNSH Cardiac Cath Lab | RNSH Pain Management | Ryde OT NLSHD_08_Monthly inspection for resuscitation trolley/ Resuscitaire equipment checklists (RNSH | HKH | Ryde | MV | MHDA | PACH-HITH)
St 5
St 6
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 Transitioning to Residential Aged Care from Hospital - NSLHD_procedure (new) Patient Identification Procedure - NSLHD_procedure (updated) Insulin Pen Use in Mental Health Drug & Alcohol Facilities: Safe Sharps Handling - MHDA_procedure (updated) Pressure Injury Prevention and Management Procedure - NSLHD_procedure (updated) Multiple Pregnancy Management - NSLHD_Guideline (new) Assessment and care for women diagnosed with Gestational Diabetes NSLHD_Guideline (new)
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: Clinician alert – Measles case in NSW - issued 6 April 2023 Disruption to supply: Heparin sodium (Pfizer®) 5000 units/5 mL injection ampoule - issued 4 April 2023 Disruption to supply: Suxamethonium chloride (Juno) 100 mg/2 mL injection - issued 4 April 2023 Updated: Use of Prone Restraint and Parenteral Medication in Healthcare Settings - issued 30 March 2023 Intravenous iron preparations and potential for skin staining - issued 29 March 2023 Updated: Paediatric stationary oxygen concentrator set-up - Absence of low flow alarm for flow rates less than 2 litres per minute - issued 28 March 2023
Medication Safety Updates including medication shortages are available on the CEC website.
For more information, contact: NSLHD-SafetyAlert@health.nsw.gov.au
Page 1 Page 2 Page 3 Page 4 Page 5 Page 6 Page 7Made with FlippingBook - professional solution for displaying marketing and sales documents online