Macquarie University Hospital

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Esther Booker
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1 Macquarie University Hospital Standard 1: Governance for Safety & Quality in Health Service Organisations Sharon Kuhn HR Director

2 Standard 1: Macquarie University Hospital Accreditation Implementation Objectives 1. Macquarie University Hospital 2. Brief Overview of the aims of Standard 1 3. Our Approach to the Accreditation process for all ten standards 4. Gap analysis findings 5. Evidence Breakdown what we prepared 6. Implementation and Role out 7. Audit outcome 1 8. Key learnings

Our Approach to the Accreditation process for all ten standards 4.

3 Macquarie University Hospital Who we are and our Triennial review against ISO9001 and NSQHS

4 Standard 1 Governance for Safety and Quality in Health Service Organisations Standard 1 provides the safety and quality governance framework for health services. The Standard underpins the application of all other standards. The governance systems are in place to set, monitor and continuously improve the performance of the organisation. The patient experience is at the centre of the intended outcome for this standard as it is wanting to ensure we have governance systems that maintain and improve the reliability and quality of patient care as well as improve patient outcomes. There is consistency across all health services across the country. 3

The governance systems are in place to set, monitor and continuously improve the performance of the organisation.

5 Approach to Triennial Accreditation The Establishment of a Senior Standards working party Allocated subject matter experts for all Standards. Buy in from Managers, Executive and the Board. Reporting of the Standards working party to all levels of the organisation. Recording of information going to the levels of the organization. Full Gap Analysis of each Standard against requirements. Use of the online resource library provided by the Commission Regular Communication with the Commission. One allocated person dedicated to ensuring consistency in application across all the standards. 4

Recording of information going to the levels of the organization. Full Gap Analysis of each Standard against requirements.

6 Gap Analysis Where we were when we started Our identified gaps Our approach to Core versus Development requirements What we did to address identified gaps The evidence we were able to provide (continues over next slides) 5

requirements What we did to address identified gaps The

7 Evidence Standard 1 Strategic Direction Strategic Plan and Business Plan Hospital By-Laws Management Commitment Governance Frameworks, Systems and Processes Quality Framework and Manual Enterprise wide Risk Management Framework Legislative Compliance Framework Policies and Procedures Document Review Procedure Committee Structure Internal and External Audit Program IT infrastructure/disaster recovery Privacy and Confidentiality Complaints Management Framework 6

Legislative Compliance Framework Policies and Procedures Document Review Procedure Committee Structure Internal and

8 Evidence Standard 1 Continued Clinical Clinical Indicator Reporting and Submission of Benchmarking Clinical trending Reports Access to Patient Rights and Responsibilities Patient Clinical records at point of care Internal Audit Schedule Quality Conformance Register Patient Information including Quality board Clinical Guidelines Clinical Risk Assessments and Clinical Risk Register (part of Enterprise Risk Framework) Patient Feedback process 7

Internal Audit Schedule Quality Conformance Register Patient Information including Quality board Clinical

9 Evidence Standard 1 Continued Employee Current organisational Structure Provision of Resources Position Descriptions Current Agency Contracts Roles, responsibilities and Accountabilities clearly defined Credentialing policy, process and audit Evidence of Succession Planning for key clinical governance positions. Delegations Manual Staff Feedback Performance Management System compliance for all staff Training and Compliance Framework A Proactive Safety Management System 8

and audit Evidence of Succession Planning for key clinical governance positions.

10 Role out and Implementation Dedicated Standards Champions Assigned Accountability with Clinical Nurse Educators An online intranet site with detailed Standard information including launch dates for each standard Standards information profiled in the Macquarie University Newsletter Routine alerts that went out daily online. Posters were developed for every standard as a visual prompt and additional information was listed on the staff noticeboards. In services were held routinely in every department. These contained case studies of examples against each Standard Every Standard had an education requirement, some more than others. We tackled this via a blended approach that involved in services, policy reviews, online learning, practical demonstrations, competency assessments. We also created trending reports for each standard. Standard 1, in part, was about ensuring compliance with all standards so everything was tracked and reported on via the online portal. 9

Posters were developed for every standard as a visual prompt and additional information was listed on the staff noticeboards. In services were held routinely in every department.

11 Outcomes Audit and Review Pre- Audit - our approach to understanding our compliance ahead of the audit Documentation of Actions and Evidence Triennial ISO Audit - information on ISO auditors approach to Triennial audit - evidence required and what was assessed Post Implementation and Certification - imbedding the standards - impact on culture 10

information on ISO auditors approach to Triennial audit - evidence required and what

Using the PDCA cycle in the real world

Using the PDCA cycle in the real world Qudos Management Pty. Ltd. Quality OHS Environmental management 320 Adelaide Street, Brisbane, QLD 4000 GPO Box 111, Brisbane, QLD 4001, Australia Tel: +61 7 3010 9259 Fax: +61 7 3010 9001 Web: www.qudos-software.com