WORKFORCE New staff receive appropriate orientation to the Service/Unit The Service/Unit has orientation guidelines, procedures, checklists and logs to ensure comprehensive orientation for the clinical workforce in key areas identified through a risk based approach Service/Unit orientation procedures, guidelines, checklists Sample of staff have orientation to Service/Unit recorded in appropriate documentation/log (*record evidence in worksheet) Staff interview Document review Offsite/Onsite IA Individual scope of practice is defined and periodically reviewed The scope of practice of individual staff in Service/Unit is documented and there is evidence of regular review after recredentialling Log of scope of practice or addendum to position description documenting approved scope of practice such as: (list procedures specfic to service/unit that require approval and credentialling check prioir to being included in indivdiual scope of practice e.g. procedural sedation) Document review Onsite IA + Clinical Expert New staff have appropriate skills and knowledge of maternity services New staff undergo initial credentialling 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: Document review Onsite IA and Clinical Expert
Existing staff are competant to undertake their defined scope of practice Periodic re credentialling of staff occurs to ensure skills and experience are appropriate to deliver defined scope of practice Evidence of system to periodically review currency of training, qualifications, registration, experience and currency of skills required to deliver defined scope of practice Includes all visiting staff Service Unit requirements include: registration status and any restrictions of scope of practice review of recent practice review of current organisaton mandatory training Document review Onsite IA+ Clinical Expert Staff undertake professional development relevant to the Service/Unit and their individual scope of practice The Service/Unit has an education plan based on: Type and frequency of competency based requirements for Service/Unit and needs analysis of staff and consideration of presentation risks Service/Unit Education Plan which includes at education to be provided by the organisation and the frequency required (e.g. annual) Regional collaboration agreement re access to education Document review, staff interview Onsite IA and Clinical Expert The education program is periodically evaluated Education evaluation, analysis and recommendations Frequency of evaluation Document review Offsite IA
Staff culture in the Service/Unit is at an acceptable level Workforce Culture at the Service/Unit level is assessed, analysed and responded to Workforce culture evaluation and analysis may include : Staff satisfaction evaluation and analysis for Service/Unit sick leave rate analysis for Service/Unit turnover rate analysis for Service/Unit Offsite Document review Offsite/Onsite IA RISK MANAGEMENT Risk identification and assessment occurrs regularly The Service/Unit undertakes the identification and analysis of risks (including clinical) Risk profile or register for Service/Unit includes clinical risks Review risk register Onsite IA A risk based methodology is applied to the approval of new procedures and equipment, within the Service/Unit Applications for use of new equipment/procedures with evidence that a risk assessment has been undertaken Staff interview. Document review Onsite IA+ Clinical Expert Monitoring of risk occurs regularly Service/Unit risks that have been identified as requiring action have assoIACTed action plans with strategies for risk reduction, timelines and responsibilities Document review Onsite IA Risk rating of identified Service/Unit risks changing over time (mitigating) Risk register shows progression of risk management Document review Onsite IA Service/Unit 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 Testing of contols identified in risk assesssment (procedures, clinical guidelines compliance) occurs periodically Audit occurs against known high risks Document review Onsite IA+Clinical Expert Risk reporting and communication is effective The risk profile of the Service/Unit is reported to relevant risk committee Periodic risk profiling and reporting Document review Offsite IA Communication to staff occurs regarding key Service/Unit risks and emerging risks and management strategies (minutes, agendas, bulletins) Staff interview, document review Onsite IA There is clear ownership of risk management through allocation of risk portfolios to Service/Unit staff Risk register demonstrates risk ownership Document review Onsite IA All incidents and near misses are reported, appropriately documentated and managed Service/Unit incidents, adverse events and near misses are recorded in the incident system Review of incident register Review of audits from patient file review for coverage of all incidents Incident database review Onsite Clinical Expert Management are able to track the incident trends in the Service/Unit and there is evidence of action taken Incident reporting finding trends data over 3yr period Report review Onsite Clinical Expert
Service/Unit Staff are familiar with the process for reporting incidents and for open disclosure Staff interview Onsite IA+Clinical Expert Root casue analysis of serious incidents or adverse events is undertaken in the Service/Unit Sample of highest category incidents have had root cause analysis undertaken (*record evidence in worksheet) Report review Onsite Clinical Expert QUALITY IMPROVEMENT Responsibility for quality improvement is clearly assigned in the Service/Unit All relevant responsbilities for quality have been allocated in Service/Unit and individuals understand and enact their responsbilities in relation to quality e.g. Responsibilities for quality plan oversight and implementation Audits and Clinical audits Monitoring and reporting on quality Development of clinical pathways Sentinel event monitoring Complaint investigation and resolution PD’s of managers and staff, Staff interview Offsite/ onsite IA The accountability and reporting mechanisms for quality of care in the Service/Unit are documented and followed Clear accountabilities for the service quality of care are reflected through relevant metrics/reports provided in line with a reporting framework to the board, relevant committees and management in relation to the Service/Unit quality of care? Evidence of scheduled reports or reporting framework with specification of reporting frequency, accountability and responsibility. Data reported may include: Mandatory indicators - Victorian Minimum Dataset and SOP KPI’s non mandatory indicators– ACHS Clinical Indicators Clinical audit reports Document review Onsite IA+Clinical Expert
Patient complaints in the Service/Unit are resolved within organisational timelines There is analysis and action in relation to Service/Unit complaints Timely response to complaints Majority of complaints resolved Staff are aware of the organisation’s open disclosure process Complaints policy and procedure Analysis of complaints process effectiveness (timeliness and resolution) Open disclosure policy understood by staff Document review Staff Interview Onsite IA INFRASTRUCTURE IT systems support recording and reporting on key data A functional electronic patient information management system that enables data reporting in Service/Unit A safe effective data system that allows: Timely reporting of Clinical Expert data Data presented in a format that enables analysis e.g. trends Secure system with password protection and timeout Staff Interview Onsite Clinical Expert The financial resources of the Service/Unit are managed appropriately A departmental budget is linked to the Service/Unit operational plan (which aligns with the organisation’s strategic plan) Service/Unit budget with links to unit operational plan and organisational strategy Document review Offsite IA The infrastructure resources of the Service/Unit are managed appropriately There is an equipment maintenance register that is current Equipment such as: resuscitation monitoring(ECG, BP, ) Document review Onsite IA+ Clinical Expert Equipment appropriate to the service is available when needed Staff interview Onsite Clinical Expert
Service/Unit procedures and protocols are evidence based and reviewed periodically Service/Unit 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 (Specificy any condition specific protocols relevant to service/unit e.g. head injured, post surgical ) (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 Clinical Expert 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. There is a current procedure/protocol for discharge from Service/Unit that address the requirements for: Safe discharge After hours discharge transfer to another hospital Discharge communication Follow up appointments Medication reconciliation Safe admission policy/protocol Transfer policy Document Review Staff interview Offsite Clinical Expert
Differential diagnoses were documented Management plan documented INTERVENTIONS An appropriate clinical response and communication to recognised escalation triggers or deterioriation is documented MONITORING Appropriate types of monitoring of clinical condition were undertaken and documented (e.g. respiratory rate, oxygen saturation, heart rate, BP, Temp, conscious state) Frequency of monitoring occurred at reasonable time intervals (as appropriate to patient condition or as specified in Service/Unit protocol)? Documentation was made of escalation communication/use of emergency code (if applicable)
Population: Additional specific population agreed with organisation Number of patients who meet criteria (Numerator) Total number of patient files examined (Denominator) Percentage (Numerator/ Denominator x 100) Average and Median Time Assessment of severity rating (high, medium and low) and Recommendations Agreed criteria for population (e.g. % patients over 65 years, paediatric, obstetric, infectious patients)