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ACSQHC National Standards at Alfred Health

2013Standard 5 Webinar

Dr. Lee Hamley, Chief Medical Officer L.Hamley@alfred.org.au

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Alfred Health – the Context

• 974 beds across 3 campuses– The Alfred (600+)– Caulfield Hospital (approx 200)– Sandringham Hospital (approx 100)

• 2012-13 Alfred Health– Treated 100,000 inpatients– Saw 155,000 outpatients– Employed nearly 8,000 staff

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Alfred Health Survey 2013

• The Alfred– Highly complex casemix with many Statewide services – heart & lung

transplantation, CF, major trauma, adult burns, HIV, haemophilia, sexual health, hyperbaric medicine & psychiatric ICU

– Also v large ICU, bone marrow transplant, renal transplant, 2 EDs, dialysis

• Caulfield Hospital– Some acute gen med, subacute services (rehab; aged care; aged

psychiatry), residential aged care, community based services, dialysis• Sandringham Hospital

– Community hospital, gen med & surgery, O&G, paeds, ED, dialysis

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Alfred Health Survey 2013

• ACHS did the survey – surveying agency may matter• Survey week 24-28 June 2013• Three campuses + numerous community facilities• 10 NSQHS, National Mental Health Standards, HACC community

services• Outcome -

– All 209 Core Standards met– All HACC requirements met– All national mental health standards met– 42/47 Developmental actions met – those NM relate to patient and

family initiated escalation in Standard 9

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It’s about compliance!!….. It’s not only about improvement

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Standard 5 – The Basics

9 Core actions – must be met;0 Developmental– not required to fully meet; must have action plansNo “prescribed actions” in Standard 5

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

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

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

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

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

5.2.2 Action is taken to reduce mismatching events

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

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

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

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The Journey……

We didn’t know what we were doing but neither did anyone else!

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The Process Generally

• We took around18 months from start to finish• Undertake a comprehensive, rigorous & honest gap analysis (CGU)

Err on the side of pessimism• At Alfred Health, less than 80% compliant at the start across all

Standards• Standard 5 - one of the least compliant for Alfred Health (3/9)

– 5.2.1 System for reporting & analysing events monitored - N– 5.3 Inpatient bands meet national specifications - N– 5.5.1 Documented process to match pts to Rx – Y

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Patient ID (3/9) - Exec Presentation Feb 2012

• Structure – Nil currently – all activity, monitoring & auditing decentralised

– Suggest working party – LH, PA, MS, PI, Path, Rad, OTS, JR, AP, IT rep

• Senior responsibility – LH • Reporting – Suggest add to Clin Gov Report when KPIs identified• Support – Nil currently – likely to need Project Officer for 6/12• Key question –

– May be significant policy changes – e.g. 3 identifiers required

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The Process

• Start by engaging your Executive & key stakeholders• Each Standard has an Exec Sponsor – Standard 5 LH• Each Standard has an Exec Officer – Clin Gov staff member

Second people into “areas of need”• Each Standard has a work plan• Focus on meeting CORE actions• Work plans entered into your Quality Information system

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Standard 5 – Where to start?

• Start with a policy (5.1.1)…..but what do you need to do first?– Establish a working party– Decide on the 3 identifiers– What special groups may we need to identify and how?– When will we positively identify patients?– What other policies/ guidelines may be impacted?– How will we report on patient ID?

• What might we be able to do in parallel?– Look at wrist bands – these should be ok!– Famous last words!

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The Three Identifiers

• Major issue for us as three campuses all with their own PMI, so potentially three UR numbers

• Inpatients –– Full name, DOB, Campus UR– (patient address)

• Outpatients –– Full name, DOB, gender– (patient address)

• Other considerations– Maternity hospitals – gender not a discriminator

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Special Groups – the Guideline

• Community patients – identified as per outpatients• Hospital in the Home - identified as per outpatients• Dialysis patients – use photo ID (often have no drivers licence for ID)• Residential aged care - photos• Mental health inpatients & ECT patients – wristbands as for inpatients• Neonates – inpatient ID band• Unknown patients in the ED – special system in ED – 24 hour rule• etc

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But when are we going to positively ID someone?

• on registration or admission; • on presentation to a Department/Ward; • prior to commencement of all operative and invasive procedures, including

venepuncture; • prior to the administration of general/epidural/spinal/regional anaesthesia

for procedures; • prior to the administration of sedation for procedures; • prior to ECT ; • for radiation therapy; • prior to transfusion of blood or blood products; • prior to all investigations e.g. Pathology, Radiology, ECG & CTG; • prior to the administration of medication; and • on handover or transfer of care

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What other policies and procedures are affected?

• Patient Registration• Consent – various policies and guidelines• Medication Administration & Management• Correct Side & Site for Surgery (Time Out)• Resident Identification Guideline• Handover (when we had one!)• Transfer of Care• Medical Record Documentation Guideline• Patient Escort Guideline

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How will we report?

• Need to develop a reporting framework for patient identification• Include key KPIs in monthly Clinical Governance report to Exec

– WBIT; Time out data; med error wrong patient; UR duplication rate• Monitor others at Patient ID Committee

– Radiology ID KPIs– Riskman data

> Wrong or no wristband> Other incorrect patient labelling> Other ID issues

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Wristbands

• 5.3.1 Inpatient bands are used that meet the ACSQHC national specifications for patient identification bands – Specifications for a standard patient identification band

– A single white band should be used for patient identification– Only exception – red band for allergy – no details of actual alert

• At least NINE different wristbands identified!• Most labels didn’t fit into wristband, so folded!• Wristbands not waterproof, so issue with scanning• Outcome – new (and cheaper) wristbands introduced across whole health

service, including both EDs and mental health inpatients

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More Wristbands – “my patients are special & different”

• Agreed to use red bands for allergies – rationale -– Permitted by ACSQHC guidelines– Allergies verified by pharmacists therefore very likely to be correct

• Variety of other bands all scrapped • Alternatives included –

– Signs on beds– Info cards for patients– Handover system– Medi-alerts

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More wristbands – one band or two ?

• Existing practice for all surgical and obstetric patients to have two wristbands

• Rationale – trauma and burns patients are often severely injured and band cut off for access

• Plan A – ALL patients to have two bands – issue: unacceptable increase in work in ED

• Plan B – risk assessment of using one versus two bands for surgical & obstetric patients

– Clearly increased risk in using only one band in this group in our patient population

– Status quo prevailed

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Wrapping Up

• Staff education– E learning– Staff information– Include in Handover packages– Clerical staff education package

• Patient information booklet • Cease “centralised” label storage – e.g. in Cardex system• Make sure all of the other relevant policies and guidelines are updated to

reflect content of Patient Identification Policy

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Moving on – Procedure Matching

• Well established procedures for Time Out plus surgical safety checklist in theatres, with good data and good results

• Endoscopy covered by Theatre• Review of procedures in Interventional Radiology, Cardiac Cath Labs &

Bronchoscopy Suite• Introduced Time Out into ECT, Radiotherapy• Considered “mini Time Out” in Radiology, Hyperbaric etc• Robust data collection for all areas

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The Final Countdown…..the last three months

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Reflective Questions – NSQHS Workbook

• “How do we know if our workforce use our patient identification processes?”

• Could we piggy back onto another audit to demonstrate this?– Observational audit of handover– Discovered poor compliance with use of 3 identifiers from JMS– Issue: Ward patient lists included Age, not DOB!

• “How do we identify, record and manage patient mismatching events and near misses?”

– At Pt ID C’tee – issue with point of care testing• “How do we inform our workforce about patient care mismatching events?”

– Use of Clinical Alerts sent out to clinical workforce

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So for 2014……

• Large numbers of “captive” staff start in January and February every year• Grads for nursing etc; JMS• Start planning NOW!• Education on Standard 5 • Make sure orientation includes a large dose of NSQHS!• Cover off training requirements where possible• Introduce 6 monthly or annual wristband audits

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And finally…..

• Implementing Standard 5 requirements on reflectionIs much more about the organisation and leadership – not something to be delegated to “Quality” staff to worry about

E.g. complete change for wristbandsIs about compliance, so more focus on auditIs generally clinically relevant, so easier to market to clinical staffPresents an opportunity - makes you focus on some things we all should have done but many didn’t – e.g. Time Out in all relevant areas

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