The Challenge of Quality and Safety in the
Emergency Department in 2014
Kylie Stark
Nurse Manager,
Sydney Children’s Hospi...
Defining Quality and Safety
The language comes from other High Reliability Organisations that want to
measure sustain and ...
History – far have we come ?
1995:
Quality in Australian Healthcare Study – Wilson, Runciman et al
Identifies 16.6% hospit...
History
1997:
Commonwealth Government commits $40 million in Acute Care Health
Reform
• Consumer participation
• Accredita...
History
1998 Health Minister Dr Wooldridge comments re the released report from
The National Expert Advisory Group on Qual...
History
“Safety First “ released – first report of ACSQHC – Health Ministers commit to
$50 million to support the agency i...
History
2001 Safety in Practice released. 2nd report of ACSQHC
• National Institute Clinical Studies established
2002: Sec...
History
“Patient Safety” released.
Towards Sustainable Improvement – ACSQHC
Strategies also released to address:
• Open Di...
2012 Release of National Standards
2014 - Are we Safe? Are we Good?
2011-2012 Australian Institute Of Health and Welfare reports 6.1% of public
hospital admi...
2014: Where are we now ?
We are more aware
We are more innovative
We are committed in a
way we never have been
We are star...
External Drivers
• National Health Budget
• State Health - priorities
• ACSQHC
• ABF
• Infrastructure
• Increasing chronic...
Internal Drivers
• Workforce:
o Scope of Practice
o Workforce behaviours
o Training needs of tomorrows’ workforce
o Multip...
Internal Drivers
• Clinical Practice:
o New practice
o Old practice
o Variance
o Guidelines – helpful or not
o Standards
o...
Governance Structures
Leadership
• Direction
• Vision
• Support
• Clarity
• Purpose
• Feedback
Data – our currency
• a HINDRENCE or a
HELP
• What to measure?
• When to measure?
• In creating an
environment that is
fre...
Valuable data … NSW Incident Management Sx
• We know what was reported
• We know how serious with
SAC scores
• We know whe...
Performance – what matters ?
• Last year triage performance mattered
• This year it’s about 240 golden minutes!
• Time bas...
Competence
• Did skilled people assess with expert eyes?
• Did the right diagnostics get ordered, completed
and interprete...
Our patients
• Was the patient informed along the way?
• Was the patient included in the decision
making?
• Was the patien...
Why still such a Challenge ?
Why so different in the emergency department ?
• Its unpredictable
• Its unplanned
• Its dyna...
Unique factors
A unique feature in the ED is the high density of clinical decision making.
Limited time and limited inform...
More Challenges
• Its unspecialised in a world of increasingly
specialised medicine
• Its loaded with time-based KPI’s
• I...
What does it look like ?
It looks different to:
• The patient
• The relative
• The doctor
• The nurse
• The administrator
...
ITIsIT Communicatio
n
Skilled
Workforce
Safety
Tools
Equipment and
Space
Audits and Data
Best Practice – minimal
variance
...
Culture is over arching solution
• Leaders that lead
• Clarity regarding product
• Clarity regarding role
• Education at e...
It’s a recipe
Grandma’s cake
• Same ingredients
• Same amount
• Same temperature
• Same vessel
• Same cook
• Same CARE
People – our greatest resource
• Make them accountable
• Respect them
• Delegate to them
• Trust them
• Value, incite, exp...
Solutions
• Ownership – find a way to create a Quality Role ( ECI Quality in ED
Project 2012-2013)
Solutions
• Make it part of everything everyday.
• A “just culture” - balance no blame with appropriate accountability
• N...
Solutions
• Measure “ CARE “ – do we have a measure?
• Listen and engage our product – Patients and Families
o “Your most ...
The one free thing !
Our future – We can never be sure ……..
Kylie Stark, Sydney Childerens Hospital - The Challenge of Quality and Safety in the Emergency Department in 2014
Kylie Stark, Sydney Childerens Hospital - The Challenge of Quality and Safety in the Emergency Department in 2014
Kylie Stark, Sydney Childerens Hospital - The Challenge of Quality and Safety in the Emergency Department in 2014
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Kylie Stark, Sydney Childerens Hospital - The Challenge of Quality and Safety in the Emergency Department in 2014

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Kylie Stark delivered the presentation at the 2014 Emergency Department Management Conference.

The 2014 Emergency Department Management Conference explored areas such as how to improve access to care, clinical redesign, NEAT compliance, patient flow, point of care testing, geriatric care, and enhance the performance of Emergency Department.

For more information about the event, please visit: http://bit.ly/edmanagement14

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Kylie Stark, Sydney Childerens Hospital - The Challenge of Quality and Safety in the Emergency Department in 2014

  1. 1. The Challenge of Quality and Safety in the Emergency Department in 2014 Kylie Stark Nurse Manager, Sydney Children’s Hospital Emergency Department and Co-Chair, Clinical Advisory Group, ECI, NSW
  2. 2. Defining Quality and Safety The language comes from other High Reliability Organisations that want to measure sustain and enhance performance. Safety = free from harm Quality = Excellence Establishing and maintaining a culture of Quality and Safety is a constant challenge in the face of dynamic Health Care Policy and the changing Face of Population Health
  3. 3. History – far have we come ? 1995: Quality in Australian Healthcare Study – Wilson, Runciman et al Identifies 16.6% hospital admits experiencing adverse event with 51% preventable. Over past 20yrs there have been numerous reports/investigations/inquiries driven by crisis in Quality and Safety in Australian Hospitals ( Macarthur/Nth Shore/Bunderberg/Garling)
  4. 4. History 1997: Commonwealth Government commits $40 million in Acute Care Health Reform • Consumer participation • Accreditation processes • Clinical practice guidelines • Performance measure and benchmarks • Innovation encouragement • Health information technology initiatives
  5. 5. History 1998 Health Minister Dr Wooldridge comments re the released report from The National Expert Advisory Group on Quality and Safe Healthcare, • “ This important report stresses the need for governments to provide leadership in improving safety and quality practices and must also ne addressed by hospital administrators, doctors and nurses in the frontline of health care “ • ARCHI funded 2000 Australian Council for Safety and Quality Health Care established (ACSQ)
  6. 6. History “Safety First “ released – first report of ACSQHC – Health Ministers commit to $50 million to support the agency in National Healthcare Quality and Safety reform First national action plan released by ACSQHC • Use data for safer care • Strengthen mechanisms to support safer clinical and organisational environments • Consumer feedback and participation • Design systems and processes of care to support a culture of safety and reliability
  7. 7. History 2001 Safety in Practice released. 2nd report of ACSQHC • National Institute Clinical Studies established 2002: Second National Action Plan released by ACSQHC • Open disclosure • Medication safety • Healthcare associated infection • Co-ordinated national action re serious adverse events
  8. 8. History “Patient Safety” released. Towards Sustainable Improvement – ACSQHC Strategies also released to address: • Open Disclosure • Healthcare Associated Infections • Safe Staffing • Accreditation Systems • Standards Settings
  9. 9. 2012 Release of National Standards
  10. 10. 2014 - Are we Safe? Are we Good? 2011-2012 Australian Institute Of Health and Welfare reports 6.1% of public hospital admissions associated with adverse event. Should we be perfect ? So many resources, reports and measures? Why still so challenging? Ownership of Role/Portfolio
  11. 11. 2014: Where are we now ? We are more aware We are more innovative We are committed in a way we never have been We are starting to measure the right things We have new challenges
  12. 12. External Drivers • National Health Budget • State Health - priorities • ACSQHC • ABF • Infrastructure • Increasing chronicity • Ageing population • Increasing ED activity • Complex treatments
  13. 13. Internal Drivers • Workforce: o Scope of Practice o Workforce behaviours o Training needs of tomorrows’ workforce o Multiple disciplines o Multiple skill sets o Skill set variance o Managing it – recruitment - retention
  14. 14. Internal Drivers • Clinical Practice: o New practice o Old practice o Variance o Guidelines – helpful or not o Standards o Safety and Quality Tools – BTF/Pathways/Handover
  15. 15. Governance Structures
  16. 16. Leadership • Direction • Vision • Support • Clarity • Purpose • Feedback
  17. 17. Data – our currency • a HINDRENCE or a HELP • What to measure? • When to measure? • In creating an environment that is free from harm and excellent in it’s delivery what data helps ? Bench-marking KPI’s Adverse events Preventable deaths DNWs
  18. 18. Valuable data … NSW Incident Management Sx • We know what was reported • We know how serious with SAC scores • We know where • We know the themes and the trends • Most common themes Communication Right patient Highest incident categories • Falls • Medication • Clinical Management • Documentation We can learn lessons and take action. Falls programme, ,BTF,PECC,Electronic Medication Mx,Time out
  19. 19. Performance – what matters ? • Last year triage performance mattered • This year it’s about 240 golden minutes! • Time based measures can reflect efficiency but do they reflect safety and quality? • What happened in that minute?? • What happened in that time??
  20. 20. Competence • Did skilled people assess with expert eyes? • Did the right diagnostics get ordered, completed and interpreted by skilled people? • Did the right treatment get ordered? • Did treatment commence? • Did monitoring continue?
  21. 21. Our patients • Was the patient informed along the way? • Was the patient included in the decision making? • Was the patient the focus of their journey? • Were compassion and empathy visible and constant? • They are the public face of safe quality healthcare
  22. 22. Why still such a Challenge ? Why so different in the emergency department ? • Its unpredictable • Its unplanned • Its dynamic • Its after hours • Its workforce is not consistent 24/7 – skill or numbers • Its cradle to the grave • Its crowded • Cognitive load • Interruptions and distractions
  23. 23. Unique factors A unique feature in the ED is the high density of clinical decision making. Limited time and limited information. Factors like fatigue and sleep debt and cognitive overload can and do threaten the quality of decision making. Safety in the ED is linked to thinking and skills. ( issues identified by International Federation for Emergency Medicine 2012)
  24. 24. More Challenges • Its unspecialised in a world of increasingly specialised medicine • Its loaded with time-based KPI’s • Its consumers have high expectations and high anxiety • Risk is a constant • Change is a constant
  25. 25. What does it look like ? It looks different to: • The patient • The relative • The doctor • The nurse • The administrator • The executive
  26. 26. ITIsIT Communicatio n Skilled Workforce Safety Tools Equipment and Space Audits and Data Best Practice – minimal variance Visible Leadership A Jigsaw Puzzle
  27. 27. Culture is over arching solution • Leaders that lead • Clarity regarding product • Clarity regarding role • Education at every level for everybody • Minimal variance • Adequate resources • Make peoples work visible • Measure and display what reflects safety and quality in your department
  28. 28. It’s a recipe Grandma’s cake • Same ingredients • Same amount • Same temperature • Same vessel • Same cook • Same CARE
  29. 29. People – our greatest resource • Make them accountable • Respect them • Delegate to them • Trust them • Value, incite, experience and compassion • Communicate •Tell everyone everything every time!!
  30. 30. Solutions • Ownership – find a way to create a Quality Role ( ECI Quality in ED Project 2012-2013)
  31. 31. Solutions • Make it part of everything everyday. • A “just culture” - balance no blame with appropriate accountability • Not everything is good for everybody – local modification of models of care/safety tools/processes (CERS) • Collect data that means something – then make it available to the people it matters to • Network and share and support. • Influence –Whole of Hospital Strategies • Celebrate the consumer commentary
  32. 32. Solutions • Measure “ CARE “ – do we have a measure? • Listen and engage our product – Patients and Families o “Your most unhappy customers are your greatest source of learning” Bill Gates • Influence and control what you can • Use data – we now know what errors happen, when and why. • Value knowledge and experience • Consider the value of Soft Systems – The Relationships (Hugh MacLeod and Dr. Mary Ditton)
  33. 33. The one free thing !
  34. 34. Our future – We can never be sure ……..
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