nadc accreditation quality improvement form · 2019-11-25 · criterion 1.2.1 contribution of...

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NADC ACCREDITATION QUALITY IMPROVEMENT FORM

Overview NADC Diabetes Quality Improvement Accreditation

The NADC accreditation for diabetes services is the only accreditation of its kind to offer comprehensive diabetes-specific accreditation aimed at the improvement of quality and safety. The accreditation model is focused on a three-pronged approach combining governance, educational and clinical criteria. The objective of the NADC accreditation is to assist diabetes services to achieve quality consumer care through improved governance, service structure, and improved educational and clinical services.

Accreditation is one tool in a range of strategies that can be used to improve safety and quality in a health based organisat ion. It is a way of verifying:

• actions are being taken

• system data are being used to inform activity

• improvements are made in safety and quality.

The NADC accreditation also aims to lift the standard of service delivered by diabetes services across Australia, in an effort to meet key goals under the National Diabetes Strategy 2016-2016. Namely, practices and procedures resulting in improved care, improved quality of life among people with diabetes, and a reduction in the prevalence of diabetes-related complications.

Self-assessment against the Standards

To achieve accreditation, you will not need to provide evidence against each criterion, however it is expected that your serv ice could provide this if asked to demonstrate how they have met each relevant indicator of the standards if audited by the NADC.

Quality Improvement Plan

All services are required to also submit a Quality Improvement Plan outlining key areas for improvement and an action plan.

It is expected that at the completion of the accreditation review, a list of action areas will have arisen that would lead to service improvement. Each service must complete the Quality Improvement Plan and execute actions documented in the plan within the timeframes outlined on the following page. The action item and stated priority levels will be reviewed by the NADC accreditation committee to ensure that these are appropriate. If they are felt to not be appropriately defined, the organisation will be contacted by the NADC to discuss these further. Where High Priority action items have been identified by either the organisation or the surveyor, the NADC will follow up with services to ensure implementation of these has been undertaken. If organisations action items, in consultation with the assessors, are felt to have not been met within an appropriate timeframe, accreditation may be withdrawn. When prioritising actions, the Risk Matrix on page 12 may be of assistance.

The length and type of plan may vary on the size and staffing of the Service, but it is expected that even Primary Care Diabetes Services will identify areas for improvement. Quality Improvement plans will only be accepted on the attached NADC template and must be attached to the application following the guidelines outlined in the workbook.

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Time Frames for Action Items When deciding the appropriate timeframe for an action item, consider using the Risk Matrix (Appendix 1)

• These items need to be completed within 90 days

• These items may pose a risk to patient or staff safety if not actioned

• Example:

• If your diabetes service needs to update their patient information processess and if not done, this may negatively

impact on patient safety

High Priority

• These action items are required to be completed within 6 months

• Example:

• If your diabetes service needs to update patient information forms

Medium Priority

• These action items can be set with realistic time frames that are appropriate for the type of item to be actioned and

current resourcing available

• Example:

• If your diabetes service building is needing renovation then this action item may take 5 years, which is appropriate

Low Priority

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Service details

Name of service: Western Health

Service type: Centre of Excellence X Tertiary Care Diabetes Service Secondary Care Diabetes Service

Primary Care Diabetes Service

Is yours a multi-site service? XYes No

Location of service being accredited: Sunshine, Footscray & Williamstown Hospitals

Name of contact person for this

application: A/Prof (Peter) Shane Hamblin

Contact person’s email: [email protected]

Contact person’s phone number: 03 8345 0860 0411403154

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Section 1 Healthcare improvement

Standards and criteria

Standard 1.1 Diagnosis and treatment Criterion 1.1.1 Evidence-based care Criterion 1.1.2 Multidisciplinary care Criterion 1.1.3 Medication management Criterion 1.1.4 Consumer rights and privacy Standard 1.2 Promotion of consumer self-management Criterion 1.2.1 Contribution of health improvement through consumer empowerment Criterion 1.2.2 Improved consumer health literacy Criterion 1.2.3 Consumer reminders Criterion 1.2.4 Individualised consumer care Standard 1.3 Improved consumer health outcomes Criterion 1.3.1 Demonstrated activities to achieve desired health targets Standard 1.4 Integrated care Criterion 1.4.1 Engagement with other services Criterion 1.4.1 Continuity of comprehensive care Standard 1.5 Decision support Criterion 1.5.1 Clinician reminders

Quality Improvement Plan for Section 1

Summary of strengths for Section 1

Strengths We have formed a Western Health Diabetes Steering Committee which meets quarterly. The idea came for Prof Peter Colman, RMH, who we invited to speak to us at one of our planning days. This forum brings together all the various stakeholders across the health service with the aim of improving quality of care to our consumers with diabetes. We have buy-in from anaesthetists, pre-admission clinic, ED, obstetrics, general medicine, inpatient reps, outpatient reps, Registrars, HMOs, University of Melbourne medical school, Quality & Safety co-ordinators, Intern educators, pharmacy and the usual groups: endocrinologists, diabetes educators, podiatrists and dietitians. It has led to several tangible benefits (improved pre-operative and post-operative processes, guidelines for colonoscopy etc). It has broken down a number of barriers and puts diabetes on the hospital map.

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Key improvements sought for Section 1

Standard/criterion 1.1.1 Evidence-based care

Identified issue We do not have a well developed preventive health program in place to encourage diagnosis and early detection of diabetes. We need to increase the testing of at risk individuals as they come through ED using the Austin Health example

Standard/criterion

1.1.2 Multi-disciplinary care

Identified issue Lack of onsite ophthalmology services


Standard/ criteria

What outcome or goal does our service want to achieve?

Priority (L/M/H/)

How will we achieve this outcome/goal? (Steps)

How will success be measured?

Deadline Progress notes

1.1.1 Increase detection of diabetes in at risk groups coming through ED

M Engage with ED team and EMR team to automate HbA1c testing of all patients over 50 admitted from ED

Number of at risk patients who have HbA1c measured

Mid 2019

1.1.2 Establish Outpatient ophthalmology service

M Engage with Head of Ophthalmology and Divisional Director to place this on the health service’s agenda

Commitment from the health service to plan for this service when the new Footscray Hospital is built

End 2018 to have agreement

New FH will probably not be built for at least 5 years

We

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Section 2 Governance and processes


Standard 2.1 Service structure and management

Criterion 2.1.1 Organisational structure Criterion 2.1.2 Leadership and accountability Standard 2.2 Service communication

Criterion 2.2.1 Information about the service



Strengths Well developed organisational structure with a particularly supportive Operations Manager. Western Health leadership is accessible and responsive. No issues of concern identified for Section 2.

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Nil


Standard/ criteria


Priority (L/M/H)




Nil

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Section 3 Management of quality and safety


Standard 3.1 Risk mitigation

Criterion 3.1.1 Risk mitigation processes Standard 3.2 Infection control Criterion 3.2.1 Mitigation of infection related incidents Standard 3.3 Quality improvement and innovation

Criterion 3.3.1 Quality improvement practices Criterion 3.3.2 Innovation programs Criterion 3.3.3 Technology Standard 3.4 Education and training

Criterion 3.4.1 Qualifications and professional development of staff Criterion 3.4.2 HR management of staff qualifications Criterion 3.4.3 Participation in knowledge-sharing Criterion 3.4.4 Consumer education programs



Strengths All Section 3 criteria met. No areas of concern identified. No quality improvement plan required.

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Standard/ criteria


Priority (L/M/H/)




Nil

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Section 4 Service management


Standard 4.1 Safety and welfare of staff, consumers and visitors

Criterion 4.1.1 Occupational health and safety Criterion 4.1.2 Management of clinical appointments Standard 4.2 Records management

Criterion 4.2.1 Business records Criterion 4.2.2 Clinical records and consumer information Criterion 4.2.3 Results management Standard 4.3 Service maintenance

Criterion 4.3.1 Cleaning and maintenance Criterion 4.3.2 Service and replacement of equipment



Strengths As we are part of a large health service, HR issues, credentialing, OH&S, clinical records, cleaning, maintenance and service/replacement of equipment are well covered.

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Standard/criterion 4.2.2 Clinical records and consumer information

Identified issue Biogrid has been in place for just under 12 months. While we have entered nearly 1000 patients, the completeness of data entered is far from complete. We need to progressively improve this situation.

Standard/criterion

[number] [Include the criterion number (left) and title of the criteria as indicated in the Section 4 table on the previous page]

Identified issue [Briefly summarise the issue identified during the self-assessment process, then complete the improvement planning table in the following section. Delete rows not required.]

Standard/criterion



Standard/criterion




Standard/ criteria


Priority (L/M/H/)




4.2.2 Increase completeness of data entered into Biogrid

M Start with type 1 patients first and at each clinic visit ensure medication/insulin dose section is complete and complication screening entered

Random audits of Biogrid entry to measure percentage of patients with type 1 diabetes who have all insulin doses/meds entered and complication screen data entered

End of 2018

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APPENDIX 1: RISK MATRIX

1 2 3 4 5

Consequences Risk Categories Tick appropriate boxes under CONSEQUENCES and

LIKELIHOOD of RECURRENCE then ascertain level of risk

Rare Unlikely Occasionally Likely Almost Certain Greater than once

every 5yrs (once every 2-5

years) (once every 1-2

years) (weekly- monthly)

(daily- weekly)

1. Insignificant

Patient/Consumer Care results in inconvenience but no harm

Low Risk Low Risk Low Risk Medium Risk Medium

Risk

Staff /Visitors Incident/near miss occurred, no injury Resources Negligible short term disruption to non-essential services Financial Minor loss resulting in only minimal impact to local area budget Reputation/Stakeholder Short term disruption to services not resulting in loss of business

2. Minor

Patient/Consumer Care results in minor harm with no loss or reduction of function

Low Risk Low Risk Medium Risk Medium Risk High Risk

Staff / Visitors First aid treatment only Resources Short term disruption to services not resulting in loss of business

Financial Loss that impacts on a s ingle service but does not threaten that service's overall budget

Reputation/Stakeholder Staff and consumer groups in local area losing trust and confidence

3. Moderate

Patient/Consumer Care results in harm with temporary loss or reduction of function

Low Risk Medium Risk Medium Risk High Risk High Risk

Staff / Visitors Injury necessitating medical treatment

Resources Short term disruption to services resulting in short term loss of business continuity

Financial Loss of more than $500,000 includes losses <$500,000 that threaten the overall budget of a single service

Reputation/Stakeholder Staff at an organisational level losing trust and confidence, adverse media coverage lasting up to 1 month

4. Major

Patient/Consumer Care results in significant harm with permanent loss or reduction in

Medium Risk Medium Risk High Risk High Risk Extreme Risk

Staff / Visitors Injury resulting in serious outcome, impacting on ability to return to previous work in the future

Resources Substantial disruption to multiple services resulting in short to medium term loss of business continuity

Financial Loss between $500,000 to $2M

Reputation/Stakeholder Staff and consumers at an organisational level, other stakeholders and Minister losing trust and confidence, adverse media coverage lasting more

5. Catastrophic

Patient/Consumer Care results in consumer death or profound impairment

Medium Risk High Risk High Risk Extreme Risk Extreme Risk

Staff / Visitors Injury resulting in permanent significant injury or unable to return to any form or work or preventable death

Resources Substantial disruption to multiple services threatening the survival or long term business continuity of the organisation

Financial Loss greater than $2M, representing insolvency

Reputation/Stakeholder Substantial loss of trust and confidence by public, regulatory or parliamentary enquiry with adverse findings, national media coverage

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nadc accreditation quality improvement form · 2019-11-25 · criterion 1.2.1 contribution of...

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