tim oon and distri t - swarh2.com.au · management of corporate documents dcs review once • •...
TRANSCRIPT
TIMBOON AND DISTRICT HEALTHCARE SERVICE
Service Wide Quality & Audit Plan
Organisation Wide Survey – June 2017
Quality & Audit Plan
2016 & 2017
Page 1 of 11
Abbreviation Position
CEO Chief Executive Officer
DCS Director Clinical Services
NUM Nurse Unit Manager
RN - SL Registered Nurse – Standard Leader
EN – SL Enrolled Nurse – Standard Leader
QM Quality Manager
EO Executive Officer / Communication
MBR Manager Business and Risk
HP Health Promotion
TM Theatre Manager
MM Maintenance Manager
OHS Occupational Health & Safety Manager
HRM Human Resource Manager
IFC Infection Control
Abbreviation Committee
EM Executive Management Team
PSQC Patient Safety & Quality Committee
MCC Medical Consultative Committee
Page 2 of 11
Standard 1 – Governance Standard leader: Gerry Sheehan 2016 2017
Activity Whom How Frequency J F M A M J J A S O N D J F M A M J J A S O N D
Policy and procedure framework DCS Review Once • •
Policy review & development DCS / QM Review Monthly • • • • • • • • • • • • • • • • • • •
Staff awareness & ability to access policy QM Audit Annual • •
Hard Copy policy manual – accuracy against PROMPT
QM Audit 6 monthly • • • •
Process for reporting of Legislative Compliance throughout organisation
MBR Review Once •
Operational plan progress / completion CEO Review Quarterly • • • • • •
Strategic plan progress / completion CEO Review Quarterly • • • • • •
KPI dashboard for Clinical Governance DCS Review Once •
Quality Framework policy and process DCS Review Once • •
Committee framework, structure, policy, process, minutes and minute storage
DCS Review Once • • •
Committee evaluation QM Audit Yearly • •
Orientation for managers HR Review Once • •
Orientation for staff / volunteers HR Review Once • •
Orientation for VMO’s and Nurse Prac DCS Review Once • •
Staff Handbook HR Review Annual •
VMO handbook DCS Develop Once • •
Risk Register MBR Review 6 monthly • • • •
Clinical Documentation / content audit QM Audit 6 monthly • • • •
Clinical Documentation staff training NUM Training Annual • •
Credentialing SOP Policy for VMO’s DCS Policy Once • •
Credentialing SOP Policy for Nurse Practitioners
DCS Policy Once • •
Allied health – credentialing, capability and competency framework principles
DCS Review Once • • •
PR&D manager training
HR Training Once •
PR&D – framework & completion HR Review Annual • • • • • • • •
Page 3 of 11
2016 2017
Activity Whom How Frequency J F M A M J J A S O N D J F M A M J J A S O N D
Review PR&D framework for VMO / NP DCS Review Once •
Explore models for accessing a Director of Medical Services
CEO Review Once • • • •
Peer review program for VMO’s DCS Review Once • • • •
Incident management reports and trending for managers and staff
QM Audit Monthly • • • • • • • • • • • • • • • • • • • • • • • •
Complaints management reports and trending for managers and staff
QM Audit Monthly • • • • • • • • • • • • • • • • • • • • • • • •
Complaints Management framework and policy
DCS Review Once • • •
Consent Policy compliance NUM Audit Annual • •
National Open disclosure standard review and compliance
QM Audit Annual • •
Advance care planning training NUM Training Annual • •
National Open Disclosure training QM Training Annual • •
Communication plan – internal EO. Review Once • • • • • •
Electronic access for contemporaneous documentation
NUM Implement Once • • •
Audit tools – across all standards DCS Review Once • • •
Implementation of electronic medical record program
DCS Review Monthly • • • • • • • • • • • • • • • • • • • • • • • •
Privacy audit QM Audit Monthly • •
Mandatory training day / SOLLE16 DCS Audit Annual • •
Patient satisfaction survey QM Audit Monthly • • • • • • • • • • • • • • • • • • • • • • • •
Page 4 of 11
Standard 2 – Engaging Consumers Standard leader: Kim White 2016 2017
Activity Whom How Frequency J F M A M J J A S O N D J F M A M J J A S O N D
Establish a Consumer Advisory Group EO Review Once • •
Patient information / brochures DCS Review Quarterly • • • • • •
The Quarterly EO Publish Quarterly • • • • • • • •
What’s On Newsletter EO Publish Monthly • • • • • • • • • • • • • • • • • • • • • • • •
Social media / webpage strategy EO Launch Once • • • •
Rights and Responsibilities NUM Audit Quarterly • • • • • •
Consumer Participation plan DCS Develop Once •
Consumer Participation plan DCS Review Annual •
Doing with you not for you framework DCS Review Once • •
WOW Moments display boards DCS Implement Once •
Health Literacy – PCP DCS Training Annual • •
Culturally and Linguistically Diverse DCS Audit Annual • • • •
Develop a Cultural Responsiveness Plan DCS Develop Once •
Cultural Responsiveness Plan DCS Review Annual •
Standard 3 – Infection Control Standard leader: Heather Power 2016 2017
Activity Whom How Frequency J F M A M J J A S O N D J F M A M J J A S O N D
Antimicrobial Stewardship education VMO
IFC Training Once •
ANTT competency – VMO’s IFC Training Once • •
Antimicrobial Stewardship - Audit IFC Audit 6 monthly • • • • Infection prevention Risk Management Plan IFC Implement Monthly • • • • • • • • • • • • • • • • • • • • • • • •
Cleaning Standards IFC Audit Monthly • • • • • • • • • • • • • • • • • • • • • • • •
Influenza vaccination program IFC Audit Annual • •
Page 5 of 11
Standard 4 – Medication Safety Standard leader: Tricia Klemm and Margaret Tesselaar 2016 2017
Activity Whom How Frequency J F M A M J J A S O N D J F M A M J J A S O N D
National Inpatient Medication Chart RN - SL Audit Annual • •
Medication related polices -streamline DCS Review Once •
Schedule 8 and schedule 11 medications RN - SL Audit Annual • •
Pharmacy Service including medication reconciliation
DCS Review Once • • • •
Medication Management System DCS Review Annual • • • •
Patient Information sheets RN - SL Review Once •
Medication fridges – monitoring / audit RN - SL Audit Monthly • • • • • • • • • • • • • • • • • • • • • • • • High risk medication review DCS Review Once •
TGA reporting policy DCS Review Once •
Review medication resources NUM Review Once •
Counselling for identified staff members following medication incidents
NUM Education PRN • • • • • • • • • • • • • • • • • • • • • • • •
IV labelling practice against the standard NUM Review Once •
Imprest and wastage DCS Audit Annual • •
Medication incidents NUM Review Monthly • • • • • • • • • • • • • • • • • • • • • • • • Discharge medication patient lists DCS Review Once •
Medication keys – system NUM Review Once •
Drugs, Poisons and Controlled Substance Permit
DCS Update Once •
Poisons Control Plan DCS Develop Once •
Poisons Control Plan DCS Review Annual • •
Page 6 of 11
Standard 5 – Patient Identification Standard leader: Michelle Selten 2016 2017
Activity Whom How Frequency J F M A M J J A S O N D J F M A M J J A S O N D
Policy and procedure DCS Review Once •
Patient Identification QM Audit Annual • •
Correct Person Correct Procedure correct Site
QM Audit Annual • •
Alert chart / Allergies NUM Review Once •
Allied Health / Community process DCS Review Once •
Standard 6 – Clinical Handover Standard leader: Lynn Marr 2016 2017
Activity Whom How Frequency J F M A M J J A S O N D J F M A M J J A S O N D
Bedside Handover – Nurse to Nurse QM Audit Annual • •
On call Handover – Medical Practitioner DCS Review Once •
Handover in UCC to Ambulance Victoria DCS Review Once •
Transfer form DCS Review Once •
Transfers Out – ward / UCC QM Audit Monthly • • • • • • • • • • • • • • • • • • • • • • • •
Discharge Planning QM Audit Annual • •
White Boards – Patient Rooms DCS Develop Once •
Patient Experience – bedside handover QM Audit Annual • •
Standard 7 – Blood and Blood Products Standard leader: Karen Kennett 2016 2017
Activity Whom How Frequency J F M A M J J A S O N D J F M A M J J A S O N D
Blood and Blood product administration QM Audit Monthly • • • • • • • • • • • • • • • • • • • • • • • •
Blood wastage QM Audit Monthly • • • • • • • • • • • • • • • • • • • • • • • •
Cold Chain Policy and Audit QM Audit Monthly • • • • • • • • • • • • • • • • • • • • • • • •
Blood fridge DCS Purchase Once •
Page 7 of 11
Standard 8 – Skin Integrity Standard leader: Michelle Selten 2016 2017
Activity Whom How Frequency J F M A M J J A S O N D J F M A M J J A S O N D
Imprest and streamline of products NUM Review Once • •
Skin Risk Assessment QM Audit Once • •
Pressure Injury Point Prevalence QM Audit Once • •
Mattress QM Audit Once • •
Pressure prevention equipment QM Audit Once • •
Patient Information DCS Review Once • •
Standard 10 – Falls Prevention Standard leader: Lynda McKenzie 2016 2017
Activity Whom How Frequency J F M A M J J A S O N D J F M A M J J A S O N D
Falls Risk Assessment QM Audit Annual • •
Falls prevention equipment QM Audit Annual • •
Patient Information QM Audit Annual • •
Standard 11 – Information about services / access and admission / patient consent / appropriate and effective care / population health Standard leader: Kim White 2016 2017
Activity Whom How Frequency J F M A M J J A S O N D J F M A M J J A S O N D
Informed consent – perioperative NUM Audit Annual • •
Preadmission process TM Review Once • • • •
Perioperative admission and waiting list prioritisation
TM Review Once • • • •
Waiting list TM Audit Annual •
LifeMap HP Review Once • • • •
Dementia & Delirium framework NUM Review Once • • • •
Dementia & Delirium framework NUM Audit Annual •
Page 8 of 11
Standard 9 – Managing the Deteriorating Patient Standard leader: Ingrid Rial and Julie Giblett 2016 2017
Activity Whom How Frequency J F M A M J J A S O N D J F M A M J J A S O N D
Fluid Balance Chart – Policy NUM Develop Once • •
Observation Chart QM Audit Annual • •
Observation – Policy DCS Review Once • •
Blood Alcohol Testing in UCC – Policy NUM Develop Once • •
Mortality review reporting QM Audit Monthly • • • • • • • • • • • • • • • • • • • • • • • •
Transfer Out of ward / UCC QM Audit Monthly • • • • • • • • • • • • • • • • • • • • • • • •
Hospital Standardised Mortality Ratio (HMSR)
DCS Audit Quarterly • • • • • • • •
Tele-Medicine set up DCS Develop Once • • •
UCC referral pathways DCS Develop Once • • •
Medical Emergency Response Policy DCS Review Once • • •
Emergency Trolley contents NUM Review Once •
Basic Life Support DCS Training Annual • • • •
Advanced Life Support DCS Training Annual • •
ALS trained staff on roster QM Audit Annual • •
Implementation of ViCTOR observation charts
DCS Implement Once • • • •
Implementation of ViCTOR UCC charts DCS Implement Once • • • •
How do patients escalate care DCS Audit Annual • •
Emergency reviews NUM Audit Monthly • • • • • • • • • • • • • • • • • • • • • • • •
Mock code blue / MER calls NUM Training Quarterly • • • •
Page 9 of 11
Standard 12 – Assessment & Care Planning / Management of Nutrition / Ongoing Care and Discharge & Transfer / End-of-Life Care Standard leader: Kim White 2016 2017
Activity Whom How Frequency J F M A M J J A S O N D J F M A M J J A S O N D
Referral to relevant service provider - internal
QM Audit Annual • •
External Service Provider
QM Audit Annual • •
Nutrition & Menu Planning policies DCS Review Once •
Screening / Assessment tool – Nutrition DCS Audit Annual • • • • • • • • • • • • • • • • • • • • • • • •
Food Services Caregiver education
DCS Training Quarterly • • • • •
Waste – supplement / food
DCS Audit Annual • •
Number of discharge summaries received by GP within 48 hours of discharge
DCS Audit Annual • •
Discharge referrals – satisfaction DCS Audit Annual • •
Discharge information brochure DCS Audit Annual • •
Care of the Dying Policy DCS Review Once •
Palliative Care Satisfaction – patients, families and caregivers
DCS Audit Annual • •
Standard 13 – Workforce Management Standard leader: Gerry Sheehan 2016 2017
Activity Whom How Frequency J F M A M J J A S O N D J F M A M J J A S O N D
PR&D System – managers & staff HRM Audit Annual • • • •
Leadership Development HRM Training Once • • •
Workforce and Succession Plan HRM Develop Once • • •
Training Matrix DCS Develop Once • • •
Position Descriptions DCS Review Once • • •
SOLLE16 DCS Implement Once • • • • •
Page 10 of 11
Standard 14 – Records / Information Management Standard leader: Kim White 2016 2017
Activity Whom How Frequency J F M A M J J A S O N D J F M A M J J A S O N D
Allied Health medical record HIM Audit Annual • •
Electronic Health Record Accelerated Program (EHRAP)
DCS Implement Once • • • • • • • • • • • • • • • • • • • • •
VAED DCS Audit Annual • •
Management of corporate documents DCS Review Once • • •
Standard 15 – Occupational Health & Safety Standard leader: Gaye McVilly, OH&S Coordinator 2016 2017
Activity Whom How Frequency J F M A M J J A S O N D J F M A M J J A S O N D
Hoist – ceiling and standing OH&S Review annual • •
Hoist - slings OH&S Audit 6 monthly • • • •
Radiation accreditation DCS Audit Annual • •
Manual Handling – No-Lift DCS Training Annual • •
Standard 15 – Waste Management Standard leader: Maintenance Manager 2016 2017
Activity Whom How Frequency J F M A M J J A S O N D J F M A M J J A S O N D
Clinical waste management DCS Review Annual • • • •
Recycling DCS Review Once • •
Standard 15 – Buildings / Plant / Equipment Standard leader: Maintenance Manager 2016 2017
Activity Whom How Frequency J F M A M J J A S O N D J F M A M J J A S O N D
Preventative Maintenance Schedule MM Audit Monthly • • • • • • • • • • • • • • • • • • • • • • • •
IProcument – South West Central Supply DCS Implement Once • • • • • •
Page 11 of 11
Standard 15 – Emergency & Disaster Management Standard leader: Gaye McVilly, OH&S Coordinator 2016 2017
Activity Whom How Frequency J F M A M J J A S O N D J F M A M J J A S O N D
Bushfire Preparedness and Response OHS Review Once • •
Emergency Manual Review OHS Review Once • •
Fire safety – external inspection OHS Review Once •
Code Brown OHS Review Once • •
Code Red – practical exercise OHS Training Quarterly • • • • • • •
Code Orange – practical exercise OHS Training Annual • •
Heat Management OHS Review Annual • •
Summer Preparedness OHS Review Annual • •
Standard 15 – External Service Providers / Contractors Standard leader: Gaye McVilly, OH&S Coordinator 2016 2017
Activity Whom How Frequency J F M A M J J A S O N D J F M A M J J A S O N D
Contractor policy and procedure OHS Review Once • • •
Contractor Handbook OHS Review Once • • •
Contractor database DCS Review Once •
Standard 15 – Physical & Personal Security Standard leader: Maintenance Manager 2016 2017
Activity Whom How Frequency J F M A M J J A S O N D J F M A M J J A S O N D
Register of staff property DCS Implement Once • •
Risk Assessment DCS Audit Once • •
Code Grey DCS Review Once • •