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Report of the ACHS EQuIPNational Organisation-Wide Survey

FWLHD Broken Hill Health Service

Broken Hill, NSW

Organisation Code: 11 01 67

Survey Date: 2-4 November 2016

ACHS Accreditation Status: ACCREDITED

©Copyright by The Australian Council on Healthcare Standards

All Rights Reserved

Table of Contents

About The Australian Council on Healthcare Standards ................................................. 1 Survey Report ................................................................................................................. 4

Survey Overview.......................................................................................................... 4 STANDARD 1 .............................................................................................................. 6 STANDARD 2 ............................................................................................................ 12 STANDARD 3 ............................................................................................................ 15 STANDARD 4 ............................................................................................................ 19

STANDARD 5 ............................................................................................................ 24 STANDARD 6 ............................................................................................................ 27 STANDARD 7 ............................................................................................................ 30

STANDARD 8 ............................................................................................................ 34 STANDARD 9 ............................................................................................................ 37 STANDARD 10 .......................................................................................................... 39 STANDARD 11 .......................................................................................................... 42

STANDARD 12 .......................................................................................................... 46 STANDARD 13 .......................................................................................................... 51

STANDARD 14 .......................................................................................................... 55 STANDARD 15 .......................................................................................................... 58

Actions Rating Summary ............................................................................................... 64

Recommendations from Current Survey ....................................................................... 92 Recommendations from Previous Survey ..................................................................... 94

Standards Rating Summary .......................................................................................... 97

The Australian Council on Healthcare Standards EQuIPNational V01: Page 1 17/01/2017

About The Australian Council on Healthcare Standards The Australian Council on Healthcare Standards (ACHS) is an independent, not-for-profit organisation, dedicated to improving the quality of health care in Australia through the continual review of performance, assessment and accreditation. The ACHS was established in 1974 and is the leading independent authority on the measurement and implementation of quality improvement systems for Australian health care organisations. The ACHS mission is to ‘improve the quality and safety of health care’ and its vision is ‘to be recognised nationally and internationally as the leading Australian organisation that independently assesses performance and promotes and improves the quality and safety of health care.’ The principles upon which all ACHS programs are developed and the characteristics displayed by an improving organisation are:

1. a customer focus 2. strong leadership 3. a culture of improving 4. evidence of outcomes 5. striving for best practice.

These principles can be applied to every aspect of service within an organisation. What is Accreditation? Accreditation is a formal process to assist in the delivery of safe, high quality health care based on standards and processes devised and developed by health care professionals for health care services. It is public recognition of achievement of accreditation standards by a health care organisation, demonstrated through an independent external peer assessment of that organisation’s level of performance in relation to the standards. How to Use this Survey Report The ACHS survey report provides an overview of quality and performance and should be used to:

1. provide feedback to staff 2. identify where improvements are needed 3. compare the organisation’s performance over time 4. evaluate existing quality management procedures 5. assist risk management monitoring 6. highlight strengths and opportunities for improvement 7. demonstrate evidence of achievement to stakeholders.

This report provides guidance for ACHS members for future quality improvement initiatives by documenting the findings from the organisations accreditation survey. This report is divided into five main sections.

1 Survey Team Summary Report 2 Action Ratings Summary Report 3 Summary of Recommendations from the Current Survey 4 Recommendations from the Previous Survey 5 Standard Ratings Summary Report


1 Survey Team Summary Report Consists of the following: Standard Summaries - A Standard Summary provides a critical analysis for organisations to understand how they are performing and what is needed to improve. It provides an overview of performance for that Standard and comments are made on activities that are performed well and indicating areas for improvement. Ratings Each action within a Standard is rated by the organisation and the survey team with one of the following ratings. The survey team also provides an overall rating for the Standard. If one core action is Not Met the overall rating for that Standard is Not Met. The report will identify individual actions that have recommendations and/or comments. The rating levels are: NM – Not Met The actions required have not been achieved SM – Satisfactorily Met The actions required have been achieved MM - Met with Merit In addition to achieving the actions required, measures of good quality and a higher level of achievement are evident. This would mean a culture of safety, evaluation and improvement is evident throughout the hospital in relation to the action or standard under review. Action Recommendations Recommendations are highlighted areas for improvement due to a need to improve performance under an action. Surveyors are required to make a recommendation where an action is rated as Not Met to provide guidance and to provide an organisation with the maximum opportunity to improve. Recommendations in the survey report need to be reviewed and prioritised for prompt action and will be reviewed by the survey team at the next on site survey. Risk ratings and risk comments will be included where applicable. Risk ratings are applied to recommendations where the action rating is Not Met to show the level of risk associated with the particular action. A risk comment will be given if the risk is rated greater than low. Risk ratings could be:

1. E: extreme risk; immediate action required. 2. H: high risk; senior management attention needed. 3. M: moderate risk; management responsibility must be specified. 4. L: low risk; manage by routine procedures

2 Actions Ratings Summary Report This section summarises the ratings for each action allocated by an organisation and also by the survey team.


3 Summary of Recommendations from the Current Survey Recommendations are highlighted areas for improvement due to a need to improve performance under a particular action. Recommendations are structured as follows: The action numbering relates to the Standard, Item and Action. 4 Recommendations from Previous Survey This section details the recommendations from the previous onsite survey. The actions taken by the organisation and comments from the survey team regarding progress in relation to those recommendations are also recorded. The action numbering relates to the month and year of survey and the action number. For example recommendation number OWS 0613. 1.1.1 is a recommendation from an OWS conducted in June 2013 with an action number of 1.1.1 5 Standards Ratings Summary Report This section summarises the ratings for each Standard allocated by the survey team.

EN OWS Organisation: FWLHD Broken Hill Health Service Orgcode: 110167


Survey Report Survey Overview

The Broken Hill Health Service with the full support and guidance of the governing body, the Executive Management group and overseen by the Director of Clinical Governance and a broad variety of personnel throughout the facility have successfully focused on quality, safety, and effectiveness of care which has prepared and presented the organisation for its organisation wide survey with vigilance, integrity, responsible planning and sustainability.

The organisation has appropriately acquitted the previous recommendations of the scheduled periodic review. Under the auspices of the governing body and with the operational articulation led by and guided by the executives within Broken Hill Health Service has resulted in a confident and well presented approach to organisational survey. Appropriate attention has been given to the 15 EQuIPNational Standards which have been satisfactorily acquitted based on the evidence presented prior to and during survey. A modest number of recommendations have been presented to further guide the organisation as it progresses on its journey aimed to maintain and constantly improve quality and effectiveness of patient care. It is noted that remote communities present healthcare organisations with a variety of unique challenges not the least being the appropriate attraction and retention of health care personnel, assisted by a skilled and committed support staff. Ongoing and effective strategies for workforce planning is challenging but critical in these remote communities. In order to deliver patient care that is contemporary and safe the application of standards, guidelines, policy directives along with a responsive and humanistic approach to patient and family centred care is pivotal for communities which look up to their healthcare organisation at times when they require health intervention and management. The Broken Hill Health Service appeared to have imbued a culture of pride backed by a system with integrity and compliance to the variety of controls that we construct as a part of the Clinical Governance and Quality Improvement Framework in healthcare. Along with education and training in a culture committed to Quality Improvement comes the necessity for appropriate monitoring and evaluation. The use of audits remains pivotal in providing information which guides the organisation in its quest to maintain and exceed the standards set. The organisation is encouraged to continue its current audit program and maintain vigilance in adhering to legislation and compliance requirements as set by the system administrator. No organisation is able to acquit its responsibilities to patients and communities without an appropriate engagement with the community which they serve. The second National standard remains a key critical mechanism by which we partner with those that we serve, our consumers. Broken Hill Health Service has commenced an engagement which both informs and guides the ongoing delivery of services. The organisation's Infection, Prevention and Control Program is well supported by the Infection Control Clinical Nurse Consultant and the Standard Team. Policy requirements are understood and well managed. Audits are undertaken and reviewed to support service improvement for all matters, including hand hygiene, aseptic technique, invasive procedures and antimicrobial stewardship. Education and training support is well managed with generally good rates of compliance. Medications and systems of medication management are central to patient treatments and the management of disease. Therapeutic drug regimes involving a vast variety of medications and other



therapeutic agents require careful and judicious use. The minimisation of medication errors and the rapid detection and Management of adverse events surrounding drug and therapeutic agent use is controlled and guided by a set of national guidelines which had measured against national audit criteria. The monitoring and recording of adverse events and near misses in respect to prescribing and dispensing of medications requires vigilance and awareness combined with a robust reporting system. Potential under-reporting may lead to a false sense of security in an area where drug errors with resultant adverse events and outcomes are commonplace internationally the Broken Hill Health Service is encouraged to further promote vigilance in reporting of all errors and near misses in medication use. Good processes are in place for the implementation and monitoring of the organisation wide patient identification system, with all patient identification bands meeting the requirements of this Standard. Clinical Handover practices are appropriate and effective that undoubtedly supports client care. It is clearly evident that there have been a number of improvements made over recent years, including the availability and use of journey boards, as well as Studer practices and principles. Handover practices on survey were seen to be appropriate with excellent multidisciplinary support evident. Patient and carer involvement in care is supported by the multidisciplinary team involvement and care follow-up as well as family and case conferences. These practices were evident for acute and Mental Health Services. Pressure injury managed was noted to be managed enthusiastically by the Standard Committee with many improvements noted evident over recent times. Policy, education, practices and equipment supports appropriate care. There are opportunities for enhanced Medical Officer involvement in care practices and recommendations will be made to support the organisation in their quest for further improvements. The use of blood and blood products is well governed and compliant with national standards. The detection and management of the deteriorating patient is well governed and involves a vigilance and notification system which initiates interventions as required in a timely and well managed manner. Prevention of fails was managed well and the engagement and organisation compliance with the standard was satisfactory to meet the standard. On survey it was noted the organisation was clean and well maintained that can only support safe and appropriate practice. What was particularly evident was the very clean and ordered maintenance, stores, kitchen and laundry areas. Throughout the survey and on discussion with staff one area for improvement was the better management of weekend discharges and handover. A recommendation will be made to assist the organisation to consider needed improvement strategies. Corporate and safety systems were noted to be appropriately managed with an improvement culture clearly in place. The soon to be released Strategic Plan has undertaken a number of reviews including consumer collaboration. An enthusiastic WH&S Committee is in place that helps to support safe practice. Maintenance, assets management and Support Services are responsive with their service accountabilities that support the patient, carer, staff and visitor. Two obvious improvements have been around contractor management and disaster management. The work undertaken was significant and collaboration excellent.



STANDARD 1 GOVERNANCE FOR SAFETY AND QUALITY IN HEALTH SERVICE ORGANISATIONS

Surveyor Summary

Governance and quality improvement systems Pre-survey and intra-survey evidence was presented to surveyors including personal presentations and discussions with senior executive staff of Broken Hill Health Service. These presentations indicate strong support and substantial understanding of both the importance of and requirements for compliance with the national safety standards in health. The reception involving the Chief Executive in addition to the Governing body Chair of the safety committee further expanded and outlined the breadth of commitment the organisation has two good governance and Quality Improvement Systems. Tangible evidence existed by way of extensive interactive discussion with key executives that were able to demonstrate their understanding and commitment to quality improvement and active Risk Management within their organisation. Responsible officers within the organisation in addition to representatives from the governing body were able to describe the legislative, regulatory and professional practice environments within which their service operated. Appropriate activities being undertaken within the organisation were able to satisfy members of the executive team and the governing body of appropriate compliance within these frameworks. The commitment to the Australian standards and understanding of the national safety and quality in health care standards was clearly articulated within the documentation in addition to the discussion with these key personnel. Patient safety and quality was given a priority within a significant proportion of meetings held within the organisation. The commitment to safety and quality was also embedded within the vision, mission and core values expressed at the time of the accreditation visit. A comprehensive list of strategic and operational plans exist and were evidenced at the time of survey. A variety of quality indicators and audit results were also available and interrogated at the time of survey. The regular operation of a monthly clinical council meeting was a particular feature in which demonstration of, and commitment to, quality activities designed to improve patient safety and experience. The Director of Clinical Governance was able to comprehensively articulate an overarching management plan which articulated the Clinical Governance Framework throughout all facets of the organisation. The Clinical Governance Framework was also attentive to the important patient carer interface which included the importance of effective and informative communication. Clinical practice The Broken Hill Health Service provides an extensive array of clinical services to address the clinical needs of the surrounding rural and regional facility processes and frameworks governing the delivery of services was comprehensively documented within the overarching organisational plan and included the articulation of variety of clinical pathways, clinical guidelines and contemporary clinical practices as determined by the relevant peak body or college. Risks associated with the undertaking of clinical procedures were regularly assessed using a comprehensive set of risk assessment tools. The minimisation of risks was achieved by strict adherence to formulated and agreed management plans, clinical pathways and locally established clinical protocols. Ongoing audit of compliance to these pathways was being undertaken and was evidenced at the time of survey. Utilisation of the incident management system to both monitor risks and adverse events and inform interventions was noted.



Broken Hill Health Service utilises a comprehensive set of policy directives formulated at a central government level to further assist and guide organisations undertaking clinical operations within their facilities. Such policy directives were able to be readily located and explained by those staff using them in the variety of clinical settings throughout the health service. Access to, and understanding of, the applicability of the various policy directives was extensively demonstrated by a broad variety of personnel interviewed at the time of survey. Substantial documentary evidence existed. Performance and skills management Across the broad spectrum of personnel working within the Broken Hill Health Service was a correspondingly broad and comprehensive set of performance monitoring programs and processes. In particular, it is noted that the process for credentialling of professional staff within the medical and dental practitioner groups complied with statewide processes and protocols consistent with national guidelines for credentialling and the delineation of clinical privileges or scope of practice. The overarching governance committee of the medical and dental appointments advisory committee was noted to be active and compliant with state Policy Directives that are applicable to the professional groups. It was noted that the function of credentialling is undertaken on behalf of the health service by the Western New South Wales Local Health District. The processes were appropriately tailored and inclusive of key personnel within the Broken Hill Health Service. A variety of processes and protocols to deal with the determination of scope of practice, the management of deviations from scope of practice or other clinical performance issues was noted within the policies and procedures within the Broken Hill Health Service. The nurses in midwifery scope of practice is also noted to be covered by the appropriate standards detailing competencies and performance. At the time of survey the health service was able to demonstrate to the survey team both a familiarity with and the application of variety of controls and guidelines used to support safe practice of all categories of staff within the organisation. Incident and complaints management Broken Hill Health Service is committed to the minimisation of adverse events, incidents or situations which lead to the generation of complaints. The health service utilising the applicable New South Wales Health Policy Directives and incident management systems strives to comply with the requirements as detailed under the relevant Acts within the health setting. The appropriate recording and active intervention which may be required as a result of clinical incidents or adverse events which may lead to harm or complaints was noted within the health service. Staff were able to demonstrate an understanding and willingness to access the incident Management system. Under the guidance of the Clinical Governance Framework risks were minimised and adverse events or complaints were managed with appropriate attention to detail and a commitment to improvement or resolution as the case may be. Information gathered within the incident Management system was appropriately interrogated and analysed to assist the organisation in quality improvement activities. Clinical engagement as well as consumer involvement was noteworthy and evidence within information provided to the surveyors. Appropriate education and familiarisation of personnel working within the organisation from students through to advanced practitioners was noted. In circumstances in which a serious adverse event resulted in harm the organisation appropriately instigated either a clinical or open disclosure process appropriate to the incident. Education and training was available to and undertaken by a broad variety of personnel within the health service.



Patient rights and engagement Strong commitment to patient rights was noted by the surveyors upon discussion with a broad variety of personnel across all disciplines within the facility. Appropriate communication with patients, carers and visitors ensured and understanding of patient rights. Compliance with Statewide Policy Directives detailing rights and responsibilities of staff, patients and carers including the policy outlining the seven basic rights contained within the Australian charter of healthcare rights was noted. Whilst it was noted that Broken Hill region contains a limited cultural diversity and also a limited number of people from non-English speaking backgrounds and appropriate approach and consideration for such groups was evidenced at the time of survey. It was particularly important to note the acknowledgement of Australia's first people within the region and the specific health care needs and approach required to enable access to and effective engagement with the health service for such people within the community. Appropriate documentation within clinical records contained relevant information and was in compliance with standards such relating to consent and the adoption and use of various clinical pathways and protocols. End-of-life care was also understood by staff interviewed with appropriate use of guidelines and contemporary practice in areas in which patients requiring this domain of care were managed.



Governance and quality improvement systems

Ratings

Action Organisation Surveyor

1.1.1 SM SM

1.1.2 SM SM

1.2.1 SM SM

1.2.2 SM SM

1.3.1 SM SM

1.3.2 SM SM

1.3.3 SM SM

1.4.1 SM SM

1.4.2 SM SM

1.4.3 SM SM

1.4.4 SM SM

1.5.1 SM SM

1.5.2 SM SM

1.6.1 SM SM

1.6.2 SM SM

Clinical practice

Ratings


1.7.1 SM SM

1.7.2 SM SM

1.8.1 SM SM

1.8.2 SM SM

1.8.3 SM SM

1.9.1 SM SM

1.9.2 SM SM

Performance and skills management

Ratings


1.10.1 SM SM

1.10.2 SM SM

1.10.3 SM SM

1.10.4 SM SM

1.10.5 SM SM



1.11.1 SM SM

1.11.2 SM SM

1.12.1 SM SM

1.13.1 SM SM

1.13.2 SM SM

Incident and complaints management

Ratings


1.14.1 SM SM

1.14.2 SM SM

1.14.3 SM SM

1.14.4 SM SM

1.14.5 SM SM

1.15.1 SM SM

1.15.2 SM SM

1.15.3 SM SM

1.15.4 SM SM

1.16.1 SM SM

1.16.2 SM SM

Patient rights and engagement

Ratings


1.17.1 SM SM

1.17.2 SM SM

1.17.3 SM SM

1.18.1 SM SM

1.18.2 SM SM

1.18.3 SM SM

1.18.4 SM SM

1.19.1 SM SM

1.19.2 SM SM

1.20.1 SM SM



Action 1.18.2 Core

Organisation's Self Rating: SM Surveyor Rating: SM

Surveyor Comment: Whilst safe consenting processes are in place, the compliance with an agreed minimum set of components of the consent documentation is incomplete. Further consultation and education is required to achieve a greater compliance.

Surveyor's Recommendation:

Enhance the education and compliance with the informed consent documentation.

Risk Level: Low



STANDARD 2 PARTNERING WITH CONSUMERS

Surveyor Summary

Consumer partnership in service planning It was evident to the survey team that consumers are at the heart of the service you provide in this region. Evidence was presented clearly demonstrating consumer involvement in the governance structure, committee representation and in the development and quality improvement of the service. The project “Unbreaking the Hill” partnering with consumers to change the health of the community and the “Staying Healthy” Focus groups were and are successful means of involving the community in the identification and development of a consumer focused health service and are to be commended. Surveyors were impressed with the extent of representation you have achieved in recruiting consumer representatives on your decision-making committees. Many examples were available to the surveyors of the positive contribution consumer representatives make to hospital activities. FWLHD has well established documentation and mechanisms to ensure partnerships with consumers and carers in the governance of the organisation. The use of Aboriginal Liaison officers to link into the local aboriginal community is working well ensuring their involvement in all aspects of the service. Good processes are in place for orientation and education for these representatives. The consumer representatives, available to speak with the surveyors throughout the week, were very positive in their views of how well you prepared them for their role and their inclusion in the in-service education programs where appropriate. They felt confident and competent to perform these roles. Consumer partnership in designing care There are excellent sustainable processes in place to obtain consumer input into all patient information material produced for distribution to patients and/or carers. It is suggested that the organisation progress the consultation, development and ratification of the Patient Information Policy currently under development. Another suggested area for improvement would be the identification in patient information that the Health Council or other consumer groups had been involved in their development or review along with a date of publication. The Caring for our Community information booklet given to all consumers admitted to Broken Hill hospital provides comprehensive information about all aspects of their care from admission to discharge involved comprehensive consumer consultation and input. The MHIU booklet “A Place to Heal Millimpilyi yukn-na” while currently in draft is also an excellent comprehensive booklet and it is suggested that its ratification and publication should be undertaken as soon as possible. Staff education in patient-centred care, aggression management and cultural awareness is commenced at orientation and continued throughout employment with consumers involved in this training through ‘Patient Stories’ and the MH award winning DVD and book on carer experiences – Intangible. The use of the Sunflower communication tool across the hospital as a means of communicating with and getting to know the patients with the aim of improving their hospital experience is an innovative means of involving both patient and family in their care and is particularly useful to staff for patients not able to provide certain information. Data presented to surveyors indicated that the organisation target of 80% staff trained was not being met in all areas and surveyors were unsure if this was accurate data or the way the data was presented. It is suggested that the data for Person Centred Care and Small acts of kindness online education be



reviewed and strategies put in place to ensure that all sections of the work force achieve the desired competency. The Health Council Champion Project links consumers to differing hospital departments to promote quality improvements and increase information links between the organisation and the community. Anecdotal information received by the surveyors on this project was positive, however it is suggested that a formal evaluation be undertaken to fully demonstrate its effectiveness and think about this project being utilised at other facilities across the district. Projects such as “PleDG”, “One in a Bed” and “Midwifery Group Practice” clearly demonstrate your commitment to place the consumer at the centre of care. Consumer partnership in service measurement and evaluation Consumer involvement in the governance structure, committee representation and in the development and quality improvements of the service is clear evidence of their involvement in service measurement and evaluation. Feedback from consumer satisfaction surveys, forums and discussions with all levels of consumers throughout the survey were positive, with specific reference made to how well the organisation responds to feedback. The community and consumers are kept well informed on the organisation’s quality and safety performance through Quality Board visual displays around the hospital, electronically, through newsletters and notices displayed across the region.



Consumer partnership in service planning

Ratings


2.1.1 SM SM

2.1.2 SM SM

2.2.1 SM SM

2.2.2 SM SM

2.3.1 SM SM

2.4.1 SM SM

2.4.2 SM SM

Consumer partnership in designing care

Ratings


2.5.1 SM SM

2.6.1 SM SM

2.6.2 SM SM

Consumer partnership in service measurement and evaluation

Ratings


2.7.1 SM SM

2.8.1 SM SM

2.8.2 SM SM

2.9.1 SM SM

2.9.2 SM SM



STANDARD 3 PREVENTING AND CONTROLLING HEALTHCARE ASSOCIATED INFECTIONS

Surveyor Summary

Governance and systems for infection prevention, control and surveillance The organisation's Infection Prevention and Control Program is managed through NSW Ministry of Health and Local policies. IP&C matters are considered at the Quality Care Committee. HETI online is accessed to completed mandatory IP&C education. Infection prevention and control strategies Staff training is undertaken and audits indicate generally good compliance. Specific questions were asked around medical officer mandatory training compliance for IP&C education. Data indicated compliance is increasing but can be better. It was noted that good support is available for medical officer orientation and training. A suggestion made was that a number of laptops or PCs be made available to orientation/training venues to facilitate training completion for those needing to do so. In these settings there is a captive audience. Staff immunisation and exposure management practices are appropriate and supportive of safe practice. The Influenza Program this year vaccinated about 400 staff and consideration of making compliance mandatory is being undertaken. Advice was provided at survey that TB TST training will soon commence. Managing patients with infections or colonisations Education is provided to staff on PPE use. Surveillance information is available and now made available to the IP&C CNC (albeit recently). The Healthcare Associated Infection Report is available to Executive. Antimicrobial stewardship Antimicrobial stewardship is effectively managed and supported appropriate for the organisation. The AMS policy is available on the intranet. Information on antibiotic use is made available to staff. A pro forma is available for antibiotic approval. Therapeutic guidelines are used and are available. Recent AMS audits have demonstrated improvements with antibiotic prescribing with results being made available to staff. data indicates that prescribing practices have improved. Matters around AMS are considered as part of the Drugs and Therapeutics Committee with ad hoc Infectious Disease Physician contact available. It is suggested arrangements be formalised. Microbiologist support is available via Pathology West. Cleaning, disinfection and sterilisation During survey the standard of environmental cleaning was good. Cleaning schedules are available and



cleaning audits are undertaken. On discussion with staff it was considered that the cleaning audit program could be strengthened and one suggestion to ensure this is to complete a schedule of audits at the commencement of the year for the upcoming 12 months based on audit policy requirements, considering critical and non-critical areas. Further, the organisation should ensure completed monthly cleaning audits are provided to department heads as well as corrective actions available to be signed off by the department head. Another suggestion the organisation may wish to consider is to complete a cleaning audit guide which is made available to staff completing audits as this may help to reduce subjectivity in completing audits and guide on what is an acceptable and non-acceptable standard. Disinfection and sterilising standards are appropriate and well managed. The department has the advantage of experienced staff providing services, meeting policy requirements. Equipment testing and maintenance is undertaken, staff training is provided and a very good relationship between SSD and Operating Theatre staff support needed service delivery. The organisation uses a manual tracking system and a suggestion to be considered is to undertake random audits in following the tracking system to the patient to ensure equipment can in fact be identified. To further support SSD practices and governance a suggestion is made that a regular report on SSD matters is provided to the Quality Care Committee, particularly considering the present and ongoing requirements to meet S4187. A procurement committee is to be established which should support effective IP&C purchasing practices. IP&C representation on this committee would be prudent. Sterile equipment storage throughout the organisation including the Stores Department was seen to be appropriate. Communicating with patients and carers Information is provided to patients and carers on IP&C matters and this is particularly evident through the availability of the Quality Boards located throughout the wards and main entrance. Hand hygiene stations are available throughout the organisation. At survey comment was made that despite efforts no consumer representative is not on the Quality Care Committee. The organisation is encouraged to continue to consider appropriate consumer representation.



Governance and systems for infection prevention, control and surveillance Ratings


3.1.1 SM SM

3.1.2 SM SM

3.1.3 SM SM

3.1.4 SM SM

3.2.1 SM SM

3.2.2 SM SM

3.3.1 SM SM

3.3.2 SM SM

3.4.1 SM SM

3.4.2 SM SM

3.4.3 SM SM

Infection prevention and control strategies

Ratings


3.5.1 SM SM

3.5.2 SM SM

3.5.3 SM SM

3.6.1 SM SM

3.7.1 SM SM

3.8.1 SM SM

3.9.1 SM SM

3.10.1 SM SM

3.10.2 SM SM

3.10.3 SM SM

Managing patients with infections or colonisations

Ratings


3.11.1 SM SM

3.11.2 SM SM

3.11.3 SM SM

3.11.4 SM SM

3.11.5 SM SM

3.12.1 SM SM

3.13.1 SM SM

3.13.2 SM SM



Antimicrobial stewardship

Ratings


3.14.1 SM SM

3.14.2 SM SM

3.14.3 SM SM

3.14.4 SM SM

Cleaning, disinfection and sterilisation

Ratings


3.15.1 SM SM

3.15.2 SM SM

3.15.3 SM SM

3.16.1 SM SM

3.17.1 SM SM

3.18.1 SM SM

Communicating with patients and carers

Ratings


3.19.1 SM SM

3.19.2 SM SM



STANDARD 4 MEDICATION SAFETY

Surveyor Summary

Governance and systems for medication safety The FWLHD Drug and Therapeutics Committee (DTC) has utilised the NSW State Acts and regulations in construction of a responsible and compliant governance framework which guides and protects against adverse events. The DTC oversees prescribing and formulary arrangements in addition to providing and mapping ongoing training requirements of clinicians involved in prescribing and dispensing. The monitoring of drug storage, supply and usage is also overseen responsibly by the pharmacy department who are all suitably credentialled and reported through DTC. Whilst medication incidents are also monitored and any interventions governed through DTC it is noteworthy that the rate on medication incident logging in the incident management system is relatively low. The potential of under-reporting is requiring consideration by the organisation. A variety of audits are regularly undertaken in accordance with state-wide guidelines and information is disseminated to clinical areas as required. Documentation of patient information Systems are in place for the recording of past medication usage and is documented in the medical record. The National Medication Management Plan is also noted to be utilised in Broken Hill Health Service. Any alterations to medication regimes are documented and communicated to relevant primary care and referral sites. The use of publications is noted for drug information and contained within patient information documents. An appropriate attention to potential and past medication allergy and adverse reactions is also noted. The monitoring within the health service incident management system is a part of the overall management plans in place. Whilst adverse drug reactions have been infrequently reported in the health service, a documented and disseminated process exists. User guides and relevant state-wide guiltiness are used appropriately and are overseen by the DTC. Medication management processes Guidelines and on-line resources are available and used by clinical staff to guide in the safe management of medications and to minimise adverse incidents or errors and promote medication safety and awareness amongst staff. Senior pharmacy staff supported by the Executive Director of Medical Services and other Senior Departmental Medical Officers are active in providing information and guidance. Compliance to relevant Standards for the safe use and storage of medications is evidenced. Quality activities including self-assessments are in place and used to refine and strengthen medication management processes throughout the facilities. Appropriate security regarding the management of scheduled medications is complied with and audited under the relevant New South Wales guidelines. A wide variety of audit results are appropriately communicated to the governing body. The storage and management of temperature sensitive medications is appropriately compliant with relevant cold chain checks in place.



Continuity of medication management Utilisation of the National medication management plan within the Broken Hill Health Service has ensured continuity of medication management including patient reviews at the time of discharge. Information provided to patients has also occurred particularly in respect to changes in medication regimes. The use of New South Wales health guidelines has governed documentation within the records. Patient's medications are documented at the time of admission and any discharge medications are provided within the discharge letters sent to either the primary care provider or to referral sites. It was particularly noted that clear guidelines for the management of inter hospital transfers have been used and were evidenced. Whilst the hospital is undergoing a transition to electronic medical record systems if was noted that there were examples of both written and electronically documented medication use. In particular it was noted that medications are documented within the Emergency Department within the electronic Medical Record. Further work is being undertaken to ensure that appropriate access by clinicians to aid in hand to over and in intra-hospital transfers was in place. Communicating with patients and carers The health service has been particularly commit to the creation of appropriate patient information sheets which are used on discharge. The sources of the information contained within these communication sheets are derived from various state resources. Medication safety awareness month is also a time when the hospital utilises a variety of public mechanisms to convey information about the safe use of medicines and includes antimicrobial stewardship features particularly relating to awareness. Evidence would indicate that patients and their families and/or carers are appropriately counselled in relation to medication use. Such counselling is complemented by the variety of written information sheets which are provided to patients and their families.



Governance and systems for medication safety

Ratings


4.1.1 SM SM

4.1.2 SM SM

4.2.1 SM SM

4.2.2 SM SM

4.3.1 SM SM

4.3.2 SM SM

4.3.3 SM SM

4.4.1 SM SM

4.4.2 SM SM

4.5.1 SM SM

4.5.2 SM SM

Action 4.4.1 Core


Surveyor Comment: Medication incidents have a lower than expected incidence. There are few incidents of any significance and the vigilance of pharmacy personnel is high. It would be desirable for a greater awareness and reporting of incidents, including near misses so as to inform improved practice across disciplines relating to prescribing and dispensing accuracy.


Increase vigilance and reporting of medication errors including no harm incidents and near miss incidents.

Risk Level: Low

Action 4.4.2 Core


Surveyor Comment: Improving the reporting of medication management errors will inform the actions required to reduce risk of adverse medication events.




No recommendation

Documentation of patient information

Ratings


4.6.1 SM SM

4.6.2 SM SM

4.7.1 SM SM

4.7.2 SM SM

4.7.3 SM SM

4.8.1 SM SM

Action 4.6.1 Core


Surveyor Comment: Medication history is a key component of a patient episode. There has been recent attention to medication reconciliation in a variety of clinical areas. Further education and compliance strategies should be continued so as to improve results.


Strategies for medication reconciliation be further developed across clinical areas championed by clinicians and assisted by pharmacy personnel.

Risk Level: Low

Action 4.8.1 Developmental


Surveyor Comment: The current emphasis on medication reconciliation is encouraged to continue and be a process which is imbued within the activities of relevant clinical staff.




No recommendation

Medication management processes

Ratings


4.9.1 SM SM

4.9.2 SM SM

4.9.3 SM SM

4.10.1 SM SM

4.10.2 SM SM

4.10.3 SM SM

4.10.4 SM SM

4.10.5 SM SM

4.10.6 SM SM

4.11.1 SM SM

4.11.2 SM SM

Continuity of medication management

Ratings


4.12.1 SM SM

4.12.2 SM SM

4.12.3 SM SM

4.12.4 SM SM


Ratings


4.13.1 SM SM

4.13.2 SM SM

4.14.1 SM SM

4.15.1 SM SM

4.15.2 SM SM



STANDARD 5 PATIENT IDENTIFICATION AND PROCEDURE MATCHING

Surveyor Summary

Identification of individual patients Good processes are in place for the implementation and monitoring of the organisation wide patient identification system, with all patient identification bands meeting the requirements of this Standard. A suite of policy supports the implementation of this service wide patient identification process. All admissions and patient presentations undergo identification verification as part of the admission process, with a minimum three patient identifiers embedded in practice. Identification is verified throughout the admission at key care points, during handover, transfer of care and discharge planning processes. The system incorporates the ability to identify same/similar names which are flagged during an admission / attendance to increase staff awareness within the clinical area. Audits are conducted to monitor compliance with policy and these are reviewed at the Clinical Council. A process is in place for incidents involving patient identification to be reported using IIMS, investigated and the report and any subsequent recommendations reviewed by the Health Care Quality Board Committee. The incidence of these events within FWLHD Broken Hill is very low, however one issue was identified relating to the incorrect labelling, recording and reporting of pathology specimens which is further discussed in “Processes to Match Patients and Their Care”. Following risk assessment, in service areas where neonates and surgical patients are present, two compliant bands are in place to support correct identification. Patient information recorded on this band is limited to three identifiers as required. Audits are undertaken with systems in place to identify and reduce the risk of mismatching especially around the areas of medication management, bloods, pathology and patient care. Patient identification was clearly demonstrated at bedside clinical handover, with the use of photo identification well established in identified areas of risk. There are good clinical review and education processes in place to manage any mismatching with audit results reported through the governance structure. Processes to transfer care There are good processes and documentation tools available to support safe and effective transfer of care between clinicians at change of shift times, when patients are being moved within FWLHD or transferred interstate, for admission, clinical investigations and procedures. Verbal and written handover protocols are utilised when patients are admitted to inpatient units from the Emergency Department, and when patients are being transferred from ICU and from operating theatres. One issue identified by the organisation involved incorrect patients being transported for x-rays and tests as wards men were only given the patients bed number. This caused frustration of the patients, and the various departments. Processes were put in place for the wards man to be given the patients identification sticker and education in identification of the patient through the three unique identifiers. The issue has been resolved and continues to be audited to identify any further areas for improvement. There are effective processes in place for handing over responsibility for ongoing care to general practitioners, community health care providers and residential care facilities. These processes are audited through chart reviews, patient, and external provider feedback and the results tabled Clinical Council before reporting through the governance and reporting structure to the Health Care Quality Board Committee.



Processes to match patients and their care The service uses a range of checklists and other tools to ensure that all patients are correctly matched to their intended procedure/ treatment or investigation. Surgical safety checklists and time-out concept is well embedded into everyday practice in operating theatres, radiology and other areas where invasive procedures are undertaken, with current compliance at 100%. Results in procedure matching documentation audits have shown improvements and up to 100% compliance is a number of areas, however a number of areas audited identified that there were still areas for improvement in documenting this process and it is suggested that strategies be put in place to improve these areas of documentation. Appropriate review, staff education and counselling is initiated should any specific incident occur and increased monitoring undertaken to ensure compliance. Policies and processes are in place to ensure care provision is linked to the correct patient, however during survey an issue was identified relating to the miss labelling of pathology specimens, and the processes followed for the recording and reporting of this issue on IIMS. Surveyors were informed that this was a frequent occurrence; however there was no data available to fully identify the size of the problem. While there had been no recorded incidents related to this issue, continued mismanagement of this process does pose a risk to patients and their care, so in this regard there is a recommendation to reduce risk and assist in improving this area of care. From the review of the incident information management system (IIMS) database on adverse incidents and patient complaints the surveyors noted that there were no recorded adverse incidents relating to patient identification.



Identification of individual patients Ratings


5.1.1 SM SM

5.1.2 SM SM

5.2.1 SM SM

5.2.2 SM SM

5.3.1 SM SM

Processes to transfer care

Ratings


5.4.1 SM SM

Processes to match patients and their care

Ratings


5.5.1 SM SM

5.5.2 SM SM

5.5.3 SM SM

Action 5.5.3 Core


Surveyor Comment: Policies and processes are in place to ensure care provision is linked to the correct patient, however during survey an issue was identified relating to the miss labelling of pathology specimens, and the processes followed for the recording and reporting of this issue on IIMS. Surveyors were informed that this was a frequent occurrence, however no data was available to clearly identify the size of the problem. While there had been no recorded incidents related to this issue, continued mismanagement of this process does pose a risk to patients and their care.


FWLHD Broken Hill review and improve its processes for the labelling and management of pathology specimens in addition to the recording, reporting and trended analysis of miss labelled specimens. Systems of reporting mislabelled specimens should involve key clinicians so as to inform improvements.



STANDARD 6 CLINICAL HANDOVER

Surveyor Summary

Governance and leadership for effective clinical handover A number of policies and processes are applied and considered to implement improvement strategies for clinical handover. Included are, Inter-hospital Transfer, Mental Health Unit Admission, ICU Admission, Maternity Consultation and Referral and Clinical Framework - ISBAR Framework. Handover tools are also available including the Locum and EDMO orientation information and the antenatal obstetric tools. To support effective handover, ED bed block at present time is not seen as a significant issue and ASET and Mental Health support in the ED is considered to be responsive. FIM scores support Rehabilitation handover and discharge practices. Data is available and reviewed for length of stay and 28 day readmissions. On discussion areas of needed improvement include some matters around length of stay and serial readmissions. Clinical handover processes During survey, clinical handover practices were seen to be supportive of effective and needed practice. The installation and use of patient journey boards and application of Studer principles and practices have supported patient handovers. Although a snapshot, a bedside handover and Journey Board meeting was viewed on survey and each was seen to be focused on the patient, ongoing care and was multidisciplinary in practice. One area identified at survey that could be better managed was with weekend patient discharge and handover. A recommendation will be made to support better practice. Relatively recent improvements include the establishment of the Discharge Lounge and Hospital in the Home (Ambulatory Care). Presently more funding is being sought to enhance the HITH Program to engage a Consultant. It was stated that good practices exist for orthopaedic transfer and information exchange and a virtual clinic is available through Flinders Hospital in Adelaide and what are seen as good links are available with Hempstead Rehabilitation in Adelaide. Patient and carer involvement in clinical handover Family meetings and case conferences occur to support this criterion. Discharge planning occurs and at survey it was acknowledged supportive practices are in place and some further improvements can be made. The organisation is encouraged to continue to evaluate practices to assist with feedback. Palliative Care support is considered to be good.



Governance and leadership for effective clinical handover

Ratings


6.1.1 SM SM

6.1.2 SM SM

6.1.3 SM SM

Action 6.1.1 Core


Surveyor Comment: One area identified at survey that could be better managed was with weekend patient discharge and handover. A recommendation will be made to support better practice.


Processes around the better management of weekend discharge and handover consisting of a multidisciplinary team approach be implemented to support more timely and appropriate discharge and handover practices.

Clinical handover processes

Ratings


6.2.1 SM SM

6.3.1 SM SM

6.3.2 SM SM

6.3.3 SM SM

6.3.4 SM SM

6.4.1 SM SM

6.4.2 SM SM



Patient and carer involvement in clinical handover

Ratings


6.5.1 SM SM



STANDARD 7 BLOOD AND BLOOD PRODUCTS

Surveyor Summary

Governance and systems for blood and blood product prescribing and clinical use Evidence-based, national guidelines consistent policy and procedures are in place, with comprehensive monitoring of all blood and blood products usage occurring. Effectiveness includes Blood safe education for all staff involved in the use of blood and blood products and increased use of processes such as, preoperative haemoglobin and iron level optimisation. Data indicates that while there are good results for training in transporting blood competency, above the organisation’s target, there is room for improvement in the Clinical Transfusion Practice training which has yet to reach targets. It is suggested that this area be reviewed and strategies initiated to ensure all staff requiring this education access it and are competent in all areas of the practice. There is a rigorous reporting system for management of incidents with escalation to appropriate governance committees, feedback to clinical areas, with comparative reports of incidence and action plans developed as required. Audit demonstrate good compliance with no blood related incidents recorded for three years. Mandated reporting to State and National bodies occurs and evidence was viewed. Documenting patient information Currently FWLHD Broken Hill is transitioning to an electronic medical record. For the interim, manual recording in the clinical record is required including consent, usage and adverse blood events and reported on the incident system. Two incidents were recorded in August relating to documentation which have been reviewed and strategies put in place to improve documentation. Managing blood and blood product safety Blood is stored in Pathology, complies with National Standards with fridges monitored and audited. Blood wastage has been targeted with the implemented policies and treatment regimens and this is reflected in the product usage audits and the reduction of the amount of blood now held in the facility. The organisation has achieved very low wastage of blood and blood products through education and monitoring of use by dates allowing units to be returned to a high usage area within NSW Health thus achieving such a wastage rate. Processes are in place to move patients currently receiving blood from ward areas to ICU overnight, ensure safe care. Communicating with patients and carers Staff has access to transfusion policy and procedures and can discuss risks and benefits based on information available and gained through Blood Safe learning packages. Patients are involved in discussion concerning transfusion when able. Consent is obtained on a specific blood transfusion consent form on the rear of the standard consent form. Consent is not required for emergency transfusions but the FWLH Broken Hill needs to be careful to document such transfusions and inform patients when able and document this information has been given. Information about blood/blood products, transfusions and associated risks is provided to patients, and included within the Caring for Community Patient Information booklet. While most information is in English, CALD patient information is available on the intranet.



Patients who have an adverse reaction during transfusion are informed of the reason it occurred, their GP notified and are given information which can be provided to future treating teams in the event that they require blood products again thereby reducing future transfusion risks.



Governance and systems for blood and blood product prescribing and clinical use

Ratings


7.1.1 SM SM

7.1.2 SM SM

7.1.3 SM SM

7.2.1 SM SM

7.2.2 SM SM

7.3.1 SM SM

7.3.2 SM SM

7.3.3 SM SM

7.4.1 SM SM

Documenting patient information

Ratings


7.5.1 SM SM

7.5.2 SM SM

7.5.3 SM SM

7.6.1 SM SM

7.6.2 SM SM

7.6.3 SM SM

Managing blood and blood product safety

Ratings


7.7.1 SM SM

7.7.2 SM SM

7.8.1 SM SM

7.8.2 SM SM




Ratings


7.9.1 SM SM

7.9.2 SM SM

7.10.1 SM SM

7.11.1 SM SM



STANDARD 8 PREVENTING AND MANAGING PRESSURE INJURIES

Surveyor Summary

Governance and systems for the prevention and management of pressure injuries A Committee is in place to manage Standard requirements. This Committee is multidisciplinary in membership however there is no medical officer involvement. This is an obvious area for improvement and a recommendation will be made for the organisation to consider appropriate Committee medical representation. The multidisciplinary team is in place to support and communicate care requirements. On discussion with staff it was considered that advice provided to medical officers at their orientation of care practices provided by allied health practitioners will support better pressure injury practices and referrals. This will undoubtedly support other areas of practice. Preventing pressure injuries The pressure injury management plan is currently being reviewed to help support best practice. An emphasis is being place on proper patient engagement. A point prevalence survey was recently completed and an action plan is being developed. One comment made was that with eMR2 being implemented there are issues with documentation and ward handovers and matters are being worked through. Waterlow scores are being completed. It was also stated some management plans are not being completed, so an obvious area for improvement. Equipment is available to prevent pressure injuries including air mattresses and gel pads in the Operating Theatre. A range of equipment is available from Allied Health to support the mobility of patients and transitioning care from the hospital into the community. Wound management in-service is provided to staff including a recent College of Nursing Course. A Wound Management Committee is also being established to support effective procurement practices. Managing pressure injuries Pressure injuries are notified via IIMS and it was noted that there have been some hospital acquired pressure injuries. However, in saying this, strategies are in place to manage these and to obviously prevent others. Communicating with patients and carers Care plans are completed in collaboration with patients and carers. Information on pressure injuries are made available on the quality board screens located throughout the organisation.



Governance and systems for the prevention and management of pressure injuries

Ratings


8.1.1 SM SM

8.1.2 SM SM

8.2.1 SM SM

8.2.2 SM SM

8.2.3 SM SM

8.2.4 SM SM

8.3.1 SM SM

8.4.1 SM SM

Action 8.2.1 Core


Surveyor Comment: A Committee is in place to manage Standard requirements. This Committee is multidisciplinary in membership however there is no medical officer involvement. This is an obvious area for improvement and a recommendation will be made for the organisation to consider appropriate Committee medical representation. The multidisciplinary team is in place to support and communicate care requirements. On discussion with staff it was considered that advice provided to medical officers at their orientation of care practices provided by allied health practitioners will support better pressure injury practices and referrals. This will undoubtedly support other areas of practice.


1. Medical officer representation be added to the Pressure Injury Committee to further reinforce the multidisciplinary team involvement and practice.

2. Medical officer orientation/induction to include advice on allied health referral information to help flag key areas of practice to support pressure injury management.



Preventing pressure injuries Ratings


8.5.1 SM SM

8.5.2 SM SM

8.5.3 SM SM

8.6.1 SM SM

8.6.2 SM SM

8.6.3 SM SM

8.7.1 SM SM

8.7.2 SM SM

8.7.3 SM SM

8.7.4 SM SM

Managing pressure injuries

Ratings


8.8.1 SM SM

8.8.2 SM SM

8.8.3 SM SM

8.8.4 SM SM


Ratings


8.9.1 SM SM

8.10.1 SM SM



STANDARD 9 RECOGNISING AND RESPONDING TO CLINICAL DETERIORATION IN ACUTE HEALTH CARE

Surveyor Summary

Establishing recognition and response systems The Broken Hill Health Service is committed to responsibly implementing systems and processes which recognise and respond to the deteriorating patient. Appropriate governance process was in place in which protocols, processes and pathways were followed in order to detect and intervene in clinical situations in which a deteriorating patient was identified. The appropriate committee was able to review a series of audits and implement appropriate training at appropriate intervals to all staff within the variety of clinical settings. The application of the appropriate applicable state approach including "between the flags" was noted. Ongoing teaching and familiarisation was a feature of the organisation's approach to the management of the deteriorating patient. Recognising clinical deterioration and escalating care A variety of clinical tools is used to assist in the detection of clinical deterioration of patients under the care of various clinical units within the Broken Hill health service. Once detected a clinical deterioration results in appropriate escalation and where indicated the implementation of an intervention to redress such deterioration. Compliance with clinical detection tools such as between the flags was regularly audited and discussed within the clinical governance system of the health service. Audit results were further interrogated and analysed by the morbidity and mortality committee in addition to being discussed at the clinical Council and where appropriate the governing body quality committee. Rapid response audits are completed on a monthly basis and were reviewed at the time of survey. The implementation of regular training which is recorded within the health service was noted. Communication relating to the detection and management of the deteriorating patient was also available to the public by way of posters which were located throughout the organisation. Such posters were provided in order to educate and inform members of the public so as to enable their involvement where necessary in the notification process. Responding to clinical deterioration The Broken Hill Health Service was able to demonstrate compliance with the New South Wales policy surrounding the recognition and response to the deteriorating patient which triggered clinical reviews and rapid responses as required. Audits are in place and were regularly reviewed. A broad variety of health care personnel was regularly refreshed with basic life-support training and appropriate access to eLearning tools pertinent to this standard. Communicating with patients and carers Consumers and families were readily able to view specifically developed posters and displays in the variety of clinical areas surrounding the detection and management of deteriorating patient. Information was also available within the patient information booklets. Specific approaches including those for adults and children are separately produced and disseminated within the inpatient area and where applicable into community settings. Statewide guidance and the utilisation of existing care directives was noted.



Establishing recognition and response systems Ratings


9.1.1 SM SM

9.1.2 SM SM

9.2.1 SM SM

9.2.2 SM SM

9.2.3 SM SM

9.2.4 SM SM

Recognising clinical deterioration and escalating care

Ratings


9.3.1 SM SM

9.3.2 SM SM

9.3.3 SM SM

9.4.1 SM SM

9.4.2 SM SM

9.4.3 SM SM

Responding to clinical deterioration

Ratings


9.5.1 SM SM

9.5.2 SM SM

9.6.1 SM SM

9.6.2 SM SM


Ratings


9.7.1 SM SM

9.8.1 SM SM

9.8.2 SM SM

9.9.1 SM SM

9.9.2 SM SM

9.9.3 SM SM

9.9.4 SM SM



STANDARD 10 PREVENTING FALLS AND HARM FROM FALLS

Surveyor Summary

Governance and systems for the prevention of falls There is an enthusiastic and dedicated team promoting this area across the hospital, with falls prevention and management well done across the hospital. Falls risk is assessed on admission and monitored throughout the patient journey, with falls data reviewed and reported through the governance structure. Outcomes are reported and reviewed at ward and unit level and throughout clinical programs, with action plans for improvement developed implemented and monitored at all levels. Data seen at survey identified a continuing downward trend in both falls and harm from falls. Staff education on falls commences at orientation and continues with online sessions on prevention, dealing with falls and post fall ensuring competency of staff. Review of the date identifies improvement in completion of training with organisation targets being achieved. The use of Falls Folders in wards and departments assist staff in staying abreast of best practice. These folders are kept up to date by the Falls working party and ward champions. Screening and assessing risks of falls and harm from falling A holistic approach has been taken for the prevention of falls and harm from falls, by linking assessment to elements of patient care, nutrition and continence management. Improvement strategies have been developed across the organisation to increase the effectiveness of falls prevention plans and equipment to manage falls is readily available. Ontario and Waterlow scales are used on admission to Broken Hill Hospital and FRAMP paper based assessment in the community with the Community Toolkit linking into acute care ensuring continuation of care. Audit demonstrates and outstanding result of 100% compliance in all areas. Despite this, two areas for improvement were identified at survey. The documentation that falls prevention strategies are developed in consultation with the patient/carer and that falls prevention information has been provided to the patient/carer so it is suggested that strategies be introduced to improve these areas. The use of the hydrotherapy pool for rehabilitation exercises for musculoskeletal patients and those diagnosed with Osteoarthritis have proven useful in the prevention of falls. Falls incidents or near misses are monitored through ‘IIMS’ with trends analysed and discussed at the Clinical Council, and at team staff meetings. Changes are initiated as necessary. Preventing falls and harm from falling The introduction of the Musculoskeletal project, “Friday on my mind” weekly falls risk review and the hourly patient rounding soon to be commended and will improve patient care in this area. Carers and where possible patients are educated on falls risks and strategies for prevention with links to programs such as ‘stepping on’ and falls clinic reviews, with falls prevention and management plans especially for post discharge developed in partnership with patients and/or carers. A post falls risk analysis reviews the education that was received by patients and carers and a client falls satisfaction survey has been introduced.



Communicating with patients and carers The survey team viewed brochures on falls prevention that are available for informing patients and their carers on ways to prevent falls and minimise harm. This information is from NSW Government, and FWHD and the information they contain is in a format that may be understood by consumers with translated material available on line for patient or carer/families from a CALD background. Patients and carers are informed of the identified risks from the falls risk assessment and are engaged in the development of a falls management plan in conjunction with staff. There is evidence of patient/carer involvement with their falls prevention interventions. Education and information is given to patients and carers on completion of the falls risk assessment and of any interventions implemented. “Hold My Hand” paediatric falls posters throughout the paediatric area are a good reminder to parents, while the Red Socks advertised and sold by the hospital kiosk are an ongoing reminder for adults. Carers and where possible patients are educated on falls risks and strategies for prevention on discharge with links to programs such as ‘stepping on’ the Musculoskeletal project and falls clinic reviews.



Governance and systems for the prevention of falls Ratings


10.1.1 SM SM

10.1.2 SM SM

10.2.1 SM SM

10.2.2 SM SM

10.2.3 SM SM

10.2.4 SM SM

10.3.1 SM SM

10.4.1 SM SM

Screening and assessing risks of falls and harm from falling

Ratings


10.5.1 SM SM

10.5.2 SM SM

10.5.3 SM SM

10.6.1 SM SM

10.6.2 SM SM

10.6.3 SM SM

Preventing falls and harm from falling

Ratings


10.7.1 SM SM

10.7.2 SM SM

10.7.3 SM SM

10.8.1 SM SM


Ratings


10.9.1 SM SM

10.10.1 SM SM



STANDARD 11 SERVICE DELIVERY

Surveyor Summary

Information about services The Broken Hill Health Service provides a variety of information sources about services provided within its facilities to consumer, patient and carer groups. The utilisation of electronic information including websites and social media was being created and expanded. Varieties of more traditional information by way of written pamphlets and booklets was also noted. Public forums including public meetings and consumer advocacy groups were amongst other processes by which information about services was conveyed. The healthcare advisory councils were also active in providing feedback and content to various publications that were created within the health service. Further exploration and evaluation of the modalities designed to communicate information about services was being undertaken in addition to the more regular patient experience surveys. Access and admission to services The Far West LHD utilises a number of systems, processes and evaluation methods to assess effectiveness of access and admission to facilities for the provision of services. Such processes include the application of a national emergency assessment targets and emergency surgery targets. The collection of data for these key KPIs informs the health service in the implementation of strategies to improve access and admission. Information and interrogation of these systems also informs the redesign program adopted by the health service. Emergency Department access is also monitored and particularly the performance relating to the various categories of patients presenting. Information is again used to inform quality improvement and effectiveness objectives. New South Wales regularly reviews the role delineation of organisations within the state. Information is provided by the organisation which leads to the production of and guidance included within such a process such that appropriateness of care remains a high priority and is in accordance with the capability of the organisation and the various professionals working within. A broad set of care planning tools is available to address the needs of the cohorts of patients presenting with various conditions that require the attention and care of the multidisciplinary teams within the health service. The continuity and appropriateness of care are guided by the adaptation and use of standardised clinical practice. An integrated grated care program is also noted to ensure continuity of care provided within an episode of care. Leadership and management across the various disciplines is provided with the appropriate designation of clinical leads within the various facets of the healthcare environment contained within the Broken Hill hospital. Consumer / patient consent Legislation surrounding requirements for appropriate informed consent was noted at the time of survey. Appropriate compliance with such standards was also evidenced during the time of survey. Ongoing training and education of applicable staff in particular medical staff undertaking a variety of procedural activities involving consent was noted to be contained within the information packs provided to both appointed staff, visiting consultants and the variety of medical trainees in various specialty fields.



Informed consent was also a topic covered within clinical competencies detailed to nursing, medical and allied health staff within Broken Hill Health Service. Documentation required for the appropriate consenting of patients was noted to have some deficits in all fields of the consent form. Whilst informed consent was applied full compliance with specific fields within the form may require further attention. Appropriate and effective care Appropriate and effective care provided within the role delineation and service capabilities of the health service was appropriately managed in accordance with a broad set of policy directives covering specific designated services. The appropriateness of care was otherwise overseen by the clinical leads within the various healthcare settings including departments and specialist service areas across Broken Hill health service. Specifics included the subspecialties. Diverse needs and diverse backgrounds The health service utilises a variety of documents, policies, procedures and where appropriate interpreter and cultural advisory services to ensure the needs of patients from culturally and linguistically diverse backgrounds are met. Engagement with variety of cultural groups and in particular the needs of first Nation people identifying from aboriginal backgrounds was particularly important within the region. Population health Population health and burden of disease data was used to tailor health programs designed to improve health and health outcomes for people within the region of Broken Hill and surrounding populations. The delivery of state programs particularly targeting obesity and smoking cessation were also being implemented within the area. Surveyors noted the utilisation of post-program implementation audits designed to evaluate the effectiveness of the of interventions and to further assist in the improvement and better compliance to treatment or health improvement programs. A variety of other initiatives including the healthy children's initiative to get healthy service and the stepping on program were showcased during the time of survey. An appropriate and comprehensive approach assisted by the Far West Local Health District personnel within population health was noted. State programs of health promotion particularly targeting at risk groups were adapted and rolled out in line with the Ministry of Health direction in a variety of areas such as obesity falls prevention tobacco control and the management of lead within the environment. The surveyors noted a significant number of reports informing interventions in addition to a variety of education programs both within the health facilities and within the communities of Broken Hill.



Information about services

Ratings


11.1.1 SM SM

11.1.2 SM SM

11.2.1 SM SM

11.2.2 SM SM

Access and admission to services

Ratings


11.3.1 SM SM

Consumer / Patient Consent

Ratings


11.4.1 SM SM

11.4.2 SM SM

Appropriate and effective care

Ratings


11.5.1 SM SM

11.5.2 SM SM

Diverse needs and diverse backgrounds

Ratings


11.6.1 SM SM

11.7.1 SM SM

11.7.2 SM SM



Population health

Ratings


11.8.1 SM SM

11.9.1 SM SM

11.9.2 SM SM

11.10.1 SM SM



STANDARD 12 PROVISION OF CARE

Surveyor Summary

Assessment and care planning At survey FWLHD Broken Hill demonstrated a fully integrated service providing appropriate, comprehensive and competent care to the community it serves. There are appropriate timeframes for assessment, acceptance, and admission/discharge planning underpinned by policy and procedures. On admission, assessment is attended in collaboration with the patient/carer and is a comprehensive process utilising a very effective multidisciplinary tool to allow patient management; its continued evolution and use is to be strongly encouraged. Planning for discharge, including prospective date of discharge begins at admission. Assessment includes physical, risk, social, psychological and spiritual aspects of care and needs, and is reviewed regularly following admission. Information is shared electronically and care provision prioritised with clinical plans and pathways in place. The standard adult general observation is in place with established compliance. Discharge audits have been conducted and demonstrate good compliance. The surveyors noted impressive working relationships between all health professionals and external care providers – this is a significant component of the culture of FWLHD Broken Hill and refreshing in nature. Management of nutrition Nutrition is an integral part of care planning from admission with nutrition staff attending handovers and multidisciplinary case reviews to support care delivery and holistic care. Cultural aspects of meal provision are taken into account, with systems in place to support families providing food for inpatients and to ensure food safety. The main patient food system is a cook fresh operation and an efficient and well maintained kitchen operation is based at the hospital. General nutrition and special dietary needs for patients are handled well with surveys providing positive feedback. Ongoing care and discharge / transfer Overall, discharge planning and liaison with external care providers is excellent. Patient satisfaction surveys and a reduced readmission rate attest to thorough processes employed in this area. The organisation has a multidisciplinary approach to ongoing care and discharge coordination. Discharge planning commences on admission and the patient admission forms section for discharge requires completion within 24 hours of admission. Discharge summaries are generated from the eMR electronic file and transferred electronically to GPs, however paper based documentation is still used for transfer to tertiary health services and remote sites across the region with verbal handover provided as necessary.

The “One in a Bed” project looking at flow management and diverting planned and non-urgent care away from DE to the HITH program and utilising the discharge lounge has proved very positive in reducing



waiting times, LOS, DNWs, and cost and improved patient outcomes and satisfaction. Medication education is provided by the pharmacists with other education material and information relevant to the individual provided by the nursing staff prior to discharge. The use of the discharge lounge to provide a discharge overview ensuring the patient has all the necessary information, medications and knowledge to support their ongoing care is a good initiative. End-of-life care FWLHD Broken Hill has a Specialist Palliative Care Team (SPCT) multidisciplinary working party to improve palliative and end-of-life care, with policies and procedures for Advanced Care Planning, Advance Care Directives, resuscitation plans, end-of-life care and care of the deceased in place. Flow charts have been developed to ensure that inpatient deaths, community palliative care and DOA patients have verification and certification of death provided in a structured and compassionate manner. Ninety-eight percent (98%) Palliative Care patients have Advance Care Directives in place, but no indication was given as to how many other categories of patients so this would be a good place to identify any areas for improvement. A quiet interdenominational room and reflective garden is available to all patients, families, carers and staff. FWLHD Broken Hill do not undertake organ donation, but are able to supply information should this be requested. The hospital has a morgue however no autopsies are carried out. Education has ensured that all areas of the hospital and community are able to provide palliative care with the support and guidance of the SPC team. With the “End of Life discussions” and Breaking bad news" included in the JMO education to assist in providing compassionate information. CEC Last Days of Life Medication management are used, with all Community Palliative Care Nurses, and RACFs caring for syringe drivers undergoing Syringe Driver competencies provided by the SPCT. A Palliative Approach Framework has been implemented following a 12 month Palliative Care nurse secondment to RACF with a suite of clinical documentation, flow charts and education material, and has demonstrated improved palliative and end of life care by Residential Aged Care Facilities and GPs, reduced unnecessary admissions to hospital, more timely referral for complex care and co-ordination of care and more patients dying in their own place. With the rollout of this framework across the FWLHD it is suggested that the review of the assessment tool and development of the ongoing assessment forma and care plan be completed as quickly of possible to ensure the success of this across the remote area. The liaison between palliative care specialist team with oncology, haematology, renal specialties, aged care and external care providers is excellent with consistently high KPIs recorded across a number of areas such as initial contact within two days - 89%, advanced care or end of life discussion documented - 99% and Patients having their wishes respected - 99%. The commitment of the specialist doctors, staff and community members involved in the review and development of the palliative care unit, the end-of-life plan and clinical pathways is commendable - such dedication is to be respected. The Palliative care nurses follows up all families known to the SPCT and provide bereavement support with referral for further support from MHS or their GP as necessary. Staff can call a meeting to discuss the care of a dying patient, with debriefs occurring within the week of a patient’s death. This has decreased staff anxiety and improved the relationship within the team with subsequent flow on effects to the relatives. Support services are available for all staff.



The organisation has introduced good and effective initiatives for patients and staff in an often emotional and demanding field. The executive leadership, multidisciplinary approach and consultant involvement has assisted with this.



Assessment and care planning

Ratings


12.1.1 SM SM

12.1.2 SM SM

12.2.1 SM SM

12.2.2 SM SM

12.3.1 SM SM

12.4.1 SM SM

Management of nutrition

Ratings


12.5.1 SM SM

12.5.2 SM SM

12.6.1 SM SM

12.6.2 SM SM

12.6.3 SM SM

12.7.1 SM SM

12.7.2 SM SM

Ongoing care and discharge / transfer

Ratings


12.8.1 SM SM

12.8.2 SM SM

12.8.3 SM SM

12.9.1 SM SM

12.10.1 SM SM

12.10.2 SM SM

12.10.3 SM SM



End-of-life care

Ratings


12.11.1 SM SM

12.11.2 SM SM

12.12.1 SM SM

12.12.2 SM SM



STANDARD 13 WORKFORCE PLANNING AND MANAGEMENT

Surveyor Summary

Workforce planning FWLHD Broken Hill has established workforce and staffing plans and strategies integrated into the facility’s strategic plan and focusing on recruitment, retention and working in the organisation. The workforce plan addresses the challenges faced by rural and remote health services and was developed collaboratively with representatives from across the region and, importantly, with consumer input through the Health Council representatives. It is comprehensive and addresses all aspects of workforce planning, including recruitment and retention strategies, staff education and professional development, culture and work health and safety. The plan reflects the challenges of providing effective health care in remote communities and allows for regional 'tailoring' to ensure that the realisation of the strategies can occur in distinct and different environments. Planning and management around workforce is an important part of the services, budgeting and performance management functions and approaches at the hospital and across the District. It will be important that the Workforce Plan is regularly evaluated to assess its effectiveness and value to the health services it supports. The FWLHD slogan of “Grow your own” was heard by all the survey team, and the School Based Education program employing Year 11 and 12 students to undertake industry recognised employment training together, with the support of AINS and ENs currently working in the district to up skill are good initiatives in recruiting future employees. While HR manage recruitment and selection processes, workforce plans are located within the medical, nursing and allied health directorates. There is a strong integration of volunteer recruitment and retention into the workforce processes and systems at the hospital. Fatigue is recognised by the organisation as a workforce risk, and overtime is actively managed across the organisation. Fatigue management policies and monitoring arrangements are in place. There was good awareness from managers about the contingency arrangements they need to put in place where there are staffing or skill mix shortfalls. The strategy of “Roving Nurses” across the district supporting and overseeing nurses in the remote sites is a good initiative. Managers within the FWLHD Broken Hill are well used to implementing such contingencies and these have proven effective, both from a service provision perspective and in ensuring the safety and quality of services provided. Recruitment processes The hospital has a clear staff establishment control system in place and this drives the programs for recruitment and appointment of staff. While still utilising locum and casual staff, the hospital has minimised the need for this. The human resources compliance team manages the necessary industrial, qualifications, licensing and other requirements associated with recruitment. There are the necessary credentialling and scope of practice committees in place. Systems are in place to ensure that registrations and licenses are checked on commencement of hiring and then annually/periodically as required for continuing staff, with processes in place to check staff who are members of an allied health profession which is not registered. Staff, irrespective of profession or tenure of appointment, including locum staff are unable to commence work until credentialling and registration authentication have been completed.



Orientation systems are in place to ensure that all locum staff is fully aware of the local policies and procedures prior to commencement. There are systems in place for the recruitment and management of volunteers in the organisation to complement the functions of the employed workforce Volunteers working in all parts of the hospital are included in the recruitment and retention policies, procedures and actions within a comprehensive system of recruitment. Volunteers attend the orientation program and undertake the mandatory education requirements to ensure patient and volunteer safety. The Credentialing Policy Framework provides for rigorous systems to ensure a qualified and competent clinical workforce with credentialling systems in place for all medical, nursing and allied health professional staff. Competencies are recorded and reported electronically ensuring both staff and managers are aware of staff credentialling levels and competencies. Complaint processes are established to guide a complaint or concern related to a clinician, as well as those relating to other staff, with all appropriate processes followed. Continuing employment and development A central personnel record is maintained by the human resources department onsite at Broken Hill Hospital. Records are kept confidential and security is the responsibility of the department. Records management systems are in place and policies cover access by staff members to their own records. The performance of all clinicians is monitored. Reports can be run by managers in specific program areas and reports are also available at an organisation level through the performance development system which is linked directly to the credentialling process. Reports showed a high completion rate for performance reviews for the overall service, however, the service is encouraged to continue to improve this compliance. Training systems to support staff and volunteers are effective, with generally high compliance across the Region. The implementation of the “Studer Framework” Yarmirri Nharatji coaching, together with the staff recognition program has seen an improvement in staff engagement with an increase of 5% demonstrated by the staff survey in 2015. The Get Healthy Far West commenced this year has been enthusiastically embraced by staff and an evaluation as to effects and outcomes following the initial awards in December will be interesting. Employee support and workplace relations The organisation provides a supportive working environment for all staff and clearly demonstrates that all staff are valued as members of the patient care team, resulting in a demonstrable positive attitude displayed by all staff employed within FWLHD Broken Hill and observed by surveyors during their visit. Excellent support is provided to the managers and workforce within FWLHD Broken Hill. The rights and responsibilities of management, staff and volunteers are defined. This is especially so in respect of addressing the issue of rural and remote isolation and the supports provided to workers, including those providing locum services. Appropriate action is taken by managers to address issues relating to workforce as they arise. Workplace relations are effective, with staff satisfaction rates routinely monitored through all staff culture surveys. The current workplace survey demonstrated some positive results in terms of the workplace and culture



and ethics of the organisation. There were improvements in ratings by staff over previous survey results, showing change. A formal employee assistant program (EAP) is in place though not located locally which was an area identified as an issue by staff in the staff satisfaction survey. Contact with the EAP provider is by phone or email rather than face to face. There may be an opportunity for EAP staff to visit Broken Hill on a regular basis or that contact could be by teleconference to address this issue.



Workforce planning Ratings


13.1.1 SM SM

13.1.2 SM SM

13.2.1 SM SM

13.3.1 SM SM

Recruitment processes

Ratings


13.4.1 SM SM

13.5.1 SM SM

13.5.2 SM SM

13.6.1 SM SM

Continuing employment and development

Ratings


13.7.1 SM SM

13.7.2 SM SM

13.8.1 SM SM

13.8.2 SM SM

13.8.3 SM SM

13.9.1 SM SM

13.9.2 SM SM

Employee support and workplace relations

Ratings


13.10.1 SM SM

13.10.2 SM SM

13.11.1 SM SM

13.12.1 SM SM

13.13.1 SM SM



STANDARD 14 INFORMATION MANAGEMENT

Surveyor Summary

Health records management Broken Hill Health Service currently operates a hybrid record system utilising both paper and electronic format. Whilst it is well recognised that high hybrid record systems create some challenges the health service has identified and managed identified and potential risks accordingly. It is noted that the records are stored in appropriate secure and controlled environment involving shelving and compactors type systems. Security is assured using secure, password and protected access to record management areas. Specialist appropriate security measures are also in place. Access to records is facilitated by an appropriately managed tracking system. Records are constructed in a standardised format enabling a systematic examination of records facilitating appropriate care. Patient registration and data collection is undertaken and compliant with the statewide records protocols and procedures. Training and education is available for new and existing staff to maintain a contemporary approach to record management. Ongoing processes for clinical coding, data collection and data analysis is assisted by personnel with particular skills in health information management and data analysis. Clinical coding audits and error reports are produced in accordance with state guidelines and are updated and acted upon by the district clinical coding manager. Privacy and regulations and legislation surrounding privacy are managed and communicated to the various staff within the facility. Privacy is also covered within Your Health Rights and Responsibilities brochures available throughout the facilities. Online training in respect privacy and current privacy legislation is also available. Specialist correspondence including patient reports, medicolegal correspondence, and other patient requests are overseen by the administration clerk and the health information management service. The release of health information is undertaken in accordance with statewide policy directives and legislation. Corporate records management The health service managers its corporate records in accordance with the state records act. Clear guidelines and responsibilities were noted at the time of survey. The corporate's record management unit was locally based in Broken Hill and operates under a corporate Records Management program which covers a variety of activities and processes in alignment with legislation and state guidelines. Retention and destruction of corporate records is in accordance with the general disposal authority. It was noted that the TRIM record keeping system was utilised as the primary means of capturing and tracking corporate documents. The following functions were also covered filing, archiving, training of staff and auditing. Secondary storage as many organisations comprises a challenge in respect to available space. Physical storage capacity is planned to be a part of current capital development. Collection, use and storage of information Broken Hill Health Service access to clinical information is controlled by appropriate security measures including username and password access. Regular audit and performance reports are produced and examined. Appropriate measures to guard privacy were in place.



Access to databases and other information requires appropriate application and approval and is consistent with statewide guidelines. Information and communication technology The Information technology service and the utilisation of communication technology is supported by the information technology service provided by the Western NSW Local Health District. Software regulation and protection is in place. The use of statewide policy directive for communications including the use and management of communication systems is noted and compliant. Overarching governance for information and communication technology was noted to have an innovative and forward-looking approach under the auspices of Picard.



Health records management

Ratings


14.1.1 SM SM

14.2.1 SM SM

14.3.1 SM SM

14.3.2 SM SM

14.4.1 SM SM

Corporate records management

Ratings


14.5.1 SM SM

Collection, use and storage of information

Ratings


14.6.1 SM SM

14.6.2 SM SM

14.7.1 SM SM

14.8.1 SM SM

Information and communication technology

Ratings


14.9.1 SM SM

14.9.2 SM SM



STANDARD 15 CORPORATE SYSTEMS AND SAFETY

Surveyor Summary

Strategic and operational planning Practices and systems are in place to support Service planning. Consultation has been ongoing, including from the community in considering the soon to be released revised strategic plan. Communication and feedback has included via the Internet and Community consultations. There is a current service agreement with the NSW Ministry of Health with KPI and activity targets review in place and ongoing. To support operational management, monthly accountability meetings are undertaken between managers and their department heads. Systems and delegation practices The organisation has a delegations manual with orders managed via Oracle. The NSW purchasing guidelines are applied. To support better practice a Purchasing Committee is soon to be established and examples were given on survey how this Committee will improve practice. For example, a recent sharps product requested and ordered that was not considered IP&C appropriate. External service providers All contracts are on ProCube and provided as needed to Department Heads. Contract management policies and plans are available to support better practice. This criterion is also supported by the Contractor Handbook and database. A previous recommendation considered matters around contract management and this is now closed with significant work undertaken to improve practices. Research governance The organisation due to operations and size is supported by the Western NSW Local Health District Research and Ethics Committee. Safety management systems A WH&S Committee meets monthly with some members recently completing WH&S Committee training. Minutes are available to staff and it was noted on survey that the WH&S notice boards were current. A range of WH&S information is available to staff on the organisation's internal team computer drive. The organisation applies safe and appropriate practice by the application of Just Culture principles and Your Say surveys. Also the IIMS system is used to log incidents, which are in turn reviewed to consider strategies for improvement. On discussion with staff in managing matters of risk, an example was given of concern with the lack of a pedestrian crossing outside the Hospital where the view is one is needed. Discussions are ongoing with Council to manage. Department monthly hazard inspections are undertaken with excellent completion rates evident. Department WIP phone testing is also undertaken and at survey it was reported minimal false alarms occur.



The Imaging Department has been fortunate to procure a range of new equipment, including lead apron replacements and has recently successfully completed NATA Accreditation. One matter of improvement noted from this Accreditation is the need for better hand hygiene completion rates. Radiation Safety matters are considered at the WH&S Committee. The laundry provides services for internal and external customers. It was reported that very good revenue is generated from external customers. One relatively recent improvement has been the purchase and commissioning of a new ironer and this was stated to have helped with better injury management. A contractor is engaged to provide regular chemical dosing equipment servicing. Buildings, plant and equipment The organisation has its own Stores Department with procurement mainly being received from Adelaide. On discussion with staff the receiving of goods occurs generally without problem. The Maintenance Department provides a full range of services for the organisation and district. A preventative maintenance is in place with completed work noted on survey. An asset management plan is in place. Vaccine and blood fridges are monitored by pager and temperature checks on medication fridges are undertaken twice daily. Asset Plus is used to manage biomedical equipment with new equipment being checked prior to use. Telemetry services can be managed by remote access. Generator testing is undertaken four times per month. Emergency and disaster management The organisation is commended for their excellent work in developing and testing disaster management practices and protocols. Resource folders are available for HASFACs. Hospital representation is included on the Local Emergency Management Committee. High staff completion rates are in place for practical fire training sessions while the completion of online HETI fire training remains work in progress. Within the last 12 months there was a full practice evacuation exercise from the staff accommodation building and it was stated this may soon be repeated. The BCA Fire Report remains current with actions completed. A recent BCA review has been undertaken with the report soon expected. To further support better fire practices hospital orientation has been provided to the local Station Officer. It is suggested that this could be expanded to all local fire officers. The internal flip charts have recently been updated and are available as a stock item from Stores. A current business continuity plan is available. Physical and personal security Duress alarms are available to support staff and it was stated response time from the Police was very good. An external security inspection was undertaken in 2016 with many actions being progressed and completed.



A GPS spot tracker is available for remote staff and it was stated at survey this has been tested and works. The Employee Assistance Program is available to staff. The organisation has a lockdown procedure and staff are able to request Security for escort to cars. It was stated Security staff have recently benefited from extra training. Waste and environmental management Waste is appropriately segregated throughout the organisation. Little recycling occurs due to the organisation's isolation. Waste reports are available and reported for waste generated. Waste audits are undertaken to support better practice and it was reported at survey that recent audits indicate less clinical waste mixed in with general waste. Detail was provided where, due to poor local water quality, a grant was provided to install a reverse water osmosis unit. This unit will soon be decommissioned due to water quality improvement but will remain available if needed again.



Strategic and operational planning

Ratings


15.1.1 SM SM

15.1.2 SM SM

15.1.3 SM SM

15.2.1 SM SM

15.2.2 SM SM

Systems and delegation practices

Ratings


15.3.1 SM SM

15.4.1 SM SM

15.5.1 SM SM

15.6.1 SM SM

15.7.1 SM SM

15.8.1 SM SM

External Service Providers

Ratings


15.9.1 SM SM

15.9.2 SM SM

Research Governance

Ratings


15.10.1 SM SM

15.10.2 SM SM

15.11.1 SM SM

15.11.2 SM SM



Safety management systems Ratings


15.12.1 SM SM

15.13.1 SM SM

15.13.2 SM SM

15.13.3 SM SM

15.14.1 SM SM

Buildings, plant and equipment

Ratings


15.15.1 SM SM

15.15.2 SM SM

15.16.1 SM SM

15.16.2 SM SM

15.17.1 SM SM

Emergency and disaster management

Ratings


15.18.1 SM SM

15.19.1 SM SM

15.20.1 SM SM

15.20.2 SM SM

Physical and personal security

Ratings


15.21.1 SM SM

15.21.2 SM SM

15.22.1 SM SM

15.22.2 SM SM

15.23.1 SM SM



Waste and environmental management

Ratings


15.24.1 SM SM

15.25.1 SM SM

15.26.1 SM SM



Actions Rating Summary Governance for Safety and Quality in Health Service Organisations

Governance and quality improvement systems

Action Description Organisation's self-rating

Surveyor Rating

1.1.1 An organisation-wide management system is in place for the development, implementation and regular review of policies, procedures and/or protocols

SM SM

1.1.2 The impact on patient safety and quality of care is considered in business decision making

SM SM

1.2.1 Regular reports on safety and quality indicators and other safety and quality performance data are monitored by the executive level of governance

SM SM

1.2.2 Action is taken to improve the safety and quality of patient care SM SM

1.3.1 Workforce are aware of their delegated safety and quality roles and responsibilities

SM SM

1.3.2 Individuals with delegated responsibilities are supported to understand and perform their roles and responsibilities, in particular to meet the requirements of these Standards

SM SM

1.3.3 Agency or locum workforce are aware of their designated roles and responsibilities

SM SM

1.4.1 Orientation and ongoing training programs provide the workforce with the skill and information needed to fulfil their safety and quality roles and responsibilities

SM SM

1.4.2 Annual mandatory training programs to meet the requirements of these Standards

SM SM

1.4.3 Locum and agency workforce have the necessary information, training and orientation to the workplace to fulfil their safety and quality roles and responsibilities

SM SM

1.4.4 Competency-based training is provided to the clinical workforce to improve safety and quality

SM SM

1.5.1 An organisation-wide risk register is used and regularly monitored SM SM

1.5.2 Actions are taken to minimise risks to patient safety and quality of care

SM SM

1.6.1 An organisation-wide quality management system is used and regularly monitored

SM SM

1.6.2 Actions are taken to maximise patient quality of care SM SM

Clinical practice


Surveyor Rating

1.7.1 Agreed and documented clinical guidelines and/or pathways are available to the clinical workforce

SM SM

1.7.2 The use of agreed clinical guidelines by the clinical workforce is monitored

SM SM

1.8.1 Mechanisms are in place to identify patients at increased risk of harm

SM SM



1.8.2 Early action is taken to reduce the risks for at-risk patients SM SM

1.8.3 Systems exist to escalate the level of care when there is an unexpected deterioration in health status

SM SM

1.9.1 Accurate, integrated and readily accessible patient clinical records are available to the clinical workforce at the point of care

SM SM

1.9.2 The design of the patient clinical record allows for systematic audit of the contents against the requirements of these Standards

SM SM

Performance and skills management


Surveyor Rating

1.10.1 A system is in place to define and regularly review the scope of practice for the clinical workforce

SM SM

1.10.2 Mechanisms are in place to monitor that the clinical workforce are working within their agreed scope of practice

SM SM

1.10.3 Organisational clinical service capability, planning and scope of practice is directly linked to the clinical service roles of the organisation

SM SM

1.10.4 The system for defining the scope of practice is used whenever a new clinical service, procedure or other technology is introduced

SM SM

1.10.5 Supervision of the clinical workforce is provided whenever it is necessary for individuals to fulfil their designated role

SM SM

1.11.1 A valid and reliable performance review process is in place for the clinical workforce

SM SM

1.11.2 The clinical workforce participates in regular performance reviews that support individual development and improvement

SM SM

1.12.1 The clinical and relevant non-clinical workforce have access to ongoing safety and quality education and training for identified professional and personal development

SM SM

1.13.1 Analyse feedback from the workforce on their understanding and use of safety and quality systems

SM SM

1.13.2 Action is taken to increase workforce understanding and use of safety and quality systems

SM SM

Incident and complaints management


Surveyor Rating

1.14.1 Processes are in place to support the workforce recognition and reporting of incidents and near misses

SM SM

1.14.2 Systems are in place to analyse and report on incidents SM SM

1.14.3 Feedback on the analysis of reported incidents is provided to the workforce

SM SM

1.14.4 Action is taken to reduce risks to patients identified through the incident management system

SM SM

1.14.5 Incidents and analysis of incidents are reviewed at the highest level of governance in the organisation

SM SM

1.15.1 Processes are in place to support the workforce to recognise and report complaints

SM SM

1.15.2 Systems are in place to analyse and implement improvements in response to complaints

SM SM



1.15.3 Feedback is provided to the workforce on the analysis of reported complaints

SM SM

1.15.4 Patient feedback and complaints are reviewed at the highest level of governance in the organisation

SM SM

1.16.1 An open disclosure program is in place and is consistent with the national open disclosure standard

SM SM

1.16.2 The clinical workforce are trained in open disclosure processes SM SM

Patient rights and engagement


Surveyor Rating

1.17.1 The organisation has a charter of patient rights that is consistent with the current national charter of healthcare rights

SM SM

1.17.2 Information on patient rights is provided and explained to patients and carers

SM SM

1.17.3 Systems are in place to support patients who are at risk of not understanding their healthcare rights

SM SM

1.18.1 Patients and carers are partners in the planning for their treatment

SM SM

1.18.2 Mechanisms are in place to monitor and improve documentation of informed consent

SM SM

1.18.3 Mechanisms are in place to align the information provided to patients with their capacity to understand

SM SM

1.18.4 Patients and carers are supported to document clear advance care directives and/or treatment-limiting orders

SM SM

1.19.1 Patient clinical records are available at the point of care SM SM

1.19.2 Systems are in place to restrict inappropriate access to and dissemination of patient clinical information

SM SM

1.20.1 Data collected from patient feedback systems are used to measure and improve health services in the organisation

SM SM

Partnering with Consumers

Consumer partnership in service planning


Surveyor Rating

2.1.1 Consumers and/or carers are involved in the governance of the health service organisation

SM SM

2.1.2

Governance partnerships are reflective of the diverse range of backgrounds in the population served by the health service organisation, including those people who do not usually provide feedback

SM SM

2.2.1 The health service organisation establishes mechanisms for engaging consumers and/or carers in the strategic and/or operational planning for the organisation

SM SM

2.2.2 Consumers and/or carers are actively involved in decision making about safety and quality

SM SM

2.3.1 Health service organisations provide orientation and ongoing training for consumers and/or carers to enable them to fulfil their partnership role

SM SM

2.4.1 Consumers and/or carers provide feedback on patient information SM SM



publications prepared by the health service organisation (for distribution to patients)

2.4.2 Action is taken to incorporate consumer and/or carers’ feedback into publications prepared by the health service organisation for distribution to patients

SM SM

Consumer partnership in designing care


Surveyor Rating

2.5.1 Consumers and/or carers participate in the design and redesign of health services

SM SM

2.6.1 Clinical leaders, senior managers and the workforce access training on patient-centred care and the engagement of individuals in their care

SM SM

2.6.2 Consumers and/or carers are involved in training the clinical workforce

SM SM

Consumer partnership in service measurement and evaluation


Surveyor Rating

2.7.1 The community and consumers are provided with information that is meaningful and relevant on the organisation’s safety and quality performance

SM SM

2.8.1 Consumers and/or carers participate in the analysis of organisational safety and quality performance

SM SM

2.8.2 Consumers and/or carers participate in the planning and implementation of quality improvements

SM SM

2.9.1 Consumers and/or carers participate in the evaluation of patient feedback data

SM SM

2.9.2 Consumers and/or carers participate in the implementation of quality activities relating to patient feedback data

SM SM

Preventing and Controlling Healthcare Associated Infections

Governance and systems for infection prevention, control and surveillance


Surveyor Rating

3.1.1

A risk management approach is taken when implementing policies, procedures and/or protocols for: • standard infection control precautions • transmission-based precautions • aseptic non-touch technique • safe handling and disposal of sharps • prevention and management of occupational exposure to blood and body substances • environmental cleaning and disinfection • antimicrobial prescribing • outbreaks or unusual clusters of communicable infection • processing of reusable medical devices • single-use devices

SM SM



• surveillance and reporting of data where relevant • reporting of communicable and notifiable diseases • provision of risk assessment guidelines to workforce • exposure-prone procedures

3.1.2 The use of policies, procedures and/or protocols is regularly monitored

SM SM

3.1.3 The effectiveness of the infection prevention and control systems is regularly reviewed at the highest level of governance in the organisation

SM SM

3.1.4 Action is taken to improve the effectiveness of infection prevention and control policies, procedures and/or protocols

SM SM

3.2.1 Surveillance systems for healthcare associated infections are in place

SM SM

3.2.2 Healthcare associated infections surveillance data are regularly monitored by the delegated workforce and/or committees

SM SM

3.3.1 Mechanisms to regularly assess the healthcare associated infection risks are in place

SM SM

3.3.2 Action is taken to reduce the risks of healthcare associated infection

SM SM

3.4.1 Quality improvement activities are implemented to reduce and prevent healthcare associated infections

SM SM

3.4.2 Compliance with changes in practice are monitored SM SM

3.4.3 The effectiveness of changes to practice are evaluated SM SM

Infection prevention and control strategies


Surveyor Rating

3.5.1 Workforce compliance with current national hand hygiene guidelines is regularly audited

SM SM

3.5.2 Compliance rates from hand hygiene audits are regularly reported to the highest level of governance in the organisation

SM SM

3.5.3 Action is taken to address non-compliance, or the inability to comply, with the requirements of the current national hand hygiene guidelines

SM SM

3.6.1 A workforce immunisation program that complies with current national guidelines is in use

SM SM

3.7.1

Infection prevention and control consultation related to occupational health and safety policies, procedures and/or protocols are implemented to address: • communicable disease status • occupational management and prophylaxis • work restrictions • personal protective equipment • assessment of risk to healthcare workers for occupational allergies • evaluation of new products and procedures

SM SM

3.8.1 Compliance with the system for the use and management of invasive devices in monitored

SM SM

3.9.1 Education and competency-based training in invasive devices protocols and use is provided for the workforce who perform procedures with invasive devices

SM SM

3.10.1 The clinical workforce is trained in aseptic technique SM SM



3.10.2 Compliance with aseptic technique is regularly audited SM SM

3.10.3 Action is taken to increase compliance with the aseptic technique protocols

SM SM

Managing patients with infections or colonisations


Surveyor Rating

3.11.1 Standard precautions and transmission-based precautions consistent with the current national guidelines are in use

SM SM

3.11.2 Compliance with standard precautions is monitored SM SM

3.11.3 Action is taken to improve compliance with standard precautions SM SM

3.11.4 Compliance with transmission-based precautions is monitored SM SM

3.11.5 Action is taken to improve compliance with transmission-based precautions

SM SM

3.12.1

A risk analysis is undertaken to consider the need for transmission-based precautions including: • accommodation based on the mode of transmission • environmental controls through air flow • transportation within and outside the facility • cleaning procedures • equipment requirements

SM SM

3.13.1 Mechanisms are in use for checking for pre-existing healthcare associated infections or communicable disease on presentation for care

SM SM

3.13.2 A process for communicating a patient’s infectious status is in place whenever responsibility for care is transferred between service providers or facilities

SM SM

Antimicrobial stewardship


Surveyor Rating

3.14.1 An antimicrobial stewardship program is in place SM SM

3.14.2 The clinical workforce prescribing antimicrobials have access to current endorsed therapeutic guidelines on antibiotic usage

SM SM

3.14.3 Monitoring of antimicrobial usage and resistance is undertaken SM SM

3.14.4 Action is taken to improve the effectiveness of antimicrobial stewardship

SM SM

Cleaning, disinfection and sterilisation


Surveyor Rating

3.15.1

Policies, procedures and/or protocols for environmental cleaning that address the principles of infection prevention and control are implemented, including: • maintenance of building facilities • cleaning resources and services • risk assessment for cleaning and disinfection based on transmission-based precautions and the infectious agent involved • waste management within the clinical environment • laundry and linen transportation, cleaning and storage

SM SM



• appropriate use of personal protective equipment

3.15.2 Policies, procedures and/or protocols for environmental cleaning are regularly reviewed

SM SM

3.15.3 An established environmental cleaning schedule is in place and environmental cleaning audits are undertaken regularly

SM SM

3.16.1 Compliance with relevant national or international standards and manufacturer’s instructions for cleaning, disinfection and sterilisation of reusable instruments and devices is regularly monitored

SM SM

3.17.1 A traceability system that identifies patients who have a procedure using sterile reusable medical instruments and devices is in place

SM SM

3.18.1 Action is taken to maximise coverage of the relevant workforce trained in a competency-based program to decontaminate reusable medical devices

SM SM



Surveyor Rating

3.19.1 Information on the organisation’s corporate and clinical infection risks and initiatives implemented to minimise patient infection risks is provided to patients and/or carers

SM SM

3.19.2 Patient infection prevention and control information is evaluated to determine if it meets the needs of the target audience

SM SM

Medication Safety

Governance and systems for medication safety


Surveyor Rating

4.1.1 Governance arrangements are in place to support the development, implementation and maintenance of organisation-wide medication safety systems

SM SM

4.1.2 Policies, procedures and/or protocols are in place that are consistent with legislative requirements, national, jurisdictional and professional guidelines

SM SM

4.2.1 The medication management system is regularly assessed SM SM

4.2.2 Action is taken to reduce the risks identified in the medication management system

SM SM

4.3.1 A system is in place to verify that the clinical workforce have medication authorities appropriate to their scope of practice

SM SM

4.3.2 The use of the medication authorisation system is regularly monitored

SM SM

4.3.3 Action is taken to increase the effectiveness of the medication authority system

SM SM

4.4.1 Medication incidents are regularly monitored, reported and investigated

SM SM

4.4.2 Action is taken to reduce the risk of adverse medication incidents SM SM

4.5.1 The performance of the medication management system is regularly assessed

SM SM

4.5.2 Quality improvement activities are undertaken to reduce the risk of patient harm and increase the quality and effectiveness of medicines use

SM SM



Documentation of patient information


Surveyor Rating

4.6.1 A best possible medication history is documented for each patient

SM SM

4.6.2 The medication history and current clinical information is available at the point of care

SM SM

4.7.1 Known medication allergies and adverse drug reactions are documented in the patient clinical record

SM SM

4.7.2 Action is taken to reduce the risk of adverse reactions SM SM

4.7.3 Adverse drug reactions are reported within the organisation and to the Therapeutic Goods Administration

SM SM

4.8.1 Current medicines are documented and reconciled at admission and transfer of care between healthcare settings

SM SM

Medication management processes


Surveyor Rating

4.9.1 Information and decision support tools for medicines are available to the clinical workforce at the point of care

SM SM

4.9.2 The use of information and decision support tools is regularly reviewed

SM SM

4.9.3 Action is taken to improve the availability and effectiveness of information and decision support tools

SM SM

4.10.1 Risks associated with secure storage and safe distribution of medicines are regularly reviewed

SM SM

4.10.2 Action is taken to reduce the risks associated with storage and distribution of medicines

SM SM

4.10.3 The storage of temperature-sensitive medicines is monitored SM SM

4.10.4 A system that is consistent with legislative and jurisdictional requirements for the disposal of unused, unwanted or expired medications is in place

SM SM

4.10.5 The system for disposal of unused, unwanted or expired medications is regularly monitored

SM SM

4.10.6 Action is taken to increase compliance with the system for storage, distribution and disposal of medications

SM SM

4.11.1 The risks for storing, prescribing, dispensing and administration of high-risk medicines are regularly reviewed

SM SM

4.11.2 Action is taken to reduce the risks of storing, prescribing, dispensing and administering high-risk medicines

SM SM

Continuity of medication management


Surveyor Rating

4.12.1 A system is in use that generates and distributes a current and comprehensive list of medicines and explanation of changes in medicines

SM SM

4.12.2 A current and comprehensive list of medicines is provided to the SM SM



patient and/or carer when concluding an episode of care

4.12.3 A current comprehensive list of medicines is provided to the receiving clinician during clinical handover

SM SM

4.12.4 Action is taken to increase the proportion of patients and receiving clinicians that are provided with a current comprehensive list of medicines during clinical handover

SM SM



Surveyor Rating

4.13.1 The clinical workforce provides patients with patient specific medicine information, including medication treatment options, benefits and associated risks

SM SM

4.13.2 Information that is designed for distribution to patients is readily available to the clinical workforce

SM SM

4.14.1 An agreed medication management plan is documented and available in the patient’s clinical record

SM SM

4.15.1 Information on medicines is provided to patients and carers in a format that is understood and meaningful

SM SM

4.15.2 Action is taken in response to patient feedback to improve medicines information distributed by the health service organisation to patients

SM SM

Patient Identification and Procedure Matching

Identification of individual patients


Surveyor Rating

5.1.1 Use of an organisation-wide patient identification system is regularly monitored

SM SM

5.1.2 Action is taken to improve compliance with the patient identification matching system

SM SM

5.2.1 The system for reporting, investigating and analysis of patient care mismatching events is regularly monitored

SM SM

5.2.2 Action is taken to reduce mismatching events SM SM

5.3.1 Inpatient bands are used that meet the national specifications for patient identification bands

SM SM

Processes to transfer care


Surveyor Rating

5.4.1 A patient identification and matching system is implemented and regularly reviewed as part of structured clinical handover, transfer and discharge processes

SM SM

Processes to match patients and their care


Surveyor Rating

5.5.1 A documented process to match patients and their intended treatment is in use

SM SM



5.5.2 The process to match patients to any intended procedure, treatment or investigation is regularly monitored

SM SM

5.5.3 Action is taken to improve the effectiveness of the process for matching patients to their intended procedure, treatment or investigation

SM SM

Clinical Handover

Governance and leadership for effective clinical handover


Surveyor Rating

6.1.1 Clinical handover policies, procedures and/or protocols are used by the workforce and regularly monitored

SM SM

6.1.2 Action is taken to maximise the effectiveness of clinical handover policies, procedures and/or protocols

SM SM

6.1.3 Tools and guides are periodically reviewed SM SM

Clinical handover processes


Surveyor Rating

6.2.1

The workforce has access to documented structured processes for clinical handover that include: • preparing for handover, including setting the location and time while maintaining continuity of patient care • organising relevant workforce members to participate • being aware of the clinical context and patient needs • participating in effective handover resulting in transfer of responsibility and accountability for care

SM SM

6.3.1 Regular evaluation and monitoring processes for clinical handover are in place

SM SM

6.3.2 Local processes for clinical handover are reviewed in collaboration with clinicians, patients and carers

SM SM

6.3.3 Action is taken to increase the effectiveness of clinical handover SM SM

6.3.4 The actions taken and the outcomes of local clinical handover reviews are reported to the executive level of governance

SM SM

6.4.1 Regular reporting, investigating and monitoring of clinical handover incidents is in place

SM SM

6.4.2 Action is taken to reduce the risk of adverse clinical handover incidents

SM SM

Patient and carer involvement in clinical handover


Surveyor Rating

6.5.1 Mechanisms to involve a patient and, where relevant, their carer in clinical handover are in use

SM SM



Blood and Blood Products

Governance and systems for blood and blood product prescribing and clinical use


Surveyor Rating

7.1.1

Blood and blood product policies, procedures and/or protocols are consistent with national evidence-based guidelines for pre-transfusion practices, prescribing and clinical use of blood and blood products

SM SM


SM SM

7.1.3 Action is taken to increase the safety and appropriateness of prescribing and clinically using blood and blood products

SM SM

7.2.1 The risks associated with transfusion practices and clinical use of blood and blood products are regularly assessed

SM SM

7.2.2 Action is taken to reduce the risks associated with transfusion practices and the clinical use of blood and blood products

SM SM

7.3.1 Reporting on blood and blood product incidents is included in regular incident reports

SM SM

7.3.2 Adverse blood and blood product incidents are reported to and reviewed by the highest level of governance in the health service organisation

SM SM

7.3.3 Health service organisations participate in relevant haemovigilance activities conducted by the organisation or at state or national level

SM SM

7.4.1 Quality improvement activities are undertaken to reduce the risks of patient harm from transfusion practices and the clinical use of blood and blood products

SM SM

Documenting patient information


Surveyor Rating

7.5.1 A best possible history of blood product usage and relevant clinical and product information is documented in the patient clinical record

SM SM

7.5.2 The patient clinical records of transfused patients are periodically reviewed to assess the proportion of records completed

SM SM

7.5.3 Action is taken to increase the proportion of patient clinical records of transfused patients with a complete patient clinical record

SM SM

7.6.1 Adverse reactions to blood or blood products are documented in the patient clinical record

SM SM

7.6.2 Action is taken to reduce the risk of adverse events from administering blood or blood products

SM SM

7.6.3 Adverse events are reported internally to the appropriate governance level and externally to the pathology service provider, blood service or product manufacturer whenever appropriate

SM SM

Managing blood and blood product safety


Surveyor Rating

7.7.1 Regular review of the risks associated with receipt, storage, collection and transport of blood and blood products is undertaken

SM SM

7.7.2 Action is taken to reduce the risk of incidents arising from the use SM SM



of blood and blood product control systems

7.8.1 Blood and blood product wastage is regularly monitored SM SM

7.8.2 Action is taken to minimise wastage of blood and blood products SM SM



Surveyor Rating

7.9.1 Patient information relating to blood and blood products, including risks, benefits and alternatives, is available for distribution by the clinical workforce

SM SM

7.9.2 Plans for care that include the use of blood and blood products are developed in partnership with patients and carers

SM SM

7.10.1 Information on blood and blood products is provided to patients and their carers in a format that is understood and meaningful

SM SM

7.11.1 Informed consent is undertaken and documented for all transfusions of blood or blood products in accordance with the informed consent policy of the health service organisation

SM SM

Preventing and Managing Pressure Injuries

Governance and systems for the prevention and management of pressure injuries


Surveyor Rating

8.1.1 Policies, procedures and/or protocols are in use that are consistent with best practice guidelines and incorporate screening and assessment tools

SM SM


SM SM

8.2.1 An organisation-wide system for reporting pressure injuries is in use SM SM

8.2.2 Administrative and clinical data are used to regularly monitor and investigate the frequency and severity of pressure injuries

SM SM

8.2.3 Information on pressure injuries is regularly reported to the highest level of governance in the health service organisation

SM SM

8.2.4 Action is taken to reduce the frequency and severity of pressure injuries

SM SM

8.3.1 Quality improvement activities are undertaken to prevent pressure injuries and/or improve the management of pressure injuries

SM SM

8.4.1 Equipment and devices are available to effectively implement prevention strategies for patients at risk and plans for the management of patients with pressure injuries

SM SM

Preventing pressure injuries


Surveyor Rating

8.5.1 An agreed tool to screen for pressure injury risk is used by the clinical workforce to identify patients at risk of a pressure injury

SM SM

8.5.2 The use of the screening tool is monitored to identify the proportion of at-risk patients that are screened for pressure injuries on presentation

SM SM

8.5.3 Action is taken to maximise the proportion of patients who are SM SM



screened for pressure injury on presentation

8.6.1 Comprehensive skin inspections are undertaken and documented in the patient clinical record for patients at risk of pressure injuries

SM SM

8.6.2 Patient clinical records, transfer and discharge documentation are periodically audited to identify at-risk patients with documented skin assessments

SM SM

8.6.3 Action is taken to increase the proportion of skin assessments documented on patients at risk of pressure injuries

SM SM

8.7.1 Prevention plans for all patients at risk of a pressure injury are consistent with best practice guidelines and are documented in the patient clinical record

SM SM

8.7.2 The effectiveness and appropriateness of pressure injury prevention plans are regularly reviewed

SM SM

8.7.3 Patient clinical records are monitored to determine the proportion of at-risk patients that have an implemented pressure injury prevention plan

SM SM

8.7.4 Action is taken to increase the proportion of patients at risk of pressure injuries who have an implemented prevention plan

SM SM

Managing pressure injuries


Surveyor Rating

8.8.1 An evidence-based wound management system is in place within the health service organisation

SM SM

8.8.2 Management plans for patients with pressure injuries are consistent with best practice and documented in the patient clinical record

SM SM

8.8.3 Patient clinical records are monitored to determine compliance with evidence-based pressure injury management plans

SM SM

8.8.4 Action is taken to increase compliance with evidence-based pressure injury management plans

SM SM



Surveyor Rating

8.9.1 Patient information on prevention and management of pressure injuries is provided to patients and carers in a format that is understood and is meaningful

SM SM

8.10.1 Pressure injury management plans are developed in partnership with patients and carers

SM SM

Recognising and Responding to Clinical Deterioration in Acute Health Care

Establishing recognition and response systems


Surveyor Rating

9.1.1 Governance arrangements are in place to support the development, implementation, and maintenance of organisation-wide recognition and response systems

SM SM

9.1.2 Policies, procedures and/or protocols for the organisation are implemented in areas such as:

SM SM



• measurement and documentation of observations • escalation of care • establishment of a rapid response system • communication about clinical deterioration

9.2.1 Feedback is actively sought from the clinical workforce on the responsiveness of the recognition and response systems

SM SM

9.2.2

Deaths or cardiac arrests for a patient without an agreed treatment-limiting order (such as not for resuscitation or do not resuscitate) are reviewed to identify the use of the recognition and response systems, and any failures in these system

SM SM

9.2.3 Data collected about recognition and response systems are provided to the clinical workforce as soon as practicable

SM SM

9.2.4 Action is taken to improve the responsiveness and effectiveness of the recognition and response systems

SM SM

Recognising clinical deterioration and escalating care


Surveyor Rating

9.3.1

When using a general observation chart, ensure that it: • is designed according to human factors principles • includes the capacity to record information about respiratory rate, oxygen saturation, heart rate, blood pressure, temperature and level of consciousness graphically over time • includes thresholds for each physiological parameter or combination of parameters that indicate abnormality • specifies the physiological abnormalities and other factors that trigger the escalation of care • includes actions required when care is escalated

SM SM

9.3.2 Mechanisms for recording physiological observations are regularly audited to determine the proportion of patients that have complete sets of observations recorded in agreement with their monitoring plan

SM SM

9.3.3 Action is taken to increase the proportion of patients with complete sets of recorded observations, as specified in the patient’s monitoring plan

SM SM

9.4.1 Mechanisms are in place to escalate care and call for emergency assistance

SM SM

9.4.2 Use of escalation processes, including failure to act on triggers for seeking emergency assistance, are regularly audited

SM SM

9.4.3 Action is taken to maximise the appropriate use of escalation processes

SM SM

Responding to clinical deterioration


Surveyor Rating

9.5.1 Criteria for triggering a call for emergency assistance are included in the escalation policies, procedures and/or protocols

SM SM

9.5.2 The circumstances and outcome of calls for emergency assistance are regularly reviewed

SM SM

9.6.1 The clinical workforce is trained and proficient in basic life support SM SM

9.6.2 A system is in place for ensuring access at all times to at least one clinician, either on-site or in close proximity, who can practise

SM SM



advanced life support



Surveyor Rating

9.7.1

Information is provided to patients, families and carers in a format that is understood and meaningful. The information should include: • the importance of communicating concerns and signs/symptoms of deterioration, which are relevant to the patient’s condition, to the clinical workforce • local systems for responding to clinical deterioration, including how they can raise concerns about potential deterioration

SM SM

9.8.1 A system is in place for preparing and/or receiving advance care plans in partnership with patients, families and carers

SM SM

9.8.2 Advance care plans and other treatment-limiting orders are documented in the patient clinical record

SM SM

9.9.1 Mechanisms are in place for a patient, family member or carer to initiate an escalation of care response

SM SM

9.9.2 Information about the system for family escalation of care is provided to patients, families and carers

SM SM

9.9.3 The performance and effectiveness of the system for family escalation of care is periodically reviewed

SM SM

9.9.4 Action is taken to improve the system performance for family escalation of care

SM SM

Preventing Falls and Harm from Falls

Governance and systems for the prevention of falls


Surveyor Rating

10.1.1 Policies, procedures and/or protocols are in use that are consistent with best practice guidelines (where available) and incorporate screening and assessment tools

SM SM


SM SM

10.2.1 Regular reporting, investigating and monitoring of falls incidents is in place

SM SM

10.2.2 Administrative and clinical data are used to monitor and investigate regularly the frequency and severity of falls in the health service organisation

SM SM

10.2.3 Information on falls is reported to the highest level of governance in the health service organisation

SM SM

10.2.4 Action is taken to reduce the frequency and severity of falls in the health service organisation

SM SM

10.3.1 Quality improvement activities are undertaken to prevent falls and minimise patient harm

SM SM

10.4.1 Equipment and devices are available to implement prevention strategies for patients at risk of falling and management plans to reduce the harm from falls

SM SM



Screening and assessing risks of falls and harm from falling


Surveyor Rating

10.5.1 A best practice screening tool is used by the clinical workforce to identify the risk of falls

SM SM

10.5.2 Use of the screening tool is monitored to identify the proportion of at-risk patients that were screened for falls

SM SM

10.5.3 Action is taken to increase the proportion of at-risk patients who are screened for falls upon presentation and during admission

SM SM

10.6.1 A best practice assessment tool is used by the clinical workforce to assess patients at risk of falling

SM SM

10.6.2 The use of the assessment tool is monitored to identify the proportion of at-risk patients with a completed falls assessment

SM SM

10.6.3 Action is taken to increase the proportion of at-risk patients undergoing a comprehensive falls risk assessment

SM SM

Preventing falls and harm from falling


Surveyor Rating

10.7.1 Use of best practice multifactorial falls prevention and harm minimisation plans is documented in the patient clinical record

SM SM

10.7.2 The effectiveness and appropriateness of the falls prevention and harm minimisation plan are regularly monitored

SM SM

10.7.3 Action is taken to reduce falls and minimise harm for at-risk patients

SM SM

10.8.1 Discharge planning includes referral to appropriate services, where available

SM SM



Surveyor Rating

10.9.1 Patient information on falls risks and prevention strategies is provided to patients and their carers in a format that is understood and meaningful

SM SM

10.10.1 Falls prevention plans are developed in partnership with patients and carers

SM SM

Service Delivery

Information about services


Surveyor Rating

11.1.1

There is evidence of evaluation and improvement of the quality of information provided to consumers / patients and the community about: • services provided by the organisation • access to support services, including advocacy.

SM SM

11.1.2 The organisation’s processes for disseminating information on healthcare services are evaluated, and improved as required.

SM SM



11.2.1 Healthcare providers within the organisation have information on relevant external services.

SM SM

11.2.2 Relevant external service providers are provided with information on the health service and are informed of referral and entry processes.

SM SM

Access and admission to services


Surveyor Rating

11.3.1

The organisation evaluates and improves its system for admission / entry and prioritisation of care, which includes: • documented processes for prioritisation • clear inclusion and/or exclusion criteria • management of waiting lists • minimisation of duplication • utilisation of information in referral documents from other service providers received on admission of the consumer / patient • management of access block.

SM SM

Consumer / Patient Consent


Surveyor Rating

11.4.1

The organisation has implemented policies and procedures that address: • how consent is obtained • situations where implied consent is acceptable • situations where consent is unable to be given • when consent is not required • the limits of consent.

SM SM

11.4.2 The consent system is evaluated, and improved as required. SM SM

Appropriate and effective care


Surveyor Rating

11.5.1

The organisation ensures appropriate and effective care through: • processes used to assess the appropriateness of care • an evaluation of the appropriateness of services provided • the involvement of clinicians, managers and consumers / patients in the evaluation of care and services.

SM SM

11.5.2 Policy / guidelines are implemented that address the appropriateness of the setting in which care is provided including when consumers / patients are accommodated outside the specialty ward area.

SM SM

Diverse needs and diverse backgrounds


Surveyor Rating

11.6.1

The organisation obtains demographic data to: • identify the diverse needs and diverse backgrounds of consumers / patients and carers • monitor and improve access to appropriate services

SM SM



• improve cultural competence, awareness and safety.

11.7.1

Policies and procedures that consider cultural and spiritual needs are implemented to ensure that care, services and food are provided in a manner that is appropriate to consumers / patients with diverse needs and from diverse backgrounds.

SM SM

11.7.2

Mechanisms are implemented to improve the delivery of care to diverse populations through: • demonstrated partnerships with local and national organisations • providing staff with opportunities for training.

SM SM

Population health


Surveyor Rating

11.8.1

Performance measures are developed, and quantitative and/or qualitative data collected, to evaluate the effectiveness / outcomes of health promotion programs and interventions implemented by the organisation.

SM SM

11.9.1 The organisation identifies and responds to emerging health trends. SM SM

11.9.2 The organisation meets its legislative requirements for reporting on public health matters.

SM SM

11.10.1

There is evidence of evaluation and improvement of strategies to promote better health and wellbeing, which include: • undertaking opportunistic health promotion / education strategies in partnership with consumers / patients, carers, staff and the community • providing education, training and resources for staff to support the development of evidence-based health promotion programs and interventions.

SM SM

Provision of Care

Assessment and care planning


Surveyor Rating

12.1.1 Guidelines are available and accessible by staff to assess physical, spiritual, cultural, psychological and social, and health promotion needs.

SM SM

12.1.2 Guidelines are available and accessible by staff on the specific health needs of self-identified Aboriginal and Torres Strait Islander consumers / patients.

SM SM

12.2.1

The assessment process is evaluated to ensure that it includes: • timely assessment with consumer / patient and, where appropriate, carer participation • regular assessment of the consumer / patient need for pain / symptom management • provision of information to the consumer / patient on their health status.

SM SM

12.2.2 Referral systems to other relevant service providers are evaluated, and improved as required.

SM SM

12.3.1 Care planning and delivery are evaluated to ensure that they are: • effective • comprehensive

SM SM



• multidisciplinary • informed by assessment • documented in the health record • carried out with consumer / patient consent and, where appropriate, carer participation.

12.4.1

Planning for discharge / transfer of care is evaluated to ensure that it: • commences at assessment • is coordinated • consistently occurs • is multidisciplinary where appropriate • meets consumer / patient and carer needs.

SM SM

Management of nutrition


Surveyor Rating

12.5.1

Policy / guidelines for: • delivery of nutritional care • prevention of malnutrition • assessment of need for assistance with meals are consistent with jurisdictional guidelines, adapted to local needs and implemented across the organisation.

SM SM

12.5.2 The organisation’s strategic and coordinated approach to delivering consumer / patient-centred nutritional care is evaluated, and improved as required.

SM SM

12.6.1 Food, fluid and nutritional care form part of an intervention and clinical treatment plan.

SM SM

12.6.2

Relevant healthcare providers use an approved nutrition risk screening tool to assess consumers / patients: • on admission • following a change of health status • weekly thereafter and referrals to nutrition-related services occur when needed.

SM SM

12.6.3 The adequacy of consumer / patient nutrition is actively monitored and reported, and improvement is made to the nutritional care as required.

SM SM

12.7.1 A multidisciplinary team oversees the organisation’s nutrition management strategy to ensure that provision of food and fluid to consumers / patients is consistent with best-practice nutritional care.

SM SM

12.7.2 Education programs for relevant staff about their roles and responsibilities for delivering best-practice nutritional care and preventing malnutrition are evaluated, and improved as required.

SM SM

Ongoing care and discharge / transfer


Surveyor Rating

12.8.1 Discharge / transfer information is discussed with the consumer / patient and a written discharge summary and/or discharge instructions are provided.

SM SM

12.8.2 Arrangements with other service providers and, where appropriate, the carer are made with consumer / patient consent and input, and

SM SM



confirmed prior to discharge / transfer of care.

12.8.3 Results of investigations follow the consumer / patient through the referral system.

SM SM

12.9.1 Formalised follow up occurs for identified at-risk consumers / patients.

SM SM

12.10.1 Formal processes for timely, multidisciplinary care coordination and/or case management for consumers / patients with ongoing care needs are evaluated, and improved as required.

SM SM

12.10.2 Systems for screening and prioritising consumers / patients with ongoing care needs who regularly require readmission are evaluated, and improved as required.

SM SM

12.10.3 Education is provided to consumers / patients requiring ongoing care and, where appropriate, to their carers.

SM SM

End-of-life care


Surveyor Rating

12.11.1 Policy and procedures for the management of consumer / patient end-of-life care consistent with jurisdictional legislation, policy and common law are available and staff receive relevant education.

SM SM

12.11.2 There is policy / guidelines for supporting staff, consumers / patients and carers involved in organ and tissue donation.

SM SM

12.12.1 Access to and effectiveness of end-of-life care is evaluated, including through the use of clinical review committees.

SM SM

12.12.2 A support system is used to assist staff, relatives, carers and consumers / patients affected by a death.

SM SM

Workforce Planning and Management

Workforce planning


Surveyor Rating

13.1.1 Workforce management functions and responsibilities are clearly identified and documented.

SM SM

13.1.2 The workforce policy, procedures, plan, goals and strategic direction are regularly reviewed, evaluated, and improved as required.

SM SM

13.2.1 Contingency plans are developed to maintain safe, quality care if prescribed levels of skill mix of clinical and support staff are not available, and in order to manage workforce shortages.

SM SM

13.3.1 The system for managing safe working hours and fatigue prevention is evaluated, and improved as required.

SM SM

Recruitment processes


Surveyor Rating

13.4.1 The organisation-wide recruitment, selection and appointment systems are evaluated, and adapted to changing service needs where required.

SM SM

13.5.1 Recruitment processes ensure adequate staff numbers and that the workforce has the necessary licences, registration, qualifications, skills and experience to perform its work.

SM SM



13.5.2

The credentialling system to confirm the formal qualifications, training, experience and clinical competence of clinicians, which is consistent with national standards and guidelines and with organisational policy, is evaluated, and improved as required.

SM SM

13.6.1 The volunteer recruitment system supports an adequate number and mix of volunteers to complement the work undertaken by paid staff.

SM SM

Continuing employment and development


Surveyor Rating

13.7.1 Accurate and complete personnel records, including training records, are maintained and kept confidential.

SM SM

13.7.2 There is a system to document training for staff and volunteers which is identified as necessary by the organisation.

SM SM

13.8.1

The performance assessment and development system includes: • review of position descriptions • review of competencies • monitoring of compliance with published codes of professional practice • assessment of learning and development needs • provision of adequate resources for learning and development • management of identified performance needs.

SM SM

13.8.2 Ongoing monitoring and review of clinicians’ performance is linked to the credentialling system.

SM SM

13.8.3 The performance assessment and development system is evaluated through appropriate stakeholder consultation, and improved as required.

SM SM

13.9.1 Processes are in place for managing a complaint or concern about a clinician, and there is evidence that they have been used.

SM SM

13.9.2 Processes are in place for managing a complaint or concern about a member of staff, including contracted staff and volunteers, and there is evidence they have been used.

SM SM

Employee support and workplace relations


Surveyor Rating

13.10.1 The workplace rights and responsibilities of management, staff and volunteers are clearly defined and communicated.

SM SM

13.10.2 Managers take action on at-risk behaviour of staff and volunteers. SM SM

13.11.1 There is a consultative and transparent system to identify, manage and resolve workplace relations issues which is evaluated, and improved as required.

SM SM

13.12.1

Strategies to: • motivate staff • acknowledge the value of staff • support flexible work practices are evaluated with staff participation, and improved as required.

SM SM

13.13.1 Performance measures are used regularly to assess staff access to an employee assistance program and to evaluate the staff support services, and improvements are made as required.

SM SM



Information Management

Health records management


Surveyor Rating

14.1.1

Health records management systems are evaluated to ensure that they include: • reference to all relevant legislation / standards / policy / guidelines • defined governance and accountability • the secure, safe and systematic storage and transport of data and records • timely and accurate retrieval of records stored on or off site, or electronically • appropriate retention and destruction of records • training for relevant staff in health records management.

SM SM

14.2.1 The system for the allocation and maintenance of the organisation-specific consumer / patient identifier, including a process for checking multiple identifiers, is evaluated, and improved as required.

SM SM

14.3.1 Healthcare workers participate in the analysis of data including clinical classification information.

SM SM

14.3.2 Clinical coding and reporting time frames that meet internal and external requirements are evaluated, and improved as required.

SM SM

14.4.1 Consumers / patients are given advice / written guidelines on how to access their health information, and requests for access are met.

SM SM

Corporate records management


Surveyor Rating

14.5.1

Corporate records management systems are evaluated to ensure that they include: • reference to all relevant legislation / standards / policy / guidelines • defined governance and accountability • the secure, safe and systematic storage and transport of data and records • standardised record creation and tracking • appropriate retention and destruction of records • training for relevant staff in corporate records management.

SM SM

Collection, use and storage of information


Surveyor Rating

14.6.1

Monitoring and analysis of clinical and non-clinical data and information occur to ensure: • accuracy, integrity and completeness • the timeliness of information and reports • that the needs of the organisation are met and improvements are made as required.

SM SM

14.6.2

The information management system is evaluated to ensure that it includes: • identification of the needs of the organisation at all levels • compliance with professional and statutory requirements for

SM SM



collection, storage and use of data • the validation and protection of data and information • delineation of responsibility and accountability for action on data and information • adequate resourcing for the assessment, analysis and use of data • data storage and retrieval facilitated through effective classification and indexing • contribution to external databases and registers • training of relevant staff in information and data management.

14.7.1

The organisation uses data from external databases and registers for: • research • development • improvement activities • education • corporate and clinical decision making • improvement of care and services.

SM SM

14.8.1 Staff have access to contemporary reference and resource material.

SM SM

Information and communication technology


Surveyor Rating

14.9.1

The ICT system is evaluated to ensure that it includes: • backup • security • redundancy • protection of privacy • virus detection • preventative maintenance and repair • disaster recovery / business continuity • risk and crisis management • monitoring of compliance with ICT policy and procedures.

SM SM

14.9.2 Licences are purchased as required to ensure intellectual property rights and title to products are retained by product owners.

SM SM

Corporate Systems And Safety

Strategic and operational planning


Surveyor Rating

15.1.1

The strategic plan that: • includes vision, mission and values • identifies priority areas for care, service delivery and facility development • considers the most efficient use of resources • includes analysis of community needs in the delivery of services • formally recognises relationships with relevant external organisations is regularly reviewed by the governing body.

SM SM

15.1.2 Leaders and managers act to promote a positive organisational SM SM



culture.

15.1.3 Operational plans developed to achieve the organisation’s goals and objectives and day-to-day activities comply with appropriate by-laws, articles of association and/or policies and procedures.

SM SM

15.2.1 Changes driven by the strategic plan are communicated to, and evaluated in consultation with, relevant stakeholders.

SM SM

15.2.2 Change management strategies are implemented to achieve the objectives of the strategic and operational plans.

SM SM

Systems and delegation practices


Surveyor Rating

15.3.1

The processes of governance and the performance of the governing body are evaluated to ensure that they include: • formal orientation and ongoing education for members of the governing body • defined terms of reference, composition and procedures for meetings of the governing body • communication of information about governing body activities and decisions with relevant stakeholders • defined duties and responsibilities and a role for strategy and monitoring.

SM SM

15.4.1 Compliance with delegations is monitored and evaluated, and improved as required.

SM SM

15.5.1 Organisational structures and processes are reviewed to ensure that quality services are delivered.

SM SM

15.6.1

There is evidence of evaluation and improvement of the system to govern and document decision making with ethical implications, which includes: • a nominated consultative body • a process to receive, monitor and assess issues • review of outcomes.

SM SM

15.7.1

Organisational committees: • have access to terms of reference, membership and procedures • record and confirm minutes and actions of meetings • implement decisions and are evaluated, and improved as required.

SM SM

15.8.1

The organisation has sound financial management processes that: • are consistent with legislative and government requirements • include budget development and review • allocate resources based on service requirements identified in strategic and operational planning • ensure that useful, timely and accurate financial reports are provided to the governing body and relevant managers • include an external audit.

SM SM

External Service Providers


Surveyor Rating

15.9.1 There is evidence of evaluation and improvement of systems to manage external service providers, which:

SM SM



• are governed by implemented policy and procedure • include documented service agreements • define dispute resolution mechanisms • monitor compliance of service providers with relevant regulatory requirements and specified standards • require evidence from service providers of internal evaluation of the services they provide • ensure that external service providers comply with organisational policy and procedures.

15.9.2

The organisation evaluates the performance of external service providers through agreed performance measures, including clinical outcomes and financial performance where appropriate, and improvements are made as required.

SM SM

Research Governance


Surveyor Rating

15.10.1

The system that: • determines what research requires ethical approval • oversees the ethical conduct of organisational research • monitors the completion of required reporting is evaluated, and improved as required.

SM SM

15.10.2 Consumers and researchers work in partnership to make decisions about research priorities, policy and practices.

SM SM

15.11.1

Systems are implemented to effectively govern research through policy / guidelines consistent with: • jurisdictional legislation • key NHMRC statements • codes of conduct • scientific review standards.

SM SM

15.11.2

The governance of research through: • documented accountability and responsibility • establishing formal agreements with collaborating agencies • adequately resourcing the organisation’s human research ethics committee (HREC), where applicable is evaluated, and improved as required.

SM SM

Safety management systems


Surveyor Rating

15.12.1

Safety management systems include policies and procedures for: • work health and safety (WHS) • manual handling • injury management • management of dangerous goods and hazardous substances • staff education and training in WHS responsibilities.

SM SM

15.13.1

The system for ensuring WHS includes: • identification of risks and hazards • documented safe work practices / safety rules for all relevant procedures and tasks in both clinical and non-clinical areas • staff consultation

SM SM



• staff education and provision of information • an injury management program • communication of risks to consumers / patients and visitors and is implemented, evaluated, and improved as required.

15.13.2 Staff with formal WHS responsibilities are appropriately trained. SM SM

15.13.3 A register of dangerous goods and hazardous substances is maintained and Material Safety Data Sheets (MSDSs) are available to staff.

SM SM

15.14.1

There is evidence of evaluation and improvement of the radiation safety management plan, which: • is coordinated with external authorities • includes radiation equipment, a register for all radioactive substances, and safe disposal of all radioactive waste • ensures staff exposure to radiation is kept as low as reasonably achievable (ALARA) • keeps consumer / patient radiation to a minimum whilst maintaining good diagnostic quality • includes a personal radiation monitoring system and any relevant area monitoring.

SM SM

Buildings, plant and equipment


Surveyor Rating

15.15.1

The procurement, management, risk reduction and maintenance system includes: • buildings / workplaces • plant • medical devices / equipment • other equipment • supplies • utilities • consumables • workplace design.

SM SM

15.15.2 Plant and other equipment are installed and operated in accordance with manufacturer specifications, and plant logs are maintained.

SM SM

15.16.1

Incidents and hazards associated with: • buildings / workplaces • plant • medical devices / equipment • other equipment • supplies • utilities • consumables are documented and evaluated, and action is taken to reduce risk.

SM SM

15.16.2 The safety and accessibility of buildings / workplaces, and the safe and consistent operation of plant and equipment, are evaluated, and improvements are made to reduce risk.

SM SM

15.17.1

Access to the organisation is facilitated by: • clear internal and external signage • the use of relevant languages and multilingual / international symbols

SM SM



• the provision of disability access • facility design that meets legislative requirements and/or is based on recognised guidelines.

Emergency and disaster management


Surveyor Rating

15.18.1

There is evidence of evaluation and improvement of the emergency and disaster management systems, which include: • identification of potential internal and external emergencies and disasters • coordination with relevant external authorities • installation of an appropriate communication system • development of a response, evacuation and relocation plan • display of relevant signage and evacuation routes • planning for business continuity.

SM SM

15.19.1

There is evidence of evaluation and improvement of staff training and competence in emergency procedures, which includes: • education at orientation • annual training in emergency, evacuation and relocation procedures • regularly conducted emergency practice / drill exercises • the appointment of an appropriately trained fire officer • access to first aid equipment and supplies, and training of relevant staff.

SM SM

15.20.1

There is documented evidence that an authorised external provider undertakes a full fire report on the premises at least once within each EQuIPNational cycle and/or in accordance with jurisdictional legislation.

SM SM

15.20.2 There is a documented plan to implement recommendations from the fire inspection.

SM SM

Physical and personal security


Surveyor Rating

15.21.1 Service planning includes strategies for security management. SM SM

15.21.2 The organisation-wide system to identify and assess security risks, determine priorities and eliminate risks or implement controls is evaluated, and improved as required.

SM SM

15.22.1 Staff are consulted in decision making that affects organisational and personal risk, and are informed of security risks and responsibilities.

SM SM

15.22.2 Security management plans are coordinated with relevant external authorities.

SM SM

15.23.1

The violence and aggression management plan is evaluated to ensure that it includes: • policies / procedures for the minimisation and management of violence and aggression • staff education and training • appropriate response to incidents.

SM SM



Waste and environmental management


Surveyor Rating

15.24.1

The waste and environmental management system is evaluated to ensure that it includes: • development and implementation of policy • coordination with external authorities • staff instruction and provision of information on their responsibilities.

SM SM

15.25.1

Controls are implemented to manage: • identification • handling • separation and segregation of clinical, radioactive ,hazardous and non-clinical waste, and the controls are evaluated, and improved as required.

SM SM

15.26.1

The system to: • increase the efficiency of energy and water use • improve environmental sustainability • reduce carbon emissions is evaluated, and improved as required.

SM SM



Recommendations from Current Survey Standard: Governance for Safety and Quality in Health Service Organisations Item: 1.18 Action: 1.18.2 Mechanisms are in place to monitor and improve documentation of informed consent


Enhance the education and compliance with the informed consent documentation.

Standard: Medication Safety Item: 4.4 Action: 4.4.1 Medication incidents are regularly monitored, reported and investigated


Increase vigilance and reporting of medication errors including no harm incidents and near miss incidents.

Standard: Medication Safety Item: 4.6 Action: 4.6.1 A best possible medication history is documented for each patient


Strategies for medication reconciliation be further developed across clinical areas championed by clinicians and assisted by pharmacy personnel.

Standard: Patient Identification and Procedure Matching Item: 5.5 Action: 5.5.3 Action is taken to improve the effectiveness of the process for matching patients to their intended procedure, treatment or investigation


FWLHD Broken Hill review and improve its processes for the labelling and management of pathology specimens in addition to the recording, reporting and trended analysis of miss labelled specimens. Systems of reporting mislabelled specimens should involve key clinicians so as to inform improvements.



Standard: Clinical Handover Item: 6.1 Action: 6.1.1 Clinical handover policies, procedures and/or protocols are used by the workforce and regularly monitored


Processes around the better management of weekend discharge and handover consisting of a multidisciplinary team approach be implemented to support more timely and appropriate discharge and handover practices.

Standard: Preventing and Managing Pressure Injuries Item: 8.2 Action: 8.2.1 An organisation-wide system for reporting pressure injuries is in use


1. Medical officer representation be added to the Pressure Injury Committee to further reinforce the multidisciplinary team involvement and practice.

2. Medical officer orientation/induction to include advice on allied health referral information to help flag key areas of practice to support pressure injury management.



Recommendations from Previous Survey Standard: Governance for Safety and Quality in Health Service Organisations Criterion: Governance and quality improvement systems Action: 1.4.3 Locum and agency workforce have the necessary information, training and orientation to

the workplace to fulfil their safety and quality roles and responsibilities

Recommendation: EN PR 0814.1.4.3

Recommendation:

Formalise and document material provided to locum doctors and agency nurses for orientation to the workplace and to inform them of their safety and quality roles and responsibilities.

Action:

The information developed for the orientation of the ED LMO's for the last PR Survey in 2014 has been expanded to now include the term rotation JMO's. All relevant information is provided to new medical staff on a FWLHD identified USB drive. In addition all JMO's attend the BHHS JMO Orientation which is provided at the beginning of the term rotation. Other Medical Officers are given the opportunity to attend the FWLHD Orientation. Information for the FWLHD Orientation is also provided to new staff on a portable USB drive. The FWLHD Dental Service which is managed the Broken Hill Health Service has recently redeveloped their orientation manual , a copy of which is provided with this report. Additionally the Nursing Directorate has developed an Nursing Orientation Policy which is currently in consultation, and a copy is provided with this report. Other departments within the Health Service have their individualised departmental orientation packages. A copy of the Dental Clinic Orientation Manual has been include as an example.

September 2016 Agency Nurses are oriented to the department they will be working in - this has been the responsibility of the NUM. Monitoring of department orientation has been identified as a gap and a checklist has been developed and wherever possible the nurse educators provide the orientation.

Completion Due By: 30/06/2015

Responsibility:

Organisation Completed: Yes

Surveyor's Comments: Recomm. Closed: Yes

The organisation has formulated an appropriate set of guiding documentation which is provided to locum doctors and agency nurses for orientation. This recommendation has been satisfactorily met.



Standard: Information Management Criterion: Health records management Action: 14.1.1 Health records management systems are evaluated to ensure that they include: • reference to all relevant legislation / standards / policy / guidelines • defined governance and accountability • the secure, safe and systematic storage and transport of data and records • timely and accurate retrieval of records stored on or off site, or electronically • appropriate retention and destruction of records • training for relevant staff in health records management.

Recommendation: OWS+NS 0612.1.1.8

Recommendation:

Broken Hill Health Service implement a clinical risk alert sheet or similar mechanism as discussed with staff at time of survey.

Action:

A Health Information Manager was appointed in September 2014. There have been significant records management issues to be addressed since this appointment. This body of work has been progressing, albeit very slowly, to enable a number of other issues to be addressed as higher priority. The recording of Alerts and Allergies in eMR and in the physical Medical Record has been reviewed and problems identified will be addressed with the review and re-development of Recording Alerts and Allergies policy which will be distributed for comment June 2015. The Alerts divider suggested in the recommendation is being introduced into the medical record where there are identified alerts through patient presentations. An appropriate Alerts Sheet will be provided when the updated policy has been endorsed to ensure its effective use. September 2016 An acting Health Information Manager is currently in place following the unexpected departure of the previous manager. There have been significant changes to patient medical records since the last survey with the implementation of electronic medical records which includes the capacity for all clinicians to record alerts at the time of patient service. The implementation of the electronic record precludes recording in the paper record and therefor the inclusion of an alerts page into the paper record has been terminated


Responsibility: Medical Records



A clinical risk alert sheet has been designed and implemented in accordance with this recommendation. Further development of the electronic medical record is noted and has to some degree overtaken the particulars of a sheet. The recommendation has been satisfactorily met.



Standard: Corporate Systems And Safety Criterion: External Service Providers Action: 15.9.1 There is evidence of evaluation and improvement of systems to manage external service providers, which: • are governed by implemented policy and procedure • include documented service agreements • define dispute resolution mechanisms • monitor compliance of service providers with relevant regulatory requirements and specified standards • require evidence from service providers of internal evaluation of the services they provide • ensure that external service providers comply with organisational policy and procedures.

Recommendation: OWS+NS 0612.3.1.4

Recommendation:

The FWLHD/BHHS finalise development of a standardised external contract framework that is supported with a centrally available register and includes key features that facilitate management, monitoring and control and is supported with policies, procedures, delegations and compliance assessment processes.

Action:

The FWLHD follows the NSW Health Contract Framework which is available through NSW Health ProcurePoint and is also supported by the NSW Health Legal Department. A Summary of the Framework (Nov 2014) is provided with this report. FWLHD has a Delegations Manual which is available through the FWLHD Intranet. A Manager Procurement/ Contracts was appointed in late 2014.The role of contract management is incorporated into the position of the of the FWLHD Distributions Supervisor and responsibilities have been included into this position description. The development of a centralised database/register of contracts has been a considerable body of work in a short period of time.

A Contractor Management Policy has been developed for the management of contractors who are required to provide service to all FWLHD facilities regardless of the existence of contract arrangements of one-of service requirements (eg pest control provider).


Responsibility: FWLHD Distributions Supervisor



The organisation has undertaken significant work to support contractor management. Examples include, the Contractor Management Plan, the Contractor Handbook and the Contractor Database with evidence of contract evaluation being made available. The organisation is commended for implementing what seems to be a robust contractor management program not only to meet this recommendation but to support effective and appropriate service delivery.

Organisation: FWLHD Broken Hill Health Service Orgcode: 110167

The Australian Council on Healthcare Standards EQuIPNational: Page 97 17/01/2017

Standards Rating Summary

Organisation - NSQHSS V01 Core Developmental Combined

Standard Not Met Met N/A Total

Standard 1 0 44 0 44

Standard 2 0 4 0 4



Standard 5 0 9 0 9

Standard 6 0 9 0 9




Standard 10 0 18 0 18

Total 0 209 0 209


Standard 1 0 9 0 9


Standard 3 0 2 0 2

Standard 4 0 6 0 6

Standard 5 0 0 0 0

Standard 6 0 2 0 2

Standard 7 0 3 0 3

Standard 8 0 4 0 4

Standard 9 0 8 0 8

Standard 10 0 2 0 2

Total 0 47 0 47

Standard Not Met Met N/A Total Overall

Standard 1 0 53 0 53 Met










Total 0 256 0 256 Met

Standard SM MM Total

Standard 1 44 0 44

Standard 2 4 0 4

Standard 3 39 0 39

Standard 4 31 0 31

Standard 5 9 0 9

Standard 6 9 0 9

Standard 7 20 0 20

Standard 8 20 0 20

Standard 9 15 0 15

Standard 10 18 0 18

Total 209 0 209


Standard 1 9 0 9

Standard 2 11 0 11

Standard 3 2 0 2

Standard 4 6 0 6

Standard 5 0 0 0

Standard 6 2 0 2

Standard 7 3 0 3

Standard 8 4 0 4

Standard 9 8 0 8

Standard 10 2 0 2

Total 47 0 47

Standard SM MM Total Overall

Standard 1 53 0 53 Met










Total 256 0 256 Met



Organisation - EQuIPNational Mandatory Non-Mandatory Combined


Standard 11 0 2 0 2

Standard 12 0 10 0 10

Standard 13 0 2 0 2

Standard 14 0 1 0 1

Standard 15 0 9 0 9

Total 0 24 0 24


Standard 11 0 14 0 14

Standard 12 0 14 0 14

Standard 13 0 18 0 18

Standard 14 0 11 0 11

Standard 15 0 30 0 30

Total 0 87 0 87







Total 0 111 0 111 Met


Standard 11 2 0 2

Standard 12 10 0 10

Standard 13 2 0 2

Standard 14 1 0 1

Standard 15 9 0 9

Total 24 0 24


Standard 11 14 0 14

Standard 12 14 0 14

Standard 13 18 0 18

Standard 14 11 0 11

Standard 15 30 0 30

Total 87 0 87







Total 111 0 111 Met

Surveyor - NSQHSS V01 Core Developmental Combined



Standard 2 0 4 0 4



Standard 5 0 9 0 9

Standard 6 0 9 0 9




Standard 10 0 18 0 18

Total 0 209 0 209


Standard 1 0 9 0 9


Standard 3 0 2 0 2

Standard 4 0 6 0 6

Standard 5 0 0 0 0

Standard 6 0 2 0 2

Standard 7 0 3 0 3

Standard 8 0 4 0 4

Standard 9 0 8 0 8

Standard 10 0 2 0 2

Total 0 47 0 47












Total 0 256 0 256 Met




Standard 1 44 0 44

Standard 2 4 0 4

Standard 3 39 0 39

Standard 4 31 0 31

Standard 5 9 0 9

Standard 6 9 0 9

Standard 7 20 0 20

Standard 8 20 0 20

Standard 9 15 0 15

Standard 10 18 0 18

Total 209 0 209


Standard 1 9 0 9

Standard 2 11 0 11

Standard 3 2 0 2

Standard 4 6 0 6

Standard 5 0 0 0

Standard 6 2 0 2

Standard 7 3 0 3

Standard 8 4 0 4

Standard 9 8 0 8

Standard 10 2 0 2

Total 47 0 47












Total 256 0 256 Met

Surveyor - EQuIPNational Mandatory Non-Mandatory Combined


Standard 11 0 2 0 2

Standard 12 0 10 0 10

Standard 13 0 2 0 2

Standard 14 0 1 0 1

Standard 15 0 9 0 9

Total 0 24 0 24


Standard 11 0 14 0 14

Standard 12 0 14 0 14

Standard 13 0 18 0 18

Standard 14 0 11 0 11

Standard 15 0 30 0 30

Total 0 87 0 87







Total 0 111 0 111 Met


Standard 11 2 0 2

Standard 12 10 0 10

Standard 13 2 0 2

Standard 14 1 0 1

Standard 15 9 0 9

Total 24 0 24


Standard 11 14 0 14

Standard 12 14 0 14

Standard 13 18 0 18

Standard 14 11 0 11

Standard 15 30 0 30

Total 87 0 87







Total 111 0 111 Met

Report of the ACHS EQuIPNational Organisation-Wide Survey … Topics... · 2020-02-05 · How to...

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