NSLHD Safety and Quality Account 2024-2025 Report | 2025-20…

Safety and Quality Account

2024-2025 Report 2025-2026 Future Priorities

Acknowledgement of Country We would like to acknowledge the Traditional Custodians of the Northern Sydney Local Health District region, the Dharug and Guringai peoples. Their spirit can be found across the land and we honour the memory of their ancestors and Elders, past and present. As we endeavour to serve the health needs within the community, we recognise the importance of the land and the waterways, as an integral part of people`s health and wellbeing.

Contents

This account provides examples of NSLHD activities and achievements realised over the financial year 2024–2025, aligned to the six dimensions of healthcare quality, the National Safety and Quality Health Service Standards (NSQHS) and the NSLHD Strategic Plan 2022–2027

Our Commitment to Safety and Quality

Achievements against Priority Initiatives

Safety

Effectiveness & Appropriateness

Timeliness & Accessibility

Patients and carers are our partners in their healthcare

THE SIX DIMENSIONS OF HEALTHCARE QUALITY

Safe, high quality connected care

Keeping people healthy and well

Equity

Efficiency

Our staff are engaged and well supported

Patient Centred Care

Research, innovation and digital advances inform and improve the delivery of patient care Our services are sustainable, efficient and committed to planetary health

NATIONAL SAFETY AND QUALITY HEALTH SERVICE STANDARDS

Our Performance in Safety and Quality

Future Priorities

ACKNOWLEDGING OUR CONTRIBUTORS We extend our heartfelt thanks to the consumers and staff who generously contributed to this year’s Safety and Quality Account. Your reflections, insights, and experiences are invaluable, and we deeply appreciate the time, effort, and dedication you’ve invested. This Account has been shaped through meaningful collaboration with consumers, ensuring it reflects the voices and perspectives of those at the heart of our services.

Appendix: Attestation Statement

Our Commitment to Safety and Quality

Exceptional Care, Leaders in Research, Partners in Wellbeing. NSLHD’s vision – “ Exceptional Care, Leaders in Research, Partners in Wellbeing ” as outlined in the NSLHD Strategic Plan 2022-2027, shapes NSLHD’s commitment to providing safe, high-quality personalised healthcare and outcomes that matter most to our patients, carers, and consumers.

NSLHD STRATEGIC PLAN 2022-2027 Patients and carers are our partners in their healthcare

Safe, high quality connected care

Keeping people healthy and well

Our staff are engaged and well supported

Research, innovation and digital advances inform and improve the delivery of patient care

Our services are sustainable, efficient and committed to planetary health

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Our Commitment to Safety and Quality

At NSLHD, we are driven by a clear purpose: to provide exceptional care that is safe, high-quality, and tailored to the people we serve. Our teams come to work each day committed to delivering healthcare that not only meets clinical standards but also respects the unique needs, preferences, and circumstances of every individual. Message from the Board Chair and Chief Executive

The Northern Sydney Local Health District (NSLHD) Board and Executive is pleased to present the 2025–2026 Safety and Quality Account. This document provides an opportunity to reflect on our performance and celebrate achievements. It also affirms our ongoing commitment to improving the safety and quality of care. This Account has been developed to ensure strategic alignment with the District’s goals and to confirm the accuracy of our performance data. It also reaffirms our collective focus on driving measurable improvements that benefit patients, carers, families, staff, and the wider community. Throughout the 2025–2026 financial year, NSLHD has continued to meet or exceed safety and quality targets, with a strong emphasis on innovation, equity, and sustainability. This year’s report highlights several outstanding initiatives that have transformed patient experience and enhanced outcomes across our hospitals and community services. Under the theme of transforming the patient experience, Ryde Hospital’s Risky Business – Eating and Drinking with Acknowledged Risk initiative has supported patient-centred decision-making in complex care. Hornsby Hospital’s Intensive Care Unit has promoted early mobilisation for critically ill patients, improving recovery times. At the Northern Sydney Cancer Centre, a new mobile app and real-time coaching in patients’ preferred languages have significantly improved the experience for culturally and linguistically diverse patients undergoing radiation therapy. Timely access to care has also been a key focus, with the implementation of the FAST-CT Stroke Pathway improving urgent care for stroke patients. We continue supporting vulnerable populations in several key ways. We’ve introduced innovations in adolescent mental health care and enhanced oral health screening for children with special needs.

We’ve also expanded child and family health services for Tibetan refugee families and strengthened support for survivors of domestic and family violence. We are also proud of our continued investment in research and innovation, with Tomorrow’s Medicine Today , a new podcast and publication, showcasing the District’s commitment to evidence-based care. A value-based approach remains central to our operations, embedding financially sustainable and environmentally conscious principles in decision-making across services. This Account reflects not just achievements but a culture of continuous improvement. It is a testament to the dedication of our staff, who work every day to ensure that patients receive the safest and highest-quality care possible. Supported by the NSLHD Board’s Attestation Statement (see Appendix) and formally endorsed by the Board, this Account reaffirms our commitment to ongoing improvement and accountability. We remain dedicated to ensuring that every person who accesses NSLHD services experiences safe, respectful, and effective care. We offer our thanks and appreciation to our dedicated NSLHD staff for their commitment to delivering patient-centred quality healthcare.

Trevor Danos AM NSLHD Board Chair

Adjunct Professor Anthony Schembri AM NSLHD Chief Executive

Our Commitment to Safety and Quality

Patient Story

A Final Wish Fulfilled: Empowering Care Through Compassionate Innovation When a 56-year-old woman living with a rare ovarian cancer expressed her heartfelt wish to visit her family’s holiday home one last time, the Northern Sydney Home Nursing Service responded with compassion, creativity, and commitment to person-centred care.

Thanks to this innovative and compassionate approach, the patient and her family were able to visit their holiday home and create cherished memories together. They also gained greater autonomy in her final weeks, reducing the need for daily nursing visits. The patient and her husband expressed deep gratitude for the care received and support, describing the experience as profoundly meaningful. This story highlights how care is being reimagined— putting people first, listening to “what matters to me,” and working “with me, not to me.” It’s a powerful example of enabling dignity, choice, and connection at life’s most important moments. Read more: Sandy’s story inspires

The patient required daily drainage of peritoneal fluid via a port—a complex procedure typically performed by nurses. With no local services available at the holiday destination and no suitable existing carer education packages, the situation presented a significant challenge. Determined to help, the Oncology Palliative Care Clinical Nurse Consultant obtained the necessary approvals and support to develop a tailored training program for the patient’s husband. The program was based on clinical procedures but adapted to meet his health literacy needs. The Nurse successfully trained him to perform the drainage safely and monitor his wife’s condition.

new protocol for complex home care – Northern Sydney Local Health District or visit https://bit.ly/4hpCetz

Andrea Firgau, Oncology Palliative Care Clinical Nurse Consultant (centre), with the patient’s family

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Achievements against Priority Initiatives

The initiatives described in this chapter are a selection of the actions undertaken across NSLHD during the 2024–2025 financial year that meet NSLHD’s strategic objectives.

Achievements against Priority Initiatives

Patients and carers are our partners in their healthcare 01

Patients and carers are empowered to make informed decisions about their care, goals and health outcomes. Northern Sydney Local Health District (NSLHD) remains firmly committed to advancing quality and safety in healthcare by delivering high-standard, patient-centred services that promote optimal health outcomes and positive experiences for all patients, consumers, families and carers. Achieving this goal necessitates a comprehensive understanding of individual circumstances, enabling the provision of tailored, equitable care that responds effectively to diverse needs. NSLHD acknowledges its responsibility to support vulnerable populations, and is enhancing its approach through strategic community engagement, active consumer involvement, and collaborative service co-design. These efforts ensure that health services are not only safe and effective, but also inclusive, responsive, and aligned with the values of the communities they serve. Celebrating Kindness and Connection: NSLHD Events That Humanise Healthcare Held from 11–15 November, the 2024 Gathering of Kindness continued to promote kindness and compassion in healthcare. This year’s theme, “ Kindness is my Superpower ,” encouraged staff and patients to reflect on how small acts of kindness can make a big difference.

During Gathering of Kindness week, NSLHD set a goal to collect 160 “Tales of Kindness” through the complement portal — and received 264 messages from staff and patients. These stories were shared to highlight how kindness supports staff wellbeing, person-centred care, and positive workplace culture. Selfie frames were also distributed across facilities to encourage staff to visually promote the theme. As part of the week, NSLHD hosted its annual NSLHD Consumer Forum , bringing together Consumer Advisors to connect and strengthen networks, and contribute to strategies and solutions that drive innovation within our health service. Workshops focused on enhancing the experience of Consumer Advisors and supporting them in navigating the use of Artificial Intelligence in healthcare. In May, NSLHD celebrated Human Experience Week with the theme “ The HeART of Healing – Humanising Healthcare ”, celebrating the role healthcare staff play in shaping patient experiences every day. The theme reflects our shared vision to humanise healthcare while embracing transformative technologies such as the Single Digital Patient Record, Artificial Intelligence, and Virtual Care. Staff and patients were invited to write messages about what Heart of Healin g meant to them. These messages were displayed on HeART of Healing posters in public areas across all facilities and services, creating a visual celebration of compassion and connection.

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RYDE HOSPITAL Risky Business – Eating and Drinking with Acknowledged Risk

The Risky Business project is revolutionising care for patients with dysphagia—swallowing difficulties that can lead to serious health risks. Many patients choose to eat and drink despite these risks to preserve their quality of life. This project introduced a pioneering approach to improve the process called Eating and Drinking with Acknowledged Risk , empowering patients to make informed choices. A multidisciplinary team led by the Speech Pathology Team at Ryde Hospital partnered with consumers to co-design a standardised protocol, including patient education resources, bedside signage, staff training, and documentation templates, enabling informed shared decision- making with patients. Better patient experience and outcomes. The Risky Business project has improved patient experience, staff knowledge, and health service efficiency while also delivering cost efficiencies and reducing waste. • Time nil by mouth reduced from an average of 4 days to 0 days, minimising risks like malnutrition and delirium. • Length of stay in hospital dropped from 20 days to 13 days, improving patient flow and experience. • Nasogastric tube feeding fell from 19% to 0%, aligning care with patient wishes. • Use of intravenous (IV) fluids decreased from 81% to 67%, reducing invasive procedures. • Hospital re-presentations declined from 33% to 17%, reflecting well-managed care in the community as per patient wishes. • Palliative care referrals rose from 19% to 58%, enhancing symptom management and dignity. • The rate of Eating and Drinking with Acknowledgment of Risk decisions being honoured rose from 61% to 100%, reflecting a significant improvement in respecting patient autonomy. • Hospital-acquired respiratory complications dropped by 71%, improving safety and outcomes.

Risky Business project team, Ryde Hospital

Patients report feeling respected and heard.

Risky Business is now embedded in practice at Ryde Hospital and primed for replication in other hospitals. The team plans to undertake a formal research study to further evaluate the initiative, enabling more widespread sharing of results and supporting broader implementation across healthcare settings. By placing patients at the heart of care, this project exemplifies how innovation, collaboration, and compassion can transform the healthcare experience. I understand my swallowing problems… I’m 80, I’m old, I just want to enjoy the time I have left and eat and drink whatever I like!”

WINNER

In recognition of its impact, Risky Business won at the 2025 NSLHD Quality and Improvement Awards for Transforming Patient Experience. A video showcasing the project can be viewed: https://vimeo.com/1096127229

Achievements against Priority Initiatives

Patients and carers are our partners in their healthcare 01

HORNSBY KU-RING-GAI HOSPITAL Helping Patients Move Forward: Early Mobilisation of Critically Ill Patients

At Hornsby Ku-ring-gai Hospital, a groundbreaking initiative is changing the way critically ill patients experience care in the Intensive Care Unit (ICU). Recognising that prolonged immobility can lead to serious physical, psychological, and cognitive complications, the ICU team launched a project to promote early mobilisation—even for ventilated patients. Partnering with patients, families, and a multidisciplinary team, the ICU introduced a Physical Activity and Movement Assessment Tool, practical guidelines, and tailored staff education to overcome barriers to movement. The outcome was a more confident, recovery-focused ICU where patients were supported and empowered to regain movement and independence. The improvements have been significant and far-reaching: • Early mobilisation rates increased from 46.5% to 75.9% • Pressure injuries dropped from 12 to just 2 • ICU length of stay reduced from 82.85 to 76.47 hours • Staff confidence in mobilising patients rose to 100% • Annual cost savings estimated at over $1.2 million Patients reported improved mental health and a sense of autonomy, while staff embraced a culture of proactive, recovery-focused care. The initiative has become embedded in ICU practice, with training integrated into staff orientation and ongoing education.

Early mobilisation project team, Hornsby Ku-ring-gai Hospital

By listening to patients and working collaboratively across disciplines, Hornsby Ku-ring-gai Hospital has set a new standard for ICU care—one that prioritises movement, dignity, and healing. This project was also recognised at the 2025 NSLHD Quality and Improvement Awards , celebrating its transformative impact on patient experience and outcomes.

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NORTHERN SYDNEY CANCER CENTRE, ROYAL NORTH SHORE HOSPITAL INSPIRE-RT: Breaking Language Barriers in Cancer Care

At the Northern Sydney Cancer Centre, a simple idea has transformed the experience of culturally and linguistically diverse (CALD) patients undergoing radiation therapy (RT). The INSPIRE-RT (Inspire Radiation Therapy) mobile app was developed to ensure CALD patients can access the same high-quality care as English-speaking patients— by delivering radiation therapy instructions in their own language. Breath-hold techniques are used during radiation therapy to protect the heart and lungs. But for many CALD patients, language barriers made these techniques difficult to explain and often inaccessible. Recognising this gap, the Radiation Oncology team partnered with a patient consumer representative to co-design a solution that would be inclusive, respectful, and effective. The app provides education and real-time coaching in six commonly spoken languages across the district, including Mandarin, Arabic, and Vietnamese. It integrates with in-room audio systems, allowing radiation therapists to guide patients through treatment in a language they understand. The results and impact on patient experience have been transformative: • 100% of CALD patients have completed breath- hold treatment by using the app —up from 0% previously. • Treatment times have halved , and interpreter time has been reduced by 2 hours per patient, saving over $11,000 annually. • Patients report feeling safer, more respected, and better prepared . One patient shared: Being spoken to in my language made me feel respected and safe.”

INSPIRE -RT project team, Northern Sydney Cancer Centre

The use of the INSPIRE-RT mobile app is now embedded in routine care at Northern Sydney Cancer Centre, Royal North Shore Hospital and is being adopted by other hospitals across Sydney.

FINALIST

In recognition of its impact, INSPIRE-RT was a finalist in the 2025 NSW Health Awards for Excellence in Multicultural Healthcare . A video showcasing the project can be viewed here: https://vimeo.com/1096130128

Achievements against Priority Initiatives

Safe, high quality connected care 02

Safe, high-quality, reliable healthcare is delivered in a personalised way across all settings.

Improving Patient Flow Across NSLHD A district-wide collaboration involving senior health leaders—such as the acting Executive Director of Operations, General Managers, Directors of Nursing and Midwifery, Directors of Medical Services, and Whole of Health Leads—has developed improved patient transfer workflows. These go beyond the requirements of the NSW Adult Critical and Specialist Care Inter-Hospital Transfer Policy (PD2025_002) . The new system was developed after six months of data analysis. Key issues affecting patient flow included long wait times for public rehabilitation beds and delays in transferring patients who weren’t admitted but still needed specialist care. To solve these problems, the new workflows: • Speed up medical acceptance of care • Create clear escalation pathways for sub-acute patients who can't be transferred • Formalise agreements between hospitals to ensure timely access to services

The new system has already seen strong Improvements, leading to faster patient transfers and better use of resources, improving hospital efficiency across NSLHD. • Return to original hospital wait time has dropped from 1.51 days to 0.92 days at Hornsby Ku-ring-gai Hospital ; from 2.27 days to 0.85 days at Ryde Hospital; and from 2.41 days to 1.47 days at Northern Beaches Hospital . • Transfer time cut for non-admitted specialties (e.g., Urology from Ryde) from 10 hours to 6 hours • Rehabilitation or sub-acute transfer time reduced from 3.05 days to 1.55 days ( Royal North Shore to Hornsby Ku-Ring-Gai Hospital ), and from 2.99 days to 1.95 days ( Royal North Shore to Ryde)

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FAST-CT project team, RNSH

ROYAL NORTH SHORE HOSPITAL FAST-CT Stroke Pathway: Saving Time, Preserving Brain Function

At Royal North Shore Hospital, a new approach to stroke care is transforming treatment pathways and improving patient outcomes. The FAST-CT model— Facilitating Accelerated Stroke Transfers to Computed Tomography (CT) — was implemented in the Emergency Department to address delays in diagnosing and treating acute stroke patients, which can lead to irreversible brain damage and prolonged recovery. The FAST-CT pathway enables eligible stroke patients arriving by ambulance to bypass traditional triage and proceed directly to CT imaging while remaining on the ambulance stretcher. This streamlined approach ensures rapid access to thrombolysis and neuro-intervention, preserving critical brain function. The results have been remarkable: • Door-to-CT time reduced from 27 to 15 minutes • Door-to-needle time for thrombolysis reduced from 57 to 32 minutes • Hospital length of stay shortened from 5 to 4 days • No critical incidents reported , suggesting that patient safety is not compromised with this approach. • Patient selection was highly accurate , with only one stroke mimic identified among 120 cases— demonstrating the pathway’s strong ability to distinguish true strokes from similar presentations.

These improvements mean more patients regain speech, mobility, and independence—outcomes that profoundly impact quality of life. The pathway is now embedded in daily practice and has been successfully replicated at Hornsby Ku-ring-gai Hospital. The project exemplifies safe, high-quality, and reliable healthcare delivered in a personalised way, tailored to the urgency and needs of each patient. It reflects the power of collaboration across Emergency, Neurology, Radiology, and NSW Ambulance teams, and highlights how innovation can drive better care without requiring additional resources.

WINNER

In recognition of its impact, the FAST-CT project won the 2025 NSLHD Quality and Improvement Award for Patient Safety First. A video showcasing the project can be viewed here: https://vimeo.com/1096123907

Achievements against Priority Initiatives

Safe, high quality connected care 02

The Brolga team

CHILD & YOUTH MENTAL HEALTH SERVICES, MENTAL HEALTH DRUG AND ALCOHOL Safe, Supported, and Heard: Innovations in Adolescent Mental Health Care

The Brolga Unit is a child and adolescent mental health unit at Hornsby Hospital. The unit has transformed how staff manage challenging behaviours in a psychiatric setting. Recognising that enforcing rules can sometimes trigger self-harm or aggression, the team partnered with staff and adolescent consumers to co-design a new behavioural expectations framework, including teen-friendly posters for patients and a written guide for staff outlining expected behaviours and consequences. This co-designed model gave staff the tools and confidence to respond consistently and therapeutically, reducing reliance on restrictive practices. Six months after implementation, the unit saw: • 65% reduction in incidents of self-harm and aggression, • 78% decrease in restraint and seclusion use, • Lower re-admission rates, from 41% to 27%. Staff reported feeling more supported, better equipped to manage challenging behaviours, and safer in their roles. The initiative also reduced the need for emergency interventions and security call-outs, improving workflow and staff wellbeing.

By embedding transparent communication and shared expectations into daily practice, the Brolga team has created a safer, more stable environment for both patients and staff—demonstrating how co-designed tools can enhance care quality and outcomes in mental health settings.

WINNER

In recognition of its impact, the Brolga’s Behavioural Expectations Initiative project won the 2025 NSLHD Quality and Improvement Award for Excellence in the Provision of Mental Health Services . A video showcasing the project can be viewed here: https://vimeo.com/1096129421

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Brookvale Safe Haven

A second Safe Haven for young people was opened in September 2024 at Brookvale Community Health Centre, expanding support for those aged 12–17 (or up to 18 if still attending school). Alongside the first youth-focused Safe Haven at Macquarie Hospital, these are the only services in NSW dedicated solely to young people needing a safe, culturally sensitive space to talk openly and feel supported during times of distress or suicidal thoughts. Early evaluation of the Brookvale Safe Haven shows promising outcomes. Staffed by trained peer-support workers, the Safe Haven provides a calm, non-clinical environment where young people feel heard and can be connected to mental health professionals when needed. This initiative reflects NSLHD’s commitment to co-designed, community-based care that prioritises safety, dignity, and early intervention—ensuring young people have access to the right support, at the right time, in a space that feels safe and respectful.

You can watch a video about the NSLHD Youth Response Team and Safe Haven services on Vimeo (https://vimeo.com/936097350), highlighting the important work of Consumer Peer Workers and the NSLHD Youth Response Team in delivering culturally sensitive, non-judgmental care to adolescents in distress.

Achievements against Priority Initiatives

Keeping people healthy and well 03

Investment is made in keeping people healthy to promote wellness and address health inequity in our community.

PRIMARY AND COMMUNITY HEALTH Oral Health Screening for Children with Special Needs

Children and adolescents with special needs face significantly higher risks of oral disease due to medical, behavioural, and communication challenges. Recognising this inequity, the Oral Health Service at Northern Sydney Local Health District launched a school-based screening initiative to bring preventive care directly to students in special education settings. The program surveyed 320 students aged 5–19 across multiple schools. Of those screened, nearly 25 percent of younger children had never visited a dentist, and 10 per cent showed signs of dental decay, with 23 per cent presenting with calculus. These findings highlight the urgent need for accessible, early intervention. To address this, the team provided onsite dental screenings, fluoride varnish applications (with parental consent), and oral health packs. Families received personalised letters with results and referrals to public dental services where needed. A co-designed social story helped prepare students—many of whom are non-verbal or have sensory sensitivities—reducing anxiety and improving participation. By embedding care in familiar environments, the initiative overcame barriers such as transport, fear, and communication difficulties. It empowered families with knowledge and resources, supported schools with health planning, and promoted long-term wellness for a vulnerable population. This project exemplifies how targeted, inclusive health programs can reduce inequity and improve outcomes. It has sparked interest from other schools and is being considered for broader rollout.

Oral Health team

WINNER

In recognition of its impact, the initiative was awarded in the 2025 NSLHD Quality and Improvement Awards – Keeping People Healthy category . A video showcasing the project can be viewed here: https://vimeo.com/1096149042

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An in-language video with Tibetan parents, encouraging child development checks and shared across community channels

PRIMARY AND COMMUNITY HEALTH Pathways to Community Child and Family Health Services for Tibetan Refugee Families

In 2024–25, NSLHD launched a targeted initiative to improve access to child health and development services for Tibetan refugee families. This project was developed in response to concerns about low engagement with Child and Family Health Nurse checks beyond the newborn stage, limited uptake of the “Blue Book” health checks, and delayed presentation of Tibetan children to early intervention services. Recognising the need for culturally responsive care, the project focused on building trust, raising awareness, and creating accessible pathways for families. Key activities included: • Health Information Session: Tibetan families attended a session focused on healthy child development, helping to bridge gaps in understanding and access. • A “You Said, We Did” presentation to provide feedback on actions taken to address issues raised in Tibetan community consultations.

• An in-language animated video co-designed with Tibetan parents. The video explained the importance of child health checks and the role of parents in supporting development, shared widely on Tibetan community social media channels. • New Referral Pathways: Families were supported through referrals from a bilingual Tibetan Project Officer, the Multicultural Health Service, and in-language reminder calls to encourage attendance at health checks. Feedback from Tibetan parents revealed that nearly all participants (30 out of 31) reported that the video significantly improved their understanding of the importance of child health and development checks. To further measure the project’s success, health services will compare the number of Tibetan children receiving checks before and after the initiative. This data will help assess improvements in access and guide future efforts to reduce health inequities.

Achievements against Priority Initiatives

Keeping people healthy and well 03

Lorikeet Clinic: Addressing Needs of Domestic and Family Violence Survivors Northern Sydney Local Health District (NSLHD) developed and delivered the Lorikeet Clinic, a groundbreaking integrated medical, forensic, and psychosocial service for individuals affected by domestic and family violence. The clinic, which began operating as a Pilot in August 2024, is the first of its kind in New South Wales. supports connections with general practitioners to ensure continuity of care. Psychosocial support includes risk assessment, adaptive safety planning, trauma counselling, advocacy including and warm referrals to community services and ongoing

supports. The clinic also supports assessment and treatment for domestic and family violence related brain injuries through an established referral pathway with the NSLHD Concussion Clinic. The clinic’s design was informed by a review of patient needs and best practices from domestic and international models. Between August 2024 and June 2025, 48 individuals accessed the clinic, with strongly positive feedback from consumers. By integrating medical and psychosocial support with forensic documentation, the Lorikeet Clinic promotes health equity and fills a critical gap in services for DFV survivors. It stands as a model for future care across NSW. For more information, contact: NSLHD-PARVANintake@health.nsw.gov.au The Lorikeet Clinic is an important step in bridging critical service gaps and improving access to holistic care for victim survivors of domestic and family violence in our district.” Rachel Wolfe, Director, PARVAN Service

The Lorikeet Clinic is a free, trauma-informed service that supports people living in the local health district who have experienced domestic and/or family violence in the past 12 months. The clinic, staffed by a doctor and senior psychosocial clinician, sees people who have unmet health needs or a need for documentation of violence, including forensic documentation of injuries, in a bookable day time clinic. Funded by the NSW Ministry of Health, the initiative was developed by NSLHD’s Prevention and Response to Violence Abuse and Neglect (PARVAN) Services to address significant gaps in care for survivors with unmet health needs. The Lorikeet Clinic provides a safe space for patients to access a range of services, including assessment of non-acute injury, forensic examination and injury documentation used for legal purposes, contraception, Sexually Transmitted Infection and cervical screening, general medical care, and referrals to specialist and community services. It also

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and well supported 04

Our staff are engaged

Staff Safety at Work Ensuring the safety and well-being of our staff is a critical priority, particularly in high-pressure environments such as emergency departments. Across the Northern Sydney Local Health District (NSLHD), several innovative initiatives have been implemented to address the growing challenges of workplace aggression and psychosocial risks. These programs reflect a proactive, person-centred approach to staff safety and wellbeing. Staff are engaged and well supported to deliver safe, reliable person-centred healthcare and equipped to respond to a changing healthcare environment.

The Aggression Prevention and Minimisation Project at Royal North Shore Hospital’s Emergency Department introduced a cutting-edge training program using virtual reality and simulation to equip staff with skills to manage aggressive behaviour. This innovative approach aimed to reduce incidents and enhance staff confidence in handling challenging situations. The initiative led to measurable improvements in safety and staff wellbeing, earning the 2025 NSLHD Quality and Improvement Award for People and Culture.

The “Personal Safety” training initiative was added to NSLHD’s induction program to support newly graduated nurses . This training combines practical techniques with online learning to help nurses feel safer and more confident when facing challenging situations in the workplace. The Sexual and Gender-Based Harassment Safety Action Plan is NSLHD’s first district-wide initiative aimed at fostering a workplace where all staff feel safe, respected, and supported—free from harassment, discrimination, and bullying. Developed using national frameworks, the plan identifies gaps and implements proactive measures to prevent and address inappropriate behaviour. Health, Safety & Wellbeing. NSLHD is strengthening workplace safety by equipping leaders to manage risks effectively. In 2024, around 100 senior staff— including Board members and managers—completed WHS Due Diligence training , fostering open discussion and critical thinking. A new Health, Safety & Wellbeing Steering Committee now meets quarterly to oversee safety efforts, improving communication and support across the district. NSLHD maintains low injury rates and supports staff recovery through strong injury management—reducing workers’ compensation costs and improving outcomes for staff.

2025 NSLHD Quality and Improvement Award for People and Culture View a video of this award-winning project: vimeo.com/1096131074

WINNER

The Psychosocial Risk Management Training is a specialised online workshop designed for managers across NSLHD. It equips them to identify and manage psychosocial risks—such as stress and burnout— while reinforcing the importance of psychological safety and legislative responsibilities. The training also introduces NSLHD’s Psychosocial Risk Assessment Tool , which managers are encouraged to apply within their teams. To date, 374 managers have completed the training, contributing to a stronger culture of psychological safety across the district.

Achievements against Priority Initiatives

and well supported 04

Our staff are engaged

2024 Applied Safety and Quality Program Graduates

Investing in Leadership Capability for Safety and Quality The Nursing and Midwifery Academy’s Springboard to Success Program is designed to empower early-career

• 26% expressed interest in improving collaboration across disciplines and sharing what they’ve learned.

Registered Nurses and Midwives to lead person- centred care and foster positive workplace cultures. The program features guest speakers and experts from across NSLHD and the NSW Ministry of Health. These include representatives from Clinical Governance, Aboriginal and Torres Strait Islander Health Services, People and Culture, Carer Support, Library Services, and Disability Services. So far, 65 nurses and midwives have taken part, with 37 enrolled in 2025. Key components of the program include interactive workshops, self-directed learning, and guided development of local quality improvement projects. These projects aim to improve patient outcomes and strengthen team engagement. As a result, three oral presentations and 15 posters were selected for the 2024 NSLHD Nursing and Midwifery Person-Centred Care Showcase. The program has shown strong results: • 82% of participants rated it as extremely valuable. • 100% reported gaining new leadership knowledge and skills. • 53% said they had improved understanding of team engagement. • 29% developed skills in change management and quality improvement. • 43% plan to involve their teams in future quality improvement projects. • 38% intend to role model their new skills in the workplace.

Since 2023, NSLHD has partnered with the Clinical Excellence Commission to deliver the Applied Safety and Quality Program – the highest-level offering under the Safety and Quality Essentials Pathway . In 2024, 17 staff graduated from the program and were recognised at a showcase ceremony at Royal North Shore Hospital. Over 12 months, participants completed intensive workshops, learning groups, and one-on-one coaching while leading workplace improvement projects. Most learning took place in the workplace, where staff led improvement projects and applied skills directly to their roles. The program aligns closely with the district’s strategic outcomes, particularly in two key areas: providing safe, high-quality, and connected care, and ensuring our staff feel engaged and well-supported These programs support NSLHD’s strategic goal by building a skilled workforce that leads change, improves patient outcomes, and strengthens a culture of person-centred care and continuous improvement.

https://bit.ly/4mF8I4r

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Parental Leave Understanding and Support Program team, RNSH Emergency Department – 2024 NSW Health Award winners

PLUS project leads: Dr Lucy Harten-Ash and Alison Partyka

ROYAL NORTH SHORE HOSPITAL Parental Leave Understanding and Support Program The Royal North Shore Hospital Emergency

With national interest and potential for replication, the program sets a new benchmark for how healthcare services can support their teams— ensuring that safe, high-quality, and reliable care is delivered by staff who feel empowered and cared for.

Department is leading the way in staff wellbeing with its Parental Leave Understanding and Support (PLUS) Program—a comprehensive initiative designed to support emergency clinicians as they transition to and from parental leave. Recognising the challenges faced by new parents in high-pressure clinical environments, the PLUS Program offers a tailored return-to-work experience. It includes mentorship, wellness sessions, lactation support, and access to a dedicated family room designed to promote psychological and physical wellbeing. By addressing the personal and professional needs of staff, the program fosters a more resilient, supported workforce and contributes to safer, more consistent patient care. Staff report feeling more valued and better equipped to balance clinical responsibilities with family life. The program has already shown promising outcomes in improving staff retention and engagement, and ongoing research is underway to evaluate its long-term impact.

WINNER

In recognition of its success, the Parental Leave Understanding and Support Program was awarded the 2024 NSW Health Award for People and Culture . A video showcasing the initiative can be viewed from: https://www.health.nsw.gov.au/awards/2024/Pages/ plus-program.aspx

Achievements against Priority Initiatives

Research, innovation and digital advances inform and improve the delivery of patient care 05

The care we deliver is digitally enabled and informed by research and data.

Tomorrow’s Medicine Today Northern Sydney Local Health District (NSLHD) has embedded clinical trials into its healthcare model, aiming to make trial participation a standard care option. Governance is led by the Chief Executive, the Executive Director of Research, and the Research, Innovation and Technology Committee. Safety and quality are maintained through ethical oversight, rigorous protocols, and partnerships with institutions like the University of Sydney and Macquarie University. The district’s research culture is supported by the Kolling Institute and the NORTH Foundation, which also drives philanthropic engagement. NSLHD has achieved global recognition for its clinical trials across oncology, geriatrics, nephrology, endocrinology, and more. Key trials in various fields of medicine include: • Radiation Oncology: Data-driven trials at Royal North Shore Hospital have improved cancer care. • Geriatric Pharmacology : The Drug Burden Index tool has reduced medication-related harm in older adults. • Kidney Disease: International trials led by Dr Brendon Neuen influenced WHO guidelines. • Rare Diseases: Trials have provided early access to life-saving treatments. • Cancer Research: The NORTH Sydney Trials and Research Van Norton Poche – NORTH STAR VNP – launched with a $20 million donation, is revolutionising cancer trials. • Consumer Engagement: Focus groups and inclusive trial designs have improved recruitment and outcomes.

NSLHD is expanding staff training, enhancing data infrastructure, and promoting inclusive trial designs. Long-term sustainability is supported by philanthropic investment and a culture of innovation.

The district’s commitment to transparency and public engagement is exemplified by the Tomorrow’s Medicine Today podcast, which features leading researchers discussing breakthroughs in care. The NSLHD Research Hub provides access to ongoing projects, trial opportunities, and community involvement, reinforcing the district’s vision of bringing tomorrow’s medicine to patients today.

Access Tomorrows medicine today podcasts from: https://www.nslhd.health.nsw.gov.au/Research/Pages/Tomorrows- medicine-today-podcast.aspx NSLHD Research Hub: https://www.nslhd.health.nsw.gov.au/Research/Pages/default.aspx

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Achievements against Priority Initiatives

NSLHD clinical trials snapshot

In 2024, there were 400 clinical investigators and staff working on 350 clinical trials across the district.

Our clinical investigators are recognised in the world’s top 2% of scientists in the prestigious Stanford/ Elsevier rankings.

Our research is published in the top scientific journals in the world, including Nature, The Lancet, JAMA, The BMJ and The New England Journal of Medicine.

We collaborate with clinical investigators and researchers

at many institutions at the University of Sydney, Macquarie University, University of Technology Sydney, NSW Health, Sydney Health Partners, Sydney North Healthcare Network, and others.

Northern Sydney Local Health District. (2024). Tomorrow’s Medicine Today Edition 1. Retrieved from: https://bit.ly/4lr1PTc

Achievements against Priority Initiatives

Our services are sustainable, efficient and committed to planetary health 06 We use a value-based approach to optimise the use of resources with a focus on embedding both planetary health and financially sustainable principles in everything we do.

NSLHD Planetary Health team – 2024 NSW Health Award winners

Carbon Footprint and Pathway to Net Zero NSLHD is committed to achieving net-zero emissions by 2035 for emissions it controls directly, and by 2050 for those it can influence. To support these goals, NSLHD’s Planetary Health team, in collaboration with Arup Australia and the NSW Department of Climate Change, Energy, the Environment and Water, led a project to measure the district’s carbon footprint and create a pathway to net zero. This project, the first of its kind in any local health district, involved three key stages: collecting data to calculate the baseline carbon emissions, identifying emission-reducing interventions based on evidence and staff consultation, and modelling a pathway to net zero, aligned with the Paris Agreement’s 1.5°C goal. This initiative has led to a comprehensive plan for reaching net zero by 2035, positioning NSLHD as a leader in sustainable healthcare. The insights gained from this work have shaped the NSLHD Planetary Health Framework 2024-2027 .

WINNER

In recognition of its achievements, this initiative was awarded the 2024 NSW Health Award for Environmental Sustainability . A video showcasing the initiative can be viewed from: https://www.health.nsw.gov.au/awards/2024/Pages/ carbon-footprint-pathway-to-net-zero.aspx

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Achievements against Priority Initiatives

ROYAL NORTH SHORE HOSPITAL More for Less: Value-Based Care for a Greener ICU

The Royal North Shore Hospital (RNSH) Intensive Care Unit (ICU) Green Team is leading the way in embedding sustainability into everyday clinical care, demonstrating how environmentally conscious healthcare can also be efficient, cost-effective, and patient-centred. The team completed two pioneering projects to reduce low-value interventions: unnecessary use of intermittent pneumatic compression devices and routine chest x-rays . These changes delivered measurable environmental and financial benefits, whilst maintaining high-quality patient care and preserving staff and patient safety. • intermittent pneumatic compression device Reduction: A targeted education campaign led to a 91 per cent drop in unnecessary use, saving over $7,600 annually and reducing 51.8 kg of CO 2 emissions—the equivalent of driving a medium-sized petrol car 160 km. • Chest x-ray Reduction: A decision-support tool and staff education reduced chest x-ray use by 15.3 per cent, estimated annual saving $223,560 and cutting 165.6 kg of CO 2 emissions—comparable to a 515 km car journey.

These interventions required no new infrastructure and designed for scalability across NSW Health. By aligning clinical practice with planetary health principles, the ICU Green Team has shown that sustainability and high-quality care go hand in hand. This project exemplifies value-based care—optimising resources, improving outcomes, and reducing environmental impact. It’s a blueprint for a resilient, low-carbon health system where sustainability is not an add-on, but a standard of care.

Our Performance in Safety and Quality

NSLHD uses high-quality data and analytics to understand clinical performance, support decision-making, and drive system and practice improvements. Performance is monitored against safety and quality benchmarks across all levels of the organisation to maintain high standards and reduce avoidable harm. Key indicators are reported through clinical governance structures, review teams, and relevant forums to ensure accountability and transparency. This section outlines NSLHD’s safety and quality performance for the 2024-2025 financial year, aligned with NSW Health outcomes.

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Our Performance in Safety and Quality (2024 - 2025 FINANCIAL YEAR)

People receive high-quality, safe care in our hospitals.

SAFETY QUALITY DIMENSION

Hospital Acquired Complications (HACs) FY2025

Bedsores Hospital Acquired Pressure Injuries

Infections Healthcare Associated Infections

180 160 140 120 100

≤ 155.0

≤ 6.7

80 60 40 20 0

3.1

100.4

NSLHD Average

NSLHD performance limit

NSLHD Average

NSLHD performance limit

NSLHD has met and exceeded the target.

Breathing complications Hospital Acquired Respiratory Complications

Blood clots in the vein Hospital Acquired Venous Thromembolism Deep Vein Thrombosis or Pulmonary Embolism

≤ 12.0

≤ 45.2

27.3

7.6

NSLHD Average

NSLHD performance limit

NSLHD Average

NSLHD performance limit

NSLHD has met and exceeded the target.

Source: NSW Health’s Enterprise Data Warehouse for Analysis, Reporting and Decision (EDWARD) Coded data.

STATUS KEY

Highly Performing Performing at, or better than target

Underperforming Performance within the tolerance range

Not performing Performance outside the tolerance range

Our Performance in Safety and Quality (2024 - 2025 FINANCIAL YEAR)

People receive high-quality, safe care in our hospitals.

SAFETY QUALITY DIMENSION

Kidney failure Hospital Acquired Renal Failure requiring haemodialysis or continuous veno-venous haemodialysis

Bleeding in the digestive tract Hospital Acquired Gastrointestinal Bleeding

16 14 12 10

≤ 12.3

≤ 3.1

8 6 4 2 0

6.9

0.4

NSLHD Average

NSLHD performance limit

NSLHD Average

NSLHD performance limit

NSLHD has met and exceeded the target.

Medication complications Hospital Acquired Medication Complications

Sudden confusion Hospital Acquired Delirium

80 70 60 50 40 30 20 10 0

≤ 10.7

≤ 60.0

6.6

38.5

NSLHD Average

NSLHD performance limit

NSLHD Average

NSLHD performance limit

NSLHD has met and exceeded the target.

Heart complications Hospital Acquired Cardiac Complications

Low blood sugar and malnutrition Hospital Acquired Endocrine Complications Malnutrition and Hypoglycaemia

40 35 30 25 20

≤ 34.9

≤ 49.4

15 10

5 0

27.3

21.8

NSLHD Average

NSLHD performance limit

NSLHD Average

NSLHD performance limit

NSLHD has met and exceeded the target.

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www.nslhd.health.nsw.gov.au

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