Executive Director Clinical Governance, Safety, Quality and Risk: Michele Gardner

It is my great pleasure to welcome Shirley Thompson as the new Director of Nursing, Clinical Governance, Safety, Quality and Risk (CGSQR). Shirley joins us from Patient Safety and Quality within Metro South Health Governance where she was the Acting Associate Director of Nursing, bringing with her a wealth of knowledge in all thing’s safety & quality.

I will have the pleasure of acting as Chief Operating Officer from 12 December 2022 – 25 December 2022 while Jane Hancock takes some very well-deserved leave. I will then be taking some leave myself for three weeks in January. Following an EOI process, Belinda Faulkner will act as Executive Director, Clinical Governance, Safety, Quality and Risk during this time. Many of you will know Belinda from her role as Director of Clinical Skills Development Service and when she has also previously acted in the Director of Nursing CGSQR role.

Short notice accreditation assessment program (SNAAP) Update:

A lot of people often ask me why we have healthcare accreditation. The Australian Commission on Safety & Quality in Health Care perfectly summarises this:

“The National Safety and Quality Health Service (NSQHS) Standards were developed by the Australian Commission on Safety & Quality in Healthcare (the Commission), in collaboration with the Australian Government, states and territories, the private sector, clinical experts, patients and carers. The primary aims of the NSQHS Standards are to protect the public from harm and to improve the quality of health service provision. They provide a quality assurance mechanism that tests whether relevant systems are in place to ensure that expected standards of safety and quality are met.”

Accreditation is an important, independent assurance that the hospital and health services delivered in Metro North Health meet the National Safety and Quality Health Service Standards. The introduction of short notice will ensure the assessment outcome reflects day to day practice, identifying gaps and supporting health service organisations to improve safety and quality systems and processes.

Benefits of short notice accreditation include:

• Supporting the continuous compliance with the NSQHS Standards and quality improvement strategies
• Removing the administrative burden from preparation for accreditation, enabling the workforce to redirect their efforts to other priorities
• Transferring the focus of assessments from preparation for assessments to assessment of day-to-day practice
• Changing the perception of a not met action from ‘systems and services failure’ to an ‘opportunity for improvement.

In 2023 we are changing from announced accreditation to short notice accreditation. The short notice accreditation model means Metro North Health will be given 24 hours’ notice for the sites which assessors will visit. All eight standards will be assessed across selected sites. We are now also being assessed as a whole hospital and health service against the eight National Standards, not individual facilities or services.

Short notice accreditation is a point in time assessment of the standard of healthcare that we provide to our community every day. No announcement is made for when assessors will visit wards, but staff will be made aware they are on site within the health service – this allows quality care to be observed as it is delivered every day.

Metro North Clinical Governance, Safety, Quality and Risk together with Directorate Executive Directors, Directors of Safety & Quality and their Safety and Quality Teams are leading work to assess how we meet the National Standards, identify gaps for improvement, and share good practice across Metro North. One of the key tools to ensure we are meeting the national standards is peer reviews. This process involves safety and quality teams visiting the facilities of their peers and undertaking a review against the eight national standards. Commencing at Caboolture, Kilcoy and Woodford last week, I would like to thank staff for their openness to assessing their services against the national standards. The peer review process will be rolled out to all Metro North Directorates over the coming months, on an ongoing basis.  The Patient Safety and Quality website now has a new webpage on accreditation information and resources. I encourage you to familiarise yourselves with the resources available.

As I visit wards and services throughout Metro North, it is reassuring to see the commitment to high quality care across our facilities and services, the examples of excellent care and practice, and the willingness to improve.

As we prepare for short notice accreditation, Metro North Health is committed to kind, safe and inclusive quality care every day.

Safety and Quality Education Program website coming soon!

Clinical Governance Safety, Quality and Risk together with the Clinical Skills Development Service has been developing the new Safety and Quality Education Program (SQEP) website.

SQEP will provide the opportunity to improve safety and quality knowledge and skills by delivering easily accessible training, education, and resources in a centralised location.

Offering online and virtual courses on topics including:

• Clinical Best Practice
• Clinical Incident Management
• Risk Management
• Communication Improvement
• Quality Improvement
• Safety Culture

The website is currently undergoing user testing and will be launching early 2023! Watch this space for the exciting launch of this great asset for Metro North Health.

Standard 3

This month I would like to put the spotlight on Standard 3 – Infection Control. Daily practices matter and one daily practice that we need to ensure we get 100% every time is providing a clean environment for our patients, families, carers and staff.

The intention of Standard 3 is to reduce the risk of patients acquiring preventable healthcare-associated infections, effectively manage infections if they occur, and limit the development of antimicrobial resistance through prudent use of antimicrobials as part of antimicrobial stewardship. While this standard has a broad scope across our health service, I would especially like to point out the importance of maintaining a clean environment.

Working in healthcare it is important that we continually ask ourselves “what processes are used to maintain a clean and hygienic environment?”. I also ask that leaders ensure they are looking at the data to ensure we meet the needs of our patients and are appropriately aligned to the Australian Guidelines for the Prevention and Control of Infection in healthcare.

I hope you all have a wonderful weekend and thank you for all of the amazing work each and every one of you do everyday.

Kind regards,

Michele