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March 2022 - Foresight Newsletter
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RECOMMEND FLIP-BOOKS
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PARTNERING WITH CONSUMERS FRAMEWORK NSLHD's Partnering with Consumer Framework is coming soon. The framework outlines our district's commitment to partnering with consumers and the broader community. Northern Sydney Local Health District's vision is to grow and support inclusive, collaborative consumer engagement through valued partnerships to inform health service planning, delivery, development and evaluation from lived experiences. The framework will be made available to all staff from the Partnering with Consumers intranet pages
IN THIS EDITION :
NSLHD Partnering with Consumers Framework Co-design with consumers Australian Charter of Healthcare Rights - new resources 2022 NSLHD Quality and Improvement Awards Patient Experience Week Patient Safety Week The safety quality dimension What did you think of this edition? Give us your feedback. Consumers bring unique and different perspectives to all parts of service development, delivery and governance. When developing ideas, start the conversation with our consumer advisors and develop the ideas together. CO-DESIGN WITH CONSUMERS This video describes how co-design thinking with consumers is a key habit for highly engaged committees
WHAT'S NEW The NSLHD Partnering with Consumers and Patient Experience intranet pages provide a wide range of resources, learning tools and webinars for staff on elevating the human experience , health literacy and engaging consumers. Check out the “What's New” intranet page and newsletter for new resources and upcoming events.
Resources:
How to recruit a consumer advisor Consumer advisor toolkit
Clinical Governance Standard
Partnering with Consumers Standard
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PATIENT SAFETY AWARENESS WEEK MARCH 1 3 - 1 9 2 0 2 2 An easy English version of the Charter My Healthcare Rights – flyers for consumers and health service organisations A range of posters Translation of the Charter into various languages for people with cognitive impairment An Auslan video Translation of the Charter into 19 languages A copy of the Charter in braille is available from Safety and Quality Managers at your facility or service AUSTRALIAN CHARTER OF HEALTHCARE RIGHTS - NEW RESOURCES The Australian Commission on Safety and Quality in Healthcare has recently released a new resource pack for the Australian Charter of Healthcare Rights. New resources include;
Partnering with Consumers Standard
Patient Experience Week is an annual event to celebrate healthcare staff impacting patient experience every day. Patient Experience Week provides a focused time for organisations to celebrate accomplishments, re-energise efforts and honour the people who impact patient experience every day. Visit NSW Health's Elevating the Human Experience website to see upcoming events and resources APRIL 25-29 2022 PATIENT EXPERIENCE WEEK
Clinical Governance Standard
Patient Safety Awareness Week is an Institute of Healthcare Improvement initiative held annually to encourage everyone to learn more about healthcare safety. According to the World Health Organization, one in every 10 patients is harmed while receiving hospital care. Preventing harm in healthcare settings is a public health concern. Everyone interacts with the healthcare system at some point in life and everyone has a role to play in advancing safe healthcare. The delivery of safe and reliable healthcare in complex clinical settings is reliant on the insight and experiences gained from healthcare staff and their voices are crucial. All staff need a psychologically safe environment to provide them with the best experience of working in the system. Psychological safety has also been shown to improve patient outcomes. The NSLHD Mental Health Drug and Alcohol (MHDA) Governance Support Unit is providing daily webinars (14-18 March) on aspects of consumer safety in MHDA services. See flyer for more information. Visit the Clinical Excellence Commission's Patient Safety Awareness Week webpage to view virtual
sessions and webinar recordings on statewide initiatives. Ref: World Health Organization, Patient Safety Fact file, 2019.
2022 NSLHD QUALITY AND IMPROVEMENT AWARDS The awards celebrate the outstanding achievements of our teams who lead change to improve patient outcomes and experience, staff experience and the quality of our health service. The 2022 NSLHD Quality and Improvement Awards are now open for entries until 29 April 2022. Visit the NSLHD Quality and Improvement Awards Intranet page for more information and to download the submission guide and entry form. Entrants are encouraged to attend an online session on how to write up an award entry on 22 March 2022 (11:00am-11:30am) Register your interest here. Contact: Catherine Rosario (Clinical Reliability Improvement Facilitator) [email protected]
Watch short video of the Towards Zero Falls project as well as all the winning projects from last year's NSLHD Quality and Improvement Awards.
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Clinical Governance Standard
In this issue we will take a closer look at one of the six dimensions of healthcare quality.
THE SAFETY DIMENSION
The safety dimension of quality is defined as c ontinuously improving the delivery of better health outcomes by minimising the risk and impact of unnecessary harm to patients. To ensure reliably safe, quality healthcare the following systems are in place.
Most often, it is the design of the system that results in a safety incident rather than human error. The majority of the time, we deliver world-class, safe, reliable and person-centred care, even in busy and complex work environments. However, there is room for improvement and NSLHD staff continuously strive to improve care. How can we play a part in making sure safety incidents are less likely to occur in your workplace? There are many examples of initiatives from NSLHD that have led to the prevention of patient harm incidents. Below are just some examples. Can you think of more? It was identified that not all GPs were receiving the information they needed for ongoing care of patients following discharge from hospital. Therefore the physiotherapy department at Mona Vale Hospital came up with a plan to “communicate for safety” as a way to ensure that GPs received the discharge information they needed in a standardised and timely way. At MHDA, an acute behavioural disturbance is prevented or minimised using violence prevention and management techniques to reduce the harm experienced by consumers (e.g. psychological impacts of seclusion) and staff (as victims of physical aggression). The healthcare environment is designed and built to minimise risk of harm from infection transmission, e.g. improved ventilation, hand hygiene stations. The hospital-wide falls prevention collaborative project Towards Zero Falls @ Ryde has achieved its aim to reduce the social, psychological and economic impact of falls on individuals, families and the community. In 2021, the team was able to show a 63 per cent reduction in serious harm falls events, a 28 per cent reduction in overall falls rate and seven consecutive months of zero falls.
Incident monitoring
Incidents reported in ims+ are reviewed to determine factors that contributed to the incident. In particular, serious harm incidents undergo formal investigations.
Safety reviews
Staff who are involved in an incident are encouraged to be reflective and engage in reviews. Their recollections from the time of the incident and their ideas to improve the system are so important.
Human factors
Most adverse events in health are not due to technical failures. All humans make mistakes and understanding the factors that reduce our ability to perform at our best can in turn assist us to propose solutions on how to reduce risks. Human factors is a science that focuses on understanding human behaviour and how people interact with each another and their environment.
Just cultures
NSLHD encourage employees to report incidents and near misses to promote a culture where individuals are treated fairly and not blamed for failures of the system. The focus is on improving the systems that enabled the incident to occur. In this way, we are learning to prevent the same types of incidents from recurring and we make our systems safer.
Psychological safety
Staff, patients, families and carers must feel psychologically safe to speak up when there is a concern. Psychological safety is the mental state in which one feels safe to learn, contribute and challenge the 'status quo' without fear of being embarrassed, marginalised or punished. Safety is optimised when people are more likely to raise a safety concern by speaking up for safety.
Contact [email protected] (Clinical Reliabilty Improvement Facilitator) for further information
NSLHD CLINICAL AUDIT SCHEDULE MARCH 2 0 2 2
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March 2022 QARS Audit (entry link) 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. March 2022 QARS Audit (entry link) 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.
NSLHD_6_Consent Audit (RNSH | HKH | MV)
NSLHD_03_Aseptic Technique
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NSLHD_04_ User applied labelling audit NSLHD_4_Monthly Accountable Drug (S4D_S8) Register Audit (RNSH | HKH | Ryde | MV | MHDA) NSLHD_05_Pressure Injury Prevention for Maternity Services (RNSH | HKH | Ryde) NSLHD_05_Surgical plume and electrosurgical audit (RNSH | HKH | Ryde) NSLHD_05_Communication and Care Cues - Cognitive Impairment
NLSHD_08_Monthly inspection for resuscitation trolley/ Resuscitaire equipment checklists
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NSLHD_8_Resuscitaire Checklist (RNSH | HKH | Ryde | MV | MHDA)
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POLICIES, PROCEDURES AND GUIDELINES New, updated and recent ly publ ished distr ict-wide PPGs.
Clinical Governance Standard
For the most up-to-date l ist , refer to NSLHD PPG Communique The fol lowing l inks to documents from the Prompt document system. Open Disclosure – Guidelines for Clinician Disclosure and Formal Open Disclosure – NSLHD Nursing Hours Per Patient Day (NHPPD) Guidelines – NSLHD Patient Controlled Analgesia (PCA) NSLHD Management of Infection Risk to Patients from Animal Visitations Opioid-Induced Ventilatory Impairment - Mechanisms and Management Admission and Discharge Criteria For NSLHD Subacute Inpatient Rehabilitation Units - NSLHD Referral to Subacute Inpatient Rehabilitation Antidepressant Medication in Pregnancy: Care Planning - NSLHD Clinical Supervision for Nurses and Midwives - NSLHD Idarucizumab (Dabigatran Reversal Agent) - NSLHD Infectious Diseases / Transmissible Micro-organisms - a Reference Guide - NSLHD
Clostridium difficile / Clostridioides difficile (C.diff) Extended Spectrum beta lactamase - (ESBL) Methicillin resistant Staphylococcus aureus - (MRSA) Multi-Resistant Acinetobacter baumannii - (MRAb) Multi-Resistant Pseudomonas aeruginosa - (MRPA) Tuberculosis - (TB) Vancomycin Resistant Enterococcus - (VRE)
SAFETY ALERTS New , u p d a t e d a n d r e c e n t l y p u b l i s h e d
Clinical Governance Standard
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:001/22 - Avoiding thrombophlebitis with intravenous amiodarone - Issued 4 March 2022 SA:002/22 - Increased risk of presentation of Japanese Encephalitis - Issued 28 February 2022 SA:001/22 - Safety Alert Red FOOD RECALL Elecare, Similac and Alimentum infant formula - Issued 21 February 2022
For more information, contact: [email protected] Medication Safety Updates Medication Safety Updates including medication shortages are available on the CEC website. Most recent medicines affected include Gadobutrol supply