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Catherine Li delivered the presentation at the 2014 Clinical Audit Improvement Conference. The Clinical Audit Improvement Conference explored the role of clinical audit in the new era of National Care Standards. For more information about the event, please visit: http://bit.ly/clinicalaudit14
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Measuring and Monitoring the Implementation of NSQHSS
---A Top-Down Approach by Utilizing the Key Principles in Governance, Risk Management & Quality Improvement
Catherine Li, Performance Review and Audit Coordinator, King Edward Memorial Hospital, WA
Key Points of NSQHSS
Identified through mock surveys & gap analysis • Governance
Who is the highest level of governance?
Are there supporting committees with oversight
of each standard?
Is there good governance for reporting,
monitoring & taking action of outcomes?
Effective management of policies and clinical
guidelines
Key Points Cont.…
• Engagement of consumers in governance, care planning and treatment, quality activities
• Risk Management – organisation wide but also of key systems
• Continuous Improvement – across the standards and organisation
How to Measure…
• Are the standards measurable?
• What audits and surveys need to be undertaken?
• How to plan for the measuring?
• Is it doable?
• How to demonstrate evidence through the auditing cycles?
The Development of NSQHS Audit Framework…
• Driven by the standards
• Be conceptually and analytically linked with each of the core actions in the accreditation workbook
• Clearly articulate the audit scope & audit KPIs
• Incorporate the key principles in Governance, Risk Management & Quality Improvement
Other Key Elements of the Framework…
• Methodologies
• Stakeholder/s accountable
• Governance committees
• Frequencies
• Monitoring plan
Key Success Factors…
• Engage key stakeholders in the development process
• Empower departments for ownership
• Be relevant to the needs of department/organisation
• Be strategic and systematic
• Be flexible
Framework for Standard 1… NSQHS
Action No. Audit Scope Audit KPIS Method
Stakeholder
Accountable
Governance
Committee Frequency Jan Feb Mar April May Jun Jul Aug Sept Oct Nov Dec
1.1.2Committee
effectiveness All major committees
Survey
MonkeySQP
WNHS
Executive
Every 2
Years
Impact on patient safety &
quality (minutes of CGC &
Exec)
Actions taken on risks
1.2.1 Data reports
Satisfaction of Exec &
CGC with safety and
quality reports
Survey SQP WNHS
Executive
Annual
1.3.1 Job descriptionsCurrency of JDFs;
inclusion of Safety &
Quality responsiblities.
Audit HR Workforce/HR
Committee
Annual
Use of checklist including
recent policy changes
Register of agency &
locum workforce
credentials
Skill appraisal & record of
competencies
1.7.2Compliance with
clinical guidelinesHigh risk guidelines
(OGCCU, WHCCU, NCCU)
Audit EBGC's
Directorate
Management
Committees
6 Monthly
Accuracy, integration,
currencyAudit
PIMMS /
EDMS
Availability for care Obs Audit
Clinical content/design Audit
1.10.2 Scope of practice
Credentialling
Audit EDMS/ED Electoral
Committee
Monthly
1.10.4
Introduction of new
clinical service,
procedure or other
technology Policy compliance
Audit EDMNPSS
Product
Evaluation &
Standardisation
Committee
(PESC)
Annual
Compliance with policies% workforce with
completed PA reviews
1.13.1 1.13.2Safety & Quality
System Feedback from workforceSurvey SQP
WNHS
Executive
Every 2
Years
1.17.2Information on
patient rights
Patient survey: O&G,
NCCU, WHCCUSurvey
Customer
Service Unit
WNHS
Executive Annual
1.18.2 Informed consent
Documentation
compliance (Surgical &
ANAES)
Audit SQP CGC 6 Monthly
HR systemHR
MR maintainence PIMMS
OutpatientSurvey All Areas 6 Monthly
InpatientSurvey All Areas
6 Monthly
Standard 1. Governance in Safety and Quality in Health Service Organisations
1.1.1
1.1.2 1.5.2
1.3.3 1.4.3
1.9.1 1.9.2
1.19.1
Audit
Minutes
Audit
WNHS
Executive
WNHS
Executive
WNHS
Executive
WNHS
Executive
High risk policies
DSQP/EDMPS
S
SQP
EDMNPSS/ED
MS/Manager
Infrastructure
1.20.1
Policy tracking
system
Business decision
making
Agency & locum
workforce
Medical record
Performance
development system
Clinical record
(restriction)
Patient experience
survey
1.11.1
1.19.2
WNHS
Executive
Annual
Annual
Annual
6 Monthly
Annual
Annual
HR Workforce/HR
Committee
Audit
Audit
WNHS
Executive
Development of Audit Tools…
• Better to be done in collaboration with relevant areas/key stakeholders
• Pilot the tools first
• Be relevant to the organisation’s practices
• Source tools from other organisations for reference but adapt through evaluation
Engagement Strategies…
• In-services
• Education and training
• Meetings (formal & informal)
• Mapping the engagement via the organisation chart
• Be proactive
• Multidisciplinary focus
Key Success Factors for Engagement…
• Open & transparent
• Appreciate the competing priorities that clinicians are facing
• Take the opportunities available at different forums
• Build on existing knowledge, skills & activities
• Accommodate diversity in a uniform system
• Provide skilled data management & analysis support
• Provide skilled support in QI/audit principles & methodologies
Managing Data from Governance Activities…
• Can be done in Excel but KEMH uses an electronic web-based database – GEKO (Governance, Evidence, Knowledge, Outcome)
• Established since 2005 @ KEMH
• Is rolling out across WA Public Health
• Built in escalation functionality
• Ability to identify accountabilities & responsibilities
• Multidisciplinary involvement through Departmental QI Committees
Home Page of GEKO…
GEKO Proposal…
GEKO Proposal…
Driving for Improvements…
• Identify priorities/opportunities through GEKO activities & Clinical Governance Reporting processes
• Recommendation for activities is essential
• Encourage communication & information sharing
• Mechanisms to follow up
Clinical Governance Reporting…
• A streamlined annual reporting process
• Links information from a range of sources
• Permits timely review and assists in targeting/tracking improvement initiatives
• NSQHSS are incorporated into the reporting process
• Report is presented to the peak Clinical Governance Committee by Director or HoD
GEKO / Research Number
Title Outcome/Actions
Standard 1: Governance
Standard 2: Consumer
Partnerships
Standard 3: Prevention and
Controlling HAI
Standard 4: Medication
Safety
Standard 5: Patient ID /
Procedure Matching
Standard 6: Clinical Handover
Standard 7: Blood/Blood
Products
Clinical Indicators… • Standardised data collection tools
• Program reviewed annually
• Data reviewed at the highest level of governance committee
• Linked to identified risks and/or priorities
• Linked to NSQHS action numbers
• Explanation provided if benchmark not met
• QI activities developed if required
• Included in the clinical governance reporting process
MONTH: YEAR:
Indicator Area: 2: Return to Operating Room
Indicator Topic: Unplanned return to the operating room during the same admission
Indicator: 2.1 UNPLANNED RETURN TO THE OPERATING ROOM DURING THE SAME ADMISSION
Rationale: Unplanned return of a patient to the operating room during the same admission may reflect less than optimal management.
Definition of Terms:
Return refers to readmissions to the operating room for a further operation/procedure.
Note:
Patients returning to the operating room from the recovery room are included in the numerator figure.
Where there are multiple returns to the operating room for one patient, that patient is counted only once.
Numerator
Denominator Total number of patients having an operation or procedure in the operating room during the time period of study.
MRN PUB/PRIV DATE
REASON FOR
RETURN TO
THEATRE
PUB PRIV
Information obtained by:
Reviewed by:
NSQHS & EQuIPNational Action No: 11.5.1
Unplanned refers to the necessity for a further operation for complication(s) related to a previous operation/procedure in the operating
An operating room is defined as a room, within a complex, specifically equipped for the performance of surgery and other therapeutic
Day stay patients are included in both the numerator and denominator figures. Day stay patients are those whose admission date
Total number of patients having an unplanned return to the operating room during the same admission during the time period of study.
OUTCOME
Numerator
Denominator
Outcome
COMMENTS
The Power of Engagement… Safety and Quality is about raising the awareness and planting the seeds into everyone’s heart so that it can be embedded into our everyday practice, words and deeds.
----- Catherine Li