Edel Murray - St Vincent's Hospital, Sydney - STANDARD 5| Auditing to Meet NSQHS Standard 5 Patient...

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)

St. Vincent’s Private Hospital, Sydney

8/25/2014 Edel [email protected]

2013• Periodic review

2014 • SASS

2015 • Full survey

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


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


Intent

1. Identification of individual patients

3 approved patients identifiers used

when providing care, therapy or

services2. Processes to transfer care

A patient’s identity is confirmed using

3 approved patient identifiers when

transferring responsibility for care3. 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 [email protected] 5

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


Resources

• National Safety & Quality Services Standards

• Hospital Accreditation Workbook

• Networking

• Queensland audit tools/CEC


Who is this?


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


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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


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


http://www.safetyandquality.gov.au/our-work/patient-identification/patient-procedure-matching-protocols/

Measurement plan


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


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 [email protected] 14

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


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 identificationKey steps:

– marking site (if necessary)

– verification of identity

– verification of procedure / site etc.

– time out

– confirmation of all documentation post-procedure


We are all


Make sure they all know they are


Responsible

Patient involvement


Report monthly

• Quality plans

• Projects from gap

analysis

• Evidence

• Audits

• Education

• Cultural shift

• Responsibilities


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


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


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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


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


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

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


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


HA ha!! ACSQH


Patient involvement


Questions?

Accreditatio

n is a

journey of

quality 8/25/2014 Edel [email protected]

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