Auditing to Meet NSQHS Standard 5
Patient Identification & Procedure Matching:
Can we do it more efficiently?
St. Vincent’...
St. Vincent’s Private Hospital, Sydney
8/25/2014 Edel Murray_QualityCoordinator_SVPHS_emurray@stvincents.com.au Page 2
201...
Why???
• Fundamental to safe care
• Risks occur when there is a mismatch between patient &
care
• Patient identification i...
Standard 5:
Patient Identification &
Procedure Matching
Standard:
• Clinical leaders & senior managers of a health service...
Intent
1. Identification of individual
patients
3 approved patients identifiers used
when providing care, therapy or
servi...
6
Structure of Standard 5
5.1.1, 5.1.2 Organisation-wide
patient identification system
5.3.1 Patient
identification
bands
...
Resources
• National Safety & Quality Services Standards
• Hospital Accreditation Workbook
• Networking
• Queensland audit...
Who is this?
8/25/2014 Edel Murray_QualityCoordinator_SVPHS_emurray@stvincents.com.au Page 8
What would we call her?
• Elizabeth Alexandra
Mary Windsor
• 1973 – : Her Majesty
Elizabeth the
Second, by the
Grace of Go...
10
What is an organisational wide
System of organisational policies, procedures & protocols :
• consistent &correct identi...
Baseline Gap analysis & auditing
Patient / procedure matching protocols
The National Safety and Quality Health Service Sta...
Measurement plan
8/25/2014 Edel Murray_QualityCoordinator_SVPHS_emurray@stvincents.com.au Page 12
Patient identification bands 5.3.1
Approved patient identifiers could include:
Patient name (family and given names)
Date ...
Patient identification bands 5.3.1
Coloured bands:
• Tradition, not evidence
• Range of different colours
& meanings – lea...
15
Handover, transfer and discharge 5.4.1
• Use of 3 identifiers in clinical handover system Standard 6: Clinical Handover...
Matching patients to their intended
care 5.5.1,5.5.2,5.5.3
Protocols for matching patients to their intended care:
Ensurin...
We are all
8/25/2014 Edel Murray_QualityCoordinator_SVPHS_emurray@stvincents.com.au Page 17
Make sure they all know they are
8/25/2014 Edel Murray_QualityCoordinator_SVPHS_emurray@stvincents.com.au Page 18
Responsi...
Patient involvement
8/25/2014 Edel Murray_QualityCoordinator_SVPHS_emurray@stvincents.com.au Page 19
Report monthly
• Quality plans
• Projects from gap
analysis
• Evidence
• Audits
• Education
• Cultural shift
• Responsibil...
Staff Education/Communication
• All staff
• Why? One misidentification/mismatch is one too many
• Documentation/near miss/...
Burden of proof
• Out of the board rooms and management and into the units
• Not sighted/not done
• Patient validation
• C...
23
Matching patients to intended care
Scope of these actions:
• Procedures and investigations
• Specific treatments – such...
Auditing requirements
• 5.1.1, 5.1.2, 5.3.1, 5.3.1 ID band and national identifiers
• Minutes and action plans tell the st...
Incident reporting
5.2.1 Incident reporting
• Alerts to managers
• Patient ID and Mismatching near miss/incident reported ...
We are all talking about it
Australian Commission on Safety and Quality in Health Care:
• Safety and Quality Improvement G...
8/25/2014 Edel Murray_QualityCoordinator_SVPHS_emurray@stvincents.com.au Page 27
HA ha!! ACSQH
8/25/2014 Edel Murray_QualityCoordinator_SVPHS_emurray@stvincents.com.au Page 28
Patient involvement
8/25/2014 Edel Murray_QualityCoordinator_SVPHS_emurray@stvincents.com.au Page 29
Questions?
Accreditatio
n is a
journey of
quality8/25/2014 Edel Murray_QualityCoordinator_SVPHS_emurray@stvincents.com.au ...
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Edel Murray - St Vincent's Hospital, Sydney - STANDARD 5| Auditing to Meet NSQHS Standard 5 Patient Identification and Procedure Matching: Can We Do It More Efficiently?

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Edel Murray 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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Edel Murray - St Vincent's Hospital, Sydney - STANDARD 5| Auditing to Meet NSQHS Standard 5 Patient Identification and Procedure Matching: Can We Do It More Efficiently?

  1. 1. Auditing to Meet NSQHS Standard 5 Patient Identification & Procedure Matching: Can we do it more efficiently? St. Vincent’s Private Hospital Sydney Edel Murray (Quality Coordinator)
  2. 2. St. Vincent’s Private Hospital, Sydney 8/25/2014 Edel Murray_QualityCoordinator_SVPHS_emurray@stvincents.com.au Page 2 2013 • Periodic review 2014 • SASS 2015 • Full survey
  3. 3. Why??? • Fundamental to safe care • Risks occur when there is a mismatch between patient & care • Patient identification is routine ‘can be seen as unimportant’ • Systems ensuring patients are correctly matched to their care means that more attention can be paid to more complex tasks 8/25/2014 Edel Murray_QualityCoordinator_SVPHS_emurray@stvincents.com.au
  4. 4. Standard 5: Patient Identification & Procedure Matching Standard: • Clinical leaders & senior managers of a health service organisation establish systems to ensure the : • correct identification of patients • correct matching of patients with their intended treatment. • clinicians & the workforce use the patient identification & procedure matching system. Intent: • Correctly identify all patients whenever care is provided & correctly match patients to their intended treatment Context: • Applied with: • Standard 1: Governance for Safety and Quality • Standard 2: Partnering with Consumers 8/25/2014 Edel Murray_QualityCoordinator_SVPHS_emurray@stvincents.com.au
  5. 5. Intent 1. Identification of individual patients 3 approved patients identifiers used when providing care, therapy or services 2. Processes to transfer care A patient’s identity is confirmed using 3 approved patient identifiers when transferring responsibility for care 3. Processes to match patients to their care Health service organisations have explicit processes to correctly match patients with their intended care Note: all actions in Standard 5 are core 8/25/2014 Edel Murray_QualityCoordinator_SVPHS_emurray@stvincents.com.au 5
  6. 6. 6 Structure of Standard 5 5.1.1, 5.1.2 Organisation-wide patient identification system 5.3.1 Patient identification bands 5.2.1, 5.2.2 Mismatching events 5.4.1 Handover, transfer and discharge 5.5.1, 5.5.2, 5.5.3 Matching patients to their intended care Put the system in place Audit / review performance of or compliance with the system Make improvements based on the results of the audit 8/25/2014 Edel Murray_QualityCoordinator_SVPHS_emurray@stvincents.com.au
  7. 7. Resources • National Safety & Quality Services Standards • Hospital Accreditation Workbook • Networking • Queensland audit tools/CEC 8/25/2014 Edel Murray_QualityCoordinator_SVPHS_emurray@stvincents.com.au Page 7
  8. 8. Who is this? 8/25/2014 Edel Murray_QualityCoordinator_SVPHS_emurray@stvincents.com.au Page 8
  9. 9. What would we call her? • Elizabeth Alexandra Mary Windsor • 1973 – : Her Majesty Elizabeth the Second, by the Grace of God, Queen of Australia and Her other Realms and Territories, Head of the Commonwealth 8/25/2014 Edel Murray_QualityCoordinator_SVPHS_emurray@stvincents.com.au Page 9
  10. 10. 10 What is an organisational wide System of organisational policies, procedures & protocols : • consistent &correct identification of patients • matching identity with 3 identifiers • workforce responsibility regarding patient identification • documentation of procedure matching • risk analysis • Auditing & reporting Must include processes: • at admission/registration • matching a patient’s identity to care, therapy or services • responsibility for care is transferred: handover, transfer & discharge • in specific service settings if they are different from those generally used across the organisation i.e. Uspace, radiology, pathology 8/25/2014 Edel Murray_QualityCoordinator_SVPHS_emurray@stvincents.com.au
  11. 11. Baseline Gap analysis & auditing Patient / procedure matching protocols The National Safety and Quality Health Service Standards require the use of documented processes to match patients and their intended care. Patient / procedure matching protocols provide guidance regarding the steps that should be taken to correctly match patients to their intended care. There are a number of different patient/procedure matching protocols available, including: • Admissions/transfer • Clinical areas • Ensuring Correct Patient, Correct Site, Correct Procedure protocol • Surgical services • World Health Organization Surgical Safety Checklist • Support services (food) • Other services radiology, nuclear medicine, radiation therapy & pathology • Ensuring Correct Patient, Correct Site, Correct Procedure protocols 8/25/2014 Edel Murray_QualityCoordinator_SVPHS_emurray@stvincents.com.au Page 11
  12. 12. Measurement plan 8/25/2014 Edel Murray_QualityCoordinator_SVPHS_emurray@stvincents.com.au Page 12
  13. 13. Patient identification bands 5.3.1 Approved patient identifiers could include: Patient name (family and given names) Date of birth Gender Address Medical record number Individual Healthcare Identifier Room & bed number should not be used as they are frequently changed and not intrinsically linked to an individual 8/25/2014 Edel Murray_QualityCoordinator_SVPHS_emurray@stvincents.com.au
  14. 14. Patient identification bands 5.3.1 Coloured bands: • Tradition, not evidence • Range of different colours & meanings – leads to patient safety risks • one white band only • Alert – replace white band with red band • Implement multi-factorial approach to identify clinical risk 8/25/2014 Edel Murray_QualityCoordinator_SVPHS_emurray@stvincents.com.au 14
  15. 15. 15 Handover, transfer and discharge 5.4.1 • Use of 3 identifiers in clinical handover system Standard 6: Clinical Handover • Patient identification processes at: • Handover • transfer • discharge 8/25/2014 Edel Murray_QualityCoordinator_SVPHS_emurray@stvincents.com.au
  16. 16. Matching patients to their intended care 5.5.1,5.5.2,5.5.3 Protocols for matching patients to their intended care: Ensuring Correct Patient Correct Site Correct Procedure (2004): – state and territory / regional / hospital policies based on original protocol – additional protocols outside surgery (2008) – radiology, nuclear medicine, radiation therapy, oral surgery WHO Surgical Safety Checklist: • adapted by Royal Australasian College of Surgeons for use in Australia • includes patient identification Key steps: – marking site (if necessary) – verification of identity – verification of procedure / site etc. – time out – confirmation of all documentation post-procedure 8/25/2014 Edel Murray_QualityCoordinator_SVPHS_emurray@stvincents.com.au
  17. 17. We are all 8/25/2014 Edel Murray_QualityCoordinator_SVPHS_emurray@stvincents.com.au Page 17
  18. 18. Make sure they all know they are 8/25/2014 Edel Murray_QualityCoordinator_SVPHS_emurray@stvincents.com.au Page 18 Responsible
  19. 19. Patient involvement 8/25/2014 Edel Murray_QualityCoordinator_SVPHS_emurray@stvincents.com.au Page 19
  20. 20. Report monthly • Quality plans • Projects from gap analysis • Evidence • Audits • Education • Cultural shift • Responsibilities 8/25/2014 Edel Murray_QualityCoordinator_SVPHS_emurray@stvincents.com.au Page 20
  21. 21. Staff Education/Communication • All staff • Why? One misidentification/mismatch is one too many • Documentation/near miss/incident/trend • How? • Tell the story of the near miss/educate • Audit result/incidents/near misses reporting • Quality plans include • Audit within audit (pressure injury/medication/AMS/AT) • Structured/non structured audits • Validation with patients • Risk management • Training in auditing/data and planning QI • Turning results into performance improvement Responsible manager , responsible staff 8/25/2014 Edel Murray_QualityCoordinator_SVPHS_emurray@stvincents.com.au Page 21
  22. 22. Burden of proof • Out of the board rooms and management and into the units • Not sighted/not done • Patient validation • Care at the bed side clinical/support services 8/25/2014 Edel Murray_QualityCoordinator_SVPHS_emurray@stvincents.com.au Page 22
  23. 23. 23 Matching patients to intended care Scope of these actions: • Procedures and investigations • Specific treatments – such as nuclear medicine, radiology, pathology etc. • It is not intended that requirements of these actions would relate to treatments such as routine provision of medications 8/25/2014 Edel Murray_QualityCoordinator_SVPHS_emurray@stvincents.com.au
  24. 24. Auditing requirements • 5.1.1, 5.1.2, 5.3.1, 5.3.1 ID band and national identifiers • Minutes and action plans tell the story 8/25/2014 Edel Murray_QualityCoordinator_SVPHS_emurray@stvincents.com.au Page 24 Frequency Audit Reported to Yearly PI/AMS/AT/Blood/Chart audit Units, NQSC,QSC Monthly Surgical Services Handover WHO Time out Deteriorating Patient Units, SSSC,NQSC,QSC Bimonthly Clinical Handover Uspace PI Audit Units, NQSC,QSC Quarterly Chart Audit/Medication Audits Units, PCS, QSC Daily SS/ICU Time out SSSC,NQSC,QSC
  25. 25. Incident reporting 5.2.1 Incident reporting • Alerts to managers • Patient ID and Mismatching near miss/incident reported monthly unit level, organisational level • Consumer participation and engagement 8/25/2014 Edel Murray_QualityCoordinator_SVPHS_emurray@stvincents.com.au Page 25
  26. 26. We are all talking about it Australian Commission on Safety and Quality in Health Care: • Safety and Quality Improvement Guide for Standard 5 • Specifications for standard patient identification bands – and FAQs and fact sheets • Ensuring Correct Patient Correct Site Correct Procedure protocols – and FAQs and fact sheets State and territory health department policies and protocols in areas such as: • Patient identification • Matching patients to their care • Clinical handover Royal Australasian College of Surgeons: • Surgical Safety Checklist World Health Organisation: • Implementation manual for the Surgical Safety Checklist 8/25/2014 Edel Murray_QualityCoordinator_SVPHS_emurray@stvincents.com.au
  27. 27. 8/25/2014 Edel Murray_QualityCoordinator_SVPHS_emurray@stvincents.com.au Page 27
  28. 28. HA ha!! ACSQH 8/25/2014 Edel Murray_QualityCoordinator_SVPHS_emurray@stvincents.com.au Page 28
  29. 29. Patient involvement 8/25/2014 Edel Murray_QualityCoordinator_SVPHS_emurray@stvincents.com.au Page 29
  30. 30. Questions? Accreditatio n is a journey of quality8/25/2014 Edel Murray_QualityCoordinator_SVPHS_emurray@stvincents.com.au Page 30

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