Safety and Quality
Quality Policy Statement
NECH is committed to:
- Providing and establishing quality systems that continually evaluate and improve the quality of care and services for our consumers
- Complying with requirements and continually improve the effectiveness of the quality management system
- Ensuring relevant health care standards and statutory requirements are met
- Ensuring risks to consumers are identified and controlled to minimise effects to consumers
- Meeting quality objectives which are reviewed annually by the Board
Quality Patient Care
NECH is committed to the ongoing improvement of patient care in all areas. While we have an excellent record in delivering quality patient care and risk management our hospital continues to focus on improvements to ensure that our services are as safe as possible and that we are minimising our risks at all times.
NECH has a strong commitment to safety and quality which is reflected in our approach to:
- Creating safe environments and systems of work for our staff
- Continually reviewing and improving the performance of our patient safety and quality systems
- Assisting our healthcare professionals and Visiting Medical Officers to monitor the safety and quality of care they provide
- Ensuring accountability for the safety and quality of care at all levels of our organisation right through to the Board of Management
Clinical Governance Framework
NECH operates under a comprehensive Clinical Governance Framework based on an integrated approach to clinical risk management and continuous quality improvement. This Framework measures four major areas in organisational performance including:
Clinical Risk Management
Making sure our services are safe and minimising risk of error
- Our culture promotes and encourages staff to report incidents, risks and near misses
- Incident Management Policy outlines the process for assessing and investigating incidents
- Clinical policies are developed in accordance with evidence based best practice
- Clinical risk and safety policies are reviewed on a regular basis and updated as required
Clinical Effectiveness
Ensuring the clinical services we provide are effective
- Quality and Safety Indicators are used to measure and monitor performance
- Quality Improvement Requests are initiated when significant issues are flagged
- Quality and Safety Indicators are benchmarked nationally
- Serious Clinical Incidents are reported and investigated
- Clinicians are represented on Governance Committees
- High risk areas are audited on a regular basis
Effective Workforce
Making sure our staff are competent and up-to-date
- Facility rules are available to all existing and new medical and allied health personnel
- Ensuring a strict process for checking credentials, registration and scope of practice for all clinical disciplines
- Targeted education and competency requirements in all clinical areas with a particular focus on high risk areas
- Staff are orientated and updated on quality and risk systems
Consumer participation
Involving our patients and carers in their care
- Consumers participate in our risk management and quality improvement activities
- Consumer complaints and feedback processed are managed in a timely way
- Consumer feedback from patient satisfaction surveys informs strategic and business planning
- Open disclosure between clinicians and consumers is actively promoted when things don’t go to plan
Information on other safety related policies
At NECH we aim to minimise the risk of infection to patients, staff and visitors who come to our facility. This hospital has a number of programs in place to detect and prevent infections that are common in health care facilities.
One of the most effective means to prevent infection spreading amongst patients is for all health professionals to wash their hands.
Hand hygiene is conducted in accordance with the “five moments” that is; before touching a patient; before a procedure; after a procedure; after touching a patient and after touching a patient’s environment.
NECH conducts regular audits to ensure compliance with the national hand hygiene strategy.
Visitors to this hospital are encouraged through appropriate signage to use antiseptic hand rub located throughout the hospital. The Hand Hygiene brochure has more information on hand hygiene.
Read more at Five Moments for Hand Hygiene
The risk of falling increases with age according to data that suggests one third of people over the age of 65 years have one or more falls a year.
Falls-related injuries can include minor skin abrasions, joint dislocation, fractures and head injuries. These injuries may result in hospitalisation or an increased length of stay in hospital. The risk of falling can greatly increase when admitted to hospital due to a range of factors including illness and unsteadiness, adapting to a new environment, the introduction of new medications and walking in unsafe footwear or slippers.
Our falls prevention program targets those patients who we identify as being at risk. We use specific criteria and tools to risk assess our patients and then put in place a number of strategies to minimise falls whilst in hospital. We do this by educating our staff to ensure that the patient’s call bell and personal items are within reach; that call bells are attended to promptly; that patients are assisted to the toilet at regular intervals and that patients have the appropriate walking aids.
We monitor any unplanned return to theatre to the operating room within the same hospital admission and review the data collected to identify if any action is required. Obviously a low rate of return to theatre is desired however sometimes a return to theatre is unavoidable and can be a life-saving measure.
Our hospital reviews patients who have an unplanned readmission to hospital following discharge. Monitoring of this information is very important as it provides an indication of the effectiveness of our discharge program.
Medicines are commonly used to treat a variety of conditions in the healthcare setting and therefore it is important to measure the risk of errors. NECH is continually reviewing and implementing a range of medication safety strategies to further improve performance in this area.
The Australian Commission on Safety and Quality in Health Care has introduced a number of safety initiatives for medication administration and reconciliation and NECH has adopted many of these strategies. This includes the National Inpatient Medication Chart which standardises the documentation on how medications are prescribed and ordered.
Adoption by NECH of the User-applied Labelling of Injectable Medicines recommendations has assisted in preventing medication errors related to the wrong route, dose or medication being administered.
In addition NECH has medication administration policies and procedures in place which have been developed using best practice principles.
NECH takes all medication errors seriously, recognising that effective reporting supports both patient safety and quality care. Staff are encouraged to report all incidents, no matter how minor. All medication incidents are investigated and actioned, with serious incidents reviewed and monitored by the Clinical Adverse Events Review Committee.
Pressure injuries can be either wounds which form as a result of prolonged pressure to an area of skin or any skin injury whilst an inpatient. Pressure injuries are recognised worldwide as a common cause of harm to patients and could cause significant pain and discomfort which may result in a slower recovery for the patient.
NECH is equipped with modern equipment and resources to assist staff in preventing pressure injuries. On admission, patients are assessed using an evidence-based risk assessment tool, and any existing wounds or pressure injuries are carefully documented.
Staff implement individualised care plans aimed at minimising the risk of pressure injuries developing. This includes regular skin inspections, moisture management, maintaining skin integrity, optimising nutrition and hydration, repositioning patients regularly, and using specialised pressure-relieving mattresses where required.