Message from the Executive Director Clinical Governance, Safety, Quality and Risk

Accreditation

Accreditation is an important way of ensuring that we continue to deliver the high quality care which our community expects. Accreditation is independent recognition that the hospital and health services delivered in Metro North meet the National Safety and Quality Health Service Standards.

In Metro North, all directorates have full accreditation against the National Standards.

In 2023, Metro North is moving to a short notice accreditation model. Previous accreditation approaches meant months of preparation.

Short notice accreditation means that we need to be ready every day to be assessed against the National Standards.

What does this mean?

• Instead of accreditation at individual facilities, Metro North will be assessed as a single hospital and health service.
• With 1 or 2 days’ notice, any number of facilities and services may be assessed against the Standards.
• The on-site accreditation will last approximately 1 week with around 16 assessors onsite.
• During the three-year accreditation cycle, Metro North will be assessed against all standards by our accrediting body, ACHS (Australian Council on Healthcare Standards).

Several hospital and health services in Queensland have already moved to short notice accreditation including Metro South (Logan Hospital) and Wide Bay and their experiences have informed Metro North preparations.

Preparatory work across all directorates is underway. We have stood up a short notice accreditation working group with the Directors of Safety and Quality from each directorate and the Metro North Clinical Governance, Safety, Quality and Risk team, to identify any gaps in preparedness as well as best practice which can be shared.

Directorates are leading a range of improvement initiatives and resources will be added to the Safety and Quality website including FAQs and specific accreditation training developed by the Clinical Skills Development Service for safety and quality staff.

I will also be sharing facts and tips to assist with preparations on staff vidcasts over the coming weeks and showcasing some of the great work underway in Directorates which demonstrates Kind, safe and inclusive quality care every day.

Discharge with Support Policy & Procedure

This week I was delighted to join Jackie Hanson, our Chief Executive, and Sherry Holzapfel, Executive Director, Aboriginal and Torres Strait Islander Leadership Team, on the Metro North Health Equity vidcast to launch the new Metro North Health Discharge with Support policy and procedure which replaces, the now rescinded, Discharge Against Medical Advice policy and procedure.

The Discharge with Support policy and procedure was developed in response to a literature review which was commissioned in 2020 by the Australian Commission on Safety and Quality – ‘Understanding leave events for Aboriginal and Torre Strait Islander peoples and other Australians from health service organisations.’

This has been a journey for Metro North Health and late last year I had the privilege to invite Aboriginal and Torres Strait Islander colleagues and representatives from all directorates to attend a workshop to discuss how we progress this body of work. Actions agreed to at this workshop were:

• Change of terminology from DAMA to Discharge with Support.
• Focus to be on Supported Discharge.
• Individual patient follow-up post-early discharge across Metro North.

The intended outcome is:

• Patients are involved in all decision making.
• Patients are aware of available treatment options and/or community support should they decide to discharge early.
• Patients are aware of any potential health risks of discharging early.
• Where a patient has made the choice to discharge early, appropriate documentation and follow-up is carried out by staff.
• Now that the policy and procedure are live, the patients will not be required to sign a release form or to legally authorise their decision to discharge early.

Metro North is committed to ensuring a safe and culturally appropriate processes are in place to best manage the process of patients who choose to leave the hospital before the completion of treatment.

In accordance with the Human Rights Act 2019 (Qld), the Australian Charter of Healthcare Rights and person-centred care, patients have the right to health care and to be included in decisions and choices about their care. Patients with decision making capacity also have a right to discharge themselves prior to completion of treatment.

I would like to acknowledge Sherry Holzapfel, Executive Director Aboriginal and Torres Strait Islander Leadership Team, Kirsty Leo, Assistant Nursing Director, Aboriginal and Torres Strait Islander Health TPCH, Aboriginal and Torres Strait Islander colleagues, the Directors of Medical Services across Metro North and all those who participated in the working group workshops on the development of these new Metro North Health policies and procedures and for their commitment to ensuring our patients are involved in all levels of decision making regarding supported discharge. I encourage you all to familiarise yourselves with this documents that are available on QHEPS.

Policy https://qheps.health.qld.gov.au/__data/assets/pdf_file/0040/2788906/006814.pdf

Procedure https://qheps.health.qld.gov.au/__data/assets/pdf_file/0039/2788905/006393.pdf

Health Expo

As the Metro North Executive Lead for the transition of health support services for Norfolk Island, I had the pleasure of attending the Norfolk Island Health and Wellbeing Expo on 10 September with staff from the Metro North Norfolk Island Support Team and Clinical Skills Development Service. The Health Expo is an annual event organised by the Norfolk Island Health and Residential Aged Care (NIHRACS) Service with a focus on promoting community health and wellbeing.

As part of a formal Intergovernmental Agreement, Metro North Health is providing a range of health support services to NIHRACS and the broader Norfolk Island community. The Health Expo was a great opportunity to consolidate our partnership and meet members of the community and hear about their experiences of receiving care in our facilities and explain our role as a health support partner. The team also had a number of meetings with NIHRACS staff to discuss key transition priorities.