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
5.5 A record is maintained of staff meeting mandatory competency/certification requirements for delivering scope in ED/UCC % of sampled Triage staff who have completed the annual online ETEK triage competency package Document review Onsite IA+ED The ED/UCC periodically reviews the scope of services provided 6.1 The conditions under which specific diagnostic groups will be transferred or admitted from the ED/UCC have been clearly defined in documentation e.g. Organisation Acute Admission Policy e.g. Safe Practice Framework or Emergency Department Admission Policy Document review Offsite IA+ED Individual scope of practice is defined and periodically reviewed 7.1 The scope of practice of individual staff in ED/UCC 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: ultrasound procedural sedation X-ray Suturing Plastering Document review Onsite IA + ED 7.2 Orientation to and review of scope of practice occurs in relation to the implementation of new procedures or equipment Evidence of training for new equipment or amendment to scope of proactice Document review Staff interview Onsite IA +ED Appropriate levels of staffing in the ED/UCC 8.1 The rosters demonstrate appropriate staffing in ED/UCC with respect to medical, nursing, administrative and other personnel. ED – 24hr triage staff 24 hour medical officers 24 hour on call access to designated senior doctor (emergency physician) UCC -24hr access to registered GP and Nurse Document review Staff interview 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
15.2 Communication to staff occurs regarding key ED/UCC risks and emerging risks and management strategies Evidence in minutes, agendas, bulletin Staff interview, document review Onsite IA 15.3 There is clear ownership of risk management through allocation of risk portfolios to ED/UCC staff Risk register demonstrates risk ownership Document review Onsite IA All incidents and near misses are reported, appropriately documentated and managed 16.1 ED/UCC 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 Staff interview, Onsite ED 16.2 Management are able to track the incident trends in the ED/UCC and there is evidence of action taken Incident reporting such as trends data over 3yr period Report review Onsite ED 16.3 Root casue analysis of serious incidents or adverse events is undertaken in the ED/UCC Sample of highest category incidents have had root cause analysis undertaken Report review Onsite ED 16.4 There is clear articluation of and familiarity with the open disclosure process Open Disclosure Policy/procedure Evidence staff familiar with process Document review Staff interview Onsite IA+ED
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
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
This third section of the clinical internal tool is used to evaluate the type of patient related data that is collected and analysed in the ED/UCC for quality improvement purposes. The data is separated in to process and outcome data. The audit does not collect and verify the raw data but looks at the units own collection and analysis of this data. CRITERIA DESIRED DATA TO ADDRESS CRITERIA EVIDENCE (record evidence sighted) METHOD Demand Data Presentations/demand data is collected and analysed in the ED/UCC Total presentations Presentation by date of week and hour of day Presentation by ambulance or self Evidence of collection and analysis of demand and peak demand times All data reviewed onsite by ED expert Process Data Complaints data is collected and analysed in the ED/UCC Number and type of complaints /10,000 ED /1000UCC presentations and trend over time Evidence of collection and analysis Incident data is collected and analysed in the ED/UCC Number and type of incidents /10,000 ED/1000UCC presentations and trend over time Evidence of collection and analysis National Emergency Access target (NEAT) data is collected and analysed in the ED 2013 (VIC) 75% of all ED patients leave within 4 hours 2014 (VIC) 84% of all ED patients leave within 4 hours 2015 (AUS) 90% of all ED patients leave within 4 hours Evidence of collection and analysis (ED only) Access block data is collected and analysed data is collected and analysed in the ED Percentage of patients with a length of stay longer than 8 hours Evidence of collection and analysis Length of stay data is collected and analysed Percentage of patients with a length of stay longer than 24 hours Evidence of collection and analysis
Population: Additional specific population agreed with organisation 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 Agreed criteria for population (e.g. % patients over 65 years, paediatric, obstetric, infectious patients)