WORKFORCE New staff receive appropriate orientation to the ED/UCC The ED/UCC has orientation guidelines, procedures, checklists and logs to ensure comprehensive orientation for the clinical workforce in key areas identified through a risk based approach ED/UCC orientation procedures, guidelines, checklists Sample of staff have orientation to ED/UCC recorded in appropriate documentation/log Staff interview Document review Offsite/Onsite IA New staff have appropriate skills and knowledge of ED/UCC New medical and ED/UCC staff undergo initial credentialling reviewed to ensure skills and knowledge are current and approriate to the individual scope of practice Credentialling policy/procedure Audit of new staff personnel files for initial credentialling including: professional credentials in emergency medicine regsitration and any restrictions of scope review of practice review of current organisation mandatory training requirement
5. Staff undertake professional development relevant to the ED/UCC and their individual scope of practice 5.1 The ED/UCC has an education plan based on competency based requirements for ED/UCC and needs analysis of staff and consideration of presentation risks ED/UCC Education Plan which includes at a minimum: Basic Life Support, Advanced Life Support Triage Pressure injury prevention Document review, staff interview Onsite IA and ED 5.2 Attendance at staff education/training sessions is recorded Sample of staff have attendance at education recorded in appropriate documentation/log Document review Onsite IA 5.3 The education program is periodically evaluated Education evaluation, analysis and recommendations Frequency of evaluation Document review Offsite IA 5.4 Individual professional development for ED/UCC is planned and implemented Professional Development Plans in Personnel file ED % of sampled staff with further emergency qualifications(grad dip emergency nursing, Advanced Life Support, Acute and Complex Medical Emergencies, Paediatric Life Support, trauma) UCC % of staff forming bank of rostered nursing staff for UCC with Scheduled Medicines(Rural and Isolated Practice) Endorsement % of staff forming bank of rostered nursing staff for UCC with Advanced Life Support certification Document review Onsite IA and ED
Appropriate access to specialist consultation 9.1 The rosters demonstrate there is appropriate access to more senior emergency services consultation and other specialist consultation ED only – 24-hour access to more senior emergency consultation, general surgery, orthopaedics, general medicine, anaesthesia, intensive care and paediatrics Evidence of contact list for external specialists Regional collaboration agreement re access to specialists/telemedicine Document review Onsite IA +ED Appropriate access to support services 10.1 The rosters demonstrate there is appropriate access to support services ED only- 24 hour per day access to pathology, radiology and operating theatres Document review Onsite IA +ED Staff culture in the ED/UCC is at an acceptable level 10.1 Workforce Culture at the ED/UCC level is assessed, analysed and responded to Workforce culture/Staff satisfaction evaluation and analysis for ED/UCC sick leave rate analysis for ED/UCC turnover rate analysis for ED/UCC Document review Staff interview. Offsite/Onsite IA RISK MANAGEMENT Risk identification and assessment occurrs regularly 12.1 The ED/UCC undertakes the identification and analysis of risks (including clinical) Risk profile or register for ED/UCC includes clinical risks Review risk register Onsite IA 12.2 Data (e.g. incident data, clinical audits, waiting time data, literature) is used to inform the identification of risks and selection of appropriate controls. Risk documentation Staff interview. Document review Onsite IA+ED
12.3 A risk based methodology is applied to the approval of new procedures and equipment, within the ED/ UCC Applications for use of new equipment/procedures with evidence that a risk assessment has been undertaken Staff interview. Document review Onsite IA+ED Monitoring of risk occurs regularly 13.1 ED/UCC risks that have been identified as requiring action have assoIACTed action plans with strategies for risk reduction, timelines and responsibilities Risk register Document review Onsite IA 13.2 Risk rating of identified ED/UCC risks changing over time (mitigating) Risk register shows progression of risk management Document review Onsite IA 13.3 ED/UCC Risk escalation is consistent with the organisation’s risk management framework Evidence if risk escalation to appropriate position Document review Onsite IA Controls put in place to manage key risks are monitored for effectiveness 14.1 Testing of contols identified in risk assesssment (procedures, clinical guidelines compliance) occurs periodically Audit occurs against known high risks Document review Onsite IA+ED Risk reporting and communication is effective 15.1 The risk profile of the ED/UCC is reported to relevant risk committee Periodic risk profiling and reporting Document review Offsite IA
Quality improvement is a planned coordinated activity 19.1 There is a quality improvement plan for the ED/UCC that has: clear links to whole of hospital strategic quality initiatives timeframes, responsibilities evaluation resulted in improvement ED/UCC quality plan demonstrating requirements that has been evaluated Document review Staff interview Onsite ED PATIENT EXPERIENCE Patient experience is periodically evaluated with appropriate tools in the ED/UCC according to organisation policy 20.1 The analysis of patient experience/satisfaction in ED/UCC is undertaken and analysed periodically to improve quality of care Recommendations from patient experience assessment implemented and evaluated e.g. Understanding of discharge self-management Understanding of medication management Understanding of follow up appointment Document review Onsite IA and ED Patient complaints in the ED/UCC are resolved within organisational timelines 21.1 There is analysis and action in relation to ED/UCC complaints Timely response to complaints Majority of complaints resolved Complaints policy and procedure Analysis of complaints process effectiveness (timeliness and resolution) Document review Staff Interview Onsite IA INFRASTRUCTURE
IT systems support recording and reporting on key data 22.1 A functional electronic patient information management system that enables data reporting in ED/UCC A safe effective data system that allows: Timely reporting of ED data Data presented in a format that enables analysis e.g. trends Secure system with password protection and timeout Staff Interview Onsite IA and ED The financial resources of the ED/UCC are managed appropriately 23.1 A departmental budget is linked to the ED/UCC operational plan (which aligns with the organisation’s strategic plan) ED/UCC budget with links to unit operational plan and organisational strategy UCC Human Resources strategy to UCC staffing roster has a risk based approach that considers potential risks such as impact on inpatient nurse/patient ratio Document review Offsite IA The infrastructure resources of the ED/UCC are managed appropriately 24.1 There is an equipment maintenance register that is current Equipment such as: resuscitation monitoring(ECG, BP, ) Document review Onsite IA+ED 24.2 Equipment appropriate to the service is available when needed Staff interview Onsite ED 24.3 There is an effective system for restocking essential items Document review Staff interview Onsite IA
ASSESSMENT Document/s support the initial assessment of patient clinical status 27.1 There is a current procedure/protocol/template for patient initial assessment that outlines: key clinical observations to be recorded Timeframes for initial assessment to be undertaken Document contains all elements Document Review Staff interview Offsite ED Document/s support the provision of a comprehensive assessment 28.1 There is a current procedure/protocol for patient comprehensive assessment with a minimum standard defined for comprehensive assessment including: Structured history Objective examination Timeframes for comprehensive assessment to be undertaken Document contains all elements Document Review Staff interview Offsite ED
Document/s support the referral of patients to support services in a timely manner 32.1 There is a current procedure/protocol for referral to support services including: Pathology, Imaging, Pharmacy,Surgery, NETS/PETS/ARV Acceptable turnaround times UCC - procedure includes criteria for activation of NETS/PETS/ARV Document Review Staff interview Offsite ED INTERVENTION
ED/UCC procedures and protocols are evidence based and reviewed periodically 33.1 ED/UCC clinical procedures and protocols reference current clinical standards and guidelines. This is supported by a system to make readily available clinical standards and guideline Sample of clinical procedures and protocols have clear references to clinical guidelines upon which they are based and evidence that they have been reviewed periodically e.g. Nurse initiated medication protocols Airways management procedure/protocol Patient transfer procedure/protocol Pneumothorax procedure/protocol Asthma management protocol Acute Coronary Syndrome protocol Stroke Protocol (record evidence in worksheet) Readily available standards and guidelines include: emergency medicine textbooks, journals, Clinical management guidelines and protocols are available on site. There should also be access to electronic sources of medical information Document Review Staff interview Offsite ED DISCHARGE
Document/s support the provision of a comprehensive timely discharge plan to all of: the person, their family and other providers involved in their care. 34.1 There is a current procedure/protocol for discharge from ED/UCC that address the requirements for: Safe discharge Transfer policy with use of NETS/PETS/ARV After hours discharge Admission to hospital Discharge communication Follow up appointments Safe admission policy/protocol Transfer policy Document Review Staff interview Offsite ED
Population: Acute Coronary Syndrome Number of patients who meet criteria (Numerator) Total number of patient files examined (Denominator) The Percentage (Numerator/ Denominator x 100) Average and Median Time Assessment of severity rating (high, medium and low) and Recommendations Chest pain assessment pathway completed and documented ECG undertaken and analysed Average and/or median time to ECG 10 minutes or less (Time of ECG –time of presentation) Fibrinolysis undertaken (STEMI)undertaken Or percutaneous coronary intervention undertaken (STEMI)undertaken Average and/or median time to Fibrinolysis less than 30 minutes (thrombolysis time- presentation time) Or Average and/or median time to percutaneous coronary intervention less than 90 minutes (thrombolysis time- presentation time) Troponins undertaken