Published on 22 May 2023

NSQHS: Standard 1: CLINICAL GOVERNANCE BULLETIN MAY | 2023

  • Introducing the Clinical Governance 'Fab 5'

    The ‘Fab 5’ team are multi-disciplinary leads brought together to the ‘Pillars’ of our Best Care Framework, bring awareness of and support ongoing National Safety & Quality Health Service (NSQHS) Standard compliance.

    The Fab 5 Team is:

    Team Lead: Lisa Gatzonis

    Quality Lead: Jodie Antoniou

    Education lead: Robyn Peel

    Allied Health Lead: Bec Tivendale

    Medical Lead: Abi Arulanandarahah

  • Do you have any questions?

    For any queries about Clinical Governance you’d like to direct to the NSQHS Std 7 Fab 5 or others, please contact BestCare@wh.org.au

  • Like to know more about Accreditation Readiness?

    Visit our Live Best Care site at https://westerly.wh.org.au/livebestcare/  or use the following QR Code to find out more about NSQHS Standard Readiness.

From Lisa

As part of Accreditation Readiness activity, a NSQHS Standard of the Fortnight initiative has been introduced. This involves a focus on one Standard per fortnight, with communications and walkarounds to help staff be aware of how Best Care at Western Health reflects this Standard, to ask staff possible Surveyor questions and answers, and to walk in a Surveyor’s shoes to see what WH practice looks like.

We are excited that NSQHS Standard 1: Clinical Governance is to be the focus of the fifth Standard of the fortnight (week). This will run from Monday 22 May to Sunday 28 May. Look out for friendly Best Care Co-ordinators, Fab 5 team members and other staff who will pop into clinical areas/departments to talk with you about Clinical Governance.

The Clinical Governance Standard aims to ensure that there are systems in place within health service organisations to maintain and improve the reliability, safety and quality of health care.

The Clinical Governance Standard supports the ‘Pillars’ of our Best Care Framework … the quality systems that support our staff to lead, drive and create Best Care.

Western Health’s comprehensive approach to Clinical Governance draws upon requirements of this Standard and uses clinical, safety, and quality systems integrated with governance processes to improve the safety and quality of health care for patients. Programs and strategies to help support clinical governance include:

  • The Best Care Policy and Framework providing guidance to all staff on how they can provide, lead, govern and support Best Care.

Mechanisms for capturing and responding to consumer feedback.

  • The Policy and Procedure Framework supporting easy access to best practice information via PROMPT.

The progressive implementation of the Electronic Medical Record

  • Live Best Care Improvement framework providing tools and resources to support staff to complete improvement activites at organisational and local levels and showcase outcomes.
  • Organisational strategies and systems for providing a safe environment such as Emergency procedure management, engineering preventative and reactive maintenance, OVA prevention and management, cleaning schedules and audits, way finding, inclusion and diversity, Aboriginal Health plan.
  •  Supporting the workforce to understand their role and responsibilities through the Best Care policy, orientation & training, credentialing, individual performance reviews and clinical supervision.
  • Utilising purposeful information collected from audits, indicators and incidents to analyse, share and respond to identified risks and opportunities.

Education and Learning programs to support staff development and growth

Our ‘Fab 5’ team have brought together nursing, medical, allied health, education, and quality expertise to support our ongoing compliance with NSQHS Std 1. We are working closely with Western Health’s Right Care committee, Best Care Steering Committee and Board Quality & Safety Committee to ensure we are continually monitoring, reviewing and improving the reliability, safety and quality of health care.

The good news is we are already providing Best Care and living up to the requirements of NSQHS Std 1 on Clinical Governance in our everyday work! It is why we performed exceptionally in the 2020 Accreditation Survey. This year’s Survey is simply a chance to show once again how well we support best care at Western Health.

Please continue reading to find out more about our clinical governance strategies, achievements and opportunities for improvement, as well as resources to help you to be Accreditation Ready for NSQHS Std 1.

Lisa Gatzonis
NSQHS Std 1 ‘Fab 5’ Team Lead
Director of Nursing & Midwifery Workforce

Resource Centre

The following resources have been put together to support staff to be aware of the NSQHS Clinical Governance Standard and Accreditation Ready for Survey against this Standard:

Patient Story on Living Best Care at Western Health

“My husband Malcom was taken to the Footscray Hospital, after he collapsed at home.
He was subsequently admitted to a ward.

From there over a period of 19 days, he had the most wonderful of care.
He was treated with respect, kindness and caring.
He was gravely ill and the medical treatment he received, was exceptional.

Dr Albert and his medical team were amazing.
The nurses explained to Malcom what they were going to do for him and what was going into him via the canula.


Nothing was too much for them, to do for him. He said there were no negatives from him.

Funny thing that Malcom commented to me in Emergency … Dr Albert came to examine Malcom and then told me he would be coming in upstairs to the ward. I told Malcom that was the doctor and he would be admitted upstairs to a ward. Malcom said “ that wasn’t a doctor, he was too young and looked like a teenager !” Funny !!! Dr Albert and his team saved my husband’s life.

Next there was a problem for me of his rehabilitation. What was going to happen ? But that was all solved by the wonderful staff.
We were set off home, with all the equipment we needed, example; toilet seat, shower seat, walking frame and of course the bottle (savior for not having to get up during the night). All Equipment was purchased by us, as we are getting older.

The next day “Gem@Home” came into our lives for two weeks. How great is this program ?!!

The team that came to visit us were exceptional! Phone call in the mornings and the professionals would come and visit Malcom, to get him through his rehab.

Malcom is now not needing to go to community Physio at Sunshine Hospital – WOW! He does his exercises every day. I could go on and on.

When I called to Purchase the equipment, I spoke to a gentleman named Ray. I asked if he had been with Footscray Hospital long and he said yes. And it works out that he provided me with a nebulizer for my daughter at the age 2 and a half … way back in 1980.
It was like a trip down memory lane. Ray provided exceptional care that night in casualty with my daughter, and was lovely, just like recently.

At our Christmas eve dinner Malcom made a little speech, and it said the if it wasn’t for the wonderful staff that looked after him at Footscray Hospital, he probably wouldn’t be with us. Thank you, with all our heart.”

 

Improvement Initiatives

There are multiple improvement initiatives underway to improve Clinical Governance. Do you know about these?

  • Development of new online Performance Dashboards supporting the monitoring of Best Care,
  • Phase 2 of EMR to ‘go live’ in July.
  • LifeQI online quality improvement platform being piloted to support projects and reporting.
  • Progressive development of the Best Care microsite as a central location for quality system communication & resources.
  • Roll out of the Best Care Excellence & Improvement Project (BCEIP), designed to support front-line staff capability to monitor, review and improvement Best Care.
  • Process redesign for the review of serious clinical incidents and the implementation and tracking of recommendations.

 

Achievements and Opportunities

We are proud of…

  • Re-instating the WH Right Care Committee.
  • Staff engagement with WH’s new Policy, Procedures & Guidelines (PPG) system, PROMPT.
  • Staff engagement in the newly introduced Serious Adverse Patient Safety Event (SAPSE) reviews.
  • Staff participation in the Best Care Excellence & Improvement Project (BCEIP), component parts of which Safer Care Victoria are considering replicating for broader application.
  • Re-instating Executive and Best Care Co-ordinator Walkarounds.

We are looking forward to…

  • Our Best Care Quality Systems encompassing Mental Health and Custodial services transitioning to WH.
  • The Go-Live of phase 2 of the EMR.
  • Capturing more of the improvements undertaken since last Accreditation Survey in 2020.
  • The launch of more NSQHS Std aligned online dashboards through the WH Dashboard Project.
  • The continued development of the WH Live Best Care microsite as the one stop shop for staff and accreditation surveyors.

Our focus continues on…

  • Reducing WH’s number of out-of-date PPGs and completing the transition of  BM/M PPGs.
  • Increasing staff engagement in mandatory training.
  • Increasing recording of completed Professional Development Plan (PDP) discussions.
  • Bringing together and refining auditing systems.
  • Reviewing credentialing processes to identify opportunities for improvement.

 

 

Key Messages

 

Data Analysis

  

Key Messages
Policies, Procedures. Guidelines (PPGs) We do a good job keeping our approximately 1,000 WH PPGs up-to-date but currently over 10% of our total number are out-of-date Let’s reduce the risk of staff not having up-to-date guidance to provide Best Care and ensuring out-of-date PPGs are reviewed and updated.

Ensure you know how to access policies and procedures via PROMPT and follow these in your work
 Patient Incidents We are doing really well reviewing the most serious patient incidents (ISR1 &2s) but there are over 1500 ISR3 & 4 (less severe) incidents that have not been closed across WH Let’s reduce the risk of patient incidents by reviewing, learning from and closing ISR3 & 4 incidents

Continue to report and follow-up near misses and incidents in Riskman
Patient Feedback Staff have really engaged in bringing down the number of open patient complaints across WH but we are still running at approximately 80 complaints open at any one time Let’s improve the patient experience by supporting the timely review and closure of patient complaints

Listen to patients / consumer feedback and try if possible to address any issues or opportunities for improved experience while they are still in your care
Performance Development Plans (PDPs) 63% of WH staff are currently recorded as having had a performance development plan discussion over the past 12 months Let’s improve support for staff to provide Best Care by identifying and actioning the 37% of staff who have not had a PDP in the past 12 months or completed PDPs that have not been recorded

Let your manager know if you haven’t had a PDP in the past 12 months
Mandatory Training We currently have an organisation-wide mandatory training compliance rate of 72% Let’s reduce the risk of adverse patient outcomes by checking which mandatory training is applicable and ensuring all staff are supported to complete any outstanding training

Complete all mandatory and required training for your role
Know How We are Doing Boards Local data and information Let’s reduce the risk of missed events and errors by:

  • Reviewing audit outcomes relevant to your area of work
  • Being aware of the local issues and strategies for improvement

Being aware of focus areas within your workspace
Improvement Activity Staff at WH are constantly coming up with innovative ways to improve the way we provide or support Best Care, however we don’t have much documentation on improvement activity Let’s record and celebrate the improvements undertaken across WH to provide or support Best Care by using the redesigned WH Improvement Register.