Health Quality and Safety Commission’s expectations for 2016/17 Annual and Regional Service Plans– updated 12 May 2016 (please note that all update sections are highlighted yellow)
Please note that this exemplar is intended to help DHBs and regions meet the Health Quality and Safety Commission’s expectations for annual and regional service plans.
AP Criteria 2016/17 / Example of an AP meeting the criteria- State the Quality & Safety Marker (QSM) and identify specific actions for each marker and the Health Quality & Safety Commission’s associated priority areas:
- Falls: 90 percent of older patients are given a falls risk assessment
- Falls: 98 percent of older patients assessed as at risk of falling receive an individualised care plan addressing the risks identified
- Hand hygiene: 80 percent compliance with good hand hygiene practice
- Safe surgery: All three parts (sign in, time out and sign out) of the surgical safety checklist are used in 100 percent of surgical procedures, with levels of team engagement with the checklist at 5 or above, as measured by the 7-point Likert scale, 95 percent of the time.
- SSI: 95 percent of hip and knee replacement patients receive cefazolin ≥ 2g or cefuroxime ≥1.5g as surgical prophylaxis
- SSI: 100 percent of hip and knee replacement patients receive prophylactic antibiotics 0-60 minutes before incision
- Medication safety: implementation of the electronic medicine reconciliation platform
Falls:
- commitment to meet and/or sustain achievement at or above the identified QSM threshold for falls risk assessment and individualised care plans
- your commitment to an integrated approach across the DHB to falls and fracture prevention, aligned with the work of the Ministry of Health’s ‘Health of Older People’ team and including a systematic approach to health of older peoples’ care pathways
- specific actions to examine your results and implement related improvements, such as interpreting falls-related data with a focus on older people to target a reduction in falls with serious harm.
- commitment to meet and/or sustain achievement at or above the identified QSM threshold for hand hygiene compliance
- how you will maintain the appropriate number of trained hand hygiene auditors and promote good hand hygiene practice messages to staff, patients and visitors
- your commitment to examining your results and taking action to improve quality and safety
- specific actions to implement related improvements, such as implementing local improvement methodology and front-line ownership.
- commitment to sustain achievement at or above the old QSM threshold of all three parts of the WHO surgical safety checklist (sign in, time out and sign out) being used in a minimum of 90 percent of operations
- commitment to ensure that the checklist is being used in paperless form, as a teamwork and communication tool rather than an audit tool
- commitment to working with the Commission to continue to implement briefing and debriefing for each theatre list.
- commitment to meet and/or sustain achievement at or above the identified QSM threshold for the clinical interventions specified by the Surgical Site Infection Improvement Programme, and that they are being adhered to in all hip and knee / cardiac operations
- commitment to examining results and taking action to improve quality and safety
- describe specific actions being taken to implement related improvements
- commitment to implement electronic medicine reconciliation in 2016/17, including a specific plan and funding allocated
- actions to spread medicine reconciliation at admission, transfer and discharge through both paper-based and/or electronic solutions.
- Identify actions to reduce patient harm including but not limited to pressure injury prevention
- This could include but is not limited to working with contracted providers, the Ministry of Health, Accident Compensation Corporation, and Health Quality & Safety Commission to:
oreport to HQSC all pressure injuries grade three and above as serious adverse events
omeasure and report pressure injury prevalence regularly and consistently
oimprove classification and documentation of pressure injuries by grade in the patient record and ensure they are coded
oimplement evidence based structured risk assessment to support clinical judgement and implement effective prevention.
- Identify actions to promote consumer engagement
- commitment to establish and maintain a consumer council (or similar) to advise the District Health Board.
- Identify actions to build quality improvement capability and clinical leadership
- commitment to maintain the necessary infrastructure to support patient safety initiatives at the local level
- commitment to report in quality accounts how you build capability for quality improvement and patient safety
- commitment to promote online quality improvement tools and methodologies to staff
- commitment to implement distributive clinical leadership and facilitate this by a clinical leadership programme, and report on this in your quality account
- commitment to promote key messages and the theme of Patient Safety Week 2016.
- Identify actions to publish annual quality accounts
- commitment to include data as outlined in HQSC quality accounts guidance
- commitment to account for quality at every DHB board meeting similar to the financial accounting process.
RSP Criteria 2016/17 / Example of an RSP meeting the criteria
- Demonstrate a structure and planned actions to support and maintain regional patient safety and quality improvement governance and working arrangements.
- Maintain and participate in regional governance approaches that ensure regional and local leadership of the campaign, and patient safety and quality improvement more generally
- Involve consumers (patients and family)
- Develop and maintain regional leadership and networks to support quality and safety and build capability for improvement.