101005_DoH Sentinel Events 0910 Web

Building foundations to support patient safety

Sentinel event program

annual report 2009–10

Building foundations to support patient safety

Sentinel event program annual report

2009–10

Sentinel event program annual report 2009–10

If you would like to receive this publication in an accessible format, please phone 03 9096 7201

using the National Relay Service 13 3677 if required, or email [email protected]

This document is also available in PDF format on the internet at www.health.vic.gov.au/clinrisk

Published by Quality, Safety and Patient Experience Branch, Victorian Government

Department of Health, Melbourne, Victoria

© Copyright, State of Victoria, Department of Health, 2010

This publication is copyright, no part may be reproduced by any process except

in accordance with the provisions of the Copyright Act 1968.

Authorised by the State Government of Victoria, 50 Lonsdale Street, Melbourne.

Printed on sustainable paper by On-Demand, 323 Williamstown Road, Port Melbourne 3207.

December 2010 (1012012)

Acknowledgements

The Department of Health thanks Victoria’s public health services, hospitals and participating private

facilities for their ongoing contribution to the sentinel event program.

The department wish to acknowledge the consultative councils and expert advisory groups that

work closely with the department to provide recommendations to health services on system issues.

The department also acknowledges the patients and their carers who have experienced adverse

patient outcomes.

Foreword

Delivering a high-quality health system in Victoria is a major priority for the government.

To ensure the system is safe, it is important to review and examine clinical incidents where

things don’t go as planned, and in particular those events deemed to be sentinel.

Investigation of clinical incidents identifi es where the breakdowns in the health system occur,

and allows health services to identify these risks and develop ways to reduce or remove the risk

where possible.

The Department of Health works together with health services, clinicians and consumers to promote

a culture of reporting when things go wrong. It is only when we are aware of something not working

that we can act to change this.

This is the eighth annual public report of the sentinel event program and it presents information

on the 57 sentinel events reported within Victorian health services during 2009–10.

The focus of the program remains on lessons learnt in order to prevent similar sentinel events in the

future, and will evolve in 2010–11 to incorporate a broader report on patient safety and all reported

clinical incidents within our health system.

Hon David Davis MLC

Minister for Health


Contents

Summary 1

Sentinel event data 3

Themes in 2009–10 13

Working together to enhance patient safety 15

Consumer participation 17

Clinical effectiveness 21

Effective workforce 25

Risk management 27

Glossary 33

Appendices 33

Appendix 1: Incident severity rating (ISR) 33

Appendix 2: Incident management process 36

Appendix 3: Source data 37

Clinical governance compliance checklist 41


1

The Department of Health (the department) is responsible for the provision of health services within

Victoria and is committed to improving the quality of these services. Review of incidents and near

miss events plays an important part in this, particularly those events deemed to result in harm

or death. In-depth investigation of these events identifi es breakdowns in the often complex health

system and allows health services to identify risk and develop ways to reduce or eliminate the risk

of reoccurrence.

In 2009–10 the department was notifi ed of 65 potential sentinel events. Eight events were

withdrawn either because they resulted from known complications of the patient’s condition

or required procedure, or because no system or process issues could be identifi ed. Therefore

57 actual sentinel events are included and analysed in this report.

In February 2010 the department began a phased 12-month rollout of the Victorian health incident

management system (VHIMS). This standardised data collection for clinical incidents provides the

department with a mechanism to analyse not only rare and potentially fatal events that are sentinel

in nature, but also the precursor for identifying system issues for less serious events.

This annual report will evolve to include all reported clinical incidents and patient safety issues and

initiatives as we progress the implementation of the VHIMS.

Snapshot of the Victorian health system

The Victorian health system is a complex and busy environment.

In the 2009–10 reporting period, the Victorian Government dedicated an estimated

$12,335 million1 to health care, employed around 74,4132 EFT (equivalent full-time) staff,

managed approximately 1.5 million1 admissions to public health facilities, and performed

more than 273,7293 surgical procedures.

1 Department of Health 2010, Your hospitals: a report on Victoria’s public hospitals July 2009 to June 2010, State Government

of Victoria, Melbourne.

2 Department of Health 2010 Workforce minimum dataset (excludes denominational and Mildura Hospital), State Government

of Victoria, Melbourne.

3 Department of Health, 2010 Victorian admitted episodes dataset, State Government of Victoria, Melbourne.

Summary

2


3

In the 2009–10 fi nancial period, 57 sentinel events were reported by Victorian public health facilities.

This number represents a decrease compared to previous years. While fewer events were reported,

overall trends remain consistent and the number represents a low incidence rate considering

Victorian public health facilities throughput and activity for the 2009–10 period. Figure 1 highlights

the reported sentinel event classifi cations expressed as a percentage.

The total number of events reported to the sentinel event program (n=57) is the lowest since the

program began in 2002–03. It is diffi cult to determine the exact reasoning as to why this fi gure

continues to decline. Generally where events are reported voluntarily, it is assumed that the number

of events reported would rise over time with improved identifi cation, reporting and confi dence in the

system. There has been considerable investment by Victoria in quality and safety throughout the last

decade by Government and by individual health services. This decline in the total number of reported

events may be refl ective of the Victorian health system developing as a mature learning culture.

Figure 1: Reported events by classifi cation as a percentage of total (n=57)

2009–10

The development of a patient-safety culture is critical to a successful clinical risk management

program. To successfully achieve quality patient care this requires individual health services, and the

department, to become learning organisations. In such organisations, staff are genuinely encouraged

to raise quality and safety issues with anyone in authority, and these issues are responded to quickly.

Responsibility and ownership for patient safety cannot be delegated. All stakeholders including

frontline staff and senior executives are actively involved in analysing adverse events and determining

action to minimise reoccurrence of similar events in the future.

Sentinel event data

4


A total of nine sentinel event classifi cations are reported in Victoria, eight are national classifi cations

and one is unique to Victoria. Figure 2 illustrates the eight national sentinel event classifi cations

reported since the Victorian program began in 2002.

Trend analysis on historical sentinel event data spanning 2002–2009 has not identifi ed any signifi cant

emerging trends as illustrated in Figure 2 other than a spike in procedures involving the wrong

patient or body part in 2007–08. In 2009 the Australian Commission on Safety and Quality in Health

Care (the commission) amended the defi nition of this sentinel event to specify only events ‘resulting

in death or major permanent loss of function’. Since the revised defi nition, Victoria has not received

any reports of events under this classifi cation.

Figure 2: Reported events by classifi cation 2002–10

* Excludes ‘other catastrophic’ classifi cation which is specifi c to Victoria

* Source data is available in appendix three

The ninth classifi cation, ‘other catastrophic event’, is unique to Victoria. Events reported in this

classifi cation include signifi cant near-miss events and cases where health services have identifi ed

an unexpected patient outcome unrelated to the patient’s condition that warrants review of causation

and potential contributing factors.

5

The 2002–10 data relating to the ‘other catastrophic event’ classifi cation is illustrated in two

distinct groups: complications of management in Figure 3a and other reported events in Figure 3b.

This separation best illustrates the emergent trends over eight years.

It is pleasing to see both groups demonstrate a predominantly downward trend.

The rebound spike in 2008–09 (n=21) of Figure 3b coincides with the commission’s defi nition

change for procedures on the wrong patient or body part. All procedures reported under the

previous defi nition that had not resulted in death or permanent loss, were moved to the ‘other

catastrophic’ classifi cation.

Figure 3a: Reported events classifi ed as ‘other catastrophic’ –

complication of management 2002–10

* Source data is available in appendix 3

6


Figure 3b: Reported events classifi ed as ‘other catastrophic events’ –

other reported events 2002–10

* Source data is available in appendix 3

Victoria continually seeks to proactively manage clinical incidents and to understand the valuable

lessons that can be learnt from both actual incidents and near miss events.

A key component of VHIMS is the methodology to determine the incident severity rating (ISR).

This methodology provides a standardised quantifi er of harm, or degree of impact, for actual

patient outcome as a result of an incident, as opposed to the popular risk-rating methodology

that is more subjective.

ISR is a process of classifying incidents and provides a standardised approach to the level

of investigation and expected organisational response. The severity is divided into four levels

ranging from one being the highest level of harm, through to four (near miss). ISR is determined

by an algorithm that incorporates three factors: degree of impact, level of care and treatment

required as a result of the incident. Defi nitions of the individual ISR factors are detailed in Appendix 1.

7

We have used the ISR to analyse the 2009–10 sentinel event data as outlined in Figure 4. Not

surprisingly, ISR 1 events were the highest category for the sentinel event classifi cations. Notably,

the classifi cation ‘other catastrophic event’ was the most frequently ranked classifi cation in this

grouping together with suicide. If we were to concentrate only on the eight national sentinel event

classifi cations, this picture would be quite different.

Considering the maturity of the Victorian sentinel event program and the impact VHIMS will have

in monitoring multi-severity level incidents, the department’s sentinel event program will focus on

high degree of impact incidents, that is ISR 1 incidents in the future. Victoria will continue to report

sentinel event data nationally as required.

Figure 4: Reported events by severity rating and classifi cation (n=57) 2009–10

ISR 1: Severe (including death) ISR 2: Moderate ISR 3: Mild ISR 4: No harm (includes near miss)

8


Figure 5: Reported events by degree of impact (n=57) 2009–10

9

Figure 6: Reported events by level of care (n=57) 2009–10

*Not applicable due to death of patient

10


Figure 7: Reported events by treatment required (n=57) 2009–10

* Not applicable due to death of patient

Not all ISR 1 incidents will be the equivalent of a sentinel event. If, on initial review by the health

service, the incident outcome was directly related to system or process issues, a root cause analysis

(RCA) should be undertaken to determine causation and indentify contributing factors.

On the other hand, if the initial review identifi es that major contributing factors were related to the

patient’s illness or management phase of their chronic illness, then an RCA is not warranted. These

cases may be reviewed using an in-depth case review to determine if any system issues contributed

to the patient’s outcome.

All incidents, irrespective of their ISR rating, should be reviewed in order to identify opportunities

for system improvement. The incident management process that underpins VHIMS is outlined

in Appendix 2. This process map illustrates how a single incident reported by frontline staff can

result in service improvement.

The department expects all public-funded health services to report clinical incidents through

VHIMS. This expectation will be supported by the implementation of the Victorian health incident

management policy in 2011.

11

Open disclosure

Open disclosure is the process of open communication with the patient or their carer following

an adverse event.

It’s important that patients and their carers are informed when an unexpected outcome

is identifi ed. In accordance with the Victorian Charter of Human Rights and Responsibilities

Act 2006 (Vic), public entities (including public health services) have a legal obligation to discuss

adverse events with the affected patient or their carer.

In 2002 the former Australian Council for Safety and Quality in Health Care (now the commission)

developed the National Standard on Open Disclosure. This was endorsed at the Australian Health

Ministers Conference in July 2003 and reviewed in 2008.

The standard outlines a clear and consistent process which includes:

• an apology or expression of regret

• a factual explanation of what occurred, including actual and potential consequences, and

• the steps being taken to manage the event and prevent its recurrence.

Open disclosure is closely linked to the incident management process, and is incorporated into the

clinical governance policy framework. Guidelines and implementation toolkits were developed in

2008, and in 2009 the department conducted a series of workshops designed to up-skill staff and

provide some practical resources to manage the disclosure process.

An open disclosure e-learning package has been developed to build on this work and previous

toolkits. This online package can be accessed at: http://www.health.vic.gov.au/clinrisk/opendisc.htm

12


13

During 2009–10, a total of 301 contributing factors were identifi ed. An analysis of these factors

underpins the health services’ development of a risk reduction action plan to minimise similar

events reoccurring. Often events involve more than one contributing factor therefore the number

of contributing factors can be greater than the number of events.

While a range of contributing factors were identifi ed, analysis of the data shows that procedures

and guidelines, human resources/staff issues and communication were the most consistently

reported contributing factors identifi ed with sentinel events for 2009–10. This continues the

trend from previous years as outlined in Figure 8 and the fi nding is consistent with national and

international trends.4 5 6

Figure 8: Reported events by contributing factors expressed

as a percentage 2002–10

*Source data is available in appendix 3

4 World Health Organization 2008, Summary of the evidence on patient safety: implications for research World Health

Organization, Geneva.

5 Clinical Excellence Commission and NSW Department of Health 2010, Clinical Incident Management in the NSW Public

Health System 2009, Government of New South Wales, Sydney.

6 WA Department of Health 2009, WA sentinel event report 2008–09, Government of Western Australia, Perth.

Themes in 2009–10

14


Contributing factors may include many components:

• the procedures and guidelines grouping is made up of clinical guidelines, behavioural and

physical assessment, physical patient observation process, patient or site identifi cation and

coordination of care

• human resources is a collective term that represents staff allocation, training, supervision,

appraisals and staff recruitment

• communication represents communication between staff, between staff and patient or family,

and translation and cultural and linguistic diversity issues

• physical environment represents environmental distractions and security or design issues, and

• facilities management represents transportation and inter-hospital issues.

Comprehending the complexities of the Victorian healthcare system is fundamental for the

department in targeting effective analysis and improvement strategies. The activity of direct

patient care is often referred to as the ‘pointy end’ of the system. The ‘blunt end’ of the system

is represented by the broader management and organisational aspects involved in supporting

the healthcare system. It includes a wide variety of factors such as policies and guidelines, health

information systems, staffi ng patterns and environmental factors. To understand why an adverse

event occurs at the pointy end, it is necessary to examine and analyse the contributing factors

at the blunt end.7

7 Canadian Patient Safety Institute 2006, Canadian root cause analysis framework, Canadian Patient Safety Institute,

Edmonton.

15

Quality of health care is increasingly recognised as one of the most signifi cant issues facing health

systems. The department is committed to ensuring quality health care within Victorian hospitals.

A key action for building capacity to facilitate quality health care is for organisations to work in

partnership. The department supports building effective partnerships within health organisations,

across health services and with other key stakeholders at state and national levels.

Initiatives highlighting these partnerships have been included throughout this report.

Clinical governance framework

Clinical governance is defi ned as: ‘the system by which the governing body, managers, clinicians

and staff share responsibility and accountability for the quality of care, continuously improving,

minimising risks, and fostering an environment of excellence in care for consumers, patients

and residents.’8

The Victorian clinical governance policy framework (the framework) was developed in 2008

to guide health services to implement a framework or review and further develop existing

frameworks to ensure quality and safety mechanisms are monitored and reviewed.

8 Department of Health 2008 Victorian clinical governance policy framework, State Government of Victoria, Melbourne.

http://www.health.vic.gov.au/clinrisk/publications/clinical_gov_policy.htm

Working together to enhance patient safety

16


Domains of quality and safety

The framework is underpinned by the four domains of quality and safety:

• consumer participation

• clinical effectiveness

• risk management

• effective workforce.

These domains provide the structure for activities and processes to enhance the delivery

of clinical care.

This report incorporates a clinical governance compliance checklist (see appendix) linking the

domains of quality and safety with the Australian Council on Healthcare Standards (ACHS) EQuIP

4 mandatory criteria. Health services can use this checklist to ensure their strategies are congruent

with the framework and the relevant ACHS mandatory criteria. The checklist has been designed

as a tear-out section for health services looking to use the resource as a periodic compliance tool

for the framework.

17

Consumer participation should occur at many levels of the organisation, through activities such

as community consultation and consumer partnership on governance and management committees,

and within improvement initiatives or clinical risk management activities. The department expects

strategies should be in place to ensure:

• consumers are empowered to participate in their care

• there is clear, open and respectful communication between consumers at all levels

of the health system

• services respond to the diverse needs of consumers and the community with humanity

• rights and responsibilities of patients are promoted to community, consumers, carers,

clinicians and other health service staff.

Case study

An elderly patient accompanied by their son presented to an emergency department (ED). The

patient took a seat in the waiting room whilst the son proceeded to register the patient.

During patient registration the receptionist requested the patient’s name and date of birth (DOB).

The son was unable to confi rm the DOB therefore the receptionist searched the system without

confi rming the spelling of the surname. A patient with the same name and a different address was

identifi ed. The elderly patient was incorrectly registered as someone younger and with a different

medical history.

At no point was there verifi cation of the patient with their details, and discussions with the patient

and their family did not identify the error in date of birth or discrepancy of past history.

The patient presented as articulate, didn’t look unwell, observations were normal and reported that

they had overdone it recently. A category four triage classifi cation was allocated to the patient.

The patient was reviewed by the ED intern who recorded a heart rate of 100bpm, longstanding

shortness of breath, and back and shoulder pain. A diagnosis of a torn muscle was made and the

patient was discharged following discussion with the ED senior doctor.

Prior to the patients discharge a junior nurse recorded observations and noted a heart rate

of 120bpm. There was no evidence that this was discussed with any nursing or medical staff.

The patient re-presented to ED a number of hours later where it was identifi ed that the patient

was incorrectly registered on the fi rst presentation to ED. The patient was diagnosed with bilateral

pneumonia which deteriorated rapidly and required intubation.

How did the health service address the issues identifi ed?

• changed the triage/registration process so that patients are seen fi rst by the triage nurse and

then registered by the administration staff

• reinforced the verifi cation of patient details to ensure name and date of birth are matched

• introduced an ED electronic tracking system to replace a paper-based system

• reviewed the patient monitoring and documentation process

• reviewed staff skill mix and rostering, and

• reviewed the patient identifi cation policy and procedures for compliance with the commission’s

patient identifi cation initiatives. This can be assessed at: http://www.safetyandquality.gov.au/

internet/safety/publishing.nsf/Content/PriorityProgram-04_Initiatives

Consumer participation

http://www.safetyandquality.gov.au/internet/safety/publishing.nsf/Content/PriorityProgram-04_Initiatives

18


Accurate identifi cation of patients can be a challenge in complex health care systems because

a variety of circumstances may lead to incorrect patient identifi cation. Patient characteristics such

as small children who are unable to identify themselves or patients with communication diffi culties

caused by dementia, impaired cognition or language barriers can increase the risk of incorrect

patient identifi cation. Additionally patients with the same or similar names can create complexity

and confusion as the previous case study illustrated.

Good health care is best achieved through an active and positive partnership between the patient

and the health care professional. Consumers need to be encouraged to be involved as much as

possible in every decision about their health. Consumers should ask questions when unsure about

the care being provided.

A booklet 10 tips for safer health care explains how and why things can go wrong, and how

consumers can work in partnership with health care professionals. This is available at

http://www.health.gov.au/internet/safety/publishing.nsf/Content/10-tips.

Monitoring patient experience

The patients’ perception of their hospital stay is a key indicator of health care quality.

The department supports a range of initiatives that promote and support consumer involvement

in decision-making about their treatment and care, in service development and quality improvement,

and more broadly, in health policy developments.

A key mechanism for monitoring patient experience for health services is the Victorian patient

satisfaction monitor survey. Patient satisfaction may be thought of as the degree to which a patient

feels they have received quality health care. Measurement of satisfaction is an essential part of

quality assessment.9

Currently 108 health services participate in this survey. More information, including an annual

report is available at: www.health.vic.gov.au/patsat/index.htm. Health services are provided with

this collated information, benchmarked against like organisations, to enable areas of strength and

opportunities for improvement to be identifi ed.

Australian Charter of Healthcare Rights in Victoria

The new Australian Charter of Healthcare Rights in Victoria was launched in September 2009,

superseding the previous Victorian Public Hospital Patient Charter.

The aim of the Charter is to ensure high quality health care provision, which embodies the seven

health care rights. The Australian Charter of Healthcare Rights in Victoria brochure can be ordered

in English, Braille and 25 other community languages and may be accessed as an audio fi le at:

http://www.health.vic.gov.au/patientcharter/.

9 A. Chow, E. K. Mayer, A.W. Darzi, T. Athanasiou 2009, ‘Patient-reported outcome measures: the importance of patient

satisfaction in surgery’. Surgery vol.146; Iss.3, pp 435-443.

19

Doing it with us not for us: Strategic direction 2010–13

In September 2009, the Minister for Health and the Minister for Mental Health approved a new

comprehensive set of standards and indicators for health services to report against to continue

monitoring the Doing it with us not for us policy implementation. These standards and the intended

outcome of the new strategic direction is for health services to work with consumers, carers and

community members to improve health policy and planning, care and treatment, and the wellbeing

of all Victorians. Health services have fi ve new standards and associated indicators to achieve and

report on, and these are set out in the policy at: http://www.health.vic.gov.au/consumer/participate.htm

Cultural responsiveness framework

The Cultural responsiveness framework: guidelines for Victorian health services, was launched

in September 2009. It consolidates the former Health Service Cultural Diversity Plan achievements,

and aims to improve and extend health services’ capacity and performance in providing culturally

and linguistically responsive health care. A copy of the framework can be accessed at:

http://www.health.vic.gov.au/cald

20


21

Clinical effectiveness mean ensuring the right care is provided to the right patient who is informed

and involved in their care at the right time by the right clinician with the right skills in the right way.

The department requires strategies to be in place to ensure:

• clinicians are empowered to improve clinical care delivery

• clinicians actively involve consumers as partners in their care

• clinical care is evidence-based

• standards of clinical care are clearly articulated and communicated, and

• quality improvement activities are reviewed externally.

Clinical effectiveness is achieved through empowering clinicians to introduce, monitor and evaluate

evidence-based practice which involves the use of performance measures, clinical indicators and

clinical audits.

To further enhance this work an evidence-based adult general observation chart is also being

developed by the commission. The fi rst phase has been completed and consisted of a research

project which compared existing charts to fi nd the best chart for recording observations. The results

of this research may be accessed at:http://www.safetyandquality.gov.au/internet/safety/publishing.

nsf/Content/RaRtCD_EBA-GOC

Retained instrument requiring further surgical procedure

Peri-operative practitioners play a vital role in enhancing the surgical patient’s safety through

ensuring the correct surgical count. However, the retention of instruments or other material may

occur in a variety of circumstances beyond operating theatres. These include procedural areas

where invasive or diagnostic procedures take place such as wards, endoscopy, radiology and

intensive care units.

The World Health Organization (WHO) Surgical Safety Checklist was launched in 2009 and includes

a core set of safety checks for use in any operating theatre environment. It is designed to improve

safety by focussing on anaesthetic safety practice, ensuring correct site surgery, avoiding surgical

site infection and improving communication within the operating team. To fi nd out more about the

WHO surgical safety checklist visit: http://www.who.int/patientsafety/safesurgery/ss_checklist/en/

index.html

There were nine events classifi ed as ‘retained instruments or other material’ reported to the sentinel

event program in 2009–10. These incidents are distinct in that patients required re-operation or

further surgical procedure to remove the foreign body. Although this classifi cation accounted for the

greatest number of events reported in 2009–10, the degree of impact from retained instruments or

other material varied from no harm to temporary reduction in function as outlined in Figure 5.

Clinical effectiveness

http://www.safetyandquality.gov.au/internet/safety/publishing.nsf/Content/RaRtCD_EBA-GOC

http://www.who.int/patientsafety/safesurgery/ss_checklist/en/index.html

22


Case study

A patient underwent a diagnostic laparoscopy for severe abdominal pain. No cause of pain

was found and the patient was discharged home the following day. The patient re-presented to

hospital on numerous occasions with various complaints over the following months. A diagnostic

laparoscopy was performed and a disposable item was found in the pelvis.

A review of this incident identifi ed that the supplied disposable item had been reported to the

supplier as faulty prior to the event, and had been replaced by the supplier.

Although there was a process for addressing defective disposable equipment, the item was

still in use several weeks after the fault was reported to the supplier. Repeat supplies of this

disposable item proved faulty again and subsequently this item was withdrawn and the product

and supplier changed.

How did the health service address issues identifi ed:

• developed a defective equipment policy and procedure

• reinforced to staff that medical device adverse events should be reported to the Therapeutic

Goods Administration (TGA)

• implemented an improved warning system for when suspected problems occur but the

disposable equipment is still in use

• reviewed the peri-operative count sheet to include certain disposable operative equipment

in the mandated operative count, and

• reminded staff of the need for vigilance when removing disposable instrumentation from patients

during surgery.

Enhancing effective communication

Quality and safe patient care relies on effective communication because of the countless daily

interactions that occur between health care providers. Lack of effective communication may occur

between staff, across disciplines, units or hospitals, and between staff and patients or their family,

carer or advocate.

When effective communication is absent, patient care is compromised as evidenced

by communication being among the most consistently reported contributing factors

to sentinel events in Victoria for the past eight years.

Improving communication requires a systems approach to include a culture that emphasises open

communication. A range of initiatives are underway, both in Victoria and nationally to facilitate timely

and clear exchange of communication between health professionals especially around the clinical

handover process.

When surveyed about the clinical handover process by the Victorian Quality Council (VQC), Victorian

health services identifi ed ‘shift-to-shift handover’ and inter-hospital transfer as two signifi cant areas

of concern. The VQC subsequently developed standardised handover tools and a range of clinical

handover resources that may be accessed at: http://www.health.vic.gov.au/qualitycouncil/activities/

handover.htm

http://www.health.vic.gov.au/qualitycouncil/activities/handover.htm

23

A national guide for improving clinical handover practices at shift change was endorsed

by Health Ministers in April 2010. Further information on this national guide can be accessed

at: http://www.safetyandquality.gov.au/internet/safety/publishing.nsf/Content/PriorityProgram-

05#NCHIPP

The Victorian Managed Insurance Authority (VMIA) is piloting a similar communication tool with

a major Victorian tertiary health service. The Identity, Situational, Background Assessment Request

(ISBAR) is a simple, practical tool to guide staff on how they structure and exchange information.

This can be accessed at: http://www.vmia.vic.gov.au/display.asp?entityid=6556

Clinical handover has also been recommended to surgeons as an essential component of care

by the Victorian Surgical Consultative Council (VSCC). Guidelines for clinical handover were issued

by the VSCC in July 2010 and can be accessed at: http://www.health.vic.gov.au/vscc/vscc-

guidelines-_and_-practice-statements#c02

This guideline will be further enhanced by the statewide rollout of standardised documentation

for post operative orders undertaken by VSCC in partnership with VMIA. Resources and tools

can be accessed at: http://www.vmia.vic.gov.au/display.asp?entityid=6556

The Victorian TeamSTEPPS (Team Strategies and Tools to Enhance Performance and Patient Safety)

overseen by the VQC is another project that is underway to enhance effective communication.

This program is an evidence-based teamwork training system designed to improve collaboration,

communication and patient safety within health care. Information can be accessed at: http://www.

health.vic.gov.au/qualitycouncil/activities/teamstepps.htm

http://www.safetyandquality.gov.au/internet/safety/publishing.nsf/Content/PriorityProgram-05#NCHIPP

http://www.health.vic.gov.au/vscc/vscc-guidelines-_and_-practice-statements#c02

http://www.health.vic.gov.au/qualitycouncil/activities/teamstepps.htm

24


25

All staff employed within health services must have, and be supported to have, the appropriate skills

and knowledge required to fulfi l their roles and responsibilities within the organisation. Processes

should be in place to support appropriate:

• selection and recruitment of staff

• credentialling of clinical staff including annual review of practice

• maintenance of professional standards, and

• control of the safe introduction of new therapies or procedures.

Case study

The patient’s post operative recovery was stable after undergoing elective abdominal surgery.

On day two the patient experienced abdominal distension and vomiting. On day fi ve, oxygen

therapy was commenced for suspected bilateral lung collapse and fl uid boluses were given, after

which the patient appeared to improve.

On day seven the attending surgeon went on leave without handing over to the on-call surgeon.

The anaesthetist reviewed the patient and was concerned about the deteriorating patient’s

condition and a scan was performed. The junior medical offi cer conveyed the scan results

to the on-call surgeon who ordered a treatment plan. Over the next 24 hours the patient’s

condition improved temporarily.

Subsequently, the patient deteriorated over the next few days and was reviewed by the junior

medical offi cer and the anaesthetist with telephone discussion with the on-call surgeon, and

a treatment plan was put in place. Further review by the junior medical offi cer noted the patient

was stable.

The next day the patient deteriorated suddenly and following resuscitation required transfer

to a tertiary hospital.

How did the health service address issues identifi ed:

• convened a multidisciplinary group to review the surgical care, clinical pathway, processes

and resources provided to major or high risk cases and identify areas for improvement

• implemented a senior medical staff leave coverage process to include a notifi cation and patient

handover process

• educated senior medical staff on responsibilities and expectations in relation to supervising

and supporting junior medical offi cers on rotation within the hospital

• updated the intern orientation manual to include general guidelines for junior medical offi cers

working on the general wards

• reviewed the clinical instability and MET policy and staff training program, and

• developed a clinical escalation policy along with a staff training program.

Effective workforce

26


Recognising and responding to clinical deterioration

Patients who experience clinical deterioration may exhibit warning signs such as abnormal vital signs

that are often not identifi ed or poorly addressed leading to unexpected outcomes. Early recognition

and response to clinical deterioration may prevent these events.

The commission commenced its Recognising and Responding to Clinical Deterioration program

in 2009. This program aims to improve the recognition of and response to patients who deteriorate

in hospitals and other acute care facilities.

A nationally agreed consensus statement regarding the essential elements for recognising and

responding to clinical deterioration has been completed and endorsed by Health Ministers in April

2010. This generic document was developed to apply to all patients in all acute care facilities in

Australia. An implementation and action guide will be developed to support use of the consensus

statement and is expected to be completed in early 2011. Further information may be accessed at:

http://www.safetyandquality.gov.au/internet/safety/publishing.nsf/Content/prog-patientsrisk-lp

Recognising and responding to clinical deterioration is a key strategic priority in Victoria and nationally.

It is one of the fi ve new draft standards being developed by the commission,10 and has been endorsed

by the Australian Health Ministers’ Advisory Council and the Australian Health Ministers’ Conference.

Clinical Engagement Program

The department has released Partnering for performance: a performance development and support

process (2010), which aims to support the process of regular performance appraisal, and review and

strengthen the relationship between senior doctors and their health services.

Partnering for performance provides a suite of processes and tools to support clinical practice

and implementation of the Credentialling and defi ning the scope of clinical practice for medical

practitioners in Victorian health services policy (2009). Included is a guide which provides tips

and checklists to assist participants with reviewing performance, performance development

conversations and goal setting.

It also includes the Understanding clinical practice toolkit which incorporates tools to aid individual

doctors, their peers and organisations to understand and monitor clinical practice. The tools

included are:

• peer review

• adverse occurrence screening and targeted case note review

• mortality and morbidity reviews

• clinical audit

• clinical indicators, and

• patient satisfaction and complaints.

The department has recently engaged a consortium led by The Royal Australasian College

of Medical Administrators (RACMA) to develop and deliver a training program to support the

implementation of Partnering for Performance focusing on undertaking performance conversations.

More information is available at: http://www.health.vic.gov.au/clinicalengagement

10 Australian Commission on Safety and Quality in Health Care, National Safety and Quality Heath Service Standards, August

2010. Accessed at: http://www.safetyandquality.gov.au/internet/safety/publishing.nsf/Content/home

27

Health services should have a risk management system in place which integrates the management

of fi nancial, occupational health and safety, plant, equipment and clinical risk.

Minimising clinical risk and improving safety of care requires a systems approach where it is diffi cult

to make errors. It also requires a just culture where systems and processes are the focus of

investigation rather than blaming individuals.

Potential risks may be reactively identifi ed or fl agged through incident reporting, screening medical

records, or analysis of administrative data for clinical incident markers.

Clinical risk management and improvement strategies should be integrated within improvement

and performance monitoring functions.

Air embolus – a rare occurrence

Air embolus or the accidental introduction of air into the blood circulation is associated with high

morbidity or mortality.11 While air embolus may occur with trauma, it most commonly occurs during

medical intervention such as intravascular catheterisation or surgery. Despite the potential risk

of air embolism associated with medical intervention, only one case of air embolism has been

reported in Victoria since the commencement of the sentinel event program in 2002. Although

sentinel events are reported voluntarily, this rare occurrence is encouraging given that Victorian

public hospitals are continuously treating a growing number of patients and performing more surgical

procedures.2 Whilst the occurrence is rare, this single case warrants review given the potential

to impact negatively on quality of life, independence, and function.

Case study

A patient was admitted for elective coronary artery bypass graft surgery. Prior to transferring

the patient into the operating room, the surgeon wanted to trial a new room confi guration to allow

easier access.

The patient was connected to the bypass machine and a pre-cardiopulmonary bypass checklist

was completed. The patient’s heart was cannulated, the bypass machine was turned on, and the

vent pump was turned on. It was observed that the air in the vent line was moving in the wrong

direction, toward the patient. The cannula in the heart was removed immediately, the patient was

placed into a trendelenburg position and the aorta was opened to allow air bubbles to escape.

It was identifi ed that a line had been placed incorrectly into the vent pump on the bypass machine,

which was rectifi ed prior to surgery recommencing.

Post-operatively the patient was slow to wake with some initial seizure activity. An MRI showed

changes that were reported as consistent with air emboli. The patient was discharged following

an intensive care unit admission, and prolonged ward and rehabilitation admission.

11 S. Sviri, W. P. D. Woods, P. V. Van Heerden 2004, ‘Air embolism: a case series and review.’ Critical Care and Resuscitation

vol. 6 pp271-276.

Risk management

28


How did the health service address issues identifi ed?

• improved the bypass machine setup to ensure easy visualisation and access

to critical components

• applied permanent highly visible directional arrow markings to the vent pump

on the bypass machine

• introduced new vent lines which contain a one-way valve, and

• introduced a policy where clamping the vent line and priming the cardioplegia prior

to connection to the patient is incorporated into all cardiothoracic surgery practice.

Medication errors – interruption during administration

Medication error may occur during any stage of the medication process of prescribing, dispensing,

storage, preparation, administration and monitoring.

Case study

During the evening medication round in an aged care hostel, the staff member opened a resident’s

dose administration aid and realised that the medication was prescribed for a non-routine

administration time, and was not due for administration until two hours later. The medication was

subsequently put aside on the drug trolley.

The staff member continued with the medication round and administered medications to four other

residents when the medication round was interrupted.

Following the interruptions the staff member resumed the medication round and inadvertently

dispensed the medication they had put aside on the drug trolley to another patient.

The event was immediately reported and the resident was transferred to the affi liated hospital.


• introduced minimal interruption procedures and a highly visible vest for staff undertaking

medication rounds to alert others not to disturb except in an emergency

• kept medications prescribed for non-routine administration times to an absolute minimum

and fl agged these medications on the medication chart

• revised the Medication Management Procedure to include procedures for medications

removed from the pack and not given immediately, and procedures for occasions when

the resident is absent, and

• developed a staff education program on medication.

Beyond compliance strategy

Beyond compliance aligns and translates concepts of safety and quality in acute health to public

sector residential aged care services (PSRACs), where appropriate, through integration within

existing organisational governance and operational frameworks. It emphasises linking the domains

of the Victorian clinical governance policy framework to promote an integrated, sustainable approach

to safety and quality.

29

There are 194 PSRACS in Victoria with at least 6,400 residential aged care beds.

Through Beyond compliance investment in research and partnerships development, a range

of initiatives has been developed. Further information can be accessed at: http://www.health.vic.gov.

au/agedcare/publications/beyond_compliance.htm

Mental health

Case study

A patient with a diagnosis of borderline personality disorder was placed in seclusion with

constant visual observation because of agitation and ongoing suicide attempts using clothing for

strangulation. All bedding was removed and the consumer was left with a mattress and a pillow.

An agency nurse was asked to conduct constant visual observations through the seclusion room

window; however the patient was not in view as they had their back to the window. Shortly after

commencement of seclusion, the agency nurse noticed the consumer tearing at the pillow. They

had tied a strip of the material around their neck. There was a delay in reaching the patient

as the agency nurse was not given a key to the seclusion room and had to seek assistance from

another nurse.

A medical emergency (Code Blue) was called; the patient was resuscitated and was transferred

to the emergency department. The patient survived with no physical adverse outcome.


• improving access to seclusion rooms – key securely centrally located

• placed a non-breakable observation mirror in the corner to view obscured angles in the room

• improved orientation of agency staff to the unit to ensure awareness of emergency alarms and

processes, and

• purchased non-shreddable mattress and pillows.

Victorian mental health quality framework

The department has developed the Victorian mental health quality framework. This framework

identifi es the key dimensions of quality, collates existing quality and safety frameworks, and

provides a reference source for national standards, legislative requirements and existing guidelines

and policies.

National Standards in Mental Health Services and Clinical Review Program

A project to implement a revised National Standards for Mental Health Services is underway.

This project aims to develop a national clinical audit tool, and to undertake promotional activities

associated with the implementation of the revised national standards to ensure a consistent

approach across all jurisdictions and sectors in Australia.

The Offi ce of the Chief Psychiatrist is embarking upon a new round of clinical service reviews, under

the auspices of the Quality Assurance Committee. It will target select service settings and functions

and practices such as, triage, community case management and seclusion and restraint practices.

http://www.health.vic.gov.au/agedcare/publications/beyond_compliance.htm

30


Working with the Suicidal Person: Clinical Guidelines for

Emergency Departments and Mental Health Services

This evidence-based clinical guideline aims to assist clinicians in emergency departments and mental

health services with the management and assessment of people who have either attempted suicide

or are at risk of suicide. The guidelines will be published with a range of accompanying reference

resources and is scheduled to be completed in 2010.

Restraint and seclusion practices

Restraint and seclusion practices in public mental health services, while regulated by legislation,

are highly restrictive interventions that impact on the freedom and autonomy of patients. In 2005,

restraint and seclusion was identifi ed as one of four national safety priorities in mental health.

The Chief Psychiatrist in partnership with the Victorian Quality Council, the Mental Health Drugs and

Regions Division and the mental health sector has focussed effort on reducing the use of restraint

and seclusion in Victoria.

This effort targeted systemic practice changes, active participation in national projects, and

implementation of several local projects, clinical leadership forums, the development and roll-out

of statewide training and education programs, and a clinical audit program.

The project report Creating safety, addressing restraint and seclusion practices (2009) recommended

that health services reduce and where possible eliminate the use of restraint and seclusion. The

new Mental Health Bill will introduce another level of safeguards to ensure restraint and seclusion

practices are used as an intervention of last resort.

31

The following terms are used frequently in this report. The department acknowledges that their

usage varies and that a number of defi nitions are used in the literature.

adverse event an unintended injury or complication that results in disability, death or prolongation

of hospital stay and is caused by health care management rather than the patient’s

disease

ABO blood

group

a system for classifying human blood based on the antigenic components of blood

cells and their corresponding antibodies

behavioural

assessment

processes involved in establishing a patient’s cognitive state, particularly whether

the patient is at risk of wandering, absconding or causing harm to staff

clinical

guidelines

any policy, procedure or guidelines concerning the processes involved in the clinical

management of patients

clinical risk

management

an approach to improving quality in health care that places special emphasis

on identifying circumstances that put patients at risk of harm and then acting to

prevent or control those risks

clinical

governance

a health service board’s accountability for ensuring a framework and rigorous

systems are established so health care safety and quality are monitored, evaluated

and continuously improved

clinical pathway a treatment regime agreed by consensus that includes all the elements of care,

regardless of the effect on patient outcomes

cost direct and indirect activities involving a negative impact, including injury, death,

increased length of stay, time loss, money loss, service disruption, and reputation,

political and intangible losses

harm death, disease, injury, harm, suffering or disability experienced by a person

hazard a source of potential harm or a situation with a potential to cause loss

incident an event or circumstance resulting from health care that could have, or did, lead to

unintended or unnecessary harm to a person and/or a complaint, loss or damage

incident severity

rating (ISR)

a method to quantify the actual or potential consequences of an incident

or near miss

monitor to check, supervise, observe critically or record the progress of an activity

or system on a regular basis to identify change

morbidity incidence of disease

mortality death rate

near miss an incident that did not cause harm

risk the chance of something happening that will have an impact on objectives; it is

measured in terms of consequence and likelihood

risk assessment the overall process of risk analysis and risk evaluation

risk evaluation the process used to determine risk-management priorities by comparing the level

of risk against predetermined standards, target risk levels or other criteria

risk

management

the culture, processes and structures that are directed to the effective management

of potential opportunities and adverse effects

Glossary

32


root cause a signifi cant factor that contributed to an incident

root cause

analysis (RCA)

a systematic process where the factors that contributed to an incident are identifi ed

risk-reduction

action plan

strategies required to reduce the risk of similar adverse patient outcomes occurring

in the future

sentinel event a relatively infrequent, clear-cut event that occurs independently of a patient’s

condition; it commonly refl ects hospital system and process defi ciencies, and

results in unnecessary outcomes for the patient

underlying cause the systems or process-cause that allow for the proximate cause of an event

to occur

VAED Victorian Admitted Episodes Data Set

VHIMS Victorian Health Incident Management System

33

Appendices

Appendix 1: Incident severity rating (ISR)

The VHIMS ISR methodology was developed following analysis of methodologies used nationally

and internationally. This included methodologies suggested by the World Health Organization and

used by the National Health Service in the United Kingdom.

The ISR methodology provides a more consistent classifi cation of incident severity. It also allows

Victorian incident data to be mapped to a variety of other methodologies.

The ISR methodology can be consistently applied across all clinical (patient) and occupational health

and Safety (OHS) incidents. The ISR is based on:

• the actual and potential impact to those involved in the incident

• the actual and potential impact to the organisation.

The impact to the people involved is automatically derived from three related questions, these are:

1. degree of impact

2. level of care

3. treatment required.

VHIMS will derive an ISR depending on the values selected by the end user in each of the three lead

questions. Following are the specifi c details relating to each element of the ISR algorithm.

ISR scale

1 Severe/death

2 Moderate

3 Mild

4 No harm/near miss

34


Defi nition – degree of impact

Where ‘Harm’ includes disease, injury, suffering, disability and death:12

• disease – a physiological or psychological dysfunction

• injury – damage to tissues caused by an agent or circumstance

• suffering – experiencing anything subjectively unpleasant. This may include pain, malaise,

nausea, vomiting, loss (any negative consequence, including fi nancial) depression, agitation,

alarm, fear or grief

• disability – any type of impairment of body structure or function, activity limitation and/or restriction

of participation in society, associated with a past or present harm.

No harm – did not

reach the subject

There was no harm to the subject, that is, the incident did not reach the subject.

No harm – did

reach the subject

The incident reached the subject, but there was no harm caused.

No harm –

signifi cantly

inconvenienced

The subject was signifi cantly inconvenienced in relation to time, travel, wages,

lifestyle and family impact as a result of the issue and/or incident.

Harm – but no

loss or reduction in

functioning

The subject experienced harm but did not have a loss or reduction in functioning

as a result of the incident.

Harm – temporary

reduction in

functioning

One or more systems/components of the subject’s body are able to operate,

fulfi lling their purpose or role, but not to the level they could prior to the incident.

The subject is likely to recover from this reduction in the short-medium term.

Harm – temporary

loss in functioning

One or more systems/components of the subject’s body are no longer able

to operate normally, fulfi lling their purpose or role. The subject is likely to recover

from this loss within the short-medium term.

Harm – permanent

reduction in

functioning

One or more systems/components of the subject’s body are able to operate,

fulfi lling their purpose or role, but not to the level they could prior to the incident.

The subject is not likely to recover from this reduction.

Harm – permanent

loss in functioning

One or more systems/components of the subject’s body are no longer able to

operate normally, fulfi lling their purpose or role. The subject is not likely

to recover from this loss.

Harm – death The subject died unexpectedly at the time of, or following the incident.

Unknown The degree of harm caused to the subject, due to the incident, is not known

at this time.

12 Australian Commission for Safety and Quality in Healthcare (ACSQHC)

35

Defi nition – level of care

No signifi cant

change

The subject did not require any signifi cant extra care or increased length of stay

and/or higher care as a result of the incident.

Current setting

–increased

observation,

monitoring and/or

length of stay

The subject required increased observation, monitoring and/or length of stay

within their current setting, for example, ward. The subject was not transferred

elsewhere to a higher level of care.

Internal transfer

to a higher level

of care and/or

specialled

The subject was transferred internally within current organisation to a higher level

of care, for example, ICU and/or required specialling that is one-on-one care.

External transfer –

non inpatient

The subject was transferred externally to another health care provider for care,

but was not admitted.

External transfer –

inpatient admission

The subject was transferred externally to another health care provider,

for a higher level of care, for example ICU.

Not applicable The Level of Care is set to ‘Not applicable’ when the degree of impact was

‘Death’.

Unknown The change in level of care required by the subject, due to the incident, is not

known at this time

Defi nition – treatment required

No treatment Following a clinical review, intervention was deemed not required.

Minor treatment

including fi rst aid

The subject required a simple/minor intervention as a result of the incident.

For example: blood tests, xray, dressings, medications e.g. panadol, peripheral

IVT, urinary catheter insertion, nasogastric tube etc.

Advanced

treatment

The subject required signifi cant medical, diagnostic or surgical intervention as

a result of the incident. For example; MRI, CT, medications such as adrenaline,

insertion CVC or PICC line.

Not applicable The treatment required is set to ‘Not applicable’ when the degree of impact

was ‘Death’.

36


Appendix 2: Incident management process

37

Appendix 3: Source data

Table 1: Source data for reported events by classifi cation 2002–10

Classifi cation of event Frequency

2002

–03

2003

–04

2004

–05

2005

–06

2006

–07

2007

–08

2008

–09

2009

–10

Procedure involving the wrong

patient or body part resulting in

death or major permanent loss

of function

16 14 25 25 20 37 0

#

0

#

Suicide in an inpatient unit 5 1 4 7 11 7 7 6

Retained instruments or other

material after surgery requiring

re-operation or further surgical

procedure

9 8 5 6 8 11 3 9

Haemolytic blood transfusion

reaction resulting from ABO

incompatibility

0 1 1 0 1 2 1 2

Medication error leading to the

death of patient reasonably

believed to be due to the

incorrect administration of drugs

3 4 1 2 3 2 1 1

Maternal death or serious

morbidity associated with labour

or delivery

4 2 9 2 2 6 3 2

Infant discharged to wrong

family

0 0 0 0 0 0 0 0

Intravascular gas embolism

resulting in death or neurological

damage

0 0 0 0 0 0 0 1

Other catastrophic event

(includes near miss events)

42 55 77 49 37 37 53 36

Total 79 85 122 91 82 102 68 57

# From 2007-08, the national defi nition was revised to focus only on events that resulted in ‘death or major loss

of function’.

38


Table 2: Source data for events classifi ed as ‘other catastrophic events including

near miss’ events 2002–10

Other catastrophic events

sub-categories

2002

–03

2003

–04

2004

–05

2005

–06

2006

–07

2007

–08

2008

–09

2009

–10

Complication of emergency

management

9 11 6 4 2 1 4 0

Complication of anaesthetic

management

* 6 1 0 0 0 2 1

Complication of surgical

management

9 10 6 5 3 6 5 5

Foetal complication of delivery 3 0 1 2 2 0 2 2

Complication of inpatient fall

(death or serious morbidity)

2 10 11 4 5 7 5 2

Complication of fall (not resulting

in death or serious morbidity)

* * 18 1 0 0 0 0

Patient absconding from

inpatient unit with adverse

outcome

2 1 1 2 0 1 1 1

Infection control breach 6 7 8 3 2 2 2 2

Hospital process issue 9 7 0 6 0 3 0 2

Medication error (not resulting

in death)

* * 9 7 3 5 1 0

Misdiagnosis and subsequent

management

* * 4 3 3 1 2 4

Communication of test results * * 3 1 0 0 1 0

Other – mental health

management

* * 4 3 6 7 6 6

Other – unspecifi ed 2 3 5 8 8 4 1 5

A good catch/near miss 3 0 0 0

Procedure involving the wrong

patient or body part NOT

resulting in permanent loss

or death

* * * * * * 21 6

Total 42 55 77 49 37 37 53 36

*Sub-category not reported during the reporting period

39

Table 3: Comparisons of events by contributing factors expressed

as a percentage 2002–10

Contributing

factor Percentage of total contributing factors per reporting period

2002–3

#n=210

2003–4

#n=283

2004–5

#n=291

2005–6

#n=337

2006–7

#n=305

2007–8

#n=302

2008–9

#n=332

2009–10

#n=301

Procedures/

guidelines

32 41 31 43 32 43 36 34

Human

resources

17 17 24 14 15 18 15 23

Communication 16 17 27 20 18 16 20 17

Health

information

7 9 4 2 12 9 8 7

Equipment 7 7 4 5 4 7 8 10

Physical

environment

9 6 6 4 6 2 3 4

Facilities

management

6 3 1 3 2 2 3 1

Patient

behaviour

* * * 5 6 3 7 1

Course of

disease *

* * * 3 1 0 0 3

Other 6 0 3 1 4 0 0 0

Total 100 100 100 100 100 100 100 100

*Contributing factor not reported for reporting period #n= total number of contributing factors for reporting period

40


41

Clinical governance compliance checklist

Domain Domain descriptor

Equip 4.0

(Mandatory

criterion) Yes WIP No

Consumer

participation

Consumers are empowered to participate in their care. 1.1.2

Services respond to the diverse needs of consumers and the

community with humanity.

1.1.1

There is clear, open and respectful communication between

consumers at all levels of the health system.

1.1.2

Consumers provide feedback on clinical care and services

delivery and services learn from the feedback.

1.1.4

Clinical

effectiveness

Clinicians are empowered to improve clinical care delivery. 1.1.4

Clinicians actively involve consumers as partners in their care. 1.1.2

Clinical service delivery processes are streamlined and effi cient. 2.1.1

Clinicians participate in designing systems and processes. 2.1.1

Quality improvement activities are planned, prioritised and have

sustainability strategies in place.

2.1.1

Clinical care delivery is evidence-based. 1.12

Standards of clinical care are clearly articulated and

communicated.

3.1.5

Performance of clinical care processes and clinical outcomes

are measured.

1.1.4

Clinical performance measures, peer review and clinical audit

are used to evaluate and improve performance.

1.1.4

New procedures and therapies are introduced assuring quality

and safety issues have been considered.

2.1.2

Effective

workforce

Workforce development is planned and provides appropriate

skills and professional group mix.

3.1.3

The health workforce has the appropriate qualifi cations and

experience to provide safe, high quality care.

3.1.3

Risk

management

Clinical incidents are identifi ed, reported and investigated and

underlying systems issues are identifi ed.

2.1.3

Risks are proactively identifi ed, assessed and reported. 2.1.2

Organisational culture supports open communication and

a systems approach to learning from incidents.

2.1.3

Clinical processes and technology supports are designed to

minimise error and ensure clear, unambiguous communication.

3.2.1

A system for managing complaints or concerns about

a clinician is in place, promoted and is regularly reviewed.

2.1.3

Legislation and relevant Australian Standards are

complied with.

3.1.5

Policies and protocols are reviewed and managed. 3.1.5

This checklist provides a broad overview of the relationship between the Victorian clinical governance policy framework and the ACHS

EQuIP 4.0 mandatory criteria. Each domain is linked to the major mandatory criterion however other criterion may also apply.

42


Documents

101005_DoH Sentinel Events 0910 Web