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.
DECEMBER 2022
EDITION 21
WHAT DOES HIGH RELIABILITY HAVE TO DO WITH SAFETY CULTURE? The term high reliability organisation (HRO) has made its way from safety critical industries such as aviation and nuclear power into healthcare. But what does it mean and how are we, in healthcare, moving towards High Reliability? HROs are so called because of their near perfect performance in ultra-high-risk environments where error has the potential to cause catastrophic harm. In healthcare, there are millions of occasions of care provided annually and therefore, plenty of opportunity for serious adverse events which can be catastrophic to patients, consumers, carers and their loved ones, as well as our staff. It’s important to mention here that most of the care we provide in NSW health is safe and harm free. However, with the increasing complexity of modern healthcare and the subsequent increase for preventable harm we have turned our lens to learn and adapt some of the habits of HROs. For example, situational awareness has become a part of the language of health, and we have adopted habits such as safety huddles to identify, anticipate and mitigate risk early. In the context of unit-based teams, HROs are the consequence of high performing teams who operate in a culture of safety. High performing teams are considered to be those that share the common characteristics of teamwork, positive safety culture, continuous improvement and reward and recognition. Safety Fundamentals enable staff to demonstrate their shared values and beliefs but also change behaviours that lead to improved staff experience and the patient/family/carer experience of care. The Safety Fundamentals are designed to help teams and organisations move towards High Reliability. Discover more about Safety Fundamentals on the CEC website
High reliability and safety culture Tissue Analytics app User Guide for Reviewing Clinical Variation (ACHS) Equity dimension of healthcare quality NSLHD Improvement Science Workshops 2023 dates Antimicrobial Awareness Week What did you think of this issue? Please give us your feedback. IN THIS EDITION:
The key elements of high reliability teams and an introduction to the Safety Fundamentals are described in the short video produced by the Clinical Excellence Commission (CEC).
Safety Fundamentals | Youtube (4 mins)
Source: CEC Academy Alumni Newsletter 28 November 2022
DECEMBER 2022 TISSUE ANALYTICS APP NSLHD is currently undertaking a trial of a wound care mobile application that uses image recognition technology to accurately measure a wound's dimensions and surface area, at a 90% greater accuracy than a traditional ruler measurement. The Tissue Analytics app is also able to analyse the tissue composition of a wound, as well as detect minute changes in wound size. These functionalities combined can greatly assist clinicians in determining the best treatment options for their patients and consumers. The app's consumer interface allows patients and consumers access to all photos and measurements of their wounds taken by the clinician. Patients and consumers are also able to take a photo and upload an image of their wounds onto the app, which alerts their treating clinician to assess, follow up or refer as required. The app is currently being trialled with 20 wound clinicians across the district until June 2023. This simple app, utilising novel technology, has the potential to revolutionise the way we care for wounds in NSLHD.
EDITION 21
Comprehensive Care Standard
Fig 1. Patient app view
Fig 2. Picture of wound
Fig 3. Tissue analytics measurements and composition analysis
Contact: Lizanne.Dalgleish@health.nsw.gov.au (A/Skin Integrity Improvement Facilitator, NSLHD Clinical Governance)
USER GUIDE FOR REVIEWING CLINICAL VARIATION
Clinical Governance Standard
The Australian Commission on Safety and Quality in Health Care has developed an interactive online User Guide for Reviewing Clinical Variation , making it easier for health services to use data to support appropriate care and access practical case studies. The User Guide can support clinicians in using a clinical variation approach to align health care with patients’ needs and prevent harm, as well as focus on the most effective care
and reduce unnecessary treatment. Why measure clinical variation?
Clinical variation is a difference in healthcare processes or outcomes, compared to peers or to a gold standard such as an evidence-based guideline recommendation. Substantial variation in healthcare outcomes or processes is an alarm bell that should make us stop and investigate whether appropriate care is being delivered. Variation in itself is not necessarily bad. When it reflects differences in patients’ needs, it can be an indicator of good quality healthcare. When it doesn’t reflect patients’ needs, it is ‘unwarranted’ and represents an opportunity for a health service to improve its performance. Regular reviews of clinical variation data to investigate and reduce unwarranted variation are a requirement of the Clinical Governance Standard in the National Safety and Quality in Health Services Standards (Action 1.28). The User Guide presents a six-step approach to using clinical variation data to improve care:
Select priority areas for exploring variation Plan the project 1. 2. 3. 4. 5. 6. Case Studies of Clinical Variation in Health Care Measure and review your data Explore reasons for variation Act to improve care Monitor and report on the impact of improvement activities.
Practical case studies showcase best practice and innovation in the review of clinical variation, across healthcare settings. They include topics ranging from hip fracture surgery, stroke, cardiac events and colonoscopy, as well as new case studies on perineal trauma in childbirth, reducing preterm and planned early term births and improving end-of-life care.
DECEMBER 2022
EDITION 21
EQUITY DIMENSION
NSLHD identified the need to create a safe and welcoming environment for Aboriginal and Torres Strait Islander people and to set the scene for the experience we commit to when engaging with and entering our health services. The NSLHD Consumer and Patient Experience Unit have partnered with the NSLHD Aboriginal and Torres Strait Islander Health Service to create a unique and culturally appropriate and tailored version of the Australian Charter of Health Care Rights (the Charter). The NSLHD version of the Charter has been designed using artwork created by NSLHD’s Aboriginal and Torres Strait Islander staff network group, Muru Dali Gili Gili (path to shine) and language adapted to make meaning of the Charter for Aboriginal and Torres Strait Island people in our community. The adapted Charter may be downloaded as an- A4 handout or A3 poster version.
Past editions of Foresight have introduced each of the six dimensions of healthcare quality in detail. In this edition, we will explore the “Equity” dimension.
Patients that present to the Emergency Department who do not have a Medicare card are still treated and are not turned away. The health environment is designed to be culturally welcoming to people of all nationalities and there are welcome to ward signs in different languages. The establishment of a state-wide medicines formulary seeks to improve patient care and equity of access to medicines, along with reduce variation and optimise safety in medicine use while maintaining appropriate clinical choice. Services across NSLHD saw an opportunity to improve access and availability of healthcare interpreters for culturally and linguistically diverse (CALD) consumers by introducing a new Virtual Interpreter service in many areas across NSLHD How equitable is our current system? There are many examples of NSLHD initiatives that have been introduced and demonstrate the delivery of equitable care. Here are just some examples. Can you think of more? Can our care or services be delivered in a different way so that we can accommodate the needs of the people we care for in an equitable way? How can you ensure that there is equity in the care you deliver or assist in delivering? Equity is when high quality care is delivered regardless of age, disability, ethnicity, gender, health status, location, religion or socio-economics. Equity is fairness to all. Equitable healthcare is about providing healthcare that is suitable for everyone and adapting it to their different needs.
The Australian Commission on Safety and Quality in Health Care have shared this valuable resource on their website to inspire other health services develop local adaptations of the Charter.
Foundations of Safety and Quality e-learning pathway on My Health Learning (course code 335318052) Enrol in a one-day NSLHD Improvement Science workshop (see following page) to enhance your skills to learn the basics of Improvement Science which can then be applied to a local improvement initiative. If you prefer self directed learning, you can complete the Introduction to Improvement Science eLearning module on My Health Learning (code: 378591148). Visit the NSLHD Safety and Quality Essentials Pathway intranet page to view all the training offerings of the pathway available. Awareness of the six dimensions of quality forms the basis of the Foundational level of the Safety and Quality Essentials Pathway. The Pathway builds safety and quality improvement capability for everyone in NSW Health Want to learn more?
Contact: NSLHD-SQEP@health.nsw.gov.au
Improvement Science Workshop NSLHD Clinical Governance
Program Overview 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
2023 Dates > Tuesday 28 February Royal North Shore Hospital > Friday 12 May Hornsby Ku-ring-gai Hospital > Wednesday 6 September Royal North Shore Hospital > Thursday 19 October Hornsby Ku-ring-gai Hospital Venue may be subject to change (e.g. face to face may be changed to virtual delivery) - see MHL for updates Please note catering is not supplied Times: 8.30am – 4.00pm To commence this pathway please enrol via My Health Learning. Course code: 42956746 Enquiries Cathy.Vinters@health.nsw.gov.au or Catherine.Rosario@health.nsw.gov.au NSLHD Clinical Governance Unit Visit the NSLHD Intranet - Safety and Quality Essentials Pathway page, to see view other training offerings available. (https://bit.ly/3G5jK13)
projects that improve the safety, quality and patient/consumer experience of your service
describe the Model for Improvement select a suitable problem for a quality improvement project demonstrate how to create and interpret a flowchart The NSLHD Improvement Science workshop is one of the intermediate-level training offerings within the Safety and Quality Essentials Pathway (SQEP) Objectives and Learning Outcomes On completion of this program you will be able to:
explain the importance of baseline data create and interpret driver diagrams
describe the steps in a Plan-Do-Study-Act (PDSA) cycle develop outcome, process and balancing measures explain ways to measure and track progress using run charts, etc explain how to spread, scale up and sustain improvement initiatives Target Audience Open to all staff with an interest in improving the safety and quality of your local service. This course would be most beneficial to participants who are undertaking or planning to undertake a quality improvement project. Pre-requisite Foundations of Healthcare Safety and Quality - The Six Dimensions of Healthcare Quality (video module) – MHL Course code: 340129036, and /or Foundations of Healthcare Safety and Quality eLearning Pathway MHL Course code: 335318052, or equivalent face to face/virtual meeting discussions or in-services (345903083)
DECEMBER 2022
EDITION 21
What can you do to help?
Antimicrobial resistance is one of the top ten threats to global health as defined by the World Health Organisation. The ongoing rise of multidrug-resistant pathogens worldwide is due in part to inappropriate or incorrect use of antimicrobials. Patients with infections caused by multi-drug resistant bacteria experience increased morbidity and mortality, which contribute to increased burden and cost to our health care system. One strategy to help combat this threat is Antimicrobial Awareness Week which takes place annually in November, to raise awareness about antimicrobial resistance and to encourage the responsible use of antimicrobials in our healthcare facilities and the community. The overarching slogan for Antimicrobial Awareness Week 2022 is "Antimicrobials: handle with care", and the theme for 2022 was ‘Preventing Antimicrobial Resistance Together’ . Overuse and misuse of unnecessarily broad spectrum antibiotics can drive antimicrobial resistance, and we all have a part to play to help reduce antibiotic resistance. A number of activities took place across our sites during antibiotic awareness week this year. Congratulations to this year's winners.
To learn more? Visit the Australian Commission on Safety and Quality in Health Care Visit the NSLHD Antimicrobial Stewardship intranet page
Preventing and Controlling Healthcare-Associated Infection Standard
Access via NSLHD Library spring board
QUALITY AND SAFETY IN THE LITERATURE BMJ QUALITY AND SAFETY
Rotteau L, Goldman J, Shojania KG, et al. Striving for high reliability in healthcare: a qualitative study of the implementation of a hospital safety programme. BMJ Quality & Safety 2022;31:867-877. McHugh S, Riordan F, Shelton RC. Breaking the quality-equity cycle when implementing prevention programmes BMJ Quality & Safety Published Online First: 08 December 2022. doi: 10.1136/bmjqs-2022-015558 Davidson C, Denning S, Thorp K , et al. Examining the effect of quality improvement initiatives on decreasing racial disparities in maternal morbidity BMJ Quality & Safety 2022; 31: 670-678.
INTERNATIONAL JOURNAL FOR QUALITY IN HEALTH CARE
JOURNAL OF PATIENT SAFETY AND RISK MANAGEMENT
The International Journal for Quality in Health Care (IJQHC) is a leading international peer-reviewed scholarly journal addressing research, policy, and implementation related to the quality of health care and health outcomes for populations and patients worldwide. Latest issue: Volume 34, Issue 4, 2022
Journal of Patient Safety and Risk Management considers patient safety and risk at all levels of the health care system, starting with the patient and including practitioners, managers, organisations, and policy makers.
Latest issue: Volume 27 Issue 6, December 2022
DECEMBER 2022
EDITION 21
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.
December 2022 QARS Audits (entry links)
NSLHD_03_Aseptic Technique
St 3
St 4
NSLHD_4_Monthly Accountable Drug (S4D_S8) Register Audit (RNSH | HKH | Ryde | MVH | MHDA)
NLSHD_08_Monthly inspection for resuscitation trolley/ Resuscitaire equipment checklists
Hypoglycaemic Kit and Glucometer Audit v2_Dec_2022 (MHDA) (RNSH | HKH | Ryde | MV | MHDA | PACH)
St 8
POLICIES, PROCEDURES AND GUIDELINES
New look PPG Intranet site
The NSLHD Policies, Procedures & Guidelines Intranet site has recently undergone a transformation to cater for a more user friendly experience. The new site provides staff and PPG Authors improved navigation with the PPG process and Prompt, the portal that houses NSLHD's Policies, Procedures, Guidelines and Standing Orders.
You can access the new site here.
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
Enterprise Risk Management Procedure - NSLHD Enterprise Risk Management Guideline - NSLHD Access and Use of Electronic Mobile Devices in Mental Health and Drug and Alcohol Inpatient Units - MHDA Subcutaneous Use of Elastomeric Infusers for Palliative Care Symptom Management
SAFETY ALERTS New, updated and recently published
SN:024/22 - P hilips 12-Lead Chest Lead-set Defect - issued 5 December 2022 SN:023/22 - N ewly registered Australian product: Risks associated with lorazepam 4 mg/1 mL solution for injection - issued 1 December 2022 SN:022/22 - Discontinuation of Jurnista® (HYDROmorphone hydrochloride) modified release tablets in Australia - issued 29 November 2022 SI:011/22 - Philips Respironics CPAP and bi-level masks containing magnets - issued 25 November 2022
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
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.
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