Implementation of the National Safety and Quality Health Service Standards The Experience and Lessons Learnt by the Australian Council on Healthcare Standards July 2012
Introduction and overview This information is based on the results of preliminary assessments against the National Standards. The organisations volunteered to undergo this assessment. This presentation is based on completed assessments for 51 organisations. By 31 December 2012 ACHS will have completed 172 gap analyses, at no charge, for member organisations. Around 70% of surveyors and most coordinators will have been on a gap analysis review with the NSQHS Standards before 1 Jan 2013.
Introduction and overview (2) Supporting information to guide both organisations and surveyors The Safety and Quality Guides has been placed on the Commission website for consultation. shortly. These excellent guides will be a vital resource for health services Surveyor training has been constrained by the amount of information available, but the gap analysis process is supporting the development of surveyor skills. Caution should be exercised in the use of this information: implementation of the National Standards is work in progress. The information reflects a point in time only.
Results of gap analyses Good sample size, but there are some precautions with the data: Gap analysis not an accreditation survey Variable levels of preparation from organisations Variable levels of familiarity with NSQHS Standards Data presented on original set of core/developmental not on recent changes to core/developmental actions.
SURVEYS COMPLETED For the period of July 2011 - May 2012 (11months) 147 EQuIP5 surveys were completed: 87% EQuIP5 surveys (n=128) 13% EQuIP5 DPC surveys (n=19) 35% of the completed EQuIP5 surveys (n=147) had an NSQHS Standards assessment (n=51): 46 NSQHS assessments with EQuIP5 surveys 5 NSQHS assessments with EQuIP5 DPC surveys
CORE ACTIONS NOT MET (51 NSQHS ASSESSMENTS) Standard Relating to No. of Not Met ratings to Core Actions Total no. of Core Actions rated per Standard % NM 1 Governance for Safety and Quality in Health Service Organisation 150 2436 6% 2 Partnering with Consumers 98 299 33% 3 Preventing and Controlling Healthcare Associated Infections 232 1926 12% 4 Medication Safety 158 1745 9% 5 Patient Identification and Procedure Matching 74 450 16% 6 Clinical Handover 138 487 28% 7 Blood and Blood Products 112 1127 10% 8 Preventing and Managing Pressure Injuries 116 980 12% 9 Recognising and Responding to Clinical Deterioration in Acute Health Care 123 765 16% 10 Preventing Falls and Harm from Falls 87 882 10% Total Not Met 1,288 11,097
NSQHS SURVEYS COMPLETED BY STATE Proportion of completed NSQHS assessment (n=51) to completed EQuIP5 surveys (n=147) by State:
NSQHS ASSESSMENTS COMPLETED 51 of the NSQHS assessments were completed and analysed for this presentation: 46 NSQHS assessments with EQuIP5 surveys 5 NSQHS assessments with EQuIP5 DPC surveys NSQHS ASSESSMENT PERFORMANCE All 51 NSQHS assessments had Not Met ratings to both the Core and Developmental actions
CONFIGURATION OF THE NSQHS STANDARDS 10 NSQHS Standards 113 Items 256 Total Actions 223 Core Actions Hospital 33 Developmental Actions Day Procedure Centre 218 Core Actions 38 Developmental Actions 1 20 53 49 (44) 4 (9) 47 (44) 6 (9) 2 9 15 6 (4) 9 (11) 6 (4) 9 (11) 3 19 41 38 (39) 3 (2) 36 (38) 5 (3) 4 15 37 35 (31) 2 (6) 34 (31) 3 (6) 5 5 9 9 0 9 0 6 5 11 10 (9) 1 (2) 10 (9) 1 (2) 7 11 23 23 (20) 0 (3) 23 (20) 0 (3) 8 10 24 20 4 20 4 9 9 23 15 8 15 8 10 10 20 18 2 18 2 113 256 223 33 218 38
CORE NSQHS STANDARDS RATINGS DISTRIBUTION: 46 HOSPITAL NSQHS ASSESSMENTS Rating No. of ratings % Satisfactorily Met 6,951 68% Met with Merit 1,594 16% Not Met 1,221 12% Not Applicable 245 2% No Rating 247 2% TOTAL 10,258 100%
FREQUENCY OF HOSPITAL CORE NSQHS STANDARDS NOT MET Std 10 Std 9 Std 8 Std 7 Std 6 Std 5 Std 4 Std 3 Std 2 Std 1 0 5 10 15 20 25 30 35 No. of organisations with Not Met ratings Standard 3 relating to Preventing and Controlling Healthcare Associated Infections have the highest number of organisations (n=35 each) with Not Met ratings Standard 1 relating to Governance for Safety and Quality in Health Service Organisation has the second highest number of organisations(n=34) with Not Met ratings Standard 2 relating to Partnering with Consumers has the third highest number of organisations (n=29) with Not Met ratings
CORE ACTIONS NOT MET (46 HOSPITALS) Standard Relating to No. of Not Met ratings to Core Actions Total no. of Core Actions rated per Standard % NM 1 Governance for Safety and Quality in Health Service Organisation 139 2201 6% 2 Partnering with Consumers 88 269 33% 3 Preventing and Controlling Healthcare Associated Infections 220 1747 13% 4 Medication Safety 144 1575 9% 5 Patient Identification and Procedure Matching 73 405 18% 6 Clinical Handover 128 440 29% 7 Blood and Blood Products 112 1012 11% 8 Preventing and Managing Pressure Injuries 113 880 13% 9 Recognising and Responding to Clinical Deterioration in Acute Health Care 122 690 18% 10 Preventing Falls and Harm from Falls 82 792 10% Total Not Met 1,221 10,011
Standard 2 - Criterion relating to Consumer partnership in service planning Consumer partnership in designing care Consumer partnership in service measurement and evaluation STANDARD 2: Partnering with Consumers Core Action *2.2.1 *2.2.2 2.4.1 2.4.2 2.6.1 2.7.1 Core Action relating to The health service organisation establishes mechanisms for engaging consumers and/or carers in the strategic and/or operational planning for the organisation Consumers and/or carers are actively involved in decision making about safety and quality Consumers and/or carers provide feedback on patient information publications prepared by the health service organisation (for distribution to patients) Action is taken to incorporate consumer and/or carers feedback into publications prepared by the health service organisation for distribution to patients Clinical leaders, senior managers and the workforce access training on patient-centred care and the engagement of individuals in their care The community and consumers are provided with information that is meaningful and relevant on the organisation s safety and quality performance The highest proportion of core actions Not Met in Standard 2: *2.2.2 (41%) 2.4.2 (38%) 2.6.1 (31%) Total no. of Core Actions rated No. of Not Met % NM 45 13 29% 44 18 41% 45 13 29% 45 17 38% 45 14 31% 45 13 29% Total 269 88 33%
Standard 6 - Criterion relating to Governance and leadership for effective clinical handover Clinical handover processes STANDARD 6: Clinical Handover Core Action Core Action relating to The highest proportion of core actions Not Met in Standard 6: 6.3.1 (41%) *6.3.2 (41%) 6.3.4 (36%) 6.1.3 (34%) Total no. of Core Actions rated No. of Not Met % NM 6.1.1 Clinical handover policies, procedures and/or protocols are used by the workforce and regularly monitored 44 11 25% 6.1.2 Action is taken to maximise the effectiveness of clinical handover policies, procedures and/or protocols 44 12 27% 6.1.3 Tools and guides are periodically reviewed 44 15 34% The workforce has access to documented structured processes for clinical handover that include: preparing for handover, including setting the location and 6.2.1 time while maintaining continuity of patient care organising relevant workforce members to participate 44 9 20% being aware of the clinical context and patient needs participating in effective handover resulting in transfer of responsibility and accountability for care 6.3.1 Regular evaluation and monitoring processes for clinical handover are in place 44 18 41% *6.3.2 Local processes for clinical handover are reviewed in collaboration with clinicians, patients and carers 44 18 41% 6.3.3 Action is taken to increase the effectiveness of clinical handover 44 12 27% The actions taken and the outcomes of local clinical 6.3.4 handover reviews are reported to the executive level of 44 16 36% governance 6.4.1 Regular reporting, investigating and monitoring of clinical handover incidents is in place 44 9 20% 6.4.2 Action is taken to reduce the risk of an adverse clinical handover incidents 44 8 18% Total 440 128 29%
STANDARD 9: Recognising and Responding to Clinical Deterioration in Acute Health Care Standard 9 -Criterion relating to Establishing recognition and response systems Recognising clinical deterioration and escalating care Core Action 9.1.1 9.1.2 9.2.1 9.2.2 9.2.3 9.2.4 9.3.2 9.3.3 Core Action relating to Governance arrangements are in place to support the development, implementation, and maintenance of organisation-wide recognition and response systems Policies, procedures and/or protocols for the organisation are implemented in areas such as: measurement and documentation of observations escalation of care establishment of a rapid response system communication about clinical deterioration Feedback is actively sought from the clinical workforce on the responsiveness of the recognition and response systems Deaths or cardiac arrests for a patient without an agreed treatment-limiting order (such as not for resuscitation or do not resuscitate) are reviewed to identify the use of the recognition and response systems, and any failures in these systems Data collected about recognition and response systems are provided to the clinical workforce as soon as practicable Action is taken to improve the responsiveness and effectiveness of the recognition and response systems Mechanisms for recording physiological observations are regularly audited to determine the proportion of patients that have complete sets of observations recorded in agreement with their monitoring plan Action is taken to increase the proportion of patients with complete sets of recorded observations, as specified in the patient s monitoring plan The highest proportion of core actions Not Met in Standard 9: 9.3.2 (39%) 9.3.3 (37%) Total no. of Core Actions rated No. of Not Met % NM 46 7 15% 46 8 17% 46 6 13% 46 5 11% 46 10 22% 46 6 13% 46 18 39% 46 17 37% 9.4.1 Mechanisms are in place to escalate care and call for emergency assistance 46 1 2% 9.4.2 Use of escalation processes, including failure to act on triggers for seeking emergency assistance, are regularly audited 46 13 28% 9.4.3 Action is taken to maximise the appropriate use of escalation processes. 46 9 20% 9.5.1 Criteria for triggering a call for emergency assistance are included in the escalation policies, procedures and/or protocols 46 5 11% 9.5.2 The circumstances and outcome of calls for emergency assistance are regularly reviewed 46 11 24% 9.6.1 The clinical workforce is trained and proficient in basic life support 46 4 9% 9.6.2 A system is in place for ensuring access at all times to at least one clinician, either on-site or in close proximity, who can practise advanced life support 46 2 4% Total 690 122 18% Responding to clinical deterioration
STANDARD 5: Patient Identification and Procedure Matching Standard 5 -Criterion relating to Identification of individual patients Processes to transfer care Processes to match patients and their care Core Action 5.1.1 5.1.2 5.2.1 5.2.2 5.3.1 5.4.1 5.5.1 5.5.2 5.5.3 Core Action relating to Use of an organisation-wide patient identification system is regularly monitored Action is taken to improve compliance with the patient identification matching system Action is taken to improve compliance with the patient identification matching system Action is taken to improve compliance with the patient identification matching system Inpatient bands are used that meet the national specifications for patient identification bands A patient identification and matching system is implemented and regularly reviewed as part of structured clinical handover, transfer and discharge processes A documented process to match patients and their intended treatment is in use The process to match patients to any intended procedure, treatment or investigation is regularly monitored Action is taken to improve the effectiveness of the process for matching patients to their intended procedure, treatment or investigation The highest proportion of core actions Not Met in Standard 5: 5.3.1 (31%) 5.4.1 (31%) Total no. of Core Actions rated No. of Not Met % NM 45 8 18% 45 8 18% 45 2 4% 45 2 4% 45 14 31% 45 14 31% 45 5 11% 45 10 22% 45 10 22% Total 405 73 18%
CORE NSQHS STANDARDS RATINGS DISTRIBUTION: DAY PROCEDURE CENTRE NSQHS ASSESSMENTS (5) Rating No. of ratings % Satisfactorily Met 740 68% Met with Merit 13 1% Not Met 67 6% Not Applicable 266 24% No Rating 4 1% TOTAL 1,090 100%
FREQUENCY OF DPC CORE NSQHS STANDARDS NOT MET Std 10 Std 9 Std 8 Std 7 Std 6 Std 5 Std 4 Std 3 Std 2 Std 1 0 1 2 3 4 No. of Day Procedure Centres with Not Met ratings Standard 1 relating to Governance for Safety and Quality in Health Service Organisation and Standard 3 relating to Preventing and Controlling Healthcare Associated Infections have the highest number of organisations (n=4 each) with Not Met ratings Standard 2 relating to Partnering with Consumers and Standard 4 relating to Medication Safety have the second highest number of organisations (n=3 each) with Not Met ratings Note: Actions required in Standard 7 relating to Blood and blood products for DPCs were all rated Not Applicable (NA)
CORE ACTIONS NOT MET (5 DPC) Standard Relating to No. of Not Met ratings to Core Actions Total no. of Core Actions rated per Standard % NM 1 Governance for Safety and Quality in Health Service Organisation 11 235 5% 2 Partnering with Consumers 10 30 33% 3 Preventing and Controlling Healthcare Associated Infections 12 179 7% 4 Medication Safety 14 170 8% 5 Patient Identification and Procedure Matching 1 45 2% 6 Clinical Handover 10 47 21% 7 Blood and Blood Products 0 115 0% 8 Preventing and Managing Pressure Injuries 3 100 3% 9 Recognising and Responding to Clinical Deterioration in Acute Health Care 1 75 1% 10 Preventing Falls and Harm from Falls 5 90 6% Total Not Met 67 1,086
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