TIMBOON AND DISTRICT HEALTHCARE SERVICE

TIMBOON AND DISTRICT HEALTHCARE SERVICE Quality & Audit Plan 2016 & 2017 Service Wide Quality & Audit Plan Organisation Wide Survey June 2017

Abbreviation CEO DCS NUM RN - SL EN SL QM EO MBR HP TM MM OHS HRM IFC Abbreviation EM PSQC MCC Position Chief Executive Officer Director Clinical Services Nurse Unit Manager Registered Nurse Standard Leader Enrolled Nurse Standard Leader Quality Manager Executive Officer / Communication Manager Business and Risk Health Promotion Theatre Manager Maintenance Manager Occupational Health & Safety Manager Human Resource Manager Infection Control Committee Executive Management Team Patient Safety & Quality Committee Medical Consultative Committee Page 1 of 11

Standard 1 Governance Standard leader: Gerry Sheehan Policy and procedure framework DCS Review Once Policy review & development DCS / QM Review Monthly Staff awareness & ability to access policy QM Audit Annual Hard Copy policy manual accuracy QM Audit 6 monthly against PROMPT Process for reporting of Legislative MBR Review Once Compliance throughout organisation Operational plan progress / completion CEO Review Quarterly Strategic plan progress / completion CEO Review Quarterly KPI dashboard for Clinical Governance DCS Review Once Quality Framework policy and process DCS Review Once Committee framework, structure, policy, DCS Review Once process, minutes and minute storage Committee evaluation QM Audit Yearly Orientation for managers HR Review Once Orientation for staff / volunteers HR Review Once Orientation for VMO s and Nurse Prac DCS Review Once Staff Handbook HR Review Annual VMO handbook DCS Develop Once Risk Register MBR Review 6 monthly Clinical Documentation / content audit QM Audit 6 monthly Clinical Documentation staff training NUM Training Annual Credentialing SOP Policy for VMO s DCS Policy Once Credentialing SOP Policy for Nurse DCS Policy Once Practitioners Allied health credentialing, capability DCS Review Once and competency framework principles PR&D manager training HR Training Once PR&D framework & completion HR Review Annual Page 2 of 11

Review PR&D framework for VMO / NP DCS Review Once Explore models for accessing a Director of CEO Review Once Medical Services Peer review program for VMO s DCS Review Once Incident management reports and QM Audit Monthly trending for managers and staff Complaints management reports and QM Audit Monthly trending for managers and staff Complaints Management framework and DCS Review Once policy Consent Policy compliance NUM Audit Annual National Open disclosure standard review QM Audit Annual and compliance Advance care planning training NUM Training Annual National Open Disclosure training QM Training Annual Communication plan internal EO. Review Once Electronic access for contemporaneous NUM Implement Once documentation Audit tools across all standards DCS Review Once Implementation of electronic medical DCS Review Monthly record program Privacy audit QM Audit Monthly Mandatory training day / SOLLE16 DCS Audit Annual Patient satisfaction survey QM Audit Monthly Page 3 of 11

Standard 2 Engaging Consumers Standard leader: Kim White Establish a Consumer Advisory Group EO Review Once Patient information / brochures DCS Review Quarterly The Quarterly EO Publish Quarterly What s On Newsletter EO Publish Monthly Social media / webpage strategy EO Launch Once Rights and Responsibilities NUM Audit Quarterly Consumer Participation plan DCS Develop Once Consumer Participation plan DCS Review Annual Doing with you not for you framework DCS Review Once WOW Moments display boards DCS Implement Once Health Literacy PCP DCS Training Annual Culturally and Linguistically Diverse DCS Audit Annual Develop a Cultural Responsiveness Plan DCS Develop Once Cultural Responsiveness Plan DCS Review Annual Standard 3 Infection Control Standard leader: Heather Power Antimicrobial Stewardship education VMO IFC Training Once ANTT competency VMO s IFC Training Once Antimicrobial Stewardship - Audit IFC Audit 6 monthly Infection prevention Risk Management Plan IFC Implement Monthly Cleaning Standards IFC Audit Monthly Influenza vaccination program IFC Audit Annual Page 4 of 11

Standard 4 Medication Safety Standard leader: Tricia Klemm and Margaret Tesselaar National Inpatient Medication Chart RN - SL Audit Annual Medication related polices -streamline DCS Review Once Schedule 8 and schedule 11 medications RN - SL Audit Annual Pharmacy Service including medication DCS Review Once reconciliation Medication Management System DCS Review Annual Patient Information sheets RN - SL Review Once Medication fridges monitoring / audit RN - SL Audit Monthly High risk medication review DCS Review Once TGA reporting policy DCS Review Once Review medication resources NUM Review Once Counselling for identified staff members NUM Education PRN following medication incidents IV labelling practice against the standard NUM Review Once Imprest and wastage DCS Audit Annual Medication incidents NUM Review Monthly Discharge medication patient lists DCS Review Once Medication keys system NUM Review Once Drugs, Poisons and Controlled Substance Permit DCS Update Once Poisons Control Plan DCS Develop Once Poisons Control Plan DCS Review Annual Page 5 of 11

Standard 5 Patient Identification Standard leader: Michelle Selten Policy and procedure DCS Review Once Patient Identification QM Audit Annual Correct Person Correct Procedure correct QM Audit Annual Site Alert chart / Allergies NUM Review Once Allied Health / Community process DCS Review Once Standard 6 Clinical Handover Standard leader: Lynn Marr Bedside Handover Nurse to Nurse QM Audit Annual On call Handover Medical Practitioner DCS Review Once Handover in UCC to Ambulance Victoria DCS Review Once Transfer form DCS Review Once Transfers Out ward / UCC QM Audit Monthly Discharge Planning QM Audit Annual White Boards Patient Rooms DCS Develop Once Patient Experience bedside handover QM Audit Annual Standard 7 Blood and Blood Products Standard leader: Karen Kennett Blood and Blood product administration QM Audit Monthly Blood wastage QM Audit Monthly Cold Chain Policy and Audit QM Audit Monthly Blood fridge DCS Purchase Once Page 6 of 11

Standard 8 Skin Integrity Standard leader: Michelle Selten Imprest and streamline of products NUM Review Once Skin Risk Assessment QM Audit Once Pressure Injury Point Prevalence QM Audit Once Mattress QM Audit Once Pressure prevention equipment QM Audit Once Patient Information DCS Review Once Standard 10 Falls Prevention Standard leader: Lynda McKenzie Falls Risk Assessment QM Audit Annual Falls prevention equipment QM Audit Annual Patient Information QM Audit Annual Standard 11 Information about services / access and admission / patient consent / appropriate and effective care / population health Standard leader: Kim White Informed consent perioperative NUM Audit Annual Preadmission process TM Review Once Perioperative admission and waiting list TM Review Once prioritisation Waiting list TM Audit Annual LifeMap HP Review Once Dementia & Delirium framework NUM Review Once Dementia & Delirium framework NUM Audit Annual Page 7 of 11

Standard 9 Managing the Deteriorating Patient Standard leader: Ingrid Rial and Julie Giblett Fluid Balance Chart Policy NUM Develop Once Observation Chart QM Audit Annual Observation Policy DCS Review Once Blood Alcohol Testing in UCC Policy NUM Develop Once Mortality review reporting QM Audit Monthly Transfer Out of ward / UCC QM Audit Monthly Hospital Standardised Mortality Ratio DCS Audit Quarterly (HMSR) Tele-Medicine set up DCS Develop Once UCC referral pathways DCS Develop Once Medical Emergency Response Policy DCS Review Once Emergency Trolley contents NUM Review Once Basic Life Support DCS Training Annual Advanced Life Support DCS Training Annual ALS trained staff on roster QM Audit Annual Implementation of ViCTOR observation DCS Implement Once charts Implementation of ViCTOR UCC charts DCS Implement Once How do patients escalate care DCS Audit Annual Emergency reviews NUM Audit Monthly Mock code blue / MER calls NUM Training Quarterly Page 8 of 11

Standard 12 Assessment & Care Planning / Management of Nutrition / Ongoing Care and Discharge & Transfer / End-of-Life Care Standard leader: Kim White Referral to relevant service provider - QM Audit Annual internal External Service Provider QM Audit Annual Nutrition & Menu Planning policies DCS Review Once Screening / Assessment tool Nutrition DCS Audit Annual Food Services Caregiver education DCS Training Quarterly Waste supplement / food DCS Audit Annual Number of discharge summaries received DCS Audit Annual by GP within 48 hours of discharge Discharge referrals satisfaction DCS Audit Annual Discharge information brochure DCS Audit Annual Care of the Dying Policy DCS Review Once Palliative Care Satisfaction patients, DCS Audit Annual families and caregivers Standard 13 Workforce Management Standard leader: Gerry Sheehan PR&D System managers & staff HRM Audit Annual Leadership Development HRM Training Once Workforce and Succession Plan HRM Develop Once Training Matrix DCS Develop Once Position Descriptions DCS Review Once SOLLE16 DCS Implement Once Page 9 of 11

Standard 14 Records / Information Management Standard leader: Kim White Allied Health medical record HIM Audit Annual Electronic Health Record Accelerated DCS Implement Once Program (EHRAP) VAED DCS Audit Annual Management of corporate documents DCS Review Once Standard 15 Occupational Health & Safety Standard leader: Gaye McVilly, OH&S Coordinator Hoist ceiling and standing OH&S Review annual Hoist - slings OH&S Audit 6 monthly Radiation accreditation DCS Audit Annual Manual Handling No-Lift DCS Training Annual Standard 15 Waste Management Standard leader: Maintenance Manager Clinical waste management DCS Review Annual Recycling DCS Review Once Standard 15 Buildings / Plant / Equipment Standard leader: Maintenance Manager Preventative Maintenance Schedule MM Audit Monthly IProcument South West Central Supply DCS Implement Once Page 10 of 11

Standard 15 Emergency & Disaster Management Standard leader: Gaye McVilly, OH&S Coordinator Bushfire Preparedness and Response OHS Review Once Emergency Manual Review OHS Review Once Fire safety external inspection OHS Review Once Code Brown OHS Review Once Code Red practical exercise OHS Training Quarterly Code Orange practical exercise OHS Training Annual Heat Management OHS Review Annual Summer Preparedness OHS Review Annual Standard 15 External Service Providers / Contractors Standard leader: Gaye McVilly, OH&S Coordinator Contractor policy and procedure OHS Review Once Contractor Handbook OHS Review Once Contractor database DCS Review Once Standard 15 Physical & Personal Security Standard leader: Maintenance Manager Register of staff property DCS Implement Once Risk Assessment DCS Audit Once Code Grey DCS Review Once Page 11 of 11