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