Measuring and Monitoring the
Implementation of NSQHSS
---A Top-Down Approach by Utilizing the Key Principles
in Governance...
Key Points of NSQHSS
Identified through mock surveys & gap analysis
• Governance
 Who is the highest level of governance?...
Key Points Cont.…
• Engagement of consumers in governance, care planning
and treatment, quality activities
• Risk Manageme...
How to Measure…
• Are the standards measurable?
• What audits and surveys need to be undertaken?
• How to plan for the mea...
The Development of NSQHS Audit
Framework…
• Driven by the standards
• Be conceptually and analytically linked with each of...
Other Key Elements of the
Framework…
• Methodologies
• Stakeholder/s accountable
• Governance committees
• Frequencies
• M...
Key Success Factors…
• Engage key stakeholders in the development process
• Empower departments for ownership
• Be relevan...
Framework for Standard 1…
NSQHS
Action No. Audit Scope Audit KPIS Method
Stakeholder
Accountable
Governance
Committee Freq...
Development of Audit Tools…
• Better to be done in collaboration with relevant
areas/key stakeholders
• Pilot the tools fi...
Engagement Strategies…
• In-services
• Education and training
• Meetings (formal & informal)
• Mapping the engagement via ...
Key Success Factors for Engagement…
• Open & transparent
• Appreciate the competing priorities that clinicians are
facing
...
Managing Data from Governance
Activities…
• Can be done in Excel but KEMH uses an electronic web-based
database – GEKO (Go...
Home Page of GEKO…
GEKO Proposal…
GEKO Proposal…
Driving for Improvements…
• Identify priorities/opportunities through GEKO activities
& Clinical Governance Reporting proc...
Clinical Governance Reporting…
• A streamlined annual reporting process
• Links information from a range of sources
• Perm...
GEKO /
Research
Number
Title Outcome/Actions
Standard 1: Governance
Standard 2: Consumer
Partnerships
Standard 3: Preventi...
Clinical Indicators…
• Standardised data collection tools
• Program reviewed annually
• Data reviewed at the highest level...
MONTH: YEAR:
Indicator Area: 2: Return to Operating Room
Indicator Topic: Unplanned return to the operating room during th...
The Power of Engagement…
Safety and Quality is about raising the awareness and
planting the seeds into everyone’s heart so...
Catherine Li - King Edward Memorial Hospital - Measuring and Monitoring the Implementation of NSQHSS: A Top-Down Approach ...
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Catherine Li - King Edward Memorial Hospital - Measuring and Monitoring the Implementation of NSQHSS: A Top-Down Approach by Utilising the Key Principles in Governance, Risk Management and Quality Improvement

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Catherine Li delivered the presentation at the 2014 Clinical Audit Improvement Conference.

The Clinical Audit Improvement Conference explored the role of clinical audit in the new era of National Care Standards.

For more information about the event, please visit: http://bit.ly/clinicalaudit14

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Catherine Li - King Edward Memorial Hospital - Measuring and Monitoring the Implementation of NSQHSS: A Top-Down Approach by Utilising the Key Principles in Governance, Risk Management and Quality Improvement

  1. 1. 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
  2. 2. 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
  3. 3. 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
  4. 4. 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?
  5. 5. 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
  6. 6. Other Key Elements of the Framework… • Methodologies • Stakeholder/s accountable • Governance committees • Frequencies • Monitoring plan
  7. 7. 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
  8. 8. 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 1.1.2 Committee effectiveness All major committees Survey Monkey SQP 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 descriptions Currency 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 1.7.2 Compliance with clinical guidelines High risk guidelines (OGCCU, WHCCU, NCCU) Audit EBGC's Directorate Management Committees 6 Monthly Accuracy, integration, currency Audit 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 1.13.2 Safety & Quality System Feedback from workforce Survey SQP WNHS Executive Every 2 Years 1.17.2 Information on patient rights Patient survey: O&G, NCCU, WHCCU Survey Customer Service Unit WNHS Executive Annual 1.18.2 Informed consent Documentation compliance (Surgical & ANAES) Audit SQP CGC 6 Monthly HR system HR MR maintainence PIMMS Outpatient Survey All Areas 6 Monthly Inpatient Survey 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
  9. 9. 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
  10. 10. Engagement Strategies… • In-services • Education and training • Meetings (formal & informal) • Mapping the engagement via the organisation chart • Be proactive • Multidisciplinary focus
  11. 11. 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
  12. 12. 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
  13. 13. Home Page of GEKO…
  14. 14. GEKO Proposal…
  15. 15. GEKO Proposal…
  16. 16. 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
  17. 17. 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
  18. 18. 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
  19. 19. 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
  20. 20. 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
  21. 21. 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

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