GAS GAS GAS

LTCOL Helen MurphySO1 Clinical Governance

Directorate Defence Clinical ServicesJoint Health Command

30 October 2010

JOINT HEALTH COMMAND

OutlineBackgroundResearch and DesignImplementationProcessIIAA ValidationCulture changeFindings

Future

JOINT HEALTH COMMAND

Background•ISO 9001:2000 – Quality Management Systems

JOINT HEALTH COMMAND

Research & Design

•Research•Continuous improvement

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Research & DesignIncluded requirement for accreditation to:

ISOACHSAGPALNATA

2 years of design of GAS including:policySOPToolsFormsRisk matrix g

JOINT HEALTH COMMAND

RiskSectio

n System SAC 1 SAC 2

SAC 3

SAC 4

1 Credentialling of Health Professionals

2 Staff Orientation

3 Clinical Practice - Physio

4 Clinical Practice - Dentistry (Reserved)

5 Radiation safety

6 Clinical Practice - Radiography (Reserved)

7 Clinical Practice - Dental Hygienist (Reserved)

8 Clinical Practice - Rehabilitation

9 Clinical Practice - Medicine

10 Clinical Handover

11 Clinical Practice - Nursing

12 Clinical Practice - Mental Health (Reserved)

13 Clinical Practice - Pharmacy

14 Medication Safety

15 Operating Theatre Practice

16 Clinical Practice - Pathology (Reserved)

17 Patient Identification

18 Sterilization

19 Infection Control

20 Mental Health Services (Reserved)

21 1800IMSICK

22 Rehabilitation Services (Reserved)

22 Rehabilitation Services (Reserved)

23Patients Rights and Responsibilities

24 Complaints Management

25 Customer Feedback Management

26 Internal Audit & Quality Improvement

27 Health Incident Management

28 Access

29 Patient Recall

30 Emergency Procedures

31 Secondary Appointments

32 Documentation

33 Medical Records Management

34 Equipment and Callibration

35 Waste Management

36 Patient Transport (Reserved)

37 Catering

38 Medical Stores Management

39 Linen

40 Cleaning

41 Building Maintenance

42 Vector Control/Pest Management

43 Financial Management (Reserved)

44 Fixed Plant

45 Contract Management (Reserved)

46 KPI IAW HD 920

47 Occupation Health (reserved)

INTERNAL & EXTERNAL VALIDATION

April 2010IIA International standards for the Professional Practice of Internal AuditingCustomer satisfaction surveys

JOINT HEALTH COMMAND

IMPLEMENTATIONCommenced Mar 2010Pilot until mid 2011Completed 9 audits (7 health and 2 dental facilities) and 2 follow-up audits

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PROCESS• Triennial audits•Ongoing internal audits

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CULTURE CHANGEAllow time for changetools for ongoing internal auditingRisk Register

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FINDINGS Poor communicationMedical Records ManagementInfection Control and SterilizationPatient Recall ProcessesMedication SafetyClinical HandoverCredentialling

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Evaluation End of pilot stageCost

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FUTURE Include an AHS/RHS moduleInclude a communication moduleInclude a HHCP module Risk based audit scheduleUse of electronic KPI data

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Summary• Sub-system of CI

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Thank you

JOINT HEALTH COMMAND