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.
JUNE 2023
EDITION 26
PATIENT SAFETY CULTURE SURVEY NSLHD launched the 2023 Patient Safety Culture Survey (PSCS) on Tuesday, 13 June. This survey is open for all NSLHD staff, both clinical and non-clinical, to share their views on how patient safety and quality are managed in their workplace. Patient safety is central to all our work in health. Our staff are often the first to recognise safety risks and issues. Sharing your perceptions and experiences at work can help identify what works well and what systems and processes need improvement. The results of this survey will be used to identify areas where we can improve patient safety and staff wellbeing. The survey addresses essential topics that impact patient safety, such as leadership, team interactions, communication, and reporting safety incidents. Results will be compiled to identify how NSLHD performs across 10 safety and quality domains, including communication about error, organisational learning, clinical handover and information exchange. Results will be fed back at team, facility and district levels to inform targeted strategies for the continual improvement of our patient safety culture across NSLHD. Teams with 100 per cent or very high completion rates will be entered into a draw for the chance to win one of twelve $1,000 cash prizes. The prize can be used by your team to purchase resources for your area or to support staff wellbeing. Set time aside during team meetings and encourage your colleagues to complete the survey. The survey will take approximately 10-15 minutes to complete, and your responses will be entirely anonymous. The survey will be open until Tuesday, 4 July.
IN THIS EDITION:
Patient Safety Culture Survey Human Experience Week Consumer tick resources Consumer Advisor activity Consumer remuneration Mona Vale Hospital’s upcoming accreditation assessment
Transitioning to Short Notice Assessments Policy, Procedure and Guideline (PPG) development - improvement project Human factors: Fatigue Hindsight: Thematic review of inpatient falls serious adverse events
What did you think of this issue? Please give us your feedback.
TELL US ABOUT PATIENT SAFETY WHERE YOU WORK!
Complete the survey by scanning the QR code or click here.
Clinical Governance Standard
JUNE 2023
EDITION 26
Consumer and Patient Experience
Partnering with Consumers Standard
Human Experience Week is an annual event celebrating healthcare staff who impact patient experience daily. The Week allows a dedicated time for NSW Health and health providers worldwide to celebrate the accomplishments, re-energise, and honour those who impact patient experience every day. Events were held at RNS, Ryde, Hornsby, Mona Vale Hospitals and Mental Health Drug and Alcohol Services, with many local activities taking place. Staff were seen wearing t-shirts with the question "Ask me about...Elevating the Human Experience", which was very effective in initiating conversations with patients, families, and staff about the importance of the week. A key highlight of the week was the official launch of the Partnering with Consumer Framework. NSLHD CELEBRATES HUMAN EXPERIENCE WEEK (MAY 1 – 7, 2023)
Photos from left, Mental Health Drug and Alcohol Services, Hornsby Ku-ring-gai Health Service, Royal North Shore and Ryde Hospital teams celebrating Human Experience week
NSLHD Consumer Advisor representatives, NSLHD Executive and Consumer and Patient Experience (CAPE) team celebrate the official launch of the Partnering with Consumers Framework
CONSUMER TICK RESOURCES Services and teams producing patient information publications are encouraged to include the Partnering with Consumers or Consumer Tick graphic or statement to their publications. The NSLHD Procedures Consumer Health Information - Approval Steps for Producing and The ConsumerTick Process has been combined into one procedure Consumer Health Information - Approval Steps for Producing and The Consumer Tick Proces s (link to Prompt). The Consumer Tick Resources intranet page has also been updated. These steps have been taken to help staff navigate the application process Resources which are created following Consumer Tick approval process are eligible to be published with the following statement "This resource has been co-designed and approved by consumers and carers" and/or use of the consumer tick graphics.
JUNE 2023
EDITION 26
NSLHD CONSUMER ADVISOR ACTIVITY From January 2020 to May 2023, NSLHD staff have used the Consumer Tick process to partner with consumers to assist with developing, co-designing and reviewing patient-facing information. Ninety-nine documents (e.g. pamphlets, brochures, posters, and booklets) have been reviewed through this process. There have been numerous other opportunities involving consumers in NSLHD activities. These have included taking part in education and training and being members of various working parties and committees. Since January 2023, we have had new Consumer Advisor representation on the following committees and/or working parties. NSLHD Community and Supported Care Falls Prevention Committee NSLHD Consumer and Patient Experience Committee (CAPE) NSLHD Clinical Trials Working Party NSLHD Patient Safety Culture Survey Working Party NSLHD Voluntary Assisted Dying Steering Committee NSLHD Consumer Engagement Video Working Party NSLHD Comprehensive Care Plan: Goal Setting Working Party RNSH Pre-Admission Redesign Project Governance Committee For more information on how to recruit a consumer adviser visit our intranet site or email NSLHDThePatientExperience@health.nsw.gov.au
MONA VALE HOSPITAL’S ASSESSMENT Two Australian Council of Healthcare Standard (ACHC) Assessors will conduct an Accreditation Assessment at Mona Vale Hospital and the new Adolescent and Young Adult Hospice (AYAH), from Wednesday 14 to Friday 16 June 2023 . This will be NSLHD’s final assessment under the existing ‘announced’ assessment program. ACCREDITATION TRANSITIONING TO SHORT NOTICE ASSESSMENTS From 1 July 2023 mandatory Short Notice Assessments (SNA) for accreditation to the NSQHS Standards (National Standards) will replace the existing ‘announced’ assessments and ‘voluntary short notice assessments’ of all health service organisations. The mandatory SNA process ensures the outcome reflects day-to-day practices, identifies gaps and supports health service organisations to improve safety and quality systems and processes. Interviews with staff, consumers, patients, families, carers, volunteers and contractors; Observations of workforce practices and interactions with consumers across all operational and clinical areas Review of documentation and records and; Examination of how the organisation’s quality improvement systems are used to reduce risks. Our Facilities and Services will be given 24 hours' notice of an assessment which means once notified, there is one full business day before the assessment commences. Under the SNA process the Assessors are required to spend at least 75% of their time in operational areas. The Assessors will continue to gather evidence from a variety of sources including; All NSLHD Facilities and Services are currently preparing for a smooth transition to Short Notice Assessments. This will mean Assessors will have more time to observe patient journeys. For further information: Contact Annette.Penney@health.nsw.gov.au, your local Quality Manager and/or refer to the Short Notice Assessment page on the Australian Commission on Safety and Quality in Health Care website.
CONSUMER REMUNERATION
NSW Ministry of Health has recently released guidelines about the remuneration of consumers.
NSW Health recognises that time commitments and other costs can be a barrier to community and consumer participation. Remuneration, through financial recognition, provides a means of recognising lived experience expertise and aims to make it easier for people to contribute to engagement and improvement activities. Payment also aims to increase the diversity of people who choose to engage with NSW Health organisations.
Find out more:
Factsheet for staff Factsheet for consumers
Consumer, carer and community member remuneration guideline (GL2023_016)
Partnering with Consumers Standard
JUNE 2023
EDITION 26
POLICY, PROCEDURE AND GUIDELINE (PPG) DEVELOPMENT IMPROVEMENT PROJECT
The Clinical Governance Unit commenced a project in January 2023 to streamline the development, review and approval process of Policies, Procedures and Guidelines (PPG) and improve the author experience.
A working group of Authors, Document Owners and NSLHD Policy and Procedure Governance Committee (PPGC) representatives met monthly from January 2023 to April 2023 to diagnose causes and to brainstorm change ideas towards improving the process for PPG development, review and approval. Solutions introduced
Updated resources for authors available on the PPG Intranet Site. 1.
Aboriginal Health Impact Statement (AHIS) intranet page with resources to assist completion of an AHIS Meeting Dates and Timelines for PPG Submissions – NSLHD PPGC, NSLHD Drug and Therapeutics Committee (DTC), Directors of Nursing & Midwifery Meeting and the NSLHD Forms Committee Prompt User Guides – How to ‘Check’ Out a Document and How to Pull Reports, found on the Prompt Staff Training and FAQs intranet page. PPG Intranet revamp is currently underway with the development of a PPG Author Resource Hub that will include a revised PPG Process Flowchart, Approval Guide, Author Guide – Tips for PPG Development and Review, Author Checklist and a revised Referencing Guide including Endnote training resources. Watch this space!
2.
3.
4.
Rebranding of ' Draft for Comment 'to ' Final Consultation' The Project Team identified a need to better utilise Final Consultation (formerly known as Draft for Comment) to ensure feedback is captured earlier in the PPG development process and to reduce delays when obtaining approvals. Key changes include:
1. 2.
The duration of documents uploaded on Final Consultation extended to two weeks Weekly distribution of the documents on Final Consultation to the facility/ service Quality Managers and PPG Representatives to distribute to relevant teams and the Directors of Nursing and Midwifery. DTC reviewers will be included in this distribution from July 2023.
The project team are testing other potential solutions such as developing a combined PPG and DTC document library and an application and approval build on SharePoint to streamline submission and approval of PPGs, and to maintain version control throughout the PPG process. Recently published NSW Health Policy Directives and Guidelines, NSLHD PPGs, Legislative Alerts and documents uploaded on Final Consultation are listed in the Weekly PPG Update in the NSLHD Weekly Bulletin. CGU acknowledges the commitment and significant contribution of the PPG Improvement Project Working Group members; Alex Chan, Anna Jamison, Annette Penney, Cathy Vinters, Elliot Williams, George Barker, Jo Tallon, Lauren Connors, Louise Buchanan, Lizanne Dalgleish, Madeleine Borys, Michelle De Vroome, Nitisha Bangera, Oriana Kaminski, Rupali Sarker, Sharyn Rose, Sibusisiwe Maturure, Sue Toomey and Vicki Fox. Central coordination of District approvals for PPGs The Policy and Procedure Manager role coordinates approval from the District Directors, Directors of Nursing and Midwifery, General Managers and Service Directors and the NSLHD Drug and Therapeutic Committee (DTC). This ensures a coordinated approach with greater oversight of PPGs under development and review. The Clinical Governance Unit (CGU) is working closely with the NSLHD DTC to align the submission process of PPGs in an effort to streamline DTC approval for PPGs that relate to the prescribing, administration and storage of medications.
Contact NSLHD-Policies@health.nsw.gov.au for any queries relating to policy, procedure and guideline development.
Clinical Governance Standard
JUNE 2023
EDITION 26
HUMAN FACTORS: FATIGUE
Fatigue can have many effects on a person’s performance. This short article will explain some of the issues contributing to fatigue and what we can do to reduce the likelihood of that having an adverse impact on others. Fatigue is defined as " A physiological state of reduced mental or physical performance capability, which may result from sleep loss or extended wakefulness, which can impair alertness and ability to safely operate or perform safety-related duties" The greatest cause of fatigue is insufficient or disrupted sleep. In the United States, the cost of fatigue in the workplace has been estimated at $18 billion per annum. 2 3 Pathological fatigue can be due to an underlying medical condition such as but not limited to, Anaemia, Diabetes, Hypothyroidism, Malabsorption states and renal failure. Physiological fatigue is related to alcohol consumption, circadian rhythms, current health, or recent physical activity. Subjective fatigue is how sleepy a person might feel. This not only relates to when they last slept and how well they slept, but also how motivated they are to do their work. Fatigue can be pathological, physiological or subjective. Effects of fatigue Fatigue is a genuine concern in high-risk industries such as healthcare. Shift work and irregular or long working hours contribute to fatigue. Signs and symptoms can be explicit (e.g. eye rubbing, head drooping, yawning) or more subtle (e.g. diminished motor skills, increasing and irresistible longing for sleep, lethargy, loss of muscle strength, and micro sleeps). The impact of fatigue can be unsettling and may lead to a catastrophic event occurring. Failure to communicate important information Failure to anticipate events or actions Misinterpreting information, disorientation, visual illusions Low alertness Lacking judgement and decision making leading to an increase in mistakes Difficulty in performing tasks that require concentration Becoming easily distracted Having diminished standards of quality Reduced hearing, vision etc. Quieter or more withdrawn than usual Tearful Irritable or grumpy with colleagues, friends or family Erratic moods, depressed, elated and energetic The effects of fatigue include: 1
Ref: Global Air Training, August 2022
Tips for better sleeping
Establish a good bedtime routine (same time to bed if possible), Take a bath or shower before bed, Avoid alcohol and caffeine within 4 hours of bed time, Heavy meals should be avoided within 2 hours of bedtime, Carefully manage naps. If taking a nap make these regular and short between 14.00hrs – 17.00hrs (any later is too close to bedtime), Avoid emotional stressors, where possible Avoid intellectual stimulation before bed, Avoid using electronic devices, including TV, in the bedroom, Exercise regularly, just not too close to bed time, Practice relaxation techniques, Try herbal remedies Lavender, Ylang Ylang, Valerian or Chamomile tea, or a warm milky drink before bed. 1 Human Factors in Healthcare Train the Trainer, Fatigue presentation, Global air training, August 2022 Caldwell JA, et al., Fatigue and its management in the workplace. Neuroscience and Biobehavioral Reviews, 2019. 96: p. 272-289 Sadeghniiat-Haghighi K and Yazdi Z, Fatigue Management in the Workplace. Industrial Psychiatry Journal, 2015. 24(1): p. 12-17 References: 1. 2. 3.
The Filthy Fifteen
Ref: Global Air Training 2022
Complacency
Pressure
Stress
Fatigue
Distraction
Lack of communication
Lack of assertiveness
Lack of Awareness
Lack of knowledge
Lack of resources
Lack of teamwork
Not admitting limitations
Norms
Lack of professionalism
Lack of operational integrity
Not interested in events or people Loss of motivation to perform duties
There is evidence to suggest that preventing and reducing fatigue in the healthcare setting could lead to better health and safety outcomes and less incidents or injuries.
Contact: NSLHD-SQEP@health.nsw.gov.au
JUNE 2023
EDITION 26
THEMES FROM STATEWIDE INPATIENT FALLS SERIOUS ADVERSE EVENTS
Of the 331 SAER reports reviewed, there were 75 reports of death following a fall. 29 patients (40 per cent) were between 80 and 89 years of age (5 per cent of patients were under 65). 50 of the inpatient falls (76 per cent) were unwitnessed. The bedside or bathroom were the locations reported where most falls occurred. Risk factors were related to the patient's physical co-morbidities (89 per cent), confusion or delirium (50 per cent), post fall management (45 percent) and the deteriorating patient (43 per cent). Most of the inpatient falls that resulted in death occurred in General Medicine (31 per cent). The specific service where the other inpatient falls occurred is spread across a range of services including Aged care (11 per cent), Cardiology (7 per cent), Emergency (7 per cent) and Rehabilitation (7 per cent). Collectively, 8 SAER reports refer to a fall occurring in a surgical service (11 per cent). The Clinical Excellence Commission has released a report following a state-wide review of the Harm Score 1 inpatient fall-related Serious Adverse Event Review (SAER) reported between April 2020 to February 2022, to identify recurring themes from findings, identify gaps, and make recommendations for system improvement. Key findings Falls in NSW Health facilities are a significant issue in the older population. Increasingly, older people with multiple co-morbidities are living longer. This has increased admissions of older people to hospitals for care.
Eight key themes were identified
Co-morbidities – Physical Patients with multiple medical conditions or co-morbidities are at an increased risk of a fall.
Communication issues between staff Communication breakdowns between staff about patient risks and care needs contributed, to an extent, to the final outcome.
Failure to recognise cognitive impairment Patients who are confused or have a delirium have been shown to be twice as likely to fall There were reports of delirium screening not completed and failure to implement appropriate interventions in response.
Communication issues with patients and families
Individual patient risk factor identification, intervention strategies and documentation There are reports of failure by health care services and clinicians to appreciate a patient’s risk of a potential fall, through routine risk screening and implementation of an appropriate management plan to mitigate risks for patients, as well as review and revise a patient’s degree of risk throughout their admission. Patient flow and allocation of rooms Several SAER reports revealed that patients were not allocated to an appropriate room suitable to meet their needs for increased observation or supervision. Staff were allocated to patients across multiple rooms, and meant that suitable observation and supervision was not always provided
Generally, there was a lack of early engagement with patients and their families regarding treatment options and expectations relating end of life care. There was considerable family distress noted due to the rapid decline of the patient’s condition as a subsequent result of the inpatient fall.
Medications Polypharmacy increases the risks of falls.
Reports indicate a lack of appreciation of the effect of the use of medications to sedate patients with behavioural issues as a potential contributing factor for a patient fall. There was also a lack of consideration given to patients on anticoagulant therapies and how they can increase a patient’s risk for potential harm following a fall
Post fall care and management Across the SAER reports, there was minimal, or no information included as to whether a safety huddle and a post- fall huddle was undertaken. A post-fall huddle provides an opportunity to engage with the patient, family / carer and to identify what actually happened at the time of the incident and to implement care strategies. Read the full Inpatient Falls Serious Adverse Events Report and access other learnings from incident reviews from the lessons learned intranet page.
JUNE 2023
EDITION 26
Comprehensive care – minimising harm model (Clinical Excellence Commission, CEC)
The CEC's Comprehensive care – minimising harm model focus on safe care for older people, especially those with frailty, cognitive impairment, and decreased mobility. It aligns with the National Safety and Quality Health Service Standards (NSQHSS), Comprehensive Care and Partnering with Consumers standards.8 There will be a shift to identifying individual patient risk factors and implementing patient-focused interventions (fall and pressure injury risks have been included in the model as components of safe care). The model incorporates team safety fundamentals including safety huddles, post fall huddles, multidisciplinary team bedside rounds and clinical bedside handover. There are seven components of care to be considered to identify patient individual risk factors, with corresponding implementation of strategies to manage the risks in hospital.
JUNE 2023
EDITION 26
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.
June 2023 QARS Audits (entry links)
NSLHD_03_Aseptic Technique
St 3
NSLHD_4_Monthly Accountable Drug (S4D_S8) Register Audit
NSLHD_04_Prescription Pad: Quality of Prescribing NSLHD_04_ Prescription Pad: Storage and handling (RNSH | HKH | Ryde | MVH | MHDA)
St 4
NSLHD_05_ Perioperative Patient Positioning (Ryde OT | HKH OT | RNSH OT) NSLHD_8_ Between the Flags (BTF) Audit-SMOC, SPOC, SAGO (HKH | Ryde | MVH) NLSHD_08_Monthly inspection for resuscitation trolley/ Resuscitaire equipment checklists (RNSH | HKH | Ryde | MV | MHDA | PACH-HITH)
St 5
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 Outpatient Rehabilitation in NSLHD_Guideline (new) Peritoneal Portacath and Drainage of Ascites – Community Nursing - NSHNS_Procedure (updated) Diabetes Mellitus: Blood Glucose Monitoring Point of Care Testing AMSL StatStrip® Xpress Meter – NSLHD_Procedure (updated) Pantoprazole Infusion for the treatment of bleeding peptic ulcers – administration in adults_Procedure (updated) Heat Wave Preparation and Actions for Mental Health Consumers – MHDA_Guideline (updated) Consumer Health Information - Approval Steps for Producing and The Consumer Tick Process- NSLHD_Procedure (updated) Clinical Emergency Response System (CERS) – Mona Vale Hospital_Procedure (Updated) Clinical Audit in QARS- NSLHD Administration of Intravenous Sodium Chloride 3% in Neurosurgical Step Down Unit (NSDU)
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 SN:013/23 Risk of burn injury from degraded insulated laparoscopic instruments 25 May 2023 SI:008/23 Updated: Reporting Adverse Events Following Immunisation 23 May 2023 SN:012/23 Disruption to supply: Potassium chloride (Pfizer) concentrate 10 mmol (750 mg) in 10 mL injection ampoule 18 May 2023 SN:011/23 Discontinuation of thiopental sodium (Pentothal®) 500 mg vial for injection 9 May 2023
Medication Safety Updates including medication shortages are available on the CEC website.
For more information, contact: NSLHD-SafetyAlert@health.nsw.gov.au
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