03 September 2010
Clinical Excellence Commission Quality Systems Assessment Report
The Deputy Premier and Minister for Health, Carmel Tebbutt, today released the Clinical Excellence Commission's 2009 Quality Systems Assessment (QSA) Report that gives a valuable insight into some of the key quality and safety issues in the NSW health system.
The QSA process is a world first and consists of a wide ranging survey of the health system that focuses on key priority areas, which in 2009 were: medication safety, clinical handover, communication in the clinical environment and treatment of the deteriorating patient.
"The report gives a valuable snapshot of the health system in September 2009 and its results confirm the work priorities of the system in continuing to improve quality and safety for patients," Ms Tebbutt said.
"Eighty-eight per cent of the 1200 doctors, nurses and allied health professionals who responded on behalf of their unit agreed that there had been an improvement in the safety and quality of patient care over the previous two years.
"One of the major thrusts of the Garling Report was to improve the culture of quality and safety in the health system and the Clinical Excellence Commission's QSA report is a valuable tool to measure what is happening and to help drive change," said Ms Tebbutt.
Prof Cliff Hughes, the CEO of the CEC said:
"This unique system has empowered all our staff to identify priorities and opportunities for change. The overwhelming response rates and the accuracy of those replies reflect the value of the QSA to our staff as they seek to improve safety and the quality of care that they provide."
Since the survey was undertaken, there has been considerable work in the priority areas identified in the report, including:
Clinical Handover
The survey showed that 58 per cent of departments or units had a policy for clinical handover. During the survey period NSW Health was developing safe clinical handover guidelines which were issued last year. The program is now mandated for implementation across the NSW health system.
Managing the Deteriorating Patient
The survey showed that approximately 75 per cent of units had a policy for managing the deteriorating patient. In January 2010, the Between the Flags Program was launched, with
over 46,000 staff already receiving first line training and 20,000 completing on line education across the system.
Communication in the Clinical Environment
The survey showed that in 2009 fewer than 46 per cent of departments or units utilise standardised communication tools or methods. The Between the Flags Program from early this year now mandates the use of a standard communication method when discussing a deteriorating patient.
The Acute Care Taskforce is also leading a specific program to improve clinical handover between junior doctors at shift change, with a key emphasis on greater senior supervision. The 2009 QSA data provides a useful baseline for future evaluation of the Safe Clinical Handover Program.
Medication Safety
The survey showed that approximately a quarter of departments or units regularly audit antibiotics. Antibiotic stewardship is a core component of NSW Health's Healthcare Associated Infection Prevention Strategy and the CEC was asked to undertake a project to improve antibiotic stewardship in intensive care units. Results should be available for wider implementation in the near future.
NSW Health has been working with doctors, nurses and pharmacists to develop a new clinical pharmacy service for hospitals, where patients with special medication needs can be reviewed.
A copy of the report can be found at www.cec.health.nsw.gov.au/programs/qsa.html
A copy of the NSW Health response to the recommendations is attached below and can also be found at www.health.nsw.gov.au
NSW Health Response to 2009 QSA State Report
NSW Health welcomes the recommendations of The 2009 QSA Report.
As this survey ended almost a year ago, it is important to note that much has been done in the surveyed areas of medication safety, clinical handover, communication in the clinical environment and the deteriorating patient since that time.The recommendations of the 2009 QSA report reflect recommendations in the Garling Report which NSW Health strongly supported through publication of Caring Together The Action Plan for NSW.
Section
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QSA Report Recommendation
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Current Status
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Medication safety
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All facilities should put in place a medication action plan which includes:
· Formal processes around antibiotic stewardship
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Considerable work is already underway.
The effective management of antibiotics is a central plank of the NSW Health infection prevention strategy:
NSW Health commissioned the CEC in May 2009 to start a project to improve antibiotic stewardship in intensive care units. The project has involved a statewide survey on the structures needed to support the principle of antibiotic stewardship. Three pilot sites have been included and are reviewing prescribing practices and introducing a medical guide for clinicians. Antibiotics associated with an increased risk of infections are being restricted. Results of this pilot will be used for a roll out across other ICU units.
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· Formal processes around high-risk medications
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Considerable work is already underway.
NSW Health is committed to reducing harm from high risk medicines. A Medication Safety Expert Advisory Committee has been established to support improvements in medication safety.
A NSW Health high risk medications website was established in June 2010 to support simple and accurate identification by clinicians of 7 groups of high risk drugs
A draft high-risk medications policy has already been circulated for consultation and will issue shortly.
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· Implementation of formal processes of medication reconciliation.
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Already Underway (Clinical Pharmacy Model-Caring Together).
Improving medication reconciliation (a method by which a patient's medication can be matched to those to be given in hospital) is part of a broad strategy developed by NSW Health involving:
- Developing a new way of providing clinical pharmacy services (Draft Clinical pharmacy model planned for implementation in 2010);
- Electronic medication management and
- Pharmacy reform.
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· NSW Heath should finalise and support implementation of anticoagulation policy and develop standard tools and resources to assist and support facilities in the implementation of these procedures.
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Already Underway
The anticoagulation policy is part of the draft high-risk medications policy which has already been circulated for consultation and will issue shortly.
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Clinical Handover
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The standard key principles of the strategy for safe clinical handover should be implemented.
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Already Underway (Caring Together)
The Safe Clinical Handover Program was launched in September 2009 with standard key principles mandated for implementation.
The Acute Care Taskforce has completed 11 site visits to monitor implementation and clinicians and managers across the health system are consistently reporting improved progress on bedside nursing handover. The Taskforce is also leading a specific program to improve clinical handover between junior doctors at shift change, with a key emphasis on greater senior supervision.
The 2009 QSA data provides a useful baseline for future evaluation of the Safe Clinical Handover Program.
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Communication in the clinical environment
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The NSW Department of Health policies regarding records policies and ward rounds should be implemented by all Areas and facilities, and that implementation should be monitored and evaluated.
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Already Underway (Caring Together)
A revised Health Records policy will shortly be released for final consultation across NSW Health. Like any NSW Health policies, Area Health Services and facilities are required to implement existing policies which remain in force.
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The NSW Department of Health should introduce a common, statewide, standardised communication method - such as ISBAR (Identify, Situation,
Background, Assessment, Request).
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Already Underway (mandated under BTF Policy - Caring Together)
The Between the Flags (BTF) policy was released by the Department in early 2010 and mandates the use of ISBAR for communicating details about patients who are clinically deteriorating.
In terms of other communication, the NSW Acute Care Taskforce did not specify a particular method for clinical communication but recommended standard key principles that can be mapped against common mnemonics such as ISBAR.
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The deteriorating patient
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All public health organisations should fully implement, support and evaluate rollout of the Between the Flags program.
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Already underway (Caring Together)
The Between the Flags Program was launched in February 2010 and implementation is well under way in all health services with monthly monitoring by the Department of Health.
Already around 46,000 staff (85% of target) have completed awareness training with 20,000 staff having completed on line learning programs and 2,300 of these having done extra half/full day practical sessions.
Over 350 trainers have been trained to rapid uptake of the practical sessions.
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All area health services, networks, clusters, facilities, departments and units should implement and monitor the use of a policy framework for 'do not resuscitate' orders using statewide guidelines.
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A current policy is already in operation.
A NSW Health policy is currently in operation.
For many years NSW Health has had policy guidance on use of advance care directives, end of life care and decision making and No Cardiopulmonary Resuscitation orders. (GL2005_056, GL2005_057 and GL2008_018)
A NSW Health End of Life Decisions Policy Advisory Group was constituted earlier this year to review these policies. NSW Health continues to consider ways in which clinicians, patients and their families can work together in relation to this sensitive area.
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NSW Health should continue to develop and support the implementation of a policy for the care of the deteriorating patient.
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Already Underway (Caring Together).
The Between the Flags (BTF) Program was announced by the Minister, with issue of a policy in early 2010 on care of deteriorating patients
NSW Health provided $3.5M in 2009/10 and a further $1.2M in 2010/11 to support implementation of the program and continues to support local doctors and nurses care for deteriorating patients.
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For a range of health information, go online to www.health.nsw.gov.au
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