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.
SEPTEMBER 2024
EDITION 34
Ongoing disruption to the supply of Intravenous (IV) fluids Why is there a disruption to the supply of IV Fluids? The ongoing global disruption to the supply (with intermittent stock available) of IV fluid bags due to manufacturing issues and increased demand has been further impacted by shipment delays. When will this be resolved? While there is no exact date of supply returning to normal at this point, HealthShare NSW, the Clinical Excellence Commission (CEC) and the Ministry of Health continue to closely monitor and will advise LHDs of a possible date of return to normal supply. How is this being managed? The Therapeutic Goods Administration (TGA) is working closely with state and territory health departments, as well as with suppliers of Australian and overseas-registered IV fluids, to address the shortage. The CEC continuously communicates up-to-date information via Safety Notices and is working with local health districts to complete twice- weekly audits of IV fluid inventory to provide visibility of stock levels across each facility, district and state-wide. What can you do? Clinicians are encouraged to Participate in safe IV Fluids conservation strategies in your clinical areas Look out for and be informed about updates on the status of the supply disruption Look out and utilise, as appropriate the resources being developed by Expert Clinical Communities of Practice to support clinical practice Report any adverse events or near misses related IV Fluids supply disruption facilities. Each hospital has an established Stewardship group to support inventory management and clinical practice adjustment where applicable. IV fluids are now ordered centrally and support the facilitation of IV fluids movement between
IN THIS EDITION: Ongoing disruption to the supply of Intravenous (IV) Fluids How to develop capability in Safety and Quality Leading for Safety and Quality Improvement - last 2-day workshop for 2024 New PRM resources for our CALD consumers Complaints help improve services - videos Increase seen in resources with the Consumer Tick ‘You said We did” posters now available New REACH Inpatient Surveys PACH transitions to Primary and Community Standards Launch of Australia’s first care standard for COPD
Find out more Frequently Asked Questions – Disruption to the supply of intravenous (IV) fluid bags. Information for NSW Health clinicians – Clinical recommendations for managing intravenous (IV) fluids shortage Information for NSW Health services – Intravenous Fluids Stewardship (IVFS) Information for clinicians – Intravenous (IV) fluid bags – International alternatives and associated safety considerations Information for clinicians – Risk of air embolism when administering intravenous (IV) fluids without in-line air detection Information for clinicians caring for maternity patients – Intravenous fluids and oxytocin infusions Poster: Sodium chloride 0.9% (Baxter USA – VIAFLOW bag) solution for infusion bag - International alternative product All resources and factsheets are linked within the Safety Alert (SA:013/24), and available on the CEC website.
SEPTEMBER 2024
EDITION 34
How can I develop my capability in Safety and Quality? In the June 2024 edition of Foresight, we featured the Healthcare Safety and Quality Capabilities set which describes the key knowledge, skills, and behaviours expected of NSW Health employees to engage in safety and quality improvement. The lists below (foundational) and on the next page (intermediate) are a series of statements (indicators) that provide examples describing these capabilities. Some may be new and some may be skills already employed and behaviours that are workplace habits. The list is not exhaustive but can be used to initiate conversations between employees, managers and teams about potential performance and development capability-building activities. To find out more visit www.cec.health.nsw.gov.au
Foundational level
Manage individual factors that influence performance at work Understand that emotions can have a positive and negative impact on work performance and relationships Regularly self-assess if you are fit for work and communicate this to your direct supervisor Engage in discussions with colleagues and supervisors to learn from mistakes , rather than assign blame Seek to understand what matters most to patients, families, carers, and customers and what drives complaints Acknowledge the physical and psychological needs of staff involved in incidents Undertake clinician disclosure and identify support for the patient, family, carer where possible Uphold a safety culture Contribute to a safety culture by asking questions, sharing ideas and concerns, and reporting incidents
Contribute to high reliability Aware of the six dimensions of quality and has started to reflect on what changes to service delivery may make things better and safer Regularly asking patients, families and/or carers about their care experience and how it can be improved Read about the Safety Fundamentals for Teams and participate in their use with your team Use the Speaking up for Safety C.O.D.E to communicate safety concerns Seek feedback on using structured and closed-loop communication during handover e.g. ISBAR Ask to see your unit or service’s safety and quality data (i.e. hand hygiene, hospital- acquired complications, real-time patient experience) and inquire how it informs decision-making to deliver reliable care Manage clinical incidents and risk Identify and notify clinical incidents, near- misses and environmental hazards that may affect safety Participate in discussions about clinical incidents, near-misses and environmental hazards Seek advice and reflect on escalating clinical incidents, near-misses and environmental hazards that may affect patient safety to your supervisor
Utilise improvement methodologies
Reflect on what changes to service delivery may make things better and safer and be confident to offer ideas Take responsibility for raising and fixing issues encountered at work Understand a range of improvement data that exists in healthcare (e.g. in QIDS) Volunteer to participate in a quality improvement project or activity such auditing
Understand the unit’s and service’s purpose, design and models of care Understand how taking action to improve service delivery might impact patients, families, carers, and staff in your or other units or services Recognise your role in a patient’s journey and how your actions can affect patient experience in other units and services health outcomes Enter information into data systems for reference along the patient journey Utilise system thinking
SEPTEMBER 2024
EDITION 34
Intermediate level
Uphold a safety culture
Manage individual factors that influence performance at work Participate in a Readiness to Lead for Safety and Quality workshop or complete the online modules Monitor own and identify emotions and physical feelings, and adapt to ensure they do not negatively impact work performance and relationships Read about cognitive bias and how it influences decision-making Reflect on how the way team members think (e.g. situational awareness and decision-making) and feel (e.g. stress and fatigue) impacts on patient safety Role-model psychological safety in your unit or service by speaking up when there is a safety concern Assist less experienced team members to discuss what matters most with patients, families, carers, and customers and what drives complaints Assist less experienced team members to provide authentic support to patients, families, carers, or other staff after an incident Participate in Open Disclosure following clinical incidents Participate in difficult conversations about clinical incidents and how that might impact organisational patient safety risks Offer physical and/or psychological wellbeing support to staff involved in incidents
Contribute to high reliability
Manage clinical incidents and risk Support your unit or service to monitor requirements regarding the organisation’s safety and quality accreditation process and other safety assurance activities Volunteer to participate in unit or service- level incident reviews following incidents Read about the characteristics of high- reliability organisations Practise assisting less experienced team members in asking patients, families and/or carers about their care experience and how it can be improved and seek feedback on your support Practise leading a Safety Fundamentals for Teams, such as Safety Huddles Practise identifying and self-reflecting on the markers of effective teamwork , which include effective communication, psychological safety to raise concerns and ask questions, and demonstration of respectful behaviour Volunteer to monitor safety and quality data over time Utilise improvement methodologies Participate in an Improvement Science workshop or complete the online modules Use knowledge, skills and experience that you have gained from other contexts to inform new ideas for service delivery improvement Practise testing ideas to demonstrate their worth in making things better and safer Be confident to push boundaries and take measured risks when appropriate to improve service delivery Collect and analyse data to inform improvement conversations and initiatives of any type, as well as near-misses. Volunteer to complete clinical risk and environmental hazard analyses requested of the work environment in a professional manner Be able and willing to participate in an improvement project that is underpinned by improvement methodologies
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
SEPTEMBER 2024
EDITION 34
Leading for Safety and Quality Improvement Last workshop for 2024
Ever wanted to improve an area of your work but don't know where to start? The final 2-day workshop for the year is taking place at Royal North Shore Hospital this October. It is open to all staff who have an interest in improving the safety and quality of their local service and would like to find out how to do so and lead others in Safety and Quality. The workshop offerings fall within the Safety and Quality Essentials Pathway to build intermediate-level healthcare safety and quality capability.
100% would recommend the workshop to their colleagues
100% felt confident or very confident in their knowledge of the quality improvement
Day 1: Oct 4 2024 (8:30 am - 4:30 pm) Readiness to Lead for Safety and Quality
92% felt increased confidence in leading others in safety and quality
Day 2: Oct 11 2024 (8:30 am - 4:30 pm) Introduction to Improvement Science Edmund Collins, Clinical Services Building, Royal North Shore Hospital
Really helpful for anyone wanting to start a quality improvement project
Lots of extremely useful information for my role. I can use what was presented here today to improve my skills and knowledge. This was the most enjoyable education session I have attended in a long time
Spaces are limited. Don't miss out!
Enrolments through My Health Learning (MHL Course Code: 518150533)
Contact: NSLHD-SQEP@health.nsw.gov.au
Leading for Safety and Quality Improvement participants
SEPTEMBER 2024
EDITION 34
Consumer and Patient Experience
Partnering with Consumers Standard
New PRM resources for our culturally and linguistically diverse consumers New resources to increase awareness and understanding of Patient Reported Measures (PRMs) are now available for health professionals and culturally and linguistically diverse consumers. The fact sheets and videos in several different languages, are hosted on the Agency for Innovation (ACI) PRM website
Understanding Patient Reported Measures video is also available in: Arabic Cantonesee Greek Mandarin Vietnamese
The Agency for Clinical Innovation in partnership with local health districts have developed these resources which explain why PRMs are an important part of patients’ clinical care. Please contact the NSLHD PRMs team on NSLHD-PRMs@health.gov.au for more information.
New videos available for people wishing to make a healthcare complaint
The Australian Commission on Safety and Quality in Healthcare has developed a series of videos for patients, families, and carers, offering practical tips on making a healthcare complaint. These short videos on the Commission’s website guide people through the complaints process and explain the healthcare rights of consumers. Developed with input from health consumers and experts, these resources aim to improve the experience of people making healthcare complaints.
Increase in health resources with the Consumer Tick
NSLHD’s Consumer Health Information - approval steps for producing and the Consumer Tick process guides staff in developing effective health information publications with consumer input. It includes a clear process for review and endorsement. Since January 2024 there have been thirty (30) approved applications, which is a 45% increase compared to the same period in 2023.
‘You said We did’ Poster now available from Design and Print
The NSLHD ‘You Said We Did’ poster, codesigned with staff and consumers, is now available in the Design & Print catalogue and has the Consumer tick. You can now download a PDF e-version of the posters (A3 and A4 versions) from the following links: NS12985-E.pdf | NS12985A-E.pdf (internal link) Please note: the e-version must be downloaded and saved before sending it to patients or external. These posters are optional for facilities and sites to use, and quarterly updates are recommended. For more information, please contact: nslhd-thepatientexperience@health.nsw.gov.au
SEPTEMBER 2024
EDITION 34
NSLHD REACH Survey
REACH is a system that helps patients, carer/s, and their family to escalate their concerns with staff about worrying changes in a patient's condition. It stands for Recognise, Engage, Act, Call, Help is on its way. REACH was developed by the Clinical Excellence Commission in collaboration with local health districts and consumers. New REACH Survey tools for inpatients have been developed in collaboration with staff and NSLHD Consumer Advisors. The survey tools are optional for use and do not replace existing audits and surveys that may already be in place at your local facility or services. Links to the survey tools and QARS reporting guide are available from the Between the Flags intranet page.
PACH transitions to adopting the National Safety and Quality Primary and Community Healthcare Standards Primary and Community Health (PACH) has commenced transitioning from the National Safety and Quality in Healthcare Service (NSQHS) Standards to the National Safety and Quality in Primary and Community Healthcare (NSQPCH) Standards. While the two sets of standards share a similar structure, the NSQPCH Standards are specifically designed to cater to the needs of primary and community healthcare settings. The NSQPCH Standards are more closely aligned with the service’s approach to delivering person- centred care for consumers and the community through efficient healthcare design. The standards will assist PACH services to facilitate improved health outcomes through enhanced safety measures, risk management strategies and a more comprehensive evaluation of performance, providing deeper insights into areas for quality improvement and innovation, to ensure continued delivery of high-quality care. To support teams in shifting to the new standards, the following activities have commenced, led by the PACH Clinical Quality and Safety Team: Delivery of education sessions to familiarise all PACH staff with the NSQPCH Standards and how they apply to work practices. The online education sessions delivered by the PACH Clinical Quality and Safety Team (initially weekly) have been received positively by PACH staff. These sessions will continue to be offered monthly for the rest of the year. Development of NSQPCH Resources and further support provided by the PACH Standard Leads to assist teams in adopting the new standards and assist with accreditation. Ongoing planning and progress will be discussed in PACH service-level management/quality meetings.
PACH staff are invited to provide feedback or suggestions regarding the change, ask questions or share concerns that may arise during the transition period by completing the online survey
For further information, contact alison.davies@health.nsw.gov.au (Acting Clinical Quality Manager, Primary & Community Health)
SEPTEMBER 2024
EDITION 34
ACHS Delivering Excellence: NSQHS Standards online training program The Accreditation Short Notice Assessment (SNA) Program against the National Safety and Quality Health Service (NSQHS) Standards requires the Assessors to spend 75 per cent of their time in the clinical/operational areas. To support the front-line staff in the SNA process, NSLHD nominated 305 staff to complete the Australian Council on Healthcare Standards’ (ACHS) Delivering Excellence: NSQHS Standards e-Learning Course . The aim was to further develop the front-line staff’s understanding and the requirements of the National Standards. As of 6 August, 214 staff completed the ACHS Delivering Excellence: NSQHS Standards online training program Survey with very positive results. The vast majority of staff who completed the course and survey believed that the course developed their understanding and knowledge of the NSQHS Standards and the accreditation process. That it was easy to navigate and would recommend it to colleagues. Q: Completing the course developed my understanding and knowledge of the NSQHS Standards and the accreditation process
The Australian Commission on Safety and Quality in Health Care will soon release the Chronic Obstructive Pulmonary Disease Clinical Care Standard to address current gaps in clinical practice, providing a pathway of quality Launch of Australia’s first care standard for COPD care for the management of COPD in community and acute settings, and the transitions of care between them. The overall goals of the clinical care standard are to: Reduce hospitalisation rates for COPD by supporting best practice care for the prevention of COPD, and the optimisation of therapy to reduce the risk of exacerbations Reduce the inappropriate use of antibiotics for the management of COPD exacerbations, and support antibiotic prescribing in line with current best- practice guidelines. Despite the availability of clinical guidelines to support the management of this condition, the Commission reports significant variation still exists in health care for COPD in Australia. The Commission is hosting a webcast to launch the new COPD clinical care standards. A panel of experts will discuss the importance of accurate diagnosis with spirometry, pulmonary rehabilitation and a step-wise approach to pharmacotherapy. Date: Thursday, 17 October 2024 Time: 12:00 – 1:00 PM AEDT This event is relevant to all clinicians providing care to people with COPD, especially GPs, respiratory physicians, emergency physicians, infectious diseases physicians, nurses, physiotherapists and other allied health professionals.
Total responses : 214
100 120
0 20 40 60 80
Strongly Agree Agree Neutral
Disagree
91
104
18
1
Q: The e-learning course is easy to navigate
Total responses : 212
100 120
0 20 40 60 80
Strongly Agree Agree Neutral
Disagree
85
109
13
5
Q: I would recommend the course to my colleagues
Total responses : 211
0 20 40 60 80 100
Strongly Agree Agree Neutral
Disagree
83
97
26
5
SEPTEMBER 2024
EDITION 34
NSLHD Clinical Audit Schedule
Clinical Governance Standard 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.
September QARS Audits ( direct links available from Clinical Audit Intranet page)
NSLHD_03_Aseptic Technique NSLHD_03_Perioperative sharps management_2024 (RNSH Ambulatory Care | RNSH ASB OT / Anaesthetics | HKH OT | Ryde OT
Standard 3
NSLHD_05_Cognitive Impairment Audit (Delirium)
Standard 5
NSLHD_06_Clinical Handover - Nursing and Midwifery BEDSIDE Shift-to-Shift (MVH | HKH | RNSH | Ryde )
Standard 6
NSLHD_06_Clinical Handover -all Clinical Disciplines NSLHD_06_ Consent Audit (MVH | HKH | RNSH | Ryde )
NSLHD_08_MONTHLY_Resuscitation trolley/backpack and Resuscitaire equipment audit (RNSH | HKH MVH | RYDE | MHDA | HITH) NSLHD_08_BIANNUAL_Resuscitation trolley/backpack & Resuscitaire equipment Audit
Standard 8
Policies, Procedures and Guidelines Click on the links below to download documents from the Prompt document system. Refer to the NSLHD weekly bulletin to access the most up-to-date list of PPGs NSLHD_05_ Perioperative Patient Positioning
For any queries relating to policy, procedure and guideline development contact NSLHD-Policies@health.nsw.gov.au
NSLHD – Recently Published Policies, Procedures, Guidelines and Standing Orders
Perinatal Infections Management - NSLHD_Guideline Infliximab Intravenous: Adult Medication Protocol Acute Behavioural Disturbance Procedure, Safe Haven, NSLHD
Emergency Services Accessing Clinical Information from MHDA Services during High Risk Situations Maternity – Breastfeeding Principles for Protecting, Promoting and Supporting - NSLHD Laser Safety in the Perioperative Environment in NSLHD Administration of Alemtuzumab (Lemtrada®) for Multiple Sclerosis in the Medical Day Procedure Unit, Ambulatory Care Centre – RNSH
Safety Alerts - New, updated and recently published
Medication Safety Updates including medication shortages are available on the CEC website.
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