Projects and Programs
Current Projects and Programs
- Between the Flags - Keeping patients safe
- Blood Watch Program
- Central Line Associated Bacteraemia in Intensive Care Units
- The Clinical Leadership Program
- The Collaborating Hospitals' Audit of Surgical Mortality (CHASM)
- Communicating for Clinical Care Project
- Falls Prevention Program
- NSW Patient Safety Program
- Performance Indicators and Medication Safety Project
- Quality of Healthcare in NSW: A Chartbook 2007
- Special Reviews
- Toward a Safer Culture Project (Phase Two)
- Quality System Assessment Program
- Venous Thromboembolism Prevention Program
Concluded Projects
A number of Clinical Excellence Commission projects are now finished and are available in our archive »
Current Projects and Programs
We are in the process of providing more information about the range of projects and programs currently undertaken by the CEC.
Between the Flags - Keeping patients safe
The Clinical Excellence Commission (CEC) in collaboration with the NSW Health Quality and Safety Branch (QSB) commenced a significant body of work to address the internationally recognised need for clinicians to identify and manage early, deteriorating patients.
The early phase of the project build commenced in November 2007 and will be addressed in two (2) phases – with the initial phase focussing on diagnostics, and the later phase identifying, testing and evaluating possible solutions to this frequently-encountered problem. These earlier phases will be conducted over an eight (8) month project timeframe.
Blood Watch - improving transfusion medicine for patients in NSW
Blood Watch is a NSW state-wide transfusion medicine improvement program and its' primary goal is to improve the safety and quality of fresh blood product transfusion in all NSW Public Hospitals.
In keeping with national trends in improvements in transfusion medicine, the Blood Watch program will focus on these six key areas: appropriateness of blood component therapy; reporting of adverse transfusion related events; clinical governance issues; accurate costing of transfusion medicine; ongoing education of health care professionals; and communication of policy to address supply and demand issues.
The Blood Watch program is supported by all NSW Area Health Services and the Australian Red Cross Blood Service.
More information »
Blood Myths »
Central Line Associated Bacteraemia in Intensive Care Units
The Central Venous Line associated bacteraemia in ICU (CLAB-ICU) project, building on the work commenced through the ‘Safer Systems Save Lives’ Project has been designed to reduce Central Venous Catheter blood stream infections in Intensive Care Units across NSW. Conducted by the Clinical Excellence Commission in collaboration with the Intensive Care Coordination and Monitoring Unit (ICCMU) and with the assistance of the NSW Department of Health Quality and Safety Branch, the project is using a modified collaborative methodology to produce a number of key outcomes/deliverables including:
- The Development of a consensus NSW Health guideline/s for the insertion and management of Central Lines in ICU in NSW
- The implementation of the guideline in all ICU’s across NSW
- The development and facilitation of simple data collection systems to monitor project outcomes/on-going BSI indicators using existing data collections wherever possible to minimise the workload for clinicians
- The achievement of a measurable reduction in BSI rates (CVC-related) across all NSW ICU’s - Specifically, a target of 20% reduction in CLABS in ICU patients by January 2008 and a further reduction by 80% in CLABS in ICU patients by January 2010
- The development of sustainable systems and processes to support on-going reduction in CLAB’s across NSW ICU’s.
More information »
Frequently Asked Questions about the CLAB - ICU Project »
CLAB-ICU Project Photo Gallery »
The Clinical Leadership Program
The CEC Clinical Leadership Program (CLP) focuses on building capacity in a strategic, supportive manner by identifying and nurturing leadership talent within the NSW health system.
The program is offered in two modalities: The Statewide program uses a practice development framework and is delivered by facilitators employed in the area health service. The Modular program is aimed at senior network and Area leaders, and is delivered in Sydney by guest presenters, with some residential components.
Over 200 participants completed the program in 2007. 2008 cohorts have similar numbers, with 180 enrolled in the Statewide program and 35 in the Modular.
The program is currently funded for a 2-year period, with applications for the second year now closed. An evaluation process is in place to review program outcomes, and to consider future directions when seeding funding ceases in January 2009.
The Collaborating Hospitals' Audit of Surgical Mortality (CHASM)
The Collaborating Hospitals' Audit of Surgical Mortality (CHASM) is a systematic peer-review audit of deaths associated with surgical care. The CHASM program has the support of the NSW State Committee of the Royal Australasian College of Surgeons (RACS), the Clinical Excellence Commission (CEC) and NSW health system and is similar to audits of surgical mortality being established in Australian states.
The program is overseen in NSW by the CHASM Committee – formerly the Special Committee Investigating Deaths Associated with Surgery (SCIDAWS) – a committee of surgical peers that reports to the Minister for Health through the CEC.
CHASM is being progressively rolled out across NSW and commenced with two Area Health Services – Sydney West and Hunter New England from 1st Jan 2008.
Communicating for Clinical Care Project
The Communicating for Clinical Care Project aims to introduce and test trigger scenarios as an effective education tool in communication for use with ward level health care staff.
The project plans to:-
- Source existing teaching tools in communication and develop additional material and tools
- Test the tools at a range of demonstration sites in NSW
- Based on successes trialling the tools and supporting materials, develop additional tools in consultation with Area Health Service (AHS) representatives, and roll this education program out across NSW Health.
Teaching tools
- Emergency Trigger DVD & handbook - Trigger scenarios on DVD (12 scenarios) based on communication and teamwork that are based in an Emergency Department and at ward level.
- The Sydney Medical Simulation Centre (SMSC) - A training and research facility that specialises in clinical skills, human factors, and patient safety training for multidisciplinary critical care teams. It houses a suite of simulators and uses a variety of educational techniques, and specialises in 'Immersive simulation' (scenario-based/reflective learning with video debrief).
Download the Communicating for Clinical Care:-
Falls Prevention Program
Fall injury is a major cause of injury-related preventable hospitalisation and loss of independence among people aged 65 years and over in NSW. No other single injury cause, including road trauma, costs the health system more than fall injury. In addition to the health service costs, there is the hidden cost of the impact on the lives of older people and their relatives and carers. Fear of falling can be debilitating and lead to severe restrictions in activity and social interaction. While the problem emerges among older people, the root of the problem most likely lies in patterns of physical activity and diet in earlier years that interact with the processes of ageing and the environments in which older people live.
A problem of this magnitude required a systematic, multifaceted approach to be put in place as an investment in reducing future costs and service demands and improving the quality of life and independence of older people in NSW.
In order to meet this challenge, in July 2004 the NSW Health Minister announced the NSW Falls Policy. The responsibility for the implementation of the NSW Falls Policy is shared by agreement, with the Centre for Health Advancement NSW Department of Health and the Clinical Excellence Commission.
A Program Leader for NSW Falls Prevention Program has been appointed to the CEC to provide state-wide co-ordination and support to the Area Health Services. Each Area Health Service has appointed an Area Falls Co-ordinator to implement the NSW Falls Policy.
NSW Patient Safety Program
The NSW Patient Safety Program builds on previous policies, frameworks and strategies already in operation within the NSW health system to create what is potentially one of the greatest ever systemic improvements to clinical quality and safety.
Originally developed in 2002 to introduce a simple, standardised system-wide approach to improving the safety of healthcare provided in NSW, the objective of the program is to reduce harm to patients through the identification and rectification of system vulnerabilities. The program focuses on the management of all incidents and involves identifying, reporting, monitoring, investigating, analysing and acting appropriately on all incidents that occur in the health system.
As part of this program, the electronic Incident Information Management System (IIMS) was introduced in all Area Health Services in November 2004. The system records all healthcare incidents, including those that resulted in, or had the potential to result in a serious adverse event. IIMS assists managers to deal with incidents in their areas, record the results of reviews and investigations of incidents and provide reports on all incidents recorded in the system in a timely manner.
The CEC has established a Patient Safety Unit responsible for the analysis of statewide clinical incident data to identify trends and recommend preventative action to reduce the likelihood of adverse events, increase patient safety and improve clinical quality within the NSW health system.
Quality of Healthcare in NSW: A Chartbook 2007
The Clinical Excellence Commission is pleased to release Quality of Healthcare in NSW: A Chartbook 2007. The Chartbook aims to make the NSW health system better and safer for patients.
It is designed to stimulate both discussion and action across the system that will lead to improvements in the quality and safety of health services. The Chartbook is not a scorecard, nor does not include information on adverse events, which are presented in detail in other CEC and NSW Health publications.
The CEC will produce The Chartbook annually as a quality improvement monitoring tool to monitor and respond to changes in key areas of safety and quality.
Performance Indicators and Medication Safety Project
The two-phased PIMS project focused on improving medication safety systems and monitoring performance in quality use of medicines (QUM) in Australian hospitals. The NSW Therapeutic Advisory Group (NSW TAG) and the Clinical Excellence Commission worked together on this important project to improve medication safety in Australian hospitals.
The first phase of the PIMS project involved adaptation for Australian use of the Medication Safety Self Assessment® for Australian Hospitals and the Medication Safety Self Assessment® for Australian Hospitals and the Medication Safety Self Assessment® for Antithrombotic Therapy in Australian Hospitals, originally developed by the Institute for Safe Medication Practices (ISMP) in the U.S. These self assessments are risk assessment tools specifically designed to help hospitals take a proactive and system-based approach to medication safety. They will assist hospitals in meeting their obligations for accreditation and can drive change by identifying, and measuring, areas for improvement. The tools allow self assessment of the medication safety practices within a hospital, identification of improvement opportunities and comparison with the aggregate experience of demographically similar hospitals.
Hospitals are actively implementing the tools in Australia. For more information about the self assessment tools email mssa@cec.health.nsw.gov.au
The second phase of the PIMS project involved the revision of the 1998 NSW TAG Manual of Indicators for Drug Use in Australian Hospitals and the NSW TAG Performance Indicators for Drug and Therapeutics Committees.
This newly revised manual of Indicators for Quality Use of Medicines in Australian Hospitals has been produced by NSW TAG in collaboration with the Clinical Excellence Commission. The manual will enable hospital managers and clinicians to guide improvements in medication management in all types of hospitals across Australia.
The manual can be downloaded in full or as individual indicators. Where indicators are downloaded individually, we recommend the front section of the manual is also downloaded. The front section contains critical information on using the indicators to facilitate change as well as information on background to the project and the indicator development process.
To facilitate use of the manual, individual indicators may be reproduced with the following conditions:
- Indicators should be reproduced in their entirety including the copyright statement
- Excerpts of these indicators may be used providing NSW Therapeutic Advisory Group is acknowledged by referencing the excerpt to the Indicators for Quality Use of Medicines in Australian Hospitals.
Recommended citation:
- Indicators for Quality Use of Medicines in Australian Hospitals: NSW Therapeutic Advisory Group, 2007.
Click here to download the manual »
Special Reviews
The Minister for Health or NSW Health Director General may from time to time request the Clinical Excellence Commission (CEC) to conduct special reviews or inquiries in relation to the quality and safety of health care or matters of public health. The specific nature of any review will be determined by the Director General. The purpose of any review will be to bring about improvements in clinical quality and patient safety within NSW.
The role of the CEC may vary depending on the nature of the matter to be reviewed, but will generally focus on identifying issues of a systemic nature that affect patient safety and clinical quality in the NSW health system and developing and recommending implementation strategies to address these issues.
The Toward a Safer Culture Project (Phase Two)
The Toward a Safer Culture Project (TASC) is a joint initiative of the NSW Clinical Excellence Commission and the Royal Australasian College of Physicians. The TASC Project aims to develop a sustainable quality system to better translate guideline recommendations into clinical practice. TASC seeks to improve the acute management of patients who present with chest pain or stroke. Its aim is to ensure that all patients with these two conditions receive the best emergency treatment and secondary prevention that is both evidence based and expeditiously provided.
Currently in phase two (February 2003 - present), 35 hospitals in 7 Area Health Services across NSW are participating in this project. A key project strategy is to empower clinicians to adopt leadership roles in initiating practice improvement within their own organisation. To support this, the TASC project is promoting evidence based clinical pathways and a measurement system to promote clinical practice improvement. As an outcome patients in the participating hospitals will be assessed, diagnosed and treated according to the best available evidence.
Phase two of this project received the silver Premiers' Award for Excellence in 2005 »
Learn about phase one of this project »
Quality System Assessment Program
The Quality Systems Assessment (QSA) program is a new initiative for the NSW health system and a key component of the NSW Patient Safety and Clinical Quality Program. The QSA program will be developed for most organisations within the public health system including the eight Area Health Services (AHS), the Ambulance Service of NSW, Justice Health and Children’s Hospital at Westmead.
The main objectives of the QSA program are to provide evidence of the following:
- Assurance with compliance of
- Policies
- Standards
- Guidelines
- Assessment of the level of development of
- A patient safety system
- Clinical quality improvement
- The level of improvement at a local, facility and systems level
- The identification of future risks to patient safety
The QSA program will focus on the systems in organisations within the NSW Health System for quality and safety and not on individual performance.
- More information about this program »
- We invite your feedback on this program »
- Download the QSA Implementation Update 2007 brochure [PDF]
Venous Thromboembolism Prevention Program
The incidence of Deep Vein Thrombosis and Pulmonary Embolism, referred to as venous thromboembolism (VTE), has been found to be 100 times greater among hospitalised patients compared to those in the community. Developed by the National Institute of Clinical Studies, the Venous Thromboembolism Prevention Program aims to improve the assessment of all patients at risk, improve the use of preventive measures and integrate effective thromboprophylaxis systems into the core business of Australian hospitals.
Over forty hospitals from across Australia are participating in the program which provides training and support to participating hospital teams, including evidence-based risk-assessment and audit tools and reminder systems to ensure that effective prevention strategies are embedded in every day clinical practice. The National Institute of Clinical Studies' Stop the Clot Guide is a practical tool to help hospitals integrate venous thromboembolism (VTE) recommendations into routine hospital care. It has been designed for use by risk managers and clinicians in a variety of hospital settings. This and other tools from the VTE program have been made available to all hospitals in Australia and can be accessed via the NICS website here »
