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Patient Safety Starts with ME

Hastings Macleay Clinical Network
Project Added:
13 July 2015
Last updated:
28 July 2015

Patient Safety Starts with ME

Summary 

This project installed a patient safety board and innovation board to engage staff in the process and allow patients and visitors to see how clinical practice impacts on safety and quality. 

Download a poster from the Centre for Healthcare Redesign graduation, 2014.

Poster

Aim

To instil a culture of patient safety in Hastings Macleay Clinical Network (HMCN) by improving staff understanding of the connection between quality, evidence-based care and patient outcomes. 

Benefits

  • Improves patient safety, experience and outcomes.
  • Improves staff understanding of Quality Systems Assessments (QSA).
  • Improves communication among stakeholders, including nursing, medical, allied health, department managers and senior management staff.
  • Keeps units accountable for key performance indicators.
  • Provides an opportunity for staff to provide feedback and closes the Incident Information Management System (IIMS) feedback loop.
  • Prelude to preparing for accreditation against the national quality and safety standards.

Project status

Project dates: October 2013 - February 2014.

Project status: Sustained - This project has been implemented and is sustained in standard business.

Background

The Patient Safety Starts with ME project was initiated after an annual QSA and network staff surveys revealed that staff understanding of patient safety culture was 16% below the state average. There was a poor level of understanding by staff how the use of quality systems such as medication safety measures, risk assessments, initial admission interviews etc. can improve/affect patient outcomes. Patient stories also demonstrated a gap in patient assessments and outcomes (e.g. a missing mental health risk assessment of a depressed patient on a surgical ward).

Based on this feedback, the following priorities were established:

  • improved communication (between patients, carers and staff as well as amongst staff)
  • IIMS (lack of feedback of the IIMS management outcomes)
  • improved feedback (lack of timely feedback at times of poor staff performance)
  • a greater focus on teamwork
  • a greater focus on accountability (where staff are more accountable for their clinical practice and direct patient outcomes)
  • equipment (training and maintenance).

Implementation

  • Staff in-service education sessions about the project and its solutions were conducted.
  • Installed a patient safety board.
  • Installed an innovation board.

Implementation sites

  • Wauchope District Hospital general wards
  • Port Macquarie Community Health
  • Kempsey District Hospital Emergency Department
  • Port Macquarie Base Hospital Medical Ward 1C. 

Partnership

NSW Agency for Clinical Innovation Centre for Healthcare Redesign.

Results

  • Patient falls reduced from 5.24 per 1000 bed days in October 2013 to 2.88 in February 2014.
  • 30 percent of staff either ‘strongly agreed’ or ‘agreed’ that there was a strong positive patient safety culture in their unit prior to the project, with 90% indicating the same response following implementation of the project.
  • Staff surveys indicated that staff felt their ideas are now valued, they are empowered to improve patient care and are now engaged in quality activities.
  • There was a 22 percent improvement in patient safety culture in HMCN (QSA) following the project.
  • Enhanced leadership skills gained by the project team.

Lessons learnt

  • The importance of following the methodology and not jumping to solutions.
  • Quick wins are not always ‘quick wins’ - the solution we identified as an easy quick fix is still not complete.
  • The importance of identifying key stakeholders.
  • Identifying barriers.
  • The importance of clear communication.

Contacts

Christoph Groger
Clinical Quality, Redesign and Innovation Manager
Coffs Harbour Health Campus
Mid North Coast Local Health District
Phone: 0427 556 734
Christoph.Groger@ncahs.health.nsw.gov.au

Susanne Pritchard
Quality Coordinator
Hastings Macleay Clinical Network
Mid North Coast Local Health District
Phone: 02 5524 2056
Susanne.Pritchard@ncahs.health.nsw.gov.au

Emily Saul
Clinical Nurse Specialist 2, Medical Assessment Unit ward
Port Macquarie Base Hospital
Mid North Coast Local Health District
Phone: 02 5524 2000
Emily.Saul@ncahs.health.nsw.gov.au

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