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.
FEBRUARY 2026
EDITION 42
NSLHD QUALITY IMPROVEMENT AWARDS Entries now open
IN THIS EDITION: 2026 NSLHD Quality Improvement Awards Small Acts of Kindness - NSLHD Award REACH Update Connecting with Consumers Webpage Mandatory Reporting of High-Risk Medical Device Adverse Events
How to Apply
Yo ur paragraph text Applications for all categories (apart from Small Acts of Kindness) should clearly describe: The problem or need addressed The QI methodology or approach used Key outcomes and impact Supporting data, evaluation results, and evidence are strongly encouraged. Criteria for Small Acts of Kindness can be found at 2026 NSLHD QI Awards Guidelines Shortlisted applicants will be notified How improvements are being sustained, scaled, or spread ahead of the awards event, where category winners will be announced and recognised for their outstanding contribution to improvement across NSLHD. Review the 2026 NSLHD QI Awards Guidelines Download and complete the application form Submit your completed application to your facility or service Local Awards Coordinator by Friday, 6 March 2026
Applications are now open for the 2026 NSLHD Quality and Improvement (QI) Awards , celebrating initiatives that
enhance the quality, safety, experience, and sustainability of care across our District.
Award Categories Submissions are invited in the following categories: Environmental Sustainability Excellence in Aboriginal Healthcare Excellence in Multicultural Healthcare Excellence in the Provision of Mental Health Services
Health Innovation Health Research Keeping People Healthy
Patient Safety First People and Culture Transforming Patient Experience Small Acts of Kindness (new in 2026)
For support or advice with your application please contact NSLHD-Awards@health.nsw.gov.au
Clinical Governance Standard
EDITION 42
FEBRUARY 2026
Small Acts of Kindness New NSLHD QI Award Category for 2026
he This award honours the NSLHD values shown through small but deeply meaningful gestures that create a positive, supportive, and uplifting environment. For the nominee, kindness isn’t an isolated moment or occasional act; it’s a defining characteristic of how they show up every day. Their thoughtful actions strengthen our sense of community, contribute to a more compassionate workplace, and enhance the experience of patients and families. Time and again, feedback from staff and consumers highlights the meaningful difference this person makes in the lives of others. In 2026, the NSLHD Quality Improvement Awards will include a new opportunity to celebrate what truly lies at the heart of exceptional healthcare: kindness. The Small Act of Kindness Award recognises an employee who consistently treats every person with dignity, respect, and humanity. This individual brings compassion and empathy to every interaction — with patients, families, and colleagues — demonstrating genuine care in the way they approach their work. Know someone who embodies kindness in everything they do? We invite you to nominate them for the Small Act of Kindness Award. Applications and nomination forms can be found on the NSLHD Quality Improvement Awards intranet site
Consumer and Patient Experience
Partnering with Consumers Standard
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REACH Update “Worried They Are Getting Worse?” will commence statewide implementation across NSW Health adult and maternity acute ‑ care settings from March 2026, expanding the established program already in place within paediatric and neonatal services.
NSLHD Digital Health Services are planning deployment of an electronic tool and the go-live date is 28 April 2026. To support implementation, the CEC have additional resources available here.
REACH single number implementation NSLHD will transition to a statewide single REACH number from 17 March 2026. From this date, any REACH calls received by the RNSH switchboard (as the transfer switchboard for NSLHD) will be redirected to the appropriate NSLHD hospital’s REACH phone. All existing local REACH numbers will remain unchanged.
Fo r more information please contact the NSLHD PRMs Team via nslhd-prms@health.nsw.gov.au.
EDITION 42
FEBRUARY 2026
Consumer and Patient Experience
Partnering with Consumers Standard
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New Connecting with Consumers Intranet Page
A new dedicated intranet resource page has been launched to support staff in strengthening partnerships with our health consumers. This page brings together clear, user ‑ friendly information to help staff understand who they need to connect with. It also provides quick links to the tools required to connect with consumers and guidance to assist you.
Here you’ll find: Consumer Engagement Toolkit –Practical templates and step-by-step guides.
Training & Education –Workshops and e-learning to build confidence in consumer collaboration. Advisory Opportunities –Connect with Consumer Advisors for committees and projects. Policies & Frameworks –Easy access to NSLHD and NSW Health standards.
Click here to access the site.
Fo r more information please contact the NSLHD PRMs Team via nslhd-prms@health.nsw.gov.au.
Northern Sydney Local Health District
Leading for Safety and Quality Improvement 2-day course
Course Overview
Describe the leadership skills and attributes required of a contemporary leader in healthcare. Examine the relationship between leadership and advocacy (sponsorship) for local patient safety and quality improvement initiatives. Demonstrate the links between safety and quality in healthcare and the role of Clinical Governance to drive the safety and quality agenda Describe the role of the team in safety and quality Explore ways to foster positive group dynamics and enhance motivation within a team Readiness to Lead for Safety and Quality * Participants will be introduced to the essential leadership practices required to be an effective safety and quality leader and gain the knowledge, tools and skills to apply the Improvement Science methodology in projects that improve the safety, quality and patient/consumer experience of their service. On course completion, participants will attain ‘intermediate level’ capability under the NSW Healthcare Safety and Quality Capabilities . This set of capabilities complements the NSW Public Sector Framework . The Learning Pathway has been developed in partnership with the Clinical Excellence Commission under the Safety and Quality Essentials Pathway . The course is comprised of the following sessions and learning objectives on completion:
Now open for enrolement 23 and 24 April @ RNSH 8:30 am - 4:30 pm More dates for 2026 to follow
Duration: 2 days, CPD 14 hours
Target Audience: Open to all staff. Staff from across the district are welcome to attend any of the available locations Enrolments: Click here to enrol on My Health Learning (MHL) Code: 630735018
Contact for inquiries:
Identify a range of opportunities for ongoing development of your leadership capability
NSLHD-SQEP@health.nsw.gov.au
Pre-requisites
Introduction to Improvement Science*
View the Six Dimensions of Healthcare Quality video ( 6
Describe the Model for Improvement Identify a problem or opportunity that is suitable for a quality improvement project Develop an effective aim statement Create and interpret a flowchart of the current process Create and interpret driver diagrams Describe the importance of data collection and measuring impact. Identify ways to measure and track progress using run charts List the steps in a Plan-Do-Study-Act (PDSA) cycle Use tools to assist in how to spread, scale up and sustain improvement initiatives.
minutes) on My Health Learning (Course code: 340129036)
Other preparation activities will be communicated closer to the course dates * Comparable self-paced e-learning modules are available on MHL - click here
FEBRUARY 2026
EDITION 42
Mandatory Reporting of Medical Device Adverse Events
These changes ensure consistent reporting and a clearer understanding of how high ‑ risk medical devices perform in real ‑ world care. They also help build safer systems by identifying trends earlier and supporting improvements across NSW Health. To make it easier for staff to enter a Medical Device Adverse Event in ims+, eHealth NSW and the Clinical Excellence Commission (CEC) have released a set of step ‑ by ‑ step instruction sheets covering each incident type. Notifying a Patient Incident Related to Medical Devices Notifying Worker Incidents Related to Medical Devices Notifying a No Person Incident Related to Medical Devices Notifying Relative/Visitor Incidents Related to Medical Devices Once entered into ims+, reports will be shared by the CEC with the Therapeutic Goods Administration (TGA) to support national monitoring and regulatory action when needed. If your team uses, manages, or supports high ‑ risk medical devices, please familiarise yourself with the new reporting requirements and the available guidance materials from the CEC website
From 21 March 2026, all NSW Health services will be required to report serious adverse events involving high ‑ risk medical devices. This change aims to strengthen patient safety, improve device monitoring, and ensure faster identification of potential risks. The new requirement applies to incidents involving Class III non ‑ IVD devices (such as implantable pacemakers, defibrillators, nerve stimulators, breast implants, neurosurgical tools, vascular catheters, and valve prostheses) and Class 4 IVDs, which include high ‑ risk blood grouping tests across the ABO, Rhesus, Kell, Kidd, and Duffy systems. These devices and tests play critical roles in patient care, and any issue can have a significant clinical impact. Under the updated process, staff must complete an incident notification in ims+ for any death, serious injury, or serious deterioration associated with these devices, using the category Devices, Gases and Consumables .
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This applies to incidents involving patients, workers, visitors/relatives, or situations where no person was directly harmed but a device fault was identified.
This infographic outlines responsibilities of all NSW Health workers in notifying, monitoring, reporting and responding to medical device related incidents.
Clinical Governance Standard
Fo r more information please contact the NSLHD PRMs Team via nslhd-prms@health.nsw.gov.au.
FEBRUARY 2026
EDITION 42
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 2025 - 2026 NSLHD Clinical Audit Schedule from the Clinical Audit Schedule Intranet page
Clinical Governance Standard
Clinical audits to be completed are listed below.
POLICIES, PROCEDURES AND GUIDELINES Refer to the PPG Weekly updates (PPG Resource hub) to access the most up-to-date list of PPGs For any queries relating to policy, procedure and guideline development contact NSLHD-Policies@health.nsw.gov.au
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Medication Safety Updates including medication shortages are available on the CEC website.
SAFETY ALERTS New, updated and recently published
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