annual report on protected quality assurance activities … · annual report on protected quality...

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Annual Report on Protected Quality Assurance Activities

Organisation Name: Family Planning Association

Reporting Period: 15.4.11 – 14.4.12

1. Name of Quality Assurance Activity

a) List any problems or issues that have been identified in the course of the activity: b) List what actions have been taken, as a result of the activity, to resolve the

identified problems/issues: c) List what recommendations have been (or are to be) made as a result of the

activity:

• Clinicians unsure of criteria for meeting new audit tool items • Notification of GPs could be improved

Sdasdsa adasd

• Discussion at Clinical Professional Services Group meeting

• Clearer instructions on criteria for meeting new audit tool items • Reminder at clinic meetings of need for GP notification when client agrees and

documentation when client doesn’t agree

Family Planning Client Record Audit Activity

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d) Describe how implementation of these recommendations will be monitored: e) Describe how any improvements to the practice or competence of your

organisation, or any of your organisation’s agents or employees, are to be managed:

f) Summarise the benefits to the health and disability consumers resulting from the

activities described in this report:

Please send to: Clinical Leadership, Protection and Regulation Ministry of Health

PO Box 5013 Wellington 6145

[email protected]

• Clinicians demonstrate understanding of criteria for meeting new audit tool items • GP notification and documentation improves at next audit

• Notes have been written and added to the audit tool to indicate how to judge whether criteria have been met

• GP notification will assist in not duplicating investigations and allowing more seamless care of individual clients

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activity:

• Clients reporting inconvenience when asked to book separate appointments when wanting several different health needs addressed

• Client complained of breach of confidentiality when there were 2 clients with the same first name in the waiting room and the wrong one was called into the consultation room

• Difficult implant removals – some clients have needed to return for another attempt when the first attempt has been unsuccessful

• Laboratory specimens mislabelled • Noted that experienced staff who were concerned about a client’s safety were not always discussing

proposed management with another senior colleague • Laboratory issues following the Christchurch earthquake – tests not done, missing results, results sent

to wrong inbox, receiving results destined for other health care providers

Sdasdsa adasd

• Discussion by management on booking consecutive appointments when client wanting several different health needs addressed

• Incident of the wrong client being called into the consultation room investigated • Discussion of difficult removals at Clinical Professional Services Group (CPSG) meeting • Reasons for mislabelling lab specimens investigated • Clinical staff reminded of Family Planning’s protocol for managing client safety issues • Issues discussed with laboratory

• Lists of what health needs can be dealt with within one appointment or as consecutive appointments agreed upon by management and clinical staff, circulated and implementation commenced

• Recommendation that clinicians always ask client for their family name and DOB before commencing the consultation

• Recommendation that if contraceptive implant rods are not easily palpable, the client should be referred to have removal under ultrasound guidance

• Addition of possibility of difficulty removing an implant, to the implant insertion request form which the client signs

• Specimen collection procedure updated • Family Planning and laboratory have had regular contact about issues

Family Planning Incident Audit

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[email protected]

• Locality teams will monitor use and reasons for booking consecutive appointments • Review Reportable Events Register (RER) to ensure that correct client is being seen, that women are

being referred for difficult implant removals appropriately, that there are fewer mislabelled lab specimens and fewer issues in receiving test results

• Notification of consecutive appointments process via weekly National Memo, reinforced by communication from the Locality Team

• National Memo advising all clinical staff to ask client for their family name and DOB before commencing the consultation

• National Memo advising clinical staff of referral procedure for impalpable implants with an example of the ACC form if needed

• The electronic implant request form was modified in each clinic

• Clients are able to attend on one occasion for a number of health care needs • Correct client identified before consultation to ensure correct records used and appropriate

management of their needs • Women requesting contraceptive implants are made aware of a possible problem with removal and are

provided with timely referral if needed • That lab specimens are correctly linked to the client and that tests ordered are received by the correct

health care provider

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a) List any problems or issues that have been identified in the course of the activity:

b) List what actions have been taken, as a result of the activity, to resolve the

identified problems/issues:

c) List what recommendations have been (or are to be) made as a result of the

activity:

d) Describe how implementation of these recommendations will be monitored:

e) Describe how any improvements to the practice or competence of your organisation, or any of your organisation’s agents or employees, are to be managed:

• Notification of GPs could be improved • Health promotion activities such as family violence and alcohol screening often omitted • Disagreement between individual paired audit results and moderation at locality and

national level re whether items were met, partially met or not met Sdasdsa adasd

• Discussion at Clinical Professional Services Group meeting (CPSG)

• Continuing encouragement of clinicians who do less well on client record audit to improve

• Minor alteration in audit instructions to clarify what is wanted

• Improvement in GP notification and health promotion activities • Better agreement between initial audit and moderation

• All staff feel more confident in using client record audit tool

Family Planning Client Record Audit Activity

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[email protected]

• GP notification will assist in not duplicating investigations and allowing more seamless care of individual clients

• Discussion of health promotion activities with a client can potentially improve the client’s health and health of community

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activity:

• Need for some nurses to be trained to manage contraceptive implant problems • Identification of staff to expand scope of practice • Locality recommends they manage nurse implant training • In one locality, need to provide service for women wanting IUD removal when strings

not visible (available in other large centres) • Part time doctors finding it difficult to access CME specific to scope of practice • Objectives for learning identified for individual clinicians • Poor documentation noted for one staff member • Breaches of standing orders noted for one nurse

Sdasdsa adasd

• Discussion on nurse implant training at Clinical Professional Services Group (CPSG) meeting

• Information on instruments and training to provide IUD removal service when strings not visible

• Ensure part time doctors aware of online methods of obtaining CME • Individual learning needs and weaknesses addressed and training in new skills

arranged

• CPSG agreed to continue this training nationally and continue to train trainers so that courses could be run more frequently

• Implant removal training for nurses will be piloted locally • IUD removal service when strings not visible to be commenced once instruments

available • Monitoring of individuals re documentation and standing orders adherence over next 3

months

Family Planning Performance Audit Activity

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e) Describe how any improvements to the practice or competence of your






[email protected]

• Quality of implant training and time to gaining competence will be monitored • Waiting times for procedures to be monitored after training completed • Client satisfaction with IUD removal when strings not visible will be monitored locally • Doctors’ CME activities will be monitored annually as usual • Clinicians’ learning objectives will be monitored annually as usual • Individual weaknesses followed up over 3 months with significant improvement noted

• National overview of training nurses to insert and remove contraceptive implants • Individual clinicians will maintain knowledge and competence and expand their

practice

• Women wanting a contraceptive implant inserted or removed will be able to access an appointment in a timely fashion with a competent operator

• Women wanting IUD services, termination of pregnancy referrals and STI treatment will be able to access an appointment in a timely fashion with a competent health professional

• Women wanting IUD removal when strings are not visible will be able to access this service from all main Family Planning clinics

• Clients are provided with high quality services provided by up to date competent clinicians

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activity:

• Need for more doctors to learn how to remove contraceptive implants • Need for some nurses to be trained to manage contraceptive implant problems • Occasional breaches of Family Planning’s Standing orders • Improvement in some individual’s documentation identified • Some staff could improve teamwork and flexibility with seeing clients

• Determination of which doctors can be trained to remove contraceptive implants • Discussion of which areas need training on managing implant problems • Discussion with nurses who have breached Standing Orders • Discussion of Family Planning’s expectations re documentation, teamwork and flexibility in

seeing clients discussed with individual staff members

• Training sessions arranged for doctors on how to remove contraceptive implants with

supervised work for first few procedures • Training sessions on managing implant problems to be arranged • Closer surveillance by someone outside the locality re use of Standing Orders instituted for one

person • Agreement with individual staff members to work on documentation, teamwork and flexibility

in seeing clients

Family Planning Performance Audit Activity

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[email protected]

• Waiting time for contraceptive implant removals to be monitored • Nurses feel more confident to manage implant problems • Improvement in following Standing Orders noted • Documentation and staff behavior will be noted at future performance reviews

• Doctors achieving competence in implant removal • Expectation that all nurses will continue to follow Family Planning’s Standing Orders

• Women wanting implant removal will be able to access an appointment in a timely fashion with a competent operator

• Women will receive accurate assessment, information and management about implant problems • Clients are managed safely under Family Planning’s Standing Orders • Clients are seen in a timely fashion and their management is documented clearly

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activity:

• Difficulty for staff in distant clinics to access peer review sessions • Need to update list of services available for HIV positive clients • Need to inform client which lab to take post vasectomy specimen too as lab will only

accept it at certain sites • Discussion of management of polycystic ovarian syndrome, which migraines exclude

combined pill use, amenorrhoea, alternatives to hormone therapy and postmenopausal bleeding

• Sexually transmitted infection (STI) screening not being offered opportunistically alongside emergency contraceptive and repeat contraceptive visits

Sdasdsa adasd

• Decisions on how to involve staff at distant sites • Discussion on various topics • Clinicians advised to offer STI screening opportunistically whenever possible

• Peer review sessions are held on different days of the week to suit commitments of clinicians

• Peer review sessions are held at different locations to enable easier attendance • Phone calls and visits are undertaken to ensure distant staff are involved • Distant staff phone into central peer review sessions • Updated list of HIV services compiled • Leaflet developed to direct post vasectomy men to correct location of suitable

laboratory • Staff can access the chapter on Menstrual Disorders in the Clinical Resource Manual

on Family Planning’s Intranet

Family Planning Peer Review Activity

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f) Summarise the benefits to the health and disability consumers resulting from the activities described in this report:



[email protected]

• Localities monitor that staff are meeting their peer review requirements annually

• National rollout of computers has enabled use of Skype and videos to allow inter-clinic communication

• Clients’ management is optimised by the opportunity of peer review and agreement on how to manage various clinical problems

• Specific clients will be managed more efficiently – referral for HIV services, post vasectomy follow up, STI screening offered opportunistically

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activity:

• Management when contraceptive implants are not easily palpable if client requesting removal

• How to investigate and manage irregular or heavy bleeding • How to manage specific complex clinical problems

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• Discussed experience on managing difficult to palpate implants • Discussion of investigation and management of irregular or heavy bleeding • Discussion with group of peers via meetings, phone, Skype on complex clinical

problems

• Interventional radiologist list circulated to all local doctors to enable appropriate referral of impalpable contraceptive implants

• Staff can access the chapter on Menstrual Disorders in the Clinical Resource Manual on Family Planning’s Intranet

Family Planning Peer Review Activity

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[email protected]

• All doctors are aware of how to manage hard to palpate implants

• Continuation of peer review opportunities using Skype and phone as well as meetings • Conflicts between local hospital advice and national guidelines taken to Clinical

Professional Services Group meetings for resolution

• Women requesting removal of hard to palpate implants are referred promptly • Women with irregular or heavy periods are managed according to evidence-based

guidelines • Clients’ management is optimised by the opportunity of peer review and agreement on

how to manage complex clinical problems

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activity:

• Review of women’s experience of contraceptive implant • Review of whether women taking combined contraceptive pill with or without pill free

interval • Audit of response to post vasectomy reminder letters • Audit on timing, reasons and any prior treatment for problems of women attending for

implant removal

Sdasdsa adasd

• Extended audit of contraceptive implant – recruitment completed and follow up completed for first 6 months

• Found that most women in that area taking contraceptive pill without regular pill free interval

• Most men did not respond to letters – either submitted specimens without a reminder or did not submit a specimen at all

• Discussion on how to inform women about contraceptive implant problems and ensure they access treatment to alleviate side effects

• Complete implant audit • Combined pill leaflet amended to inform women that they can take the pill with or

without a pill free interval • Potential to use text messaging to remind post vasectomy men • Reiteration of message that contraceptive implants may cause irregular bleeding and

that this can be managed by various medications

Family Planning Patient Care Activity

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[email protected]

• The audit results will be collated – already it is clear that the majority of women are pleased with their implant

• Monitor that all women attending Family Planning for implant insertion are aware of potential bleeding problems and that they can by managed without removal

• Once information is available, audit results will be disseminated to all staff using Family Planning conference in October 2013 and national Clinical Memos

• Implant pamphlet has been amended and is available on website

• Information from implant audit will be used to inform women of other people’s experience so they are better informed

• Women with irregular bleeding caused by a contraceptive implant who want to continue using this method will know to seek treatment for the bleeding

• Potential for more effective pill taking and lower accidental pregnancy rate when combined pill is taken without a pill free interval

• Post vasectomy men may find text messaging more convenient as a reminder to submit specimens and find out the operation has been successful

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activity:

• Concern at the number of clients returning to have their contraceptive implant removed prematurely

• It should be noted that a number of other Patient Care Activities were undertaken

relating to termination of pregnancy referral services, discussing breast screening with women 45 years old or more, and continuous use of combined contraceptive pills – they did not raise problems or issues

Sdasdsa adasd

• The issue of premature removal of contraceptive implants has been discussed at the Clinical Professional Services Group meeting

• Funding has been obtained to do an expanded audit on the experiences of women having an implant inserted in a Family Planning clinic and following them over at least one year – ethics committee approval has been obtained

Family Planning Patient Care Activity

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[email protected]

• The audit results will be collated

• It is anticipated that we will be better able to counsel women about what they can expect while using a contraceptive implant

• Women will have better information to make a decision on contraceptive implant use • Women will continue to get timely access to termination of pregnancy services • Breast screening will reduce breast cancer rates • Women will have the option of using the combined pill continuously with a possible

enhancement of efficacy

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• Laboratory specimens mislabelled or unlabelled • Large number of young clients needing referral to a statutory agency because they

have been identified as being at risk of harm • Difficult implant removals continue • Occasional breaches of standing orders – medication given when client’s condition

made this medication unsuitable • Client noted potential breach of confidentiality when client name was added to a list in

a procedure room • Client complained that another health professional was able to access her lab results

• Management of on-going specimen labelling problems discussed by Reportable Event Register (RER) review committee and Clinical Professional Services Group (CPSG) and a new system agreed upon

• Locality teams throughout the country noted improvement in clinician confidence and management of young clients presenting with abuse issues

• In one area where there has been a particularly high number of clients at risk of harm, a number of activities have been put in place

• Protocols for managing difficult implant removals in place • Each identified breach of standing orders is investigated by locality team at the time and

discussed by RER team quarterly • Potential breach of confidentiality discussed by RER team and recommendation made • Staff member reminded about discussing Testsafe sharing of lab results with every

client

Family Planning Incident Audit

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c) List what recommendations have been (or are to be) made as a result of the activity:






Please send to: Clinical Leadership, Protection and Regulation

Ministry of Health PO Box 5013

Wellington 6145

• A new system of checking lab specimens with a second person is being introduced • In the area where there is a high number of young people at risk of abuse, there has

been a multidisciplinary meeting with Family Planning staff and police and youth support services

• In this area, nurses visiting schools have been given more support to handle situations where young people are identified as being in abusive situations

• When more than one standing order breach is noted relating to a nurse, the team has put in place a closer monitoring system

• The book recording procedures is no longer necessary now there are electronic records so clinics have been instructed to cease its use

• Reminder about Testsafe sharing to be moved to more visible place on electronic record

• Locality teams will continue to monitor these items at their meetings • Reportable Events Register (RER) review committee will look at these items at their

quarterly meetings

• Discussion at Managers meetings and CPSG meetings with instructions to implement changes in their locality

• Weekly National Clinical Memo used to notify all clinical staff of changes

• That lab specimens are correctly linked to the client so that repeat tests are not needed

• That young clients in abusive situations are identified and referred appropriately and in a timely fashion

• That clients facing difficult implant removals are managed appropriately • That clients receive appropriate management in relation to standing orders • That potential sources of breach of confidentiality are minimised

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[email protected] PQAA Reports F-N 21

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Organisation Name: Gillies Hospital

Reporting Period: 2 March 2013 to 2 March 2014




activity:

No issues or problems have been identified this year Sdasdsa adasd

No actions have therefore been taken

As above

Gillies Hospital Quality Assurance Activity Quarterly Mortality and Morbidity Peer Review meetings

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[email protected]

We continue to monitor implementation of previous incidents however no new monitoring has been undertaken

There are no current issues relating to competence or practice management

Consumers receive treatment and care with up to date technology utilised according to good practice guidelines

PQAA Reports F-N 23

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Organisation Name: Gillies Hospital

Reporting Period: 2 March 2012 to 2 March 2013




activity:

A muscle relaxant was drawn up and given instead of midazolam. This incident has been investigated and causal factors indentified:

• Sharing ampoules for more than one patient • Similar ampoules • Preparation of drugs for the following case prior to end of current case • Anaesthetist felt the need to rush

• Prefilled Midazam syringes have been purchased and have replaced midazolam ampoules • All used open vials are now disposed of after each case (section 3.3 ANZCA’s Professional

Document PS28) • Medications prepared for following cases are now be placed in a covered tray • Minimise noise and interruptions while drugs are being drawn up in Operating Room

As above

Gillies Hospital Quality Assurance Activity Quarterly Mortality and Morbidity Peer Review meetings

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Please send to: Population Health Ministry of Health

PO Box 5013 Wellington

[email protected]

A survey six months after the incident showed that all actions were were being followed On going monitoring will ensure compliance with the recommendations.

There are no current issues relating to competence or practice management

Consumers receive treatment and care with up to date technology utilised according to good practice guidelines

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Organisation Name: Hawke’s Bay District Health Board

Reporting Period: 1 December 2011 – 30 November 2012




activity: d) Describe how implementation of these recommendations will be monitored:

• Non achievement of 100% standard for completion of required nursing documentation • Lack of understanding amongst some staff of documentation requirements for restraint • Lack of weekly checks of resuscitation trolleys in some clinical areas • Failure to achieve required controlled drug documentation in some clinical areas • Failure to offer referral to Maori Health Services for some Maori patients

Sdasdsa adasd

• Establishment of project team to address nursing documentation compliance – planning small scale trial of alternative nursing forms

• Refinement of Falls Risk Assessment tool • Use of monthly audit results as a learning tool for staff • Revision of resuscitation trolley checking process with regular monitoring by Emergency

Response team • Maori Health Services team monitors results at a unit level so team members can follow-up to

increase awareness of service scope as required.

As for b) Continue monthly audits in 2013 – scope has increased to cover inpatient and community/ ambulatory settings

Monthly reporting to Clinical Manager group

Clinical Managers’ (Monthly) Audit

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[email protected]

Due to variation in results by department, Clinical Managers are required to implement improvements (as required) at a service level. Audit is a KPI of Clinical Managers.

Activity demonstrates to our consumers that we are concerned with meeting our standards. Raised awareness of core standards by staff -> increased awareness supports improved practice standards. Raised awareness of patients’ rights (Code of rights component of audit) by patients and staff. Improving compliance with documentation will support improved communication between staff and patients.

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activity: d) Describe how implementation of these recommendations will be monitored: e) Describe how any improvements to the practice or competence of your




Nil. Significant improvement in door to needle times noted from prior audit, times are consistent with National Guidelines. Sdasdsa adasd

Nil

Nil

N/A

N/A

Ongoing quality control and maintenance of clinical standards

Rapid Thombolytic Therapy for Acute ST Segment Elevation Myocardial Infarction

PQAA Reports F-N 28

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[email protected]

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• Admissions at weekends are more likely to fail the target.

• If the referral to the medical team is delayed (eg >180 mins) then the target is unlikely to be met.

Sdasdsa adasd

• There was a review of the junior and senior staffing during the winter period. This needs reviewing??

Need to bring together all participants in “unplanned care” stream.

Crudely by the MoH performance indicator concerning the shorter stay in ED?!

-

Retrospective review of CEO dashboard data concerning medical admissions

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[email protected]

The ideal of swifter care provided to individuals through the organisation is reflected in less time spent at the initial point of assessment in ED, thus there is the expectation that quality of care will improve.

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1. Unable to perform full scope of audit if the LMC’s MMPO antenatal records are not filed in the health records. 2. Not all staff aware of the postnatal care for women who sustain a third or fourth degree tear 3. There was no documentation in the health records of women who did not attend an appointment Sdasdsa adasd

1. Request that LMCs put the MMPO antenatal print out in the healthcare notes 2. Incorporate care pathway checklist into new maternity documentation or produce a stamp or

sticker for third or fourth degree tears so the care plan is recognised & initiated 3. Incorporate care pathway checklist into new maternity documentation or produce a stamp or

sticker for DNAs in maternity outpatients so the standard of documentation is consistent

As above

Implementation will be project managed by the Maternity Quality Coordinator

The results of this audit and the actions arising from it will be discussed at staff meetings and included in the Maternity Governance Newsletter

Incidence of third and fourth degree tears in selected primipara as defined by The Australian Council on Healthcare Standards Clinical Indicators

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[email protected]

Consumers should receive the correct care for a third or fourth degree tear Consumers who DNA maternity appointments will be followed up and consistent documentation made.

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Too early in programme to yet identify any trends. Anticipate to release first reports Feb – March 2013. Sdasdsa adasd

Data collection period. Not enough data points yet to identify trends

Patient harm trends that may be identified will be discussed with CMO and DoN and patient safety advisory group.

As yet too early to determine, will depend on what is found.

As for d)

Global Trigger Tool Programme

PQAA Reports F-N 34

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[email protected]

Any patient harm trend identified through the programme will have action plans developed to address.

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The indications for Emergency Caesarean Section appeared appropriate, with no obvious trends identified that raised concerns. However inadequacies were identified in two specific areas in documentation, recording abdominal palpation and describing CTG. Sdasdsa adasd

Make audit result available to the service; ensure clinical educator and senior Medical Staff aware of documentation concerns.

Documentation education—ongoing and for all staff in the area. Encourage the use of CTG descriptive tools.

Ongoing documentation review, under the guidance of the Maternity Quality and Safety Coordinator.

Education: Presentations: RN’s for example, have already attended a documentation presentation. Individual support where needed.

Emergency Caesarean Section in Selected Primipara

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[email protected]

Accuracy of documentation and remove individual (subjective) interpretation. Reduction of risk especially around CTG interpretation. Improved patient outcomes.

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The results of cord bloods taken routinely at elective caesarean section to assess the acid base balance status of the umbilical cord blood at birth is not looked at if the baby’s Apgar scores are good. This in turn means it is not documented on the labour & birth summary although it is available in the ECA system should it need to be accessed if the baby developed any problems in the neonatal period Sdasdsa adasd

Hold education sessions on importance of documentation

Include documentation education on maternity study days

Through the Maternity Clinical Governance Group

Re-audit in 2014 and feedback to staff

Audit of cord blood pH in Elective CS

PQAA Reports F-N 38

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[email protected]

The consumers benefit indirectly as improved documentation equals improved communication in the team

PQAA Reports F-N 39

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• Variation in colonoscopy completion rates by clinician • Variation in colonoscopy polyp detection rates by clinician • Variation in procedure times by clinician • Lack of user-friendly data collection and reporting system

Sdasdsa adasd

• Enrolment in national Global Rating Scale (GRS) programme • Additional training need flagged with national lead • Further detailed audit/review planned in 2013 with focus on incomplete colonoscopies

(possible contributing factors and subsequent follow up/outcomes) • Internal reporting timeframes changed from six monthly to quarterly to provide more timely

data • Business case for acquisition of endoscopy database with reporting capability

Continue monitoring with issues based audits/reviews as need arises.

Review of quarterly reports. Regular Endoscopy Service Group meetings whereby audit is a standing item.

Colonoscopy Clinical Indicators Programme

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[email protected]

Ongoing audit and review using internal and comparative benchmarking data (enrolled in Australian Council on Healthcare Standards programme).

Reporting on service and clinician performance supports the raising of practice standards to a consistent level. The result to patients is a more responsive and acceptable service to patients.

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• Staff on leave making the department short of staff-Need to share clinical workload when short of staff-time constraints

• Need to complete the clinical work load in the assigned area-time constraints Sdasdsa adasd

• Two auditors • Prospective study-daily screening of notes is less time consuming. • Prioritising clinical workload if time is a significant issue on a particular day

• Use of Rigid removal dressing to reduce swelling and as a protective device=promote stump healing, these needs to be applied at the theatre after the surgery

• Use of stump protectors at all times to protect the stump in acute settings. • Will discuss with clinical nurse specialist-wound care, the precautions can be taken to reduce

stump wound infections, if wound infections delaying discharges.

• Will liaise with physiotherapy colleagues to order stump protectors soon after a surgery.-Will check monthly at the physiotherapy staff meeting

• Provide with a check list for Physiotherapy intervention in acute settings

Audit of Lower Limb Amputation Practice & Factors Affecting Delayed Discharges in Amputees

PQAA Reports F-N 42

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[email protected]

• In-service of the summary of the audit results and recommendations to the physiotherapy colleagues.

• Add the recommendations to Amputee guidelines on Nettie • Place a copy of Guidelines and audit report in Physiotherapy Shared drive(I drive)

• Identify causes for delayed discharge and implement procedures to avoid or improve those causes. Aiming to reduce the length of stay after a lower limb amputation (BKA/AKA).

• Reduced length of stay is associated with better quality of life for the patient and also less cost for DHB.

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• Unclear relationship between Public Health and Ministry of Primary Industries • Complicated and complex event • Need to ensure an organised approach to an event of this nature Sdasdsa adasd

• Relationship building with Ministry of Primary Industries • Clarification of statutory responsibilities

• Provision of information to vulnerable patients • Design and implement a mini CIMS for such events

Via the Emergency Response Service

No issues identified re: practice or competence of staff involved

Listeria debrief

PQAA Reports F-N 44

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[email protected]

• Provision of information regarding risks of immuno-suppression medication • Provision of dietary advice to frail, elderly, pregnant, neonatal and immuno-compromised patients • Heightened benefits in general community

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• Service provision on target – approximately 2 cognitive assessments per month • Dual assessment (paediatrician and psychologist) occurred in >90% • Investigation of children with suspected ID is at an appropriate level • 60% of children had had a hearing test and 45% had had a vision test which is below what we

should aim for • Prenatal alcohol exposure was positive in 2 children but not asked about pre referral in 9

children. Outcomes were not affected in this group but without this information, referrals cannot be triaged optimally and the team are then at risk of jumping FASD assessments up the waitlist.

• The SYSTEMS screen is however widely being used by the Paediatricians to guide referrals in 5-11 yr olds.

• 100% of children assessed had a comprehensive report including information provided by Education services

• Psychosocial stability as an indicator for suitability and appropriateness of cognitive assessment was inconsistently reported in medical referrals.

• All those identified as having ID were offered needs assessment with OHB and most were given medical certificates for CDA.

• 5 children who were listed as ‘cognitives’ actually needed broader assessments. Four of these had a full neuropsychological assessment which takes up significantly more psychology time and 1 needed a speech-language assessment which disrupted the flow of the wider DAP team’s provision of MDT assessments.

Feedback to Paediatricians re: • Paediatric referrers will be asked to document the presence or absence or prenatal alcohol

exposure in all patients where a cognitive assessment is being requested as well as a comment on school / social stability.

• Social worker to visit and review all cognitive referrals, reallocating to full DAP assessment and therefore longer waitlist if required. SW to check re vision and hearing referrals.

Audit of care pathway for children suspected of having Intellectual Disability (ID)

PQAA Reports F-N 46

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[email protected]

Where children have not had vision or hearing tests at the time of cognitive assessment, the referral should be made. For vision testing this would be a recommendation to visit a community optometrist.

Repeat audit in 2 years

Friendly discussion

Continually improving service which provides equitable timely provision of appropriate assessment and intervention to all those requiring it

PQAA Reports F-N 47

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Overall adherence to the Hypnosedative Guidelines was good. The main issues arising were: * Large quantities of hypnosedatives supplied on discharge prescriptions to existing users,

regardless of their length of stay. * Most new hypnosedatives being prescribed within two nights of admission, suggesting non-

pharmacological methods of decreasing sleep disturbance were not being adequately trialled. * No limits on use (e.g. maximum four times weekly) being annotated on chartings for new hypnosedatives, resulting in some patients receiving greater than the recommended limit in the guidelines. Sdasdsa adasd

* Guidelines will be extended to cover discharge prescriptions to existing users. * Non-pharmacological methods check-list to be added to guidelines to assess before prescribing

new hypnosedatives for insomnia. * Guidelines to be reinforced to staff, through Pharmacy and Therapeutics Bulletin and Clinical

Pharmacists to optimise prescribing and administration practices regarding new hypnosedatives to inpatients.

* Clinical pharmacists to educate new users on hypnosedatives to promote patient cooperation and understanding of the importance of these limits.

Audit of compliance with Hypnosedatives Policy

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• Reinforce and increase awareness of guidelines to staff, with a focus on using non-pharmacological methods to decrease sleep disturbance first-line. Have a check-list (e.g. avoid oral fluids at bedtime, reduce ward noise, no medical interventions late at night) for staff.

• Address care problems before prescribing hypnosedatives (e.g. chronic pain, constipation, depression, nocturia).

• Users of hypnosedatives who stay for only one night must not be given a discharge prescription.

• Users of hypnosedatives who are given a discharge prescription should be prescribed no greater than 10 days’ supply.

• Patients prescribed a new hypnosedative for insomnia in hospital should have the chart annotated with “Maximum four doses per week” and a review date (e.g. every 3-4 days).

• Discourage the charting of users’ regular hypnosedatives as dose ranges, rather than the patient’s usual dose (especially the higher dose range e.g. 7.5mg to 15mg), unless the patient is actively participating in an attempt to reduce their usage, which they will continue with after discharge.

• Patients prescribed new hypnosedatives in hospital should be educated about the need for limiting use of the medicine. The zopiclone or benzodiazepine “Patient Information Leaflets” on Nettie may be of use.

• Encourage completion of the “indication” box for PRN (as required) prescriptions - so nurses are clear about when it is appropriate to administer a hypnosedative.

Peter McIntosh (Team Leader Clinical) will present the results to the hospital Pharmacy and Therapeutics Committee, highlight the guidelines and additional recommendations in Pharmacy and Therapeutics Bulletin and communicate them to the clinical pharmacists to monitor on the wards.

Clinical pharmacists will monitor hypnosedative charting, administration and discharge prescribing on the wards and ensure they are in line with the hospital guidelines. If issues arise, they can discuss these with the staff involved.

• More controlled use of hypnosedatives for new users in hospital, decreasing their risk of

experiencing adverse effects from them when used for the first time in hospital. • Increased awareness of the risks of using hypnosedatives and understanding why they must

be limited. • Existing users to have discharge prescriptions limited to promote regular review of their

hypnosedative use by their GP and prevent unnecessary continuation.

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Hawke’s Bay Hospital has a low rate of index cholecystectomy and fails to meet current international standards for management of acute gallstone disease. A large proportion of those patients treated conservatively re-present with ongoing problems with considerable additional morbidity and financial cost. There are significant barriers to improving these standards in a secondary centre with limited resources. Sdasdsa adasd

Surgical department to present a statement to DHB management regarding the results of this audit to make a case for attempting to move towards greater numbers of acute cholecystectomies being performed for gallstone disease. Significant barriers will need to be overcome including – attitudes of theatre staff to the importance of acute cholecystectomy, potentially employing a further surgeon, having an acute surgeon on site during the day to supervise registrars performing the surgery.

Greater effort needed to perform acute cholecystectomy during the index admission to prevent re-presentation with complications.

Audit can be repeated in a few years to assess progress.

Timely Cholecystectomy for acute gallstone disease: a continuing challenge for a secondary centre

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[email protected]

Discuss the above with surgeons, registrars, DHB management, anaesthetists and theatre nursing staff.

Recognition of the poor management of acute gallstone disease in Hawke’s Bay, resulting in additional morbidity of patients. If efforts can be made to improve this, then patients will ultimately benefit.

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• Surgical trolley preparation time varies from case to case due to knowledge and experience of staff preparing trolley and type of operation.

• Patient preparation affects set up time as there may be more difficult anaesthetic requirements, or patient positioning before trolley enters theatre.

Sdasdsa adasd

When re-auditing, a finish setting up time will be added to the audit tool to ascertain the time trolley set up and the time of operation commencement.

Overall all theatres set up ‘just in time’ however the documentation shows that 53% of trolleys were set up for longer than 30 minutes prior to operation commencement. A change in the audit tool will identify this.

By adding this set up finish time the true time a surgical trolley is prepared for is ascertained and this will show which theatres are setting up ‘just in time’ and which theatres need to improve their time management.

Surgical Trolley preparation is determined by the scrub nurse. Less experienced nurses will take longer and need longer to set up their surgical trolley in order to be well prepared for their case.

Maintaining a Sterile Field Audit

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[email protected]

The time to prepare a surgical trolley in our operating theatre should be ‘just in time’ in order to meet our peri-operative nursing standards. By having our trolleys set up in minimal time the risk of contamination to the trolley is reduced therefore reducing the risk of infection to our patients. It also enables the staff to better utilise their time in theatre providing safe nursing care to patients.

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• Poor detection and awareness of delirium • Issues with coding this when the diagnosis (delirium) is made.

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• Education of medical staff, also of multidisciplinary team on AT&R ward, Orbit team and gerontology nurses.

• Medical staff to consider diagnosis of delirium in confused older patients and those at risk

Through a repeat audit in 12 months

-

Older Persons Acute Admissions Audit

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[email protected]

Improvement in diagnosis, management and coding of delirium in inpatients

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activity:

1. Patients weighed in only 25% of visits to neurology clinic 2. Of 10 patients offered PEG feeding 4 already had a vital capacity less than 50% expected

(increasing risk of procedure.) 3. Patients had good monitoring of respiratory function but this did not lead onto BIPAP being

offered in the majority of cases. (BIPAP trialled in 2 of 14 patients referred to Respiratory service. 4 other patients could have benefited.)

In some cases speed of deterioration not appreciated by other clinicians and in one case symptoms and signs of respiratory failure not recognized. adasd

1. Clinic nurse reminded to monitor weight in all MND patients. Audit presented to other physicians and in particular recommendations discussed with Respiratory colleagues

1. All MND patients to be monitored regularly in Neurology clinic 2. Patients to be referred to other services (SLT, Gastroenterology, Respiratory and Palliative

Care services) well before major complications occur 3. Patients should be referred for PEG feeding early, aiming for this to be offered before

respiratory function is compromised 4. When monitoring shows a drop in respiratory function to close to the level requiring

intervention then further monitoring to be done more frequently. 5. Patients need to be fully informed about the effects of respiratory failure and BIPAP offered

when there is evidence of nocturnal hypoventilation

Motor Neurone Disease Management Audit

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[email protected]

Patients will be monitored in Neurology clinic. Once respiratory dysfunction occurs there is also regular monitoring in respiratory clinic.

Other services have been fully briefed and shown international guidelines. Support staff including clinic nurses and respiratory technician fully informed. (This technician also reports any patient concerns to me.)

Patients with MND will be followed by staff who know about this condition. Complications regarding nutrition and respiratory function will be more readily recognised, anticipated and managed, with resultant increase in life expectancy and improvement in quality of life.

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Organisation Name: NZ Radiology Group Limited T/A Mercy Radiology

Reporting Period: Year to 7 April 2013




activity:

None Sdasdsa adasd

Health Practitioners Notice SR2006/90

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[email protected]

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Organisation Name: NZ Radiology Group Limited T/A Mercy Radiology

Reporting Period: Year to 7 April 2012




activity:

None Sdasdsa adasd

Health Practitioners Notice SR2006/90

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[email protected]

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Organisation Name: Mercy Hospital Dunedin Limited

Reporting Period: 6 July 2012 to 6 July 2013




activity:

Mercy Hospital Surgical Audit activity has been in place for several years. In 2012 we reformatted the process due to:

• continued poor compliance by Credentialed Specialists in providing information, and • difficulties with the audit provider’s provision of information.

Mercy Hospital staff now manage the surgical audit programme by:

• sending out individual surgeon’s data every month; • collecting and collating responses; • disseminating and discussing audit data via Mercy Hospital’s Medical Advisory Committee; • putting action plans in place where required.

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Since the inception of this process, compliance with surgical audit has improved, such that in the six months prior to April 2013 all credentialed specialists had contributed to audit on at least one occasion. At June 2013, 40 of 46 credentialed specialists supplied audit data for the month.

• Patient issue with pressure area post surgery. Related to positioning of equipment. Reviewing pressure area equipment in theatre. • Staff management issue where a performance conversation was held prior to surgery which led to distracted staff and premature switch off of suction change process in terms of staff management.

• Monitoring haematomas has begun as a result of audit data highlighting an increasing number of haematomas, some of which required intervention in the post-operative period.

Mercy Hospital

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[email protected]

• Pressure areas are monitored via. internal incident management process. • Haematoma development will be monitored via. Surgical Audit. • Staff management processes via team meetings, incident forms, patient complaints

• Where the hospital has actions identified, these are followed up by the Director of Clinical Services to ensure compliance.

• Incident Management Programme • Complaints Management Programme

Feedback from Surgical Audit is disseminated:

• via a quarterly meeting with Credentialed Specialists; • 6 monthly report to Credentialed Specialists;

Surgical Audit process identifies areas for improvement. Now that this process is managed internally, the organisation is also able to identify what specific actions the organisation may need to undertake. Inclusion of the organisation in Surgical Audit feedback ensures greater adherence with actioning issues.

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Organisation Name: Hutt Valley District Health Board

Reporting Period: 12 months to June 2013


a) List any problems or issues that have been identified in the course of the activity: b) List what actions have been taken, as a result of the activity, to resolve the identified

problems/issues:

• Process issues leading to increased waiting times for patients • Clinical decision making algorithms • Communication with patients and families • Educational opportunities • Need for updated guidelines and policies

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• Audit of treatment times • Work on creation of sub-‐regional waiting list • Changes in process of reporting to improve timeliness • Targeted lectures on subjects identified • In service mentoring • Improved patient communication • Work and improvement of protocols and policies hospital wide • Ongoing review of national and international guidelines and adoption of appropriate versions

for local use

• Clinical Audit Activity – Unit based • Mortality & Morbidity Meetings

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c) List what recommendations have been (or are to be) made as a result of the activity: d) Describe how implementation of these recommendations will be monitored: e) Describe how any improvements to the practice or competence of your organisation, or

any of your organisation’s agents or employees, are to be managed: f) Summarise the benefits to the health and disability consumers resulting from the activities

described in this report:

• Improved education programmes for staff • Better and timely communication with relatives regarding treatment and discharge • Education on triage • Pamphlets and video resources made available for patients • Ensuring all department guidelines and policies are updated and made available on the

intranet • Ongoing monitoring of outpatient clinics, new referrals and waiting times

• Regular feedback and discussion at handover meetings • Teaching sessions • Hospital management of risk escalation • Credentialing of departments ongoing • Any issues that are not able to be resolved at a departmental forum will be escalated to the

appropriate committee or manager through the HOD • Alterations, improvements in practice will be monitored and reviewed • Ongoing feedback from staff on new guidelines and policies to review and update • New staff orientation to hospital wide guidelines and policies

• Ongoing monitoring and discussion with directorates and senior management teams • Recommendations and actions to be reviewed at departmental meetings • Ongoing departmental audits to address potential issues and to implement protocols • CHOD responsible for follow through of reports on progressing major clinical or system issues • Ongoing peer review • Waiting list monitoring

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[email protected]

• Improved treatment times and improved outcomes for patients • Improvement in safety and quality for patients • Satisfaction for staff in knowing that they are part of an organisation participating in up to

date quality practices • Improved discharge planning with better clarity of process • Improved knowledge of health providers • Improved communication between services • Monitored and improved regional and sub regional processes

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Organisation Name: Hutt Valley District Health Board

Reporting Period: 12 months to July 2012


a) List any problems or issues that have been identified in the course of the activity: b) List what actions have been taken, as a result of the activity, to resolve the identified

problems/issues:

• Waiting times for patients • Communication between clinicians and other staff groups • Communication with patients and families • Educational opportunities • Need for updated guidelines and policies

Sdasdsa adasd

• Audit of treatment times • Audit of documentation • External reviews • Changes in process of reporting to improve timeliness • Targeted education on subjects identified • Improved patient communication • Work and improvement of protocols and policies hospital wide • Ongoing review of national and international guidelines and adoption of appropriate versions

for local use. Also discussions on regional and sub regional level held.

• Clinical Audit Activity – Unit based • Mortality & Morbidity Meetings

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c) List what recommendations have been (or are to be) made as a result of the activity: d) Describe how implementation of these recommendations will be monitored: e) Describe how any improvements to the practice or competence of your organisation, or

any of your organisation’s agents or employees, are to be managed: f) Summarise the benefits to the health and disability consumers resulting from the activities

described in this report:

• Improved education programmes for staff • Better and timely communication with relatives regarding treatment and discharge • Education on appropriate and timely documentation • Ongoing review of individual and teams clinical practice • Ensuring department guidelines and policies are to update and made available on the intranet

• Regular feedback and discussion at handover meetings • Teaching sessions • Alterations, improvements in practice will be monitored and reviewed • Ongoing feedback from staff on new guidelines and policies to review and update • New staff orientation to hospital wide guidelines and policies

• Ongoing monitoring and discussion with directorates and senior management teams • Recommendation and actions to be reviewed at future team meetings with Chairperson/HOD

responsible for following through • Ongoing department audit to address potential issues and to implement protocols • CHOD responsible for follow through of reports on progressing major clinical or system issues • Ongoing peer review and review at morbidity and mortality meetings

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[email protected]

• Improved treatment times and improved outcomes for patients • Improvement in patient safety and staff satisfaction • Improved discharge planning • Improved knowledge of health providers • Improved communication between services • Monitored and improved regional and sub regional processes

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Organisation Name: Royal Australasian College of Surgeons Reporting Period: 15 April 2011-14 April 2012






activity:

During preparations for the implementation of the Standards Assessment Process, figures showed that a significant number of NBCA participants are not currently meeting the threshold for Key Performance Indicator (KPI) 4: Percentage of in situ cases undergoing breast conserving surgery without axillary surgery.

Feedback from contributors and discussion at the NBCA Steering Committee level has brought into question whether KPI 4 is still an appropriate measure of quality surgical performance given the uptake of sentinel node biopsy over recent years. Large ductal carcinoma in situ (DCIS) tumours, for example, may warrant a sentinel node biopsy if invasion is suspected. A review of this KPI is currently underway. If the KPI is updated, performance on this KPI will be reassessed to determine if the data still shows a problem with surgical performance in this area.

Breast Surgeons of Australia and New Zealand Inc. (BreastSurgANZ) intends to officially implement the NBCA Standards Assessment Process (identifying and managing outliers) in 2012. All Full members of BreastSurgANZ will be required to submit all cases for the year. Their performance will then be assessed against KPI 1, 2, 3 and 5. KPI 4 is currently under reassessment. A sixth KPI is also in development, relating to referral to a medical oncologist for chemotherapy.

Current benchmarks: KPI 1: Percentage of invasive cases undergoing breast conserving surgery referred for radiotherapy (threshold = 85%) KPI 2: Percentage of oestrogen positive invasive cases referred for hormonal therapy treatment (threshold = 85%) KPI 3: Percentage of invasive cases undergoing axillary surgery (threshold = 90%) KPI 5: Percentage of high risk invasive cases undergoing mastectomy referred for radiotherapy (threshold = 85%)

National Breast Cancer Audit (NBCA)

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[email protected]

The online NBCA system allows surgeons to monitor their own performance against set KPIs and against aggregated peer results in four pre-determined areas of interest. These reports are updated in real-time and can be accessed whenever necessary, allowing surgeons to monitor improvements. Feedback was sought from participants in late 2011/early 2012 on this system, including the usefulness of online reporting for performance monitoring. The response was mostly positive with 83% of respondents satisfied with the current reporting suite and 97% satisfied with the completeness alerts. A number of respondents provided suggestions on how to improve the current system and the NBCA is seeking a quote on updates based on these suggestions to ensure the system remains a relevant and useful tool for self-audit.

Starting in 2012, BreastSurgANZ intend to implement an annual assessment for all Full members of the society as part of the Standards Assessment Process. Members who fall short of the threshold for any KPI will be reported to the NBCA Steering Committee, a subcommittee of BreastSurgANZ Executive Council. The cases of the member in question will be examined to determine if there are adequate reasons for divergence from the KPI (e.g patient refusal or mitigating factors such as age or co-morbidity).

Participating surgeons self-manage and monitor improvements. In 2012, BreastSurgANZ intends to implement the Standards Assessment Process, which involves a more active role for the audit in management and monitoring. It will be the responsibility of the Steering Committee to document the formal process for addressing outliers as part of this implementation. The process may include writing to the surgeon in question, giving a period of time to demonstrate improvement, which is then checked and reassessed at that time. It may also include a representative for that region (e.g. New Zealand) contacting the surgeon and initiating discussion and improvement. Surgical performance will be monitored through further annual assessments. Improvement in performance must occur for membership to be retained.

Participation in the National Breast Cancer Audit promotes the awareness of best practice guidelines for surgical treatment of early breast cancer and ductal carcinoma in situ and encourages quality surgical treatment for all patients. Key Performance Indicators are based on guidelines of best practice. The NBCA Standards Assessment Process will provide assurance for health consumers that Full members of BreastSurgANZ are delivering quality surgical care according to best practice guidelines. Full members must participate and must achieve a target threshold for performance against quality indicators based on guidelines for clinical management of breast cancer.

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Organisation Name: Royal Australasian College of Surgeons Reporting Period: 15 April 2012–14 April 2013



The Standards Assessment Process (outliers process) is still in development. Research utilising NBCA collected data has shown that:

1. In New Zealand, a significant number of high risk patients were found not receiving post mastectomy radiotherapy, as well as a lack of endocrine treatment in some patients with hormone receptor positive tumours.

2. In both Australia and New Zealand, node-negative patients with tumours bigger than 1 cm and patients over 70 years of age show a lower proportion of adherence to guidelines from Cancer Australia for the use of trastuzamab.

3. Comparing treatment in Australia and New Zealand with the corresponding Van Nuys Prognostic Index treatment algorithm indicated that some patients at low risk of recurrence following breast conserving surgery (BCS) may have been over treated by the addition of post-operative radiotherapy. In addition, patients at intermediate risk of recurrence following BCS who did not receive radiotherapy, and patients at high risk of recurrence following BCS who did not undergo mastectomy may have been under-treated.

Australian-specific data was also analysed as part of a collaboration with Cancer Australia. For your information, this analysis showed:

4. lower survival rates for breast cancer in women under 40 and those 70 and older 5. a higher breast cancer mortality in patients treated in inner regional compared with major city

centres and in those treated by surgeons with lower annual case-loads 6. higher mastectomy rates for residents of remote areas, women treated by surgeons with low

annual case-loads and patients with large tumours. 7. Further investigation was conducted into the risk factors for poor outcomes in patients residing

in remote areas of Australia. Results indicated that patients from more remote areas were more likely to be of lower socio-economic status and treated at inner regional and remote rather than major city centres. Patients from more remote areas were less likely than those from major cities to be treated by breast conserving surgery, as opposed to mastectomy, and less likely to have adjuvant radiotherapy when having breast conserving surgery. They had a higher rate of adjuvant chemotherapy.

National Breast Cancer Audit (NBCA)

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activity:


The results of the investigations mentioned in section A were published in peer-reviewed journals and were promoted to surgeons and consumers through the College website, as well as various reports and presentations, as outlined below:

1. Ooi, C. Campbell, I. Kollias, J. de Silva, P. National Breast Cancer Audit: overview of invasive breast cancer in New Zealand. New Zealand Medical Journal. 2012 Aug 10; 125 (1359). The findings were also outlined in a report to BreastScreen Aotearoa.

2. Whitfield, R. Kollias, J. De Silva, P. Zorbas, H. Maddern, G. The use of Trastuzumab in Australia and New Zealand - results from the National Breast Cancer Audit. ANZ Journal of Surgery, 2012 Apr;82(4):234-9. Results were also presented to surgeons at the 2010 Annual Scientific Congress run by the College.

3. Whitfield, R. Kollias, J. De Silva, P. Turner, J. Maddern, G. Management of ductal carcinoma in situ according to Van Nuys Prognostic Index in Australia and New Zealand. ANZ Journal of Surgery, 2012 Jul/Aug; 82(7-8):518-23. Results were also presented to surgeons at the 2010 Annual Scientific Congress run by the College.

4. Roder, D. De Silva, P. Zorbas, H. Kollias, J. Malycha, P. Pyke, C. Campbell, I. Age effects on survival from early breast cancer in clinical settings in Australia. ANZ Journal of Surgery, 2012 Jul/Aug; 82(7-8):524-8. The findings were also reported to Cancer Australia in 2010.

5. Roder, D. De Silva, P. Zorbas, H. Kollias, J. Malycha, P. Pyke, C. Campbell, I. Survival from breast cancer: an analysis of Australian data by surgeon case load, treatment centre location, and health insurance status. Australian Health Review. 2012 Aug;36(3):342-8. The findings were also reported to Cancer Australia in 2010.

6. Roder, D. Taylor, C. Zorbas, H. Webster, F. Kollias, J. Pyke, C. Campbell, I. Factors predictive of treatment by Australian breast surgeons of invasive female breast cancer by mastectomy rather than breast conserving surgery. Asian Pacific Journal of Cancer Prevention, 2013;14(1):539-45.

7. Roder, D. Zorbas, H. Kollias, J. Pyke, C. Walters, D. Campbell, I. Taylor, C. Webster, F. Risk factors for poorer breast cancer outcomes in residents of remote areas of Australia. Asian Pacific Journal of Cancer Prevention, 2013;14(1):547-52.

Further investigation is recommended for the issues mentioned in section A.

Continued data collection on these issues and a review of data at a later date to determine any changes.

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[email protected]

Breast Surgeons of Australia and New Zealand, Inc. (BreastSurgANZ) will monitor the issue through continued research and may take further action if warranted.

NBCA research is promoted to surgeons through presentations at scientific conferences and through the College website. BreastSurgANZ members will also be informed of research through the society’s newsletter. Surgeons can reflect on their own practice and adjust treatment recommendations as necessary to ensure patients are receiving best practice treatment.

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Organisation Name: The Ascot Hospital and Clinics (Trading as MercyAscot)

Reporting Period: 08/05/2011 – 07/05/2012



b) List what actions have been taken, as a result of the activity, to resolve the identified problems/issues:

The CAB and specific specialties review detailed audit material at each meeting. Some actual or potential issues related to care provided by specific surgeons/anaesthetists have been discussed and followed up as noted in minutes of meetings. The MercyAscot Quality & Risk Management Group also monitor incidents including sentinel events. Audit material reviewed includes:

• Morbidity & Mortality Reports and Post Discharge Reports from each individual Specialist (includes Infections, DVT, PE, Haemorrhage, Unplanned admission to ICU/HDU/CCU, Return to Operating Theatres, Anaesthetic Event, Unplanned external transfer, Readmission to MercyAscot, Readmission to other facility/Hospital, Deaths, Other event that falls outside of the expected plan of care).

• All unplanned deaths, sentinel events • National Joint Register

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Specific issues have been reviewed by the CAB or other Specialty meetings at each meeting and followed-up with the individual surgeon/anaesthetist by either the Medical Advisor or the Chair of the specific Speciality group and ongoing monitoring processes have been put in place as noted in minutes of meetings. Some issues highlighted are:

• Complication rates of Gastrointestinal surgery • Complication rates of a Cardio-thoracic surgery • Issues with availability of appropriate skilled specialists for complex cases • Issues with user error within the Safer Sleep system • Review of timeframe for validity of consent • Antibiotic Audit – Use of Ceftriaxone for surgical prophylaxis • Suggested issue of complacency with Time Out processes • Specific Sentinel events issues: reviewed MercyAscot report, Surgeon/anaesthetists reports,

outcome and changes to practice noted in CAB minutes and the Quality & Risk Management group minutes

The MercyAscot Clinical Advisory Board (CAB) meets two monthly. The members of the CAB include MercyAscot Medical Advisor, the Chief Operating Officer, Clinical Services Managers of Operating Rooms and Inpatient Services as well Credentialed Specialists from specific specialities. The chair is the Chief of Surgery. Other Specialties meet during the year; Anaesthetic Advisory Group: 2 monthly, other groups meet quarterly; Orthopaedic, Cardiac, General Surgery, and Endoscopy.

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c) List what recommendations have been (or are to be) made as a result of the activity:




Please send to: Population Health, Ministry of Health, PO Box 5013, Wellington, [email protected]

The recommendations following review of specific issues highlighted have included: • Audit of all Gastrointestinal surgery • Ongoing monitoring of individual specialists • Implementation of a review of medical cover by an external consultant in progress • Updated to Version 6 Safer Sleep software in progress, agreed to implement use of barcoding • Consent policy reviewed to allow three month validity of consent forms • New policy developed, ceftriaxone withdrawn from use, recommended regimes information made

available placed in scrub bays for easy referral by specialists • Time Out processes to continue to be implemented and issues reported via incident process for

followup by Medical Advisor. • Specific issues addressed in person with other individual surgeons/anaesthetists/radiologists

Clinical issues/problems are monitored by the meetings of the CAB and specific specialties through the reporting process as stated above.

MercyAscot Medical Advisor, Chief Operating Officer and all Clinical Services Managers are responsible to ensure recommendations are followed up and implemented. Incident management system robust in investigating and following up other issues, including sentinel events.

MercyAscot sets high standards through its vision and values (recently reviewed early 2012) and policies and procedures. Vision: MercyAscot will be New Zealand’s leading provider of health services, always delivered with excellence and value. Values: Adaptability, Accountability, Customer Service and Communication.

Medical Specialists and MercyAscot employees are encouraged to highlight issues/problems through discussion with department managers, documenting the issue on the Morbidity & Mortality form or an Incident Form. The CAB, MercyAscot Executive Team and Quality & Risk Management group review all reports and are charged with following up any issues involving Medical specialists or employees or implementing changes to systems, policies, procedures and processes as necessary.

Newsletters are sent to specialists as a way of communicating changes in processes throughout the year. In 2012 a Pharmacy Bulletin has been introduced and has been received favourable by specialists. A review of the MercyAscot Bylaws has commenced in 2012.

Involvement in Certification and Accreditation audits by external Delegated Authority – completed April 2012 awaiting response from MoH.

Care of consumers will always meet best practice guidelines.

MercyAscot has robust Quality Assurance processes that enables any clinical issues/problems to be reviewed and investigated and improvements to practices implemented.

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Organisation Name: Nelson-Marlborough District Health Board

Reporting Period: 1 Jan 2013 to 30 November 2013




activity:

Many of the issues that have arisen in the reports provided by the specialities relate to system and process issues related to clinical care. The need to improve the dissemination of new information to all relevant clinical staff. Need to develop ways of sharing learning from stories related to health care to engage clinicians but preserving patient confidentiality. Events that cross organisational boundaries e.g. to general practice hard to review and hard to share learning. Issues which impact on patient care and are outside the relevant services area of responsibility are referred through the medical and management leadership line. Dadas adasd

Improvements in the dissemination of information amongst clinicians in both secondary and primary care through the clinical care pathways site Changes to systems and processes to incorporate new knowledge/information or improve the outcome for patients both within the service and system wide The refreshing of the internal Clinical Guidelines site has enabled consensus on treatment options for certain disease processes.

Extreme caution needed where hybrid digital and paper systems mix. With digital information search engines may find documents which were not intended, house keeping needed.

Case Review and Clinical Audit have been the key activities conducted under QAA this year. Case Review and clinical audit has been undertaken in the following specialties during the reporting period: Medicine/cardiology, Emergency Department, Paediatrics, Anaesthesia, Maternal & Perinatal Review

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c) Continued







[email protected]

Recommendations are monitored within the individual activities by designated clinicians who liaise with senior clinicians and management as required. In some cases changes in clinical practice can be monitored by our clinical dashboard tools.

The improvements are managed through communication by the Chair of each activity reporting to the medical head of department who in turn reports to the Leadership team of the service which includes clinical and non clinical staff. Every effort is made to close feedback loops with PDSA cycles.

Ongoing learning and competence of clinical staff as real events and patient stories modify future care. Improvements and practice in procedure. Implementation of recommendations designed to improve systems and reduce likelihood of recurrence of systemic errors with the view to improving patient outcomes and experience.

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Organisation Name: Nelson-Marlborough District Health Board

Reporting Period: 2011 - 2012




activity:

No specific problems or issues were identified in the information available Dadas adasd

System and process issues related to links between departments and the availability of timely information on which clinicians could base decisions.

Development of clinical based information systems are seen as key to resolving many issues. Clinicians clear and managers agree that they need to be appropriately represented on user groups developing new clinical electronic systems.

Case Review and Clinical Audit have been the key activities conducted under QAA during this period. Case Review and clinical audit has been undertaken in the following specialties who have reported activities during the reporting period: Medicine/cardiology, Paediatrics, Maternal & Perinatal Review

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c) Continued







[email protected]

Recommendations are monitored within the individual activities by designated clinicians who liaise with senior clinicians and management as required.

The improvements are managed through communication by the Chair of each activity reporting to the head of department who in turn reports to the Leadership team of the service which includes clinical and non clinical staff.

Improvements in systems, practice and procedure to improve patient safety. Improvement in clinical electronic systems enable more timely decision making.

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Organisation Name: New Zealand Orthopaedic Association (NZOA)

Reporting Period: March 2012 – March 2013





c) List what recommendations have been (or are to be) made as a result of

the activity:

Eighteen out of 24 planned Practice visits occurred in 2012/2013 year. When a planned visit for some reason (e.g. clinical emergency, family member death) cannot go ahead, the PvP team needs to reschedule quickly. This is an administrative function that the NZOA is working on. Colleague peer reviews have not been as extensive as the PvP Committee think appropriate to give a wide view of a visitee. This has been corrected for 2013/2014 by stating the actual range of colleagues required.

Funding The question of who should fund the practice visits was considered. It was decided that this should be through the Association’s membership fees rather than charging individual members. Membership fees rose 2% to cover this cost. This means that visitors are reimbursed for their costs and it takes away any unfairness if for example a visitor from Auckland is required to conduct a practice visit in Invercargill and vice versa. It also contributes to the concept of a professional team of orthopaedic surgeons in New Zealand. Subspecialty visits The programme of visits for the year endeavoured to match surgeons working in specific subspecialties in order for each other to be able to learn and or take advantage of any expertise visitors and visitee could offer each other. International Medical Graduates The PvP is to be used to assist those IMGs who practise in the regions and may not have strong colleague support. The visitors chosen for the IMG visit are ones who will be able to develop a mentoring and reference role for the IMG and usually have links to larger centres. This means that if an IMG wants advice they will have a colleague in a larger centre they can go to seek advice from.

NZOA Practice Visit Programme (PvP)

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Recommendations 1. The Colleague questionnaire – This is to have the number and occupation of the

colleagues detailed so that a full 360 view can be completed. Responses will be expected from a minimum of 8 people with whom the surgeon works closely.

2. Patient Questionnaire – There is to be an addition to show if the patient is either a public or a private patient.

3. Checking to ensure review of 20 patient questionnaires is statistically valid. 4. On the day of visit the visitee is to make sure that the visitor sees both public and

private sites of work. 5. Practice Profile form – this is to be clarified to show details of other aspects which

should be considered. The aim of these additions is to be able to give the visitor an opportunity to speak with the member about any aspects of work that are troubling, or inhibiting the member from conducting their practice.

6. The member should also add in their CPD compliance printout. 7. The grading needs to be changed on the Practice Visit Report to ensure better

feedback is given. Grades: A Satisfactory visit – will include both positive and negative feedback related to

improving “best practice” B Moderate deficiencies (change to some areas requiring reflection and change)

– report to include both positive and negatives. Suggest changes to be made and require confirmation from the Visitee of those changes to the Practice Visit Committee within 12 months

C Severe deficiencies ( change to significant deficiencies ) – insist on changes to be made and a further visit must be made at 12 months to check

D Outrageous deficiencies (change to severe deficiencies) – which must be corrected immediately and a revisit within one week. If the deficiencies are still at the extreme then legal advice over further action will be sought being cognisant of the Medial Councils requirement to report any inappropriate behaviour.

8. The visitor report needs to have more in depth analysis so suggesting that at least

two recommendations for change or quality improvement need to be detailed in the Practice Review Report.

d) Describe how implementation of these recommendations will be monitored: CEO will ensure changes to visitee and visitor packs are made. CEO to employ statistician to check for validity PvP Committee to audit 5% of practice visits. Practice visit manager to provide statistical analysis to the Practice Visit Committee of all visit reports to appropriate colleague reports and 20 patient reports.

e) Summarise the benefits to the health and disability consumers resulting from

the activities described in this report:

The Practice Visit programme gives good peer feedback, helps to spread ‘best practice’ ideas and gives greater consistency between surgeons. As it is conducted in both private and public hospitals it also assists with consistency of practise between these two sectors. The focus for the coming few years is to ensure that not only technical ability is of a high standard but to check more carefully each surgeon’s work/lifestyle balance. The aim is to be able to encourage dialogue where the surgeon being visited may speak freely of any concerns he/she has and what remedies may be available.

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Signed Mr R Maxwell FRACS Chair of Practice Visit Programme Committee New Zealand Orthopaedic Association



[email protected]

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Organisation Name: Braemar Hospital

Reporting Period: March 2013 – March 2014




activity:

No specific problems identified. All case reviews conducted under open disclosure. Sdasdsa adasd

N/A

Development of targeted educational updates following review of new and existing protocols.

1. Clinical audits 2. Case Reviews 3. Protocol reviews

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[email protected]

The Clinical Committee will monitor the implementation of new and revised protocols via case reviews.

Targeted education; seminars and workshops. Competency assessments.

Increase in range of clinical procedures and services provided. Provision of contemporary best practice.

PQAA Reports F-N 85

annual report on protected quality assurance activities … · annual report on protected quality...

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