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The Clinical Excellence Commission The eChartbook


QUALITY SYSTEMS ASSESSMENT - OVERVIEW For more information, click here
A key component of the Patient Safety and Clinical Quality Program
For more information about this CEC program, click here
 


Why is this important?


The Walker Inquiry into Campbelltown and Camden Hospitals (2004) [1] found gaps in systems of safety and quality that had led to adverse patient outcomes. This resulted in the development and implementation of the NSW Patient Safety and Clinical Quality Program - PD2005_608 [2].


The Clinical Excellence Commission was appointed to oversee its implementation across NSW and to develop a Quality Systems Assessment (QSA) as a critical piece of infrastructure to monitor the rigor of safety and quality systems.


The Quality Systems Assessment (QSA) is a multi-level and system-wide clinical risk management framework that aims to benefit patient safety and clinical quality, through a focus on annual priority risk topics.


eChartbook
Note: Districts/Networks include both Acute and Community Health Services

To succeed, a foundation principle of the QSA is that it seeks to understand practice as it happens, not whether it is right or wrong. Focusing on practice as it happens creates a safe and direct voice for clinicians and unit level managers into the systems that impact their work.


The QSA exists in an open and just context that supports honesty at all levels, with an obligation to act on risks as they are identified. In this manner, the QSA contributes to ongoing organisational learning and resilience. Resilience means that a system stands up under pressure, recovers quickly and, most importantly, learns when it fails. A learning system is one that adapts and improves to changes in its environment.


The QSA is a commitment to risk management and learning in health care. As such, it is a commitment to the people of NSW and their confidence in the NSW public health system.


To honour this commitment, it is important that the effort of identifying strengths and risks in safety and quality systems is matched by the effort and effectiveness of continuous improvement.


References

[1] Final Report of the Special Commission of Inquiry into Campbelltown and Camden Hospitals, Bret Walker SC, 30 July 2004
[2] NSW Patient Safety and Clinical Quality Program - PD2005_608
[4] Final Report of the Special Commission of Inquiry into Acute Care Services in NSW Public Hospitals, Peter Garling SC, 27 November 2008 (Garling Report)
[5] Clinical Excellence Commission, 2014, Safer Systems Better Care - Quality Systems Assessment Statewide Report (2013), Sydney: CEC


Findings


The QSA has a high self-assessment participation and accuracy rate (both > 97 per cent annually). Accuracy is demonstrated in the verification of self-assessment answers at the onsite visits. This means that the system, and local teams, can have confidence in the findings and recommendations of the QSA clinical risk management approach.


Across the system level, there is a perception of a positive patient safety culture, with 56 per cent of respondents strongly agreeing (97 per cent Agree + Strongly Agree) in 2014 (Chart QSA02). This is a significant improvement to the 2009 figures, where only 34 per cent of respondents strongly agreed that there was a positive patient safety culture in their clinical unit. It should be noted that 2009 aligned with the time of the Special Commission of Inquiry to Acute Care Services [4] and was before devolution to local health districts.


The perception of clinical governance structures remains the same as that in 2013, with 38 per cent all Strongly Agreeing that their organisation has clear, integrated and effective processes for safety and quality, including risk management and clinical incident management systems (Chart QSA03). The perceived alignment of resources and training to achieve the organisations safety and quality goals remains relatively unchanged as well, with 23 per cent strongly agreeing in 2014, compared to 22 per cent in 2013 (Chart QSA04).


Identifying patients, their carers and families as integral to the health care team has shown improvements across NSW since 2012. In 2014, 40 per cent of respondents strongly agreed that patients and carers are integral to the health care team (88 per cent strongly agreed + agreed), compared to 33 percent strongly agreeing in 2012 (81 per cent strongly agreed + agreed) (Chart QSA05). It is important that QSA findings generate appropriate local and system level improvement responses.


From the self-assessment and the onsite visit process, a number of system level recommendations are made in the annual QSA: Safer Systems Better Care Report. Since the initial QSA in 2007/08, these now number 79 recommendations in total.


Implementation of these recommendations is monitored annually through self-reporting from the organisation to the CEC and via presentation during the onsite visits. As at February 2014, 66 per cent of all recommendations were reported as "fully implemented", showing a consistent incremental improvement in total recommendation implementation, while new recommendations are identified each year (2015 implementation progress is currently being reviewed and will be updated shortly).


Each year's topics have their own findings and recommendations to consider, specific to the annual priority clinical topics. If you would like to find out more, please click below:


Implications


Ultimately, good information supports improved decision making. The QSA provides a unique multi-level perspective of the connections between local organisation level structures and clinical unit practice.


In an evolving health landscape with multiple variables, QSA data indicates that there are gradual net improvements to clinical governance, safety and quality.


There are also consistently high QSA participation and accuracy rates, as well as gradual improvements in the total proportion of QSA recommendations being fully implemented. This further indicates the commitment to quality and safety across NSW health and that the QSA, itself, is an important piece of that commitment.


What we don't know


The QSA seeks to understand practice as it happens, not whether it is right or wrong. For this reason, care must be taken to interpret QSA data in the local context. At the system level it is impossible to know whether a local response is representative of:

  • A gap in systems, structures or processes
  • A gap in perceptions between local clinical specialties/teams
  • A gap in perceptions between organisation levels
  • A local disruption, such as a change of governance structures, introduction of a new clinical system, a significant clinical incident, or contentious media event.

While the QSA provides critical infrastructure and information to identify local and system level risks, and monitors the level of recommendation implementation by the organisations, we do not know:
  • The tangible outcomes and impacts of implementation in each organisation
  • The full penetration of implementation to some, most or all clinical units
  • What local improvement processes were initiated in addition to, or instead of the system level recommendations
  • What methods, capabilities and resources are required to optimise local implementation outcomes
  • The degree to which the QSA alone adds value
  • How the health system needs may change in coming years may impact on its needs, structures and functions from the QSA.

Chart QSA01 - Annual QSA Topic areas
 
eChartbook
Source: Quality Systems Assessment, Clinical Excellence Commission.


Chart QSA02 - Quality and Safety culture by LHD/SN and year
 
Agreement of unit level respondents (per cent) for "There is a positive patient safety and quality culture in our department or clinical unit" by LHD (acute services only) /SN and ASNSW (n=1,446)

eChartbook
Source: Quality Systems Assessment, Clinical Excellence Commission.


Chart QSA03 - Clinical Governance (systems /structure) by LHD/SN & year
 
Agreement of unit level respondents (per cent) for "The organisation has clear, integrated and effective processes for safety and quality, including risk management and clinical incident management systems" by LHD (acute services only) /SN and ASNSW (n=1,446)

eChartbook
Source: Quality Systems Assessment, Clinical Excellence Commission.


Chart QSA04 - Clinical Governance (resources) by LHD/SN and year
 
Agreement of unit level respondents (per cent) for "All staff are provided with adequate information, resources, training and professional development to support the organisation's quality & safety processes" by LHD (acute services only) /SN and ASNSW (n=1,446)

eChartbook
Source: Quality Systems Assessment, Clinical Excellence Commission.


Chart QSA05 - Patient Based Care by LHD/SN and year
 
Agreement of unit level respondents (per cent) for "Patients and their families and / or carers are viewed as integral members of the health care team" by LHD (acute services only) / SN (n=1,446)

eChartbook
Source: Quality Systems Assessment, Clinical Excellence Commission.


Chart QSA06 - QSA Evaluation by LHD/SN and year
 
Agreement of all respondents for "The QSA self-assessment is a valuable process that assists our Department or Clinical Unit to improve our quality and safety systems" by LHD (acute services only) /SN and ASNSW (n=1,577)

eChartbook
Source: Quality Systems Assessment, Clinical Excellence Commission.


End Matter


Contributors
Drafted by: CEC Quality Systems Assessment team
Data analysis by: CEC eChartbook team
Reviewed by: CEC Quality Systems Assessment team
Edited by: CEC eChartbook team


Suggested citation
Clinical Excellence Commission (2014). eChartbook Portal: Quality Systems Assessment. Sydney: Clinical Excellence Commission. Available at:http://www.cec.health.nsw.gov.au/echartbook/cec-indicators-intro-chartbook/qsa-overview/ Accessed [insert date of access].


© Clinical Excellence Commission 2014
This work is copyright. Apart from any use as permitted under the Copyright Act 1968, no part may be reproduced without prior written permission from the Clinical Excellence Commission (CEC). Requests and enquiries concerning reproduction and rights should be directed to the Director, Corporate Services, Locked Bag 8, Haymarket NSW 1240


Reported elsewhere
http://www.cec.health.nsw.gov.au/quality-improvement/organisational-development/qsa - Link


Definitions


Chart: QSA02 - QSA05

Admin Status: Current, 2014

Indicator Name: An overview of QSA, 2012-2014

Description: An overview of QSA program by LHD/SN and year of implementation

Dimension: Patient safety

Clinical Area: Initiatives in safety and quality health care

Data Inclusions: Responses from Unit level respondents in three domains (Acute, JH&FMHN and ASNSW).

Data Exclusions: Responses from the following levels; District, Division and Facility. Data from the Community domain were excluded.

Numerator: Number of participants by response categories for each question

Denominator: Total number of participants responded to each question

Standardisation: None (crude rate per 100 was calculated)

Data Source: QSA 2012, QSA 2013, and QSA 2014 data, Clinical Excellence Commission, NSW Ministry of Health

Comments: Not Applicable
 
Chart: QSA06

Admin Status: Current, 2014

Indicator Name: An overview of QSA, 2012-2014

Description: An overview of QSA program by LHD/SN and year of implementation

Dimension: Patient safety

Clinical Area: Initiatives in safety and quality health care

Data Inclusions: Responses from all level respondents (District, Division and Facility) in three domains (Acute, JH&FMHN and ASNSW)

Data Exclusions: Data from the Community domain were excluded

Numerator: Number of participants by response categories for each question

Denominator: Total number of participants responded to each question

Standardisation: None (crude rate per 100 was calculated)

Data Source: QSA 2012, QSA 2013 and QSA 2014 data, Clinical Excellence Commission, NSW Ministry of Health

Comments: Not Applicable