28 Jun Quality Care June 2019 – Ward Governance Update
Welcome to Quality Care, a monthly update with important information for Ward Governance Committees to implement in their ward and then share with their team by email, huddles, posting on your noticeboard or in your communications book.
We know that most people like to get information face-to-face, but we also know that the nature of shift work means that this isn’t always possible. The important part is to share the information so please, refer to these important items in your Ward Governance meetings, link to the newsletter in your emails and pop a copy on the noticeboard.
And if you have any suggestions for content or how we can help you communicate better, please email our Public Affairs and Communications team, or call or email me.
Executive Director, Quality, Safety and Patient Experience
Serious Clinical Incident Case Study
All Programs work with the Quality Unit to review adverse events. Once a month we will include an anonymised case study to highlight common themes we see in these reviews. Please review these learnings with your team and implement them to improve your clinical practice.
Case of the Month
A 79 year old lady, Mrs B was admitted for elective surgery. She had a past history that included open appendicectomy, hypertension, chronic back pain and ischaemic heart disease.
[The full, detailed Case Study, although anonymised does contains confidential information. A copy is available from your Ward Governance Committee or by contacting the Quality Team.]
What we want you to do and note:
- Ensure all craft groups enter adequate notes in the medical record, documenting name and unit, date and time of review, and where required a conclusion and plan
- Where unit specific ward round templates exist, that these are completed and the relevant sections are filled in. Alerts in the EMR and pathways will not work if the triggers for these are not entered.
- Ensure all fluid balance charts are completed, that the volumes are entered and the nature of the drain fluid is entered
- Severe post-operative pain needs to make you think of an operative complication, particularly if associated with abnormal vital signs
- Order blood for the following day the evening prior to ensure bloods are taken first thing in the morning. Ensure timely review of pathology tests and unusual /abnormal results are followed up promptly
- Vital signs may follow a pattern that should raise concern, even before they get into review or MET criteria, for example:
- maintaining an acceptable saturation but requiring progressively increasing doses of oxygen to achieve these
- A drop in blood pressure in conjunction with a rise in pulse rate
- Remember to look at the patient as a whole not just the part of the body that is of concern to your specialty
- Escalate concerns to a more senior nurse, to the nurse manager, DCO, overnight co-ordinator and for doctors to a registrar or fellow and if not directly to the consultant
Revised Point of Care Audit
The Point of Care Audit and Self-Assessment Audit Schedule has been redesigned to make the process easier and more accessible. The MARS audit is being rolled out now. Please ensure 10 patients per month are audited in your area every month. It ensures:
- A comprehensive audit program is available to inform ward governance teams;
- A reduction in the duplication across audit tools;
- Data informs improvement work;
- Implementation of the revised National Standards (second edition)
The audit will continue to be completed on MARS with monthly reports available for your local areas.
A PROMPT procedure document is available. Please contact Standards Manager, Rachel Vogelsang (Rachel.firstname.lastname@example.org or extension 44072) if you have any questions or feedback regarding the implementation of the audit and schedule.
Employee Flu Vaccinations at 78%
Get your flu shot now – don’t wait, the flu this year is severe and starting early.
Congratulations to the 12,388 Monash Health employees who have taken action against influenza! Thank you for taking this step and protecting yourself, your patients, your colleagues and your family.
This year there have been more than 26,000 influenza cases, which is a significantly higher number than in recent years and we want our organisation to be safe.
We know there are still 3,520 employees that haven’t had their vaccine yet. If this is your team, then they need to get their free vaccination as soon as possible. If they’ve already received the vaccination elsewhere or cannot receive a vaccination, then they must complete this simple online declaration form. Vaccinations are available at Dandenong, Casey, Cranbourne, Kingston, Monash Medical Centre, Moorabbin, Pakenham, and Thomas Street. The schedule is available on the intranet.
EMR Program Update
We have completed the Integration Testing phase of our EMR. This substantial body of work is vital to be able to produce a fit-for-purpose, safe and stable EMR. The work involved in completing this phase is impressive and moves us one step closer to Go-Live.
For all the latest news on EMR visit emrmonashhealth.org and create a shortcut on your smartphone. This website can be accessed from any device.
Mandatory training and performance appraisals
- Completion of mandatory training (Fire, iBelong, Social Media and OH&S) is below 90%.
- Completion of performance appraisals is at 48%.
How is your team performing? All employee must ensure they are up to date with their mandatory training and performance reviews. Accreditation will take place next year- don’t leave it to the last moment.
The Medication Storage and Security Audit
This audit is undertaken every six months and focuses on the legislative requirements related to medication storage and security. This includes medication refrigerators, trolleys, bedside lockers, imprest cupboards and documentation in Schedule 8 and 11 registers. In most cases, a pharmacist completes the audit in conjunction with the nurse/midwife manager (or delegate) in each area to improve awareness and timely actioning of areas for improvement.
Suboptimal results were noted in the following areas:
- Only 64% of medication trolleys not in use were locked — a 25% decrease on the last audit.
- In 33% of areas the medication trolley key was NOT held by a nurse/midwife or in a key safe — a 29% decrease on the last audit.
- Only 59% of areas had daily documentation (for the past 7 days) of the medication fridge temperature — a 5% decrease on the last audit.
Individual area results have been sent to Managers and Directors of Clinical Operations. Ensure actions to close all areas of non-compliance are documented on your Quality Improvement Plan. Note any deficiencies and ensure that these are corrected and if not escalated so that they can be resolved.
No eReferral means no specialist consulting appointment!
Doctors – once eReferral has been implemented in your unit an internal referral using eReferral in SMR is REQUIRED for a patient to receive a post discharge Specialist Consulting appointment. A discharge summary will no longer be accepted as a referral source.
An internal referral is quick and easy – complete the electronic referral via SMR! Click here for more information. Quick reference guides are available on Latte, the Monash Health Learning system. Search eReferral.
Remember, no e-referral, no appointment. If a patient needs review in outpatients following discharge, there must be an e-referral.
Policy, Procedure and Guideline update May 2019
Every month we release policy, procedure and guideline updates on Prompt. Review these updates and implement the changes to improve your clinical practice. Every month we will highlight key changes or new documents to prioritise across Monash Health:
Clinical Guideline: Pressure Injury: Prevention and Management
This document aims to standardise pressure injury prevention and management at Monash Health by amalgamating the existing pressure injury documents for various clinical settings into a clinical guideline. Pressure injuries are a frequently occurring, but largely preventable, health issue that cause significant physical, psychosocial and financial burden to individuals, families and healthcare organisations. A pressure injury can develop in as little as thirty minutes in an at-risk person. Early identification of an individual’s risk for pressure injury development is vital to determine care priorities and to ensure that pressure relieving strategies are implemented in a timely manner.
Procedure: Standard and Transmission Based Precautions are changing
Monash Health has new standard precautions from 1 July 2019 and they must be practiced at all times. Check the new procedures on Prompt and make sure you know what this means for your clinical practice: Transmission Based Precautions and Standard Precautions.
RED precautions will no longer be used:
- Well patients, with VRE or MRSA, will not require isolation
YELLOW precautions will be used for all patients with:
- Diarrhoea or uncontained stoma/faecal incontinence
- difficile, CRE and other multidrug resistant organisms
- Increased risk of infection transmission including scabies and extensive skin disease
Policy procedure and guideline update May 2019
|Pressure Injury: Prevention and Management||Standardises pressure injury prevention and management by amalgamating documents for various clinical settings into one clinical guideline.|
|Daily Operating Rhythm||Reflects the new flow of meetings to ensure patient access, timely decision making and escalation.|
|Ultrasound Transducers Disinfection||Describes the high level disinfection required for all ultrasound transducers.|
|Management of Risk – Guidance for Risk and Action Owners||Describes the steps to follow once a risk has been identified.|
|Template Checklist for Policy or Non-Clinical procedure||New checklist for non-clinical PROMPT documents.|
Surgical and Interventional Services
|Surgery for a Child or Baby with a Life-limiting Condition||Describes the process for documenting procedurally – relevant goals of care when children with life-limiting conditions undergo surgical or procedural intervention.|
|Insulin Dose Adjustment (Paediatric)||A framework for Diabetes Nurse Educators to provide advice to families of Monash Children’s outpatients requiring insulin dose adjustment.|
|Low Risk Febrile Neutropenia||New model of care for Monash Health (already in place at Royal Children’s) linked to state-wide guideline.|
Women’s and Newborn
|Bougie use for intubation (Neonatal)||Bougie use is increasing within Monash Newborn, and often forms part of an anaesthetic response in the setting of a difficult intubation. This procedure is intended to provide guidance on how to safely use (and/or assist others using) a bougie.|
|Inhaled nitric oxide use in pulmonary hypertension (Neonates)||Inhaled nitric oxide (iNO) is proven therapy for pulmonary hypertension in late preterm and term infants. This provides guidance on the use of iNO in newborn infants with pulmonary hypertension.|
|Transition to Home (Parent/ Carer accommodation rooms) Monash Newborn||Provides guidance for staff managing parent accommodation rooms.
|Transition to Home Checklist – Monash Newborn|
|Glidescope use for intubation (Neonatal)||Provides guidance on the use of video laryngoscopy (and specifically the Glidescope) in Monash Newborn.|
|Pathway for Mental Health Care for Refugees and Asylum Seekers||To guide staff to the correct referral pathway for refugees and asylum seekers for access to Mental Health Services.|
|Compounding Services – Aseptic and Cytotoxic Suite Cleaning||Internal pharmacy documents moved to PROMPT.|
|Compounding Services – General Principles of Cleaning||Internal pharmacy documents moved to PROMPT.|
|Compounding Services – Gowning and Degowning||Internal pharmacy documents moved to PROMPT.|
|Lisinopril (Oral) Monash Newborn Medication Profile|
|Vecuronium Monash Newborn/NeoMed Medication Profile|
|Junior Medical Staff (JMS) On-Call & Fatigue Management||Provides guidance managing the rostering of junior medical staff when there is concern regarding fatigue.|
|Ward 44 Discharge information for Patients, Families and Carers|
|Cardiac Care Unit Important Discharge Information|
|Calcium intake in pregnancy|
|Pelvic Organ Prolapse|
|Patient Information Approval Checklist|
|My Passport Coronary Care Unit (CCU) (patient information)|
|My Passport Monash Newborn (SCN) (patient information)|
|My Passport Moorabbin|
|My Passport Refugee Clinic (patient information)|
|Charter of Aged Care Rights (external)|
|Specialist Consulting Referrals|
Health Information Services
|iPM Discharge Date/ Time||Covers EMR implementation.|
|iPM Ward Transfers||Covers EMR implementation.|
People and Culture
|Employee Privacy||Describes the management of employee information, including the collection, use, disclosure and access.|
Revised Procedures and Guidelines