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The Clinical Excellence Commission The eChartbook


QUALITY SYSTEMS ASSESSMENT - 2011 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 Quality Systems Assessment (QSA) is a clinical risk management tool which provides clinical teams and managers with a means of assessing compliance with policy and standards, identifying clinical risks and deficiencies in practice and highlighting and sharing exemplary practice relating to clinical quality and patient safety. Its main strength is that it provides a comparative self-assessment of performance against high priority patient safety and quality policies and standards. This data can be used by health services managers and clinical teams to drive improvement.


Unlike much of the quantitative data in The Chartbook, the QSA charts reflect data based on the perceptions of managers and clinical staff working in local health districts (LHDs). The results provided here, unless stated otherwise, reflect data provided at the department/clinical unit level for the LHDs and networks. This section used data from the QSA self-assessment 2011, that focused on sepsis, delirium, mental health and paediatrics. Between September and November 2011, the self-assessment was undertaken by over 1,500 respondents across and at various levels of the NSW health system. The overall response rate was 96 per cent.


Findings


Sepsis (Charts QS01 to QS07):

Sepsis is a potentially deadly medical condition that is associated with high mortality. The key to improving sepsis outcomes is implementation of pre-hospital and hospital-wide systems that assist early recognition of at-risk or septic patients and lead to rapid administration of effective therapy.Across NSW, at the clinical unit level, more than 80 per cent of respondents treat or manage patients at risk of sepsis "often", "sometimes" or "rarely". Of those, 33 per cent agreed that it was managed optimally and the remaining 67 per cent of facilities indicated that management of sepsis in their department/unit needed improvement (Chart QS02). This response was reasonably consistent across all LHDs. Chart QS03 demonstrated a high level of awareness of sepsis by staff across all LHDs. On average in NSW, 73 per cent of facilities have a standardised approach to sepsis management. It varies across LHDs between 42 and 85 per cent. Three-quarters of departments/clinical units "strongly agreed" or "agreed" with the statement "the skills and knowledge of staff are sufficient to manage the identification and optimal management of sepsis" (Chart QS04). Sixty per cent of departments/clinical units reported that they have developed guidelines/protocols for the management of sepsis patients (Chart QS05). At the clinical unit level, 42 per cent monitor some aspects of sepsis incident care and 57 per cent of departments/clinical units reviewed all sepsis cases at local morbidity and mortality meetings. The rates vary across LHDs (Charts QS06 & QS07).


Delirium (Charts QS08 to QS13):

Delirium is a common problem, affecting up to two-thirds of older people admitted to hospital. It remains, however, under-recognised by health care professionals. Delirium is associated with increased length of stay, increased falls and often results in discharge to long-term care or increased mortality.It represents one of the most common potentially preventable adverse events for hospitalised older persons. The QSA 2011 survey revealed that across NSW, 16 per cent of departments/clinical units managed delirium patients optimally and the remaining 84 per cent needed improvement (Chart QS08). The rate of optimal management was quite lower in rural LHDs. About two-thirds (67%) of facilities either "strongly agreed" or "agreed" that executive/senior management are aware of the challenges that delirium presents for clinical staff (Chart QS09). More than half (56%) of the departments/clinical units indicated that they have developed guidelines/protocols in place for the safe management of delirium. Thirty-one per cent of facilities had no guidelines at all (Chart QS10). About 53 per cent of departments/clinical units reported that "all" (100%) or "most" (67-99%) relevant clinical staff have been orientated and trained in the use of the guidelines/protocols (Chart QS11). Two-thirds of departments/clinical units reported that there was a geriatric assessment team in their facility and 47.7 per cent of them were guided by a consultant geriatrician (Charts QS12-QS13). This rate widely varies across LHDs.


Mental health (Charts QS14 to QS20):

Most patients with severe mental illness are in frequent contact with primary care services. For many, this can be their only contact with health services. There is evidence to suggest that this may not necessarily mean they always receive good care [1]. Across NSW, 73 per cent of departments/clinical units indicated the management of suicide risk could be improved (Chart QS14). On average, 51 per cent of facilities reported a standardised screening tool being used when conducting a suicide risk assessment. The rate was higher in rural and regional LHDs (Chart QS15). About 36 per cent of facilities reported that staff skills required to manage suicidal patients were reviewed. Rates in metropolitan LHDs were below the State average. Facilities reported (62.3%) that suicide risk assessment was conducted in a timely manner. This varies widely across LHDs. In response to the co-ordinated/integrated treatment process of suicidal patients, most rural and regional LHDs reported below the State average of 51.5 per cent (Chart QS17). On average, 51 per cent of facilities reported that a comprehensive care plan was developed before discharge/transition of care. The rate was quite lower in rural LHDs (Chart QS18). About 43.3 per cent of facilities indicated that the system for ensuring that follow-up appointments are attended was functioning optimally or moderately.


Paediatric (Charts QS21 to QS24):

The management of children poses challenges for health care. It is crucial for organisations and hospitals to recognise how caring for paediatric patients raises different quality and patient safety issues and for them to develop a targeted approach to protecting this vulnerable patient population.More than three quarters (77.3%) of facilities either "strongly agreed" or "agreed" that, overall, the BTF program has benefitted patient safety in their facilities. Across NSW, 64.8 per cent of departments/clinical units agreed that the 'blue zone' on the BTF chart has assisted earlier detection and management of patients at risk of deteriorating. Similarly, more than 74 per cent of facilities agreed that both yellow and red zones have also assisted earlier detection or rapid response to manage patients at risk of deteriorating. There were significant differences across metropolitan and rural/regional facilities in the level of agreement.



References

[1] Phelan M, Stradins L, Morrison S. Physical health of people with severe mental illness. BMJ. 2001;322:443-444.


Implications


The QSA self-assessment responses should always be interpreted in the local context. The responses do, however, provide an opportunity to highlight areas which may require improvement at a system level. In summary, the results from the 2011 QSA indicate that:

  • while sepsis is managed by the majority of clinicians in the system, improvement is required in relation to standardised approach, the use of guidelines and the review and monitoring of outcomes
  • the use of guidelines and protocols for management of patients with delirium needs to improve, as does education of clinicians in the management of delirium
  • a high percentage of patients treated by the public health system have a mental health co-morbidity, but there is a lack of education programs, guidelines or protocols available for staff
  • the paediatric BTF program is being well received within the system.


What we don't know


The responses given by participants may reflect a practice and/or perception gap. The action plans developed as a result of the self-assessment may have resulted in changes/improvements that have occurred since. Local context or implementation stage for programs/practices being assessed may influence the responses provided.


QS01 - 2011 Quality Systems Assessment Survey: sepsis awareness
 

Percentage of departments/clinical units reporting that staff were aware of sepsis by LHD in NSW 2011

eChartbook
Source: Quality Systems Assessment, Clinical Excellence Commission.


QS02 - 2011 Quality Systems Assessment Survey: sepsis management
 

Percentage of departments/clinical units reporting how well sepsis is managed by LHD in NSW 2011

eChartbook
Source: Quality Systems Assessment, Clinical Excellence Commission.


QS03 - 2011 Quality Systems Assessment Survey: sepsis standardised approach
 

Percentage of departments/clinical units reporting a standardised approach for suspected sepsis by LHD in NSW 2011

eChartbook
Source: Quality Systems Assessment, Clinical Excellence Commission.


QS04 - 2011 Quality Systems Assessment Survey: sepsis staff skills
 

Percentage of departments/clinical units reporting that skills of staff regarding sepsis is sufficient by LHD in NSW 2011

eChartbook
Source: Quality Systems Assessment, Clinical Excellence Commission.


QS05 - 2011 Quality Systems Assessment Survey: sepsis guidelines
 

Percentage of departments/clinical units reporting that they have guidelines for management of sepsis by LHD in NSW 2011

eChartbook
Source: Quality Systems Assessment, Clinical Excellence Commission.


QS06 - 2011 Quality Systems Assessment Survey: sepsis case review
 

Percentage of departments/clinical units reporting that they monitor any aspects of sepsis incidence, care and management by LHD in NSW 2011

eChartbook
Source: Quality Systems Assessment, Clinical Excellence Commission.


QS07 - 2011 Quality Systems Assessment Survey: sepsis care review including transferred patients
 

Percentage of departments/clinical units reporting that sepsis cases, including patient transferred to ICU or another hospital, are reviewed at local morbidity and mortality meeting by LHD in NSW 2011

eChartbook
Source: Quality Systems Assessment, Clinical Excellence Commission.


QS08 - 2011 Quality Systems Assessment Survey: delirium management
 

Percentage of departments/clinical units reporting how well delirium is managed by LHD in NSW 2011

eChartbook
Source: Quality Systems Assessment, Clinical Excellence Commission.


QS09 - 2011 Quality Systems Assessment Survey: delirium senior management awareness
 

Percentage of departments/clinical units reporting that senior management are aware of challenges related to delirium by LHD in NSW 2011

eChartbook
Source: Quality Systems Assessment, Clinical Excellence Commission.


QS10 - 2011 Quality Systems Assessment Survey: delirium guidelines
 

Percentage of departments/clinical units reporting that they have guidelines for management of delirium by LHD in NSW 2011

eChartbook
Source: Quality Systems Assessment, Clinical Excellence Commission.


QS11 - 2011 Quality Systems Assessment Survey: delirium standardised approach
 

Percentage of departments/clinical units reporting a standardised approach for suspected delirium by LHD in NSW 2011

eChartbook
Source: Quality Systems Assessment, Clinical Excellence Commission.


QS12 - 2011 Quality Systems Assessment Survey: delirium and geriatric assessment team
 

Percentage of departments/clinical units reporting that they have a geriatric assessment team for delirium patients, a standardised approach for suspected delirium by LHD in NSW 2011

eChartbook
Source: Quality Systems Assessment, Clinical Excellence Commission.


QS13 - 2011 Quality Systems Assessment Survey: delirium and geriatric assessment team with geriatrician
 

Percentage of departments/clinical units reporting that a geriatric assessment team guided by geriatrician is involved with delirium patients by LHD in NSW 2011

eChartbook
Source: Quality Systems Assessment, Clinical Excellence Commission.


QS14 - 2011 Quality Systems Assessment Survey: suicide management
 

Percentage of departments/clinical units reporting how suicide is managed by LHD in NSW 2011

eChartbook
Source: Quality Systems Assessment, Clinical Excellence Commission.


QS015 - 2011 Quality Systems Assessment Survey: suicide risk assessment
 

Percentage of departments/clinical units reporting that they have a standardised screening tool for suicide risk assessment, how suicide is managed by LHD in NSW 2011

eChartbook
Source: Quality Systems Assessment, Clinical Excellence Commission.


QS016 - 2011 Quality Systems Assessment Survey: suicide staff skills
 

Percentage of departments/clinical units reporting staff skills required to manage suicide patients by LHD in NSW 2011

eChartbook
Source: Quality Systems Assessment, Clinical Excellence Commission.


QS17 - 2011 Quality Systems Assessment Survey: suicide timely risk assessment
 

Percentage of departments/clinical units reporting that suicide risk assessment was conducted in a timely manner by LHD in NSW 2011

eChartbook
Source: Quality Systems Assessment, Clinical Excellence Commission.


QS18 - 2011 Quality Systems Assessment Survey: suicide treatment
 

Percentage of departments/clinical units reporting that treatment for suicide is co-ordinated/integrated by LHD in NSW 2011

eChartbook
Source: Quality Systems Assessment, Clinical Excellence Commission.


QS19 - 2011 Quality Systems Assessment Survey: suicide management plan
 

Percentage of departments/clinical units reporting that have comprehensive plan for suicide patients by LHD in NSW 2011

eChartbook
Source: Quality Systems Assessment, Clinical Excellence Commission.


QS20 - 2011 Quality Systems Assessment Survey: suicide follow-up
 

Percentage of departments/clinical units reporting the status of follow-up for suicide patients by LHD in NSW 2011

eChartbook
Source: Quality Systems Assessment, Clinical Excellence Commission.


QS21 - 2011 Quality Systems Assessment Survey: paediatric BTF 'blue zone'
 

Percentage of departments/clinical units reporting about paediatric BTF 'blue zone' by LHD in NSW 2011

eChartbook
Source: Quality Systems Assessment, Clinical Excellence Commission.


QS22 - 2011 Quality Systems Assessment Survey: paediatric BTF 'yellow zone'
 

Percentage of departments/clinical units reporting about paediatric BTF 'yellow zone' by LHD in NSW 2011

eChartbook
Source: Quality Systems Assessment, Clinical Excellence Commission.


QS23 - 2011 Quality Systems Assessment Survey: paediatric BTF 'red zone'
 

Percentage of departments/clinical units reporting about paediatric BTF 'red zone' by LHD in NSW 2011

eChartbook
Source: Quality Systems Assessment, Clinical Excellence Commission.


QS24 - 2011 Quality Systems Assessment Survey: benefit of paediatric BTF program
 

Percentage of departments/clinical units reporting the benefit of the BTF program by LHD in NSW 2011

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 [access year]. eChartbook Portal: Safety and Quality of Healthcare in New South Wales. Sydney: Clinical Excellence Commission. Available at: http://www.cec.health.nsw.gov.au/echartbook/cec-indicators-intro-echartbook/qsa-2011 Accessed [insert date of access].



© Clinical Excellence Commission 2013
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 A4062, Sydney South NSW 1235.



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


Definitions


Chart: QS01-QS07

Admin Status: Current

Indicator Name: QSA Survey 2011: Sepsis management

Description: QSA Survey 2011: Sepsis management related indicators (how well sepsis managed, staff awareness of sepsis, standardised approach for suspected sepsis, skills of staff, guidelines for sepsis management, monitoring & reviewing system in place) by local health district

Dimension: Patient safety

Clinical Area: Initiatives in safety and quality health care

Data Inclusions: Total number of respondents in QSA survey by responses

Data Exclusions: None

Numerator: Total number of units/facilities in QSA survey by responses

Denominator: Total number of respondents by local health district

Standardisation: None (crude rate per 100 was calculated)

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

Comments: Not Applicable
 
Chart: QS08-QS13

Admin Status: Current

Indicator Name: QSA : Delirium management

Description: QSA Survey 2011: Delirium management related indicators (how well delirium managed, staff awareness of delirium, guidelines for delirium management, involvement of geriatrician with delirium management team) by local health district

Dimension: Patient safety

Clinical Area: Initiatives in safety and quality health care

Data Inclusions: Total number of respondents in QSA survey by responses

Data Exclusions: None

Numerator: Total number of respondents in QSA survey by responses

Denominator: Total number of respondents by local health district

Standardisation: None (crude rate per 100 was calculated)

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

Comments: Not Applicable
 
Chart: QS14-QS20

Admin Status: Current

Indicator Name: QSA : Mental health: management of patients at risk of suicide

Description: QSA Survey 2011: Mental health related indicators (how well patients at risk of suicide are managed, staff skills, comprehensive plan for mental health patients, follow-up of patients) by local health district

Dimension: Patients safety

Clinical Area: Initiatives in safety and quality healthcare

Data Inclusions: Total number of respondents in QSA survey by responses

Data Exclusions: None

Numerator: Total number of respondents in QSA survey by responses

Denominator: Total number of respondents by local health district

Standardisation: None (crude rate per 100 was calculated)

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

Comments: Not Applicable
 
Chart: QS21-QS24

Admin Status: Current

Indicator Name: QSA : Paediatric management related to Between the Flags (BTF) program

Description: QSA Survey 2011: Paediatric management related to BTF program (importance of the 'blue zone', 'yellow zone' and 'red zone' on the BTF chart, to earlier detection and management of deteriorating patients, benefit of BTF program) by local health district

Dimension: Patients safety

Clinical Area: Initiatives in safety and quality healthcare

Data Inclusions: Total number of respondents in QSA survey by responses

Data Exclusions: None

Numerator: Total number of respondents in QSA survey by responses

Denominator: Total number of respondents by local health district

Standardisation: None (crude rate per 100 was calculated)

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

Comments: Not Applicable