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

Quality and safety are everyone’s business!

As many of you will be already aware, from 1 July this year, Metro North is moving to the new short notice assessment model which is being implemented across all Australian health services.

What does short notice accreditation assessment mean for Metro North Health?

• Instead of each individual Metro North hospital or directorate being assessed, Metro North will be assessed and accredited as a single Hospital and Health Service.
• Metro North will be assessed against all eight National Safety and Quality Health Service (NSQHS) Standards during our accreditation assessment.
• We will be provided with 24 hours’ notice of the commencement of our accreditation assessment for all Metro North hospitals and directorates.
• The on-site accreditation will last approximately one week with up to 50 assessors onsite. A large proportion of their time will be spent in clinical areas talking to staff and patients around how Metro North implements the NSQHS Standards in delivery of our daily healthcare services.
• A ‘not met’ or a ‘met with a recommendation received against components of the eight NSQHS Standards will apply to all of Metro North, not just an individual hospital or directorate.

In partnership with directorates, Metro North Clinical Governance, Safety, Quality and Risk (CGSQR) unit have developed an action plan and gap analysis to prioritise key bodies of work and will continue to work in partnership with all directorates in preparation and readiness for accreditation from July 2023.

Fact sheets and checklists for readiness and frequently asked questions are available on the new accreditation page on the Metro North Quality and Safety intranet site. Further information will be provided in the coming months including vidcasts with our Chief Executive Jackie Hanson, myself and other senior executives who chair the eight Metro North NSQHS Standards Committees.

It is an exciting time for our health service to undergo accreditation as one entity.  Our last accreditation assessment was four years ago and, therefore, it’s really important we take this opportunity to ensure we are embedding the NSQHS Standards as business as usual and to ensure we are providing kind, safe and inclusive quality care every day.

To our Metro North Executive Directors and directorate teams, Quality and Safety leaders and their teams, Metro North CGSQR unit and all Metro North staff, I would like to personally thank you and acknowledge the work undertaken so far and your great ‘can-do’ approach. I and the Metro North CGSQR team look forward to working in partnership with you all in the coming months and on an ongoing basis as we embed the new approach to accreditation assessment from our accreditation agency, the Australian Council of Healthcare Standard (ACHS).

For further information and resources on NSQHS Standards and accreditation please visit the QHEPS page. If anyone has any questions on the NSQHS Standards, feedback or ideas on our accreditation readiness, please reach out to your hospital and directorate leaders and/or your Safety and Quality teams or get in touch with myself or the Metro North CGSQR unit via MN_ClinGovQandRisk@health.qld.gov.au.

Standard 8

I would like to highlight Standard 8 of the National Quality Health Services (NSQHS) Standards after taking a deep dive this month – Recognising and Responding to Acute Deterioration. The intent of Standard 8 is to ensure that a person’s acute deterioration is recognised promptly, and appropriate action is taken.

When we think of acute deterioration, we may initially consider physiological changes, but Standard 8 also encompasses acute changes in cognition and mental state, such as that which occurs with delirium, for example.

The early identification of acute deterioration is key and Metro North directorates are prioritising and implementing number strategies to improve the detection and recognition of physiological and mental state (including delirium) deterioration.

New Safety and Quality Education Program website

I’m delighted to announce the launch of a new website for safety and quality education resources. Metro North CGSQR together with Clinical Skills Development Service have established the website to support healthcare professionals. The Safety and Quality Education Program website provides easy access to safety and quality education resources including courses, videos, guidelines, and tools on:

• Risk management
• Clinical incident management
• Communication
• Quality improvement
• Accreditation
• National standards

Courses and other resources are being developed and will be added to the website, providing users with an ever-expanding collection of valuable information and educational opportunities.

Visit the website for more information.

Norfolk Island

In January 2023, Metro North has reached a key milestone delivering a range of health support services to the Norfolk Island Health and Residential Aged Care Service (NIHRACS) for over 12 months. Metro North is providing a range of support services as part of a formal Intergovernmental Agreement between the Commonwealth Government and the Queensland State Government which came into effect from 1 January 2022.

As the Metro North Executive Lead for Norfolk Island, I have been amazed by the excellent support provided across our facilities and corporate areas to deliver on the approved suite of services, making a real difference to NIHRACS health staff and the broader Norfolk Island community.

On a recent visit to Norfolk Island, I had the privilege of meeting with the family of a patient that received care at RBWH in their final days. The family wanted me to pass on their thanks to a wonderful physio Sam and the team at the RBWH who made a real difference to their family, providing exceptional care to their family member. The family also asked if I would give Sam a copy of the funeral service booklet commemorating the life of their loved one. I was very pleased to be able to meet with Sam (who is currently on secondment to Metro South) to personally thank her on behalf of the family. Sam was extremely touched and noted she had some lovely memories of caring for this patient and meeting their family.

Metro North Norfolk Island Support Team

I’d also like to take the opportunity to acknowledge Karen Ryan, Director Norfolk Island Support Program and thank the Norfolk Island support team for the great work they have undertaken over the past 12 months transitioning NIHRACS from New South Wales to Queensland with Metro North as their nominated Health Support Service.

In addition, I’d like to thank all of the Metro North leaders and staff who reached out to myself to ensure NIHRACS were safe during the recent cyclone. We were all pleased to hear that they were not significantly impacted and were able to continue to deliver health care services.

If you have any questions about the support Metro North is providing to Norfolk Island, please contact the Norfolk Island Support Team via email NISupport@health.qld.gov.au

Kind regards,

Michele.