Embedding safety & quality into everyday practice, words and deeds

Jan 15
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Once upon a time when I first took on a role in safety and quality, the most common response I had from clinical managers when I followed up with outcomes of clinical audits and/or clinical indicators was ‘patient comes first, quality comes second, I don’t have time for quality activities’…I was frustrated and disappointed whenever that happened as I could not figure out how quality and patient could be distinguished in such a way: isn’t patient safety and health outcome the purpose of quality? However there was no point to fight as I understood there were lots of other factors contributing to such a statement. In a word, it is the competing priorities that clinicians have to face every day…as a registered nurse who had been providing direct patient care in a clinical environment for over 15 years; I totally understand what it is like…

I started thinking about how to turn this kind of situation around and most importantly how to help staff realise the value of quality activities. I was very excited when the NSQHS Standards were introduced as I feel the languages that are used in each of the standards are so close to the heart of clinicians – hospital acquired infection, medication safety, patient identification etc. aren’t they what we do every day in our practice? and most of them are specific enough to measure!

With a passion, I completed the development of my first version of NSQHSS Audit Framework in December 2012, a month before the official implementation of NSQHSS across the country. I incorporated the key principles of governance, risk management and quality improvement in the framework and clearly link each of the measure/audit to the action numbers in the NSQHSS, outlining the audit scopes, audit KPIs, methodologies to be used, governance committees, frequencies and stakeholders accountable for each of the measure. I also developed the tools that could be used for those measures with reference to relevant policies and guidelines. The framework and tools were endorsed, piloted and successfully implemented for accreditation.   

The second time when I developed the framework for my current employer King Edward Memorial Hospital (KEMH), I went further to consult all key stakeholders who were responsible for each standard to make the framework suit their needs by building on existing knowledge, skills and activities. There was successful buy-in from each of the group who happily took on and worked collaboratively with me for lots of other activities and projects…

This is the pleasure and joy I have in my role as the Performance Review and Audit Coordinator for KEMH, Women and Newborn Health Service in Western Australia.

It is all about engagement and collaboration, about understanding and appreciation.

I do everything I can to help staff from all levels understand governance, safety and quality; I help staff who hold an interest in quality improvement (QI) to design and conduct QI projects; I work collaboratively with Directors, Heads of Department and other key staff to produce high quality comprehensive annual report, not only do we work together to demonstrate the achievements that departments/committees have made in safety and quality for each reporting period but we also work together to identity issues such as issues with data quality and find strategies for mitigation…

Last but not least, I would like to say that Safety and Quality is about raising the awareness and planting the seeds into everyone’s heart so that it can be embedded into our everyday practice, words and deeds. 

The Improving performance against the NSQHS standards Conference, taking place in May 2016, will explore approaches to making accreditation sustainable to prepare for the revised standards. Book your place by March 11th to save $500.

NSQHS Conference

Submitted by Catherine Li, Performance Review & Audit Coordinator, King Edward Memorial Hospital, Women & Newborn Health Services, WA

Catherine Li, Performance Review & Audit Coordinator, King Edward Memorial Hospital, Women & Newborn Health Services, WA

She holds a passion in safety and quality in health with a particular interest in quality improvement.

Catherine has previously worked as a Quality and Risk Coordinator and Learning and Organisational Development Coordinator.

Her background is in nursing with over 15 years’ experience in acute areas such as Emergency Services, Intensive Care and Cardiac Nursing.

She holds a Masters in Health Economics and Policy, Graduate Certificate in Economics and Graduate Diploma in Cardiac Nursing, all from the University of Adelaide, South Australia.

One thought on “Embedding safety & quality into everyday practice, words and deeds

  1. patient care does come first, the removal of so many staff members to attend quality meetings increases taking them away from the patient care which so rightly should be considered first. Agreed quality certainly does have a place but it should be done at an appropriate level.

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