NSQHS Standards – Implementation Feedback

[hr]National Safety and Quality Health Service Standards (NSQHS Standards) were introduced in January 2013 to set out minimum standards for safety and quality, and provide quality assurance guidelines and improvement mechanisms to achieve them. [hr]
[insert_menu title="Menu"]
[link to="Standard 2: Partnering with Consumers"]Standard 2: Partnering with Consumers[/link]
[link to="Standard 4: Medication Safety"]Standard 4: Medication Safety[/link]
[link to="Standard 8: Preventing and Managing Pressure Injuries"]Standard 8: Preventing and Managing Pressure Injuries[/link]
[/insert_menu]
During 2013, the Commission consulted widely with health service organisations about the types of concerns and challenges experienced in implementing the NSQHS Standards. Feedback has been sought through a variety of mechanisms including through accreditation agency surveys, an accreditation hotline, network teleconferences and meetings with stakeholders.
In this issue, the Australian Commission on Safety and Quality in Health Care summarises feedback received from health service organisations in relation to the implementation of NSQHS Standards 2, 4 and 8.[hr]
[title from="Standard 2: Partnering with Consumers"]Standard 2: Partnering with Consumers[/title]

NSQHS Standard 2: Partnering with Consumers requires the engagement of consumers in the processes of developing and reviewing health services, and is based on the premise that people ‘have the right and duty to participate individually and collectively in the planning and implementation of their health care.’ 1 The actions identified in NSQHS Standard 2 build on emerging evidence about the benefits that partnerships with consumers can bring.2 For example, involving consumers in service planning, delivery, monitoring and evaluation is more likely to result in services that are more accessible and appropriate for users3-4, which can contribute to improvements in patient outcomes.
How consumer partnerships are progressing
Feedback received from health service organisations implementing the NSQHS Standards indicated some found the actions in NSQHS Standard 2 particularly challenging. In response to this, the Commission conducted a survey of health service organisations to identify:

• which actions were seen to be the most challenging and why this was the case, and


• what type of materials and resources would help healthcare organisations to better understand how to meet these more challenging actions.

Results of the survey indicate the most difficult actions to achieve were those requiring involvement of consumers and carers in clinical workforce training (action 2.6.2) and in governance (action 2.1.1). Establishing partnerships with consumers and carers to design and redesign health services (action 2.5.1) was also reported as difficult.
Some respondents provided comments on why they found these actions challenging. Private hospital and day procedure respondents reported organisational barriers to achieving the actions, while those from public hospitals reported problems with staff acceptance of the actions. All health services, including community services, cited various difficulties in involving consumers, many of which are related to knowledge about identifying and engaging consumers effectively.
There was much clearer agreement over the actions which were seen as easier to implement. Respondents said that engaging consumers and carers to provide feedback on patient information publications and incorporating that feedback (actions 2.4.1 and 2.4.2) were easier to implement than other actions.
Continuing support for health service organisations
The Commission is looking at the results of this survey and will be working closely with organisations undertaking accreditation throughout 2014 to identify and develop tools and materials to improve understanding of how to meet the actions under NSQHS Standard 2. These will include fact sheets, case studies and potentially train-the-trainer materials, as well as materials tailored to different types of health services organisations, such as day procedure services and dental services. To contribute to this process, email mail@safetyandquality.gov.au with your feedback or case study recommendations.

More information
 
More information and resources to support implementation of the NSQHS Standards are available on the Commission’s web site at www.safetyandquality.gov.au or by contacting the Commission’s Advice Centre on 1800 304 056 or accreditation@safetyandquality.gov.au.
[hr]

References

1. Declaration of Alma-Ata; 1978. World Health Organization.
2. Australian Commission on Safety and Quality in Health Care. Patient-Centred Care: Improving Quality and Safety through Partnerships with Patients and Consumers. Sydney. ACSQHC, 2011.
3. Crawford MJ, Rutter D, Manley C, Weaver T, Bhui K, Fulop N, et al. Systematic review of involving patients in the planning and development of health care. British Medical Journal 2002;325(7375):1263.
4. Consumer Focus Collaboration. The evidence supporting consumer participation in health. Canberra. Consumer Focus Collaboration, 2001.
5. Van Den Bos J RK, Gray T, Halford M, Ziemkiewicz E. The $17.1 Billion Problem: The Annual Cost of Measurable Medical Errors. Health Afairs 2011;30(4):596-603.
6. Graves N BF, Whitby M. Modelling the economic losses from pressure ulcers among hospitalised patients in Australia. Wound Repair andRegeneration 2005;13(5):462-467.
[top]
[hr]
[title from="Standard 4: Medication Safety"]Standard 4: Medication Safety[/title]

NSQHS Standard 4: Medication Safety describes the elements of a safe medication management system with the aim of reducing the prevalence of avoidable adverse medication incidents. The intention is to ensure competent clinicians safely prescribe, dispense, and administer appropriate medicines to informed patients and carers. In May 2013, the Commission held a workshop to discuss issues for health service organisations meeting the requirements of NSQHS Standard 4. The key challenges identified, solutions and guidance are summarised below.
Undertaking quality improvement activities to enhance the safety of medicines use (action 4.5)
Health service organisations should prioritise areas for improvement (as identified in risk assessments) to those of highest risk to patients. Audits should be conducted to measure the effect of quality improvement activities undertaken. Small, more frequent, audits targeted at high risk patients, medicines or processes are appropriate. The Indicators for Quality Use of Medicines in Australian Hospitals are a useful resource for undertaking baseline audits and measuring quality improvement.
The clinical workforce reviewing the patient’s current medication orders against their medication history and prescriber’s medication plan, and reconciling any discrepancies (action 4.8)
This action is particularly challenging for smaller health service organisations with no onsite pharmacy service. Health professionals other than pharmacists, such as nurses, doctors, and pharmacy technicians, can reconcile medicines provided they receive appropriate training. A multidisciplinary approach is recommended with responsibilities assigned to the relevant professional groups, including responsibility at weekends and after hours when there may be no pharmacy service. Health service organisations with limited resources should prioritise medication reconciliation for patients at higher risk of medicine misadventure. The Commission recommends that the National Medication Management Plan (MMP) be used to document medication histories and reconcile medicines on admission, during intra-hospital transfer and on discharge from the health service. It should be kept with the current National Inpatient Medication Chart (NIMC) during the episode of care. The MMP is available from the Commission’s web site.
Ensuring a current comprehensive list of medicine, and the reason(s) for any change, is provided to the receiving clinician and the patient during clinical handover (action 4.12)
Where there is no pharmacist on site to prepare and provide a medicines list to the patient on discharge, the list may be provided through a number of different mechanisms. Each health service organisation needs to determine what system best serves their needs. Examples of systems are provided in the workshop outcomes in the Accreditation section of the Commission’s website.
Identifying high-risk medicines in the organisation and ensuring they are stored, prescribed, dispensed and administered safely (action 4.11)
Some organisations are not familiar with the term highrisk medicines and the process of identifying them within their organisation. Information about high risk medicines is available from the Commission’s web site in Medication Safety, Medication Alerts. The APINCH mnemonic for high risk medicines i.e. anti-infectives, potassium, insulin, narcotics, chemotherapy and heparin (and other anticoagulants) is a good place to start. Actions to address risks identified with high-risk medicines can be prioritised.
General guidance for implementing NSQHS Standard 4
Health service organisations are encouraged to use a risk based approach to identify areas in which the organisation does not meet NSQHS Standard 4 action items. All hospitals should use the Medication Safety Self Assessment (MSSA) Tool to assess the safety of their medication management system irrespective of their size and whether public or private (action item 4.2). The identified gaps can be prioritised according to risk (using the Commission’s risk matrix tool) and serve as a focus for quality improvement activities. Day procedure services can use the Day Procedure Services Accreditation Workbook as the basis for their risk assessment.
Hospitals and day surgery services are required to use the relevant National Inpatient Medication Chart (NIMC) for their setting. Services using medication charts that have been modified from the NIMC should check whether their changes comply with the NIMC Local Management Guidelines produced by the Commission. They will need to transition to the NIMC if the changes do not comply.
[top][hr]
[title from="Standard 8: Preventing and Managing Pressure Injuries"]Standard 8: Preventing and Managing Pressure Injuries[/title]

Pressure injuries are a major source of harm to patients within the health system.5-6 In the majority of cases, pressure injuries are preventable. The intention of NSQHS Standard 8 is to prevent patients from developing avoidable pressure injuries and to ensure effective management of pressure injuries when they do occur.
In the following case study, Tracy Nowicki, Clinical Nurse Consultant, shares her tips and experience from the implementation of NSQHS Standard 8 at Prince Charles Hospital in Queensland.
Case study: The highs and lows of implementing NSQHS Standard 8
“When the NSQHS Standards were introduced in January 2013, we at The Prince Charles Hospital wondered ‘where do we start?’ when we saw Standard 8. Getting our strategies together was essential. Once these were in place, the actions seemed much more manageable. 
Key practice development initiatives highlight the importance of a sustained and strategic focus on education, the use of appropriate pressure injury prevention devices and strategies, together with committed executive support.
The first priority is to establish your team. Reflect on the great work you have done and what you are currently doing. Accreditation is all about demonstrating the great work you are doing and looking at how you can improve your quality. Keep all your evidence: measure, measure, measure.
Governance (action 8.1)
Our journey goes back to the 1990’s. There were many highlights in relation to nurse-led quality improvement projects.
Some years ago we established a Tissue Viability Committee. The strength of this group is that is it multi-disciplinary and hassustainability.
Key performance indicators are identified in the Nursing Services Strategic Plan which identifies PI prevention as a priority research area. Ensure you have strong leadership and executive buy-in.
Prevention (action 8.2)
Standard 8 requires a ‘Comprehensive Skin Inspection’. This is not a quick look at the patient’s sacrum. It is a head-to-toe anterior and posterior skin inspection. To meet the standards, we need to remember the patient is at the centre of care. We need to also remember that staff are met with many competing priorities. Skin inspection needs to be built into daily care. This is all about cultural change: where the fundamental basics are important to all of us. At The Prince Charles Hospital, we developed a skin inspection form. This promotes clear communication on admission, between transfers and on discharge. There is little writing required. To encourage thorough skin inspection and correct completion of the form we also launched an educational campaign, ‘Look, Listen & Feel’. The adjunct posters direct staff to look at the skin, listen to the patient and feel the skin. Damaged skin will feel different. This campaign took the mystery out of anatomical locators, sites of higher risk and what to do for ‘at risks’ sites.
We also reviewed our high-risk units (i.e. Adult Intensive Care). For patients who we knew would be bed bound for long periods of time, we commenced the ‘Hips, Heads and Heels’ campaign. The aim of this was to ensure that the high-risk sites were protected before the patient was intubated and sedated. It was also a reminder to staff who care for these patients that the risks are always present.
We standardised an evidenced based skin care program, moving away from ritualistic practice to evidenced based practice. This included eliminating surplus continence and skin care products. Ensuring that all areas use the same products regardless of where the patient is situated in the hospital. Continence education was woven into the PI and Falls education.
Management (action 8.3)
When PI are documented through the Incident Reporting System, an immediate response to review the incident report was initiated. This ensured that staff saw a timely response to the documentation, a review of best practice, engagement of the patient and analysis of the incident to ensure credibility.
Consumer Engagement (action 8.4)
The Prince Charles Hospital conducts regular courses for PI/Falls and Continence courses. We ensure that each of these features a presentation from a consumer. This has been invaluable in the enhancement of staff knowledge. Patient stories have a strong impact and can instigate change at the frontline of care.
At a state level, we have worked to standardise the patient handout on ‘Keeping Bedsores at Bay’. However it is one thing to distribute a patient leaflet, it is another to ensure the patient understands it. At The Prince Charles Hospital we are continuing to work in this space.”
There are many resources available on the Commission’s website to assist hospitals implement the NSQHS Standards and provide evidence that each standard is being met. www.safetyandquality.gov.au/our-work/accreditation/resources-toimplement-the-national-safety-and-quality-health-service-standards/” www.safetyandquality.gov.au/our-work/accreditation/resources-to-implementthe-national-safety-and-quality-health-service-standards/
[top]