1. Australian Health Service Safety and Quality Accreditation Scheme Advice Centre Network Meeting Margaret Banks Senior Program Director February 2013

2. Risk Assessment Risk management approach Risk management is the design and implement of activities to identify and avoid or minimise risks to patients, employees, visitors and the institution. Then: Health services will need to demonstrate they have undertaken a comprehensive risk analysis Strategies that are implemented need to focus on areas of greatest risk Risks will vary across wards/facilities of health service, so not all strategies will be applicable or a priority in all parts of the health service.

3. Implementing the NSQHS Standards Not achievable without the engagement throughout the organisation Standard 1 requires: Patient safety and quality of care to be considered in business decision making Governance body to receive reports on safety and quality and takes action to improve safety and quality The workforce to be aware of the delegated safety and quality roles and responsibilities Risk management Training in safety and quality

4. What does this mean for Accreditation? No longer possible to achieve accreditation if: The organisations relies on ‘events management’ The Quality Manager is responsible for the organisation achieving accreditation The new requirements mean that: Standards are no longer assessed ‘on balance’ and Health services must provide evidence that each action is met Again – it is not possible to meet accreditation requirements without the participation of the whole organisation

5. Reducing duplication, preventing gaps Hierarchy of processes Jurisdiction Local Health District Facility or Service Stream Ward / Unit Need to clarify the roles and responsibilities at each level to prevent duplication, gaps and inconsistencies in: Policies and processes Expectations Communication Resource allocation

6. Data and Monitoring Required throughout the Standards eg: 3.2 Surveillance of healthcare associated infections 4.10.3 Monitoring of temperature-sensitive medicines 7.8.1 Monitoring blood wastage Key to: Measuring and managing risks Change management Information for decision making Identify areas for improvement Driving and evaluating continuous quality improvement Providing evidence for accreditation

7. Tools and Guides Available and or referenced in: Safety and Quality Improvement Guides Other Commission resources eg Anti-microbial Stewardship in Australian Hospitals Tallman lettering Jurisdiction material – Between the Flags Quality Use of Medicines Locally developed forms and systems Pan Pacific Clinical Practice Guidelines for the Prevention and Management of Pressure Injury

8. Providing evidence for accreditation Quality improvement processes generate documentation Evidence for accreditation should come from the normal business of providing care and driving improvement Accreditation should not be a ‘Paper War’ Accreditation Workbooks provide a checklist only

9. Reviewing support systems Supporting systems include: Coding Forms and records Credentialling processes Performance management systems Contracts with cleaning providers, locum agencies