NSQHS Accreditation Bulletin – October 2023

NSQHS ACCREDITATION BULLETIN OCTOBER | 2023

Welcome

Welcome to the October 2023 NSQHS Accreditation Bulletin.

This publication has been developed to provide key messages and information about preparing for org-wide NSQHS Accreditation Survey.

For those who would like to just view a summary of this Bulletin, click on the four headings below:

• Key Messages October 2023
• Upcoming Milestones
• Resource Centre
• Contact for Accreditation Questions/Support

For those who would like a more comprehensive read, continue reading the Bulletin sections below or select areas of interest from the index to the right.

Best Care Governance & Support Division

Staff notification when accreditation survey is called and what happens next

We have developed a plan to activate when we are given our 24 hour notice that Accreditation Surveyors will be visiting Western Health. Note: We will be given notice on a Thursday, with a Survey commencing on the Monday and concluding on the Friday.

This plan includes a number of ways to notify staff, services and patients, including emails, PA announcements and screen savers.

Communication will tell staff to access the home page of the Live Best Care site. A big banner with a link to FAQs and tools with be visible to support you through the Accreditation Survey. The link will take you to the following page which will be updated when survey is announced: NSQHS Accreditation Survey FAQs and Tools – Live Best Care (wh.org.au)

NSQHS Standard Accreditation Re-Cap

The National Safety and Quality Health Service (NSQHS) Standards provide a nationally consistent statement of  the level of care consumers can expect from health services. NSQHS Standards compliance activity and accreditation surveys supports us to monitor, review and continually improve Best Care.

The eight NSQHS Standards are:

• From 1 July 2023, no scheduled accreditation surveys; only short-notice assessments with 24 hours notice. We will be notified on a Thursday that a week long survey will commence on the Monday.
• As WH’s current NSQHS Accreditation status lapses in May 2024, the short-notice assessment will be at some point between 1 July 2023 and 31 December 2023. It is looking likely survey will happen fairly close to November 2023.
• We will have a team of approximately 13 accreditation surveyors visiting all of our campuses for a week
• Accreditation surveyors will return 65 days post survey if there are any recommendations from Survey
• Surveyors will spend up to 75% of survey time in clinical wards and departments providing or supporting care and facilities
• Transitioned Mental Health services will be included in survey
• Dame Phyllis Frost Centre will not be included in this survey

Survey Week

In order for ACHS to confirm the number of Surveyors required for Accreditation Survey and link us with a Lead Surveyor for Survey planning, a number of documents have been submitted to ACHS, These include a full listing of WH campuses, services, bed numbers/activity and workforce numbers. Transitioning mental health service details were included in the documentation as well as WH Clinical Trial activity which is a new focus for accreditation survey.

A NSQHS Standard short notice response plan was activated when we had mock accreditation survey in June. Thank you to staff who replied to our survey about how this went. Activation appeared to go smoothly, with positive feedback from staff.

A centralised NSQHS Standard evidence portal for Surveyors while on site at WH has been completed.

Fab 5 Teams

NSQHS Standard Fab 5 Teams have gone from strength to strength, and are working in conjunction with key Western Health committees to ensure our Best Care quality systems are being used to continually monitor, review and improve organisation-wide compliance against the NSQHS Standard requirements. Each team has as a minimum designated nursing, medical, allied health, education and best care co-ordinator leads.

Led by Nursing Leads (Directors of Nursing & Midwifery) and supported by BAU Action Plans, the Fab 5 Teams are having an impact. Each Team has completed what will become annual organisation-wide WH Practice Summaries and Reflective Compliance Reviews against their aligned NSQHS Standard and are driving/supporting clinical practice improvement.

Organisation-wide WH Practice Summaries have been updated to reflect current practice and highlight improvement activity against the NSQHS Standards. These documents will be added to the Live Best Care site.

The teams have also supported NSQHS ‘Standard of the Fortnight’ activity. Due to positive feedback on this initiative, it will continue in 2024, with a NSQHS ‘Standard of the month’ program implemented.

Accreditation Readiness Focus

Current areas of focus for accreditation readiness:

• Excessive clutter – the hard rubbish collection at the start of October was a great success. ‘Embrace Your Space’ tips have also been distributed to support  initiatives being planned to support areas decrease clutter
• Some areas have items such as dirty linen stored on the floor – ‘no more on the floor’ campaign launched 
• Training and performance management to meet our targets – make sure you are up-to-date, with specific focus on lifting the rates of BLS and OVA training, as well as uploading PDPs to WH Register
• Clinical Auditing – a centralised clinical audit register has been developed, with links to surveys and results
• Shared development of patient goals and preferences – make sure you are using of the ‘About Me form’
• Improvements to medication storage and disposal – new medication disposal bins have been rolled out
• Screening and assessment processes to minimise patient harm across all sites –  Bacchus Marsh Hospital going live with new risk assessment tools in the week commencing 24 October
• We need to be consistent in practice and use of WH (not localised) tools for handover – training materials on using the EMR to support clinical handover currently being distributed
• We need to be consistent in checking of points of patient ID for practices such as handover – WH PPG on points of patient ID revised
• KHWD Boards are a good tool, but there is opportunity to improve the way they are being used – guidelines & support for use of KHWD boards reviewed, with engagement start with front-line staff to update and fully understand their KHWD Board where indicated

Focus on Managers Accreditation Manual

As mentioned In last month’s Nursing & Midwifery News we are focusing on ensuring consistency of practice across our wards, areas, and departments to ensure we are all delivering Best Care safely and reliably.

The Managers Accreditation Checklist has been a useful tool in the past and has been reinvented with checklist items under the relevant NSQHS Standard; the Checklist is helpful in achieving the consistency in service delivery and best care that our consumers can expect across the organisation.

The Manager Accreditation Checklist has been incorporated in a Managers Accreditation Manual which contains the Checklist and Embrace your Space Tips.

The checklist contains items that require action to ensure the area and staff are prepared for NSQHS Accreditation; not all items on the checklist will be relevant to particular areas. Within the checklist some items may contain a hyperlink to an Embrace Your Space Tip.

The Embrace Your Space Tips are key messages for frontline staff with a practical solution for managers, assistant managers, and portfolio holders. The Embrace Your Space Tip provides practical information to action an item on the checklist.

Managers are responsible for completing the checklist and delegating items on the checklist as appropriate. The checklist should be completed monthly; managers are expected to re-visit the checklist for completion as needed and within 24 hours of receiving notice of NSQHS Accreditation.

This resource tool will be useful to remain prepared for short notice NSQHS Accreditation into the future.

Engagement of Front Line Staff

Key initiatives included in the communications and engagement plan to support staff be ‘Accreditation Ready’ by end June 2023 have been reviewed for ongoing use.

The diagram to the left summarises activity that will continue as business as usual to maintain staff awareness and engagement in accreditation readiness.

Spotlight on the Live Best Care Microsite

The Live Best Care Microsite is our central information portal for staff on WH’s Quality Systems supporting Best Care and compliance with NSQHS Standards

The  ‘Are you ready for NSQHS Accreditation?’  section of the Site contains FAQs and links to resources to help staff be ‘Accreditation Ready’