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2. Statewide initiatives

Quality & Safety

These statewide initiatives have been developed under the NSW Patient Safety and Clinical Quality Program.

• 10 Tips for Safer Health Care
  NSW Health has produced the 10 Tips for Safer Health Care flyer for distribution to all NSW public hospitals. The flyer advises patients on how to take part in decisions, learn about their condition and treatment, understand their medication, and discuss treatment options with their health care givers.
  
  
• Complaint Management
  NSW Health is committed to improving the overall quality of health care. One of the challenges in this objective is to identify and promote strategies and practices that enhance services provided to the community and that engender community trust in those who administer and provide those services. Complaints and compliments provide unique information about the quality of health care from the perspective of consumers and their carers. The challenge for health care services is collect better information about consumers' views to ensure the safe delivery of care.

• Correct Patient/Patient ID
  In November 2004, the Patient Identification - Correct Patient, Correct Procedure and Correct Site Model Policy was released and has been widely disseminated to NSW health facilities. In 2006, NSW Health included non-interventional wrong site, wrong procedure as serious events, and health services are now required to report these to the Department as Severity Assessment Code 1 (SAC 1) incidents. Statewide specialist working groups were established to represent radiology, nuclear medicine, radiation oncology and dental to discuss policy concerns and to develop strategies to reduce these types of serious incidents to zero.

• Health Care Associated Infections (Intranet)
  Prevention of healthcare associated infections (HAIs) and multi-resistant organism (MRO) colonisations is one of the key patient quality and safety initiaties for NSW Health. The goal of the HAI program is to prevent every patient from acquiring a HAI or MRO colonisation during all stages of their care and treatment. The targets for the program are to reduce HAIs and MRO colonisations by 10 per cent 2008/2009, 50 per cent by 2010/2011 and 80 per cent 2013/2014.

• IIMS (Intranet)
  The Incident Information Management System (IIMS) assists healthcare professionals in NSW to identify, track and manage clinical, workforce and corporate incidents across the public health system.

• Incident Management
  Incident management is an important component of the NSW Patient Safety and Clinical Quality Program. All serious clinical (SAC 1) incidents are reported to the NSW Department of Health via a Reportable Incident Brief (RIB) process and are investigated in detail using the Root Cause Analysis (RCA) methodology. Since 1 August 2005, legislation has required all Clinical SAC 1 incidents to be investigated using the RCA methodology.

• Lessons Learned in Quality & Safety (Intranet)
  We invite the health community of NSW to share experiences of incidents and proven solutions to quality and safety issues that arise in the health system. Contribute your knowledge of how and when mistakes are made and join in on an ongoing dialogue on quality and safety issues.

• Management of Complaint about a Clinician
  Whilst the statewide incident management system focus is on systemic issues, it is acknowledged that at times there is reason to raise a concern about an individual. To provide assistance to AHSs in developing local policies for managing a complaint or concern about the performance of a clinician, the 2001 guideline was revised in collaboration with the NSW Medical Board, the HCCC and the AHS.

• Medication Safety
  The medication use system involves many health care providers and steps, each associated with a risk of patient harm. Estimates suggest that each year in excess of 70,000 hospital admissions are associated with an adverse drug event, resulting in 8000 deaths and $350 million in direct hospital costs. The NSW Medication Safety Strategy brings together a range of activities that focus on all stages in the medication management pathway in order to minimise the level of adverse outcomes.

• Open Disclosure
  Open Disclosure is a frank discussion with a patient and their support person about a patient-related incident that may have resulted in harm or injury to the patient. The NSW Government wants to ensure that if an incident occurs, patients receive an apology and explanation and are treated with empathy, honesty and transparency in a timely manner. Similarly, NSW Health recognises that staff also need to be supported through such incidents and is committed to providing the right environment, resources and culture to guide staff.

• Qualified Privilege
  The granting of qualified privilege is rare and comes with certain duties and obligations. The Health Administration Act 1982, Division 6B, sets out the rights and responsibilities of committees that have been granted qualified privilege. The provision of qualified privilege to approved quality assurance committees is designed to encourage health care professionals to participate in quality improvement activities by protecting the documents and proceedings of the committee.

• Safety Alert Broadcast System (SABS)
  The Safety Alert Broadcast System (SABS) has been developed to provide a systematic approach to the distribution and management of patient safety information to NSW health services. Each alert specifies action to be taken by health services, the timeframe in which such action must occur, and specific responsibility for the actions.