July 2022 - Foresight Newsletter

JULY 2022

EDITION 16

NSLHD CLINICAL GOVERNANCE FRAMEWORK 2022 - 2025

IN THIS EDITION:

NSLHD Clinical Governance Framework Sepsis Clinical Care Standard Where to find the latest PPG Communique

Northern Sydney Local Health District strives to be recognised as a leader in patient safety, patient experience and the delivery of high-quality care and clinical outcomes. Our recently released NSLHD Clinical Governance Framework (the Framework) acknowledges Clinical Governance as an integrated component of organisational governance. It ensures that everyone – from frontline clinicians to managers and members of our governing bodies, including the Board, is accountable to our patients and the community for assuring the delivery of safe, effective and high-quality services. The Framework expresses the necessary elements, structure and systems to deliver safe, high-quality care and promotes an organisational culture of openness, transparency and continuous quality improvement. The objectives are based on the interrelated clinical governance components outlined in the ACSQHC’s National Model Clinical Governance Framework and our patients’ and consumers’ expectations of the health service. As reflected in the National Clinical Governance Framework and the National Safety and Quality Service Standards, NSLHD’s six interrelated Clinical Governance components are;

Fine Print newsletter - new legislation Accreditation Assessment Progress Privilege in Serious Adverse Event Investigations Patient-Centred Care Quality dimension Clinical Audits - July

What did you think of this issue? Give us your feedback.

Governance Leadership and Culture, Partnering with Consumers, Aboriginal and Torres Strait Islander Health, Patient Safety and Quality Systems, Clinical Performance and Effectiveness, Safe and Welcoming Environment.

The central component relates to patients and consumers, who are at the centre of NSLHD’s Clinical Governance Framework. The NSLHD Clinical Governance Framework 2022 – 2025 builds on and replaces the NSLHD Clinical Quality Improvement Framework 2016 – 2022.

Click image to download the NSLHD Clinical Governance Framework 2022 - 2025

Clinical Governance Standard

JULY 2022

EDITION 16

The National Clinical Care Standards (ACSQHC) Describe the care patients should be offered by health professionals and health services for specific clinical conditions or defined clinical pathways in line with current best evidence. Play a vital role in reducing unwarranted variation. Are developed in collaboration with a topic working group of clinicians, researchers and consumers. Public consultation is also conducted before finalisation. Describe high-priority areas for quality improvement. They are based on areas of current variation, information about what we know works in terms of treatments, procedures and processes, and what care should be offered to a patient. Visit the Commission's website for a full list of National Clinical Care Standards in use and in development (ACSQHC) The NSLHD Weekly Bulletin dropped into your email inbox is where you will find the latest policies, procedures and guidelines (PPG) Communique. WHERE DID THE PPG COMMUNIQUE GO? Released weekly, the Communique provides information on;

The Australian Commission on Safety and Quality in Health Care (ACSQHC) has recently released the national Sepsis Clinical Care Standard, in partnership with The George Institute for Global Health. The standard outlines optimal care for patients in hospital with suspected sepsis – from the onset of signs and symptoms, through to discharge from hospital and follow- up care. Each year more than 8,700 Australians die from sepsis[i], a condition that is triggered by an infection and can turn into a deadly disease if undetected. People with sepsis can deteriorate quickly, and the early signs and symptoms can be hard to recognise. It is crucial to ask, ‘Could it be sepsis?’ . Using the standard will support our clinicians to recognise the signs of sepsis and identifying patients who need urgent assessment and treatment. The standard highlights the need to plan and coordinate care, including for post-sepsis syndrome which can affect up to 50% of adults. The standard provides guidance for clinicians on timely recognition of sepsis, early and appropriate antimicrobial therapy and continuity of care when patients are discharged from the hospital and may need support for longer-term effects from sepsis. The Sepsis Clinical Care Standard was informed by leading clinical experts and consumers and translates evidence into clinical practice to reduce preventable death or disability caused by sepsis. The Sepsis Clinical Care Standard was launched via webcast on Thursday, 30 June 2022.

Recently published NSLHD PPG, Recently rescinded NSLHD PPG,

Most recently published MoH Directives, Guidelines and Information Bulletins, NSLHD PPG Drafts for comment, NSLHD PPGs approved to start development.

Click on the image to view the webcast recording of experts launching this clinical care standard.

You tube | 56mins

Contact: [email protected]

Reference: [i] Rudd KE, Johnson SC, Agesa KM, Shackelford KA, Tsoi D, Kievlan DR, et al. Global, regional, and national sepsis incidence and mortality, 1990– 2017: analysis for the Global Burden of Disease Study. Lancet 2020;395(10219):200–11. A clinicians fact sheet on the standard is available and lists the seven quality statements in the Sepsis Clinical Care Standard and describes what each statement means for clinicians involved in sepsis care. It outlines key considerations for clinicians in regard to equity and cultural safety.

FINE PRINT NEWSLETTER

The Fine Print newsletter is prepared by the Ministry of Health that highlights recent legislative, regulatory and other governance developments. The August 2022 edition can be accessed here.

Recognising and responding to acute deterioration standard

Clinical Governance Standard

JULY 2022

EDITION 16

ACCREDITATION ASSESSMENT PROGRESS

Royal North Shore Hospital (has) a culture of safety and quality improvement in all areas. RNSH shared many examples of creative, innovative practices and changes that have been implemented to continually support safety and quality for their consumers. There is a strong and genuine commitment to consumer engagement within Royal North Shore Hospital. Considering the constraints and challenges that the COVID-19 pandemic has brought over the last two years, these results have been remarkable achievements. NSLHD is proud to see the high quality of care provided to our patients recognised by the Assessors. Primary and Community Health (PACH) continue to prepare for their accreditation assessments, scheduled for 22 – 26 August . We wish them well. Contact your local Quality and Safety or Clinical Governance Unit, or [email protected] (National Safety & Quality Health Service Accreditation Manager) for more information

Partnering with Consumers Standard [1] Reportable Incident: All clinical Harm Score 1 incidents; Chief Executive determined specific clinical incidents Harm Score 2-4 where there are serious systemic problems; Term Babies with suspected or confirmed harm (early neonatal deaths/ severe brain injury diagnosed in the first seven days of life). Incident Management PD2020_047 Statutory privilege protects Preliminary Risk Assessment (PRA) and Serious Adverse Event Review (SAER) team members and documents they produce during a review from use as admissible evidence in any legal proceedings. PRA and SAER team members are bound by strict confidentiality requirements, making it an offence for them to disclose information obtained during the PRA or SAER, unless it is for the purpose of the PRA or SAER or in other limited defined circumstances. and serious clinical incidents to improve patient safety and care outcomes. All staff involved in any serious clinical incident and or adverse event should understand what 'privilege' is and the process of a privileged investigation. What is privilege? When a reportable incident [1] occurs, it is important that staff feel safe to speak frankly about what happened and what they observed. Health Services can then learn from such incidents. Privilege supports people who feel concern for their confidentiality when asked for their recollections of an incident. In May 2022, the Australian Council of Healthcare Standards (ACHS) confirmed that Hornsby Ku-ring-gai Hospital and Royal North Shore Hospital met all the requirements of the National Safety and Quality Health Service Standards 2nd edition. The ACHS Assessors provided very positive feedback for both hospitals such as; Hornsby Ku-ring-gai Hospital’s Patients, Carers and Consumers all verbalised how proud they are of the Hospital. Evidence was sighted of an extensive commitment to consumer engagement and partnerships with an inclusive approach to the local Aboriginal and Torres Strait Islander community. Staff reflected their commitment and engagement in everything they do to deliver a high-quality healthcare service. This shines through in the care provided and the outcomes achieved for their patients.

'PRIVILEGE' MEANING AND REQUIREMENTS IN SERIOUS ADVERSE EVENT INVESTIGATION NSLHD is committed to learning from adverse events

How is privilege created? The Chief Executive appoints a team to undertake a PRA or SAER. Teams are appointed under Section 20M of the Health Administration Act 1982. Statutory privilege applies to team members from the time the

PRA or SAER team is appointed. What does privilege apply to?

Clinical Governance Standard Refer to Incident Management PD2020_047 or contact for more information [email protected] (NSLHD Patient Safety Manager) Clinical Governance Standard What can be disclosed? The SAER final findings report and recommendations report remain privileged, in that they cannot be used in legal proceedings, however, they can be lawfully provided to any person. During the PRA and SAER process, the team will generate many documents including preliminary notes, records of interviews with staff/clinicians, minutes of discussions, and records of discussions with various people either involved in the incident or with fundamental knowledge about the incident or processes involved. All this material is privileged. What does privilege not apply to? Privilege does not apply to documents produced previously including the IMS+ incident reports, or medical records.

JULY 2022

EDITION 16

Sensory modulation resources were acquired and made available in a sensory modulation room that allowed consumers in the mental health inpatient unit who were experiencing distress to access the appropriate equipment to manage their condition, e.g. listen to music, use weighted blanket. A patient centred care plan was designed for all patients who entered the Osteoarthritis chronic care program (OACCP) across NSLHD There are many examples of NSLHD initiatives which have been introduced that adopts patient centred care practices. Here are just some examples. Can you think of more? Ryde Hospital undertook refurbishments to support, comfort and dignify the family experience of palliative care, by creating a more home-like environment for families and carers of palliative care patients. This involves the refurbishment of three discreet spaces; a Family & Carer Restoration Suite, Family Accommodation and a dedicated and private Outdoor Garden space to create a tranquil and user-friendly outdoor space for families of palliative care patients to relax and reflect. To ensure that clients' needs were being met, the “Have your say” client satisfaction survey was introduced by Allied Health (AH). The responses mean that Residential aged care facility residents were more involved in the decision-making regarding their care and the AH department were better meeting client expectations

In this edition, let's dive deeper into another of the six dimensions of healthcare quality .

PATIENT CENTRED CARE

Nothing about me, without me!

Patient centred care is care that respects and responds to individual patient preferences, needs & values.

Does your daily routine consider the patient’s needs or impede their experience of comfortable, timely, reliable and safe care? Do you gather feedback from patients about the experience of their care to help you guide your improvement ideas? Do you involve patients and families in prioritising your improvement efforts according to what matters most to them? How can you play a part in making sure that the care you provide is patient centred in your workplace? A culture of patient centred care is marked by behaviours that are trustworthy, inclusive and respectful in order to improve the experiences of the patient, and their families or carers across the continuum of care. These behaviours also promote mutually beneficial partnerships between healthcare employees, patients and their families or carers. Care that is patient-centred refers to the whole person, beyond their symptoms and treatment. It is care that considers the desires of patients and respects their cultural background.

Find out more

Contact: [email protected] or [email protected] (Clinical Reliability Improvement Facilitators, Clinical Governance) Monthly Drop-in clinics are open to anyone undertaking an improvement project or has an interest in resources and tools to run a successful improvement project. Foundations of Safety and Quality e-learning pathway on My Health Learning (course code 335318052) The Safety and Quality Essentials Pathway (CEC) NSLHD Quality Improvement Intranet page. Join in the next virtual one-day Improvement Science workshop on 6 September 2022. Enrol via MHL course code 42956746.

Partnering with Consumers Standard

Clinical Governance Standard

JULY 2022

EDITION 16

M&M PODCAST SERIES NOW ON SPOTIFY

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.

The CEC's four-season Guiding Principles of Morbidity and Mortality (M&M) meetings in action podcast series is now available to listen to on your phone or desktop via Spotify. This podcast series provides insights and an engaging narrative with clinical leaders and is a useful resource in supporting the Guidelines for Conducting and Reporting Morbidity and Mortality / Clinical Review Meetings (CEC, 2020)

July 2022 QARS Audit (entry links below)

NSLHD_03_Peripheral Intravenous Cannula (PIVC) Insertion & Management - NEW VERSION NSLHD_4_Monthly Accountable Drug (S4D_S8) Register Audit (RNSH | HKH | Ryde | MV | MHDA)

St 3

St 4

Visit the Mortality Review page on the NSLHD Intranet for more resources.

St 7

NSLHD_07_Patient Blood Management - MEDICAL 2022

NLSHD_08_Monthly inspection for resuscitation trolley/ Resuscitaire equipment checklists (RNSH | HKH | Ryde | MV | MHDA | PACH)

St 8

Clinical Governance Standard

POLICIES, PROCEDURES AND GUIDELINES New, updated and recently published district-wide PPGs.

Clinical Governance Standard

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 Falls Prevention and Management - Adults - NSLHD Procedure Falls Prevention and Management - NSLHD Policy Paediatric Falls Prevention and Management - NSLHD Procedure Administration of Fibrinogen Concentrate (RiaStap®) NSLHD Guideline Referral to Community Nursing Services –NSLHD_Procedure Medication Handling in Primary and Community Health –NSLHD_Procedure Care Zoning Clinical Practice Guidelines Community MHDA_Guideline

LESSONS LEARNED FROM SERIOUS ADVERSE EVENT REVIEWS

Clinical Governance Standard

Did you know that the Clinical Excellence Commission shares findings from serious incidents that have occurred across NSW to aid in reducing preventable risk of a similar event occurring to another patient? Recent publications include: Lessons from Prevention and Response to Violence Abuse and Neglect Serious Incident Reviews across NSW - June 2022 Lessons and learnings from Mental Health, Alcohol and Other Drugs Serious Incident Reviews - Intoxicated persons in ED and care across services - July 2022 More publications are available from the lessons learned intranet page. The scenarios depicted in the publications have been drawn from a variety of cases across NSW in order to maintain the confidentiality of consumers and staff. It is acknowledged that the issues identified in these cases represents a small portion of care.