Transcript 02 Sep PPTx

TQCSI
HEALTHY AUDITORS TRAINING
#3/16
Healthy Auditors Training – #3/16
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www.tqcsi.com
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Members/Auditors Area Login – username & password
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Documents, NSQHS Standards Information:
• Advisory Documents
• anything you want – just let us know
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WI 35A (Healthcare – NSQHS Standards & NSMHS)
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TQCSI Forums
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MJ now coordinating Healthy Auditors Training!
Healthy Auditors Training – #3/16
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www.safetyandquality.gov.au
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National Standards and Accreditation:
• Accreditation and the NSQHS Standards
• Clinical Care Standards
• Mental Health.
Healthy Auditors Training – #3/16
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TQCSI Forums – Health, now live
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NGPAS – CBs can apply – TQCSI not participating –
Audit Teams need a doctor!
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NSQHSS Version 2 - consultation on draft version
ended
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final Version 2 scheduled for release late 2017
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assessments from 1/1/19.
Healthy Auditors Training – #3/16
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Guide to the NSQHS Standards for Health Service
Organisation Boards (2015)
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Credentialing Health Practitioners and Defining their
Scope of Clinical Practice: A Guide for Managers &
Practitioners (2015)
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Guide to the NSQHS Standards for Community
Health Services (2016)
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all on the TQCSI website.
Healthy Auditors Training – #3/16
Advisory #16/02 – Application of the requirements for
general observation charts
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8 April 2016 - Standard 9, Action 9.3.1
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clarify requirements for implementation of Obs Charts
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recording psychological observations & identifying
triggers to escalate care
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if not a general Obs Chart, then alternate mechanisms
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policy and supporting protocols required
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9.3.1 is N/A when Obs Chart is not used.
Healthy Auditors Training – #3/16
Advisory #16/03 – Reprocessing of reusable medical
devices in health service organisations
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3 June 2016 - Standard 3, Action 3.16.1
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AS 4187
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gap analysis and document implementation plan over
five years from 1/1/16 (therefore Action Plan from
Dec 2016 – Dec 2021)
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3.16.1 is Met if progressing implementation.
Healthy Auditors Training – #3/16
Advisory #16/06 – Medication management plan
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Draft – Sep 16
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Standard 4, Action 4.14.1
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add to strategic plan
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4.14.1 Met if 4.6.1, 4.7.1-4.7.3, 4.8.1, 4.12.1-4.12.4,
4.13.1-4.13.2 & 4.15.1-4.15.2 are Met.
Healthy Auditors Training – #3/16
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consideration when audit planning – two hours, how many staff
on ND
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what if an overnight admission
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what if an overnight admission to ED
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how are internal emergencies/code blue calls managed
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call in additional staff – who has ALS training, how is ALS
trained clinician assessed if not on site
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how are clinical deteriorations requiring transfer managed?
Healthy Auditors Training – #3/16
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how do you access medical records for an overnight admission
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what duties are required on ND (duties list)
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how are medications administered and checked with ND staffing
levels (eg if 1 RN & 1 EN on in entire facility, at different ends,
review administration of IV meds (S4 & S8)
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how do you communicate any changes/updates to patient care
(besides ND to Early Shift handover) – Communication Book?
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observe process: DDA count, clinical handover +/- bedside
handover per facility’s policy, equipment records (per duties list)
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good opportunity for a medical record review.
Healthy Auditors Training – #3/16
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usually audited on second day of multi-day audit
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only health auditor is to attend an earlier start
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usually start at 0600 to observe last hour of ND and transition to
day shift
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therefore work 0600–1400 that day
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consider your safety.
Healthy Auditors Training – #3/16
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ND tasks
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clinical handover; ND to AM shift and A/H Coordinator to Day
Coordinator/DON/NUM
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o/n admissions
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recognition and response processes A/H
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retrieval of medical records
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staff communication – with each other and Coordinators
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medication administration – skill mix.
Healthy Auditors Training – #3/16
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A/H Coordinator handover to Day Coordinator
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issues found; clinical handover
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what to do if no acute inpatients?!
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use as an opportunity to review patient case notes
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ND staff love being directly involved in the audit….mostly! 
Healthy Auditors Training – #3/16
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any night duty auditing experiences to share?
Healthy Auditors Training – #3/16
What to look for when auditing
credentialing and scope of practice.
Healthy Auditors Training – #3/16
A system is in place to define and regularly review the
scope of practice for the clinical workforce:
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credentialing process – Committee, outsourced
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records – is scope of practice defined
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re-credentialing processes
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single surgeon private practice?
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all clinicians – not just MO’s.
Healthy Auditors Training – #3/16
Mechanism are in place to monitor that the clinical
workforce are working within their agreed scope of
practice.
 performance appraisals
 attendance at training & competence
 observations by colleagues.
Healthy Auditors Training – #3/16
Organisational clinical service capability, planning
and scope of practice is directly linked to the clinical
services roles of the organisation.
 scope of practice should reflect clinical services
provided.
Healthy Auditors Training – #3/16
The system for defining the scope of practice is used
whenever a new clinical service, procedure or other
technology is introduced.
 assess what processes are in place for review of scope
when changes occur.
Healthy Auditors Training – #3/16
Supervision of the clinical workforce is provided
whenever it is necessary for individuals to fulfil their
designated role.
 processes for supervision of junior staff
 performance management of staff
 appraisal processes.
Healthy Auditors Training – #3/16
What to look for when auditing CSSD.
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Compliance with AS 4187 for cleaning,
disinfection and sterilisation is monitored.
Healthy Auditors Training – #3/16
Cleaning is an essential part of reprocessing reusable equipment
as it ensures that the disinfectant or sterilant can access the
instrument or item. Items that are not cleaned cannot be
disinfected or sterilised.
 observe cleaning process if possible
 ask staff how cleaning process verified as effective
 ask how ultrasonic tested (if used) and frequency of test; sight
records.
Healthy Auditors Training – #3/16
Disinfection is a process that inactivates infectious agents, using
either thermal or chemical means. This is required when reusing
equipment or instruments which are for use in semi-critical and
non-critical sites.
 check batch records are verified
 check log book
 microbiological testing of scopes
 Tristel Wipes.
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calibration records – electronic or hardcopy – check
availability
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validation records – Bowie & Dick, vacuum test records
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biological/chemical indicators.
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All items which have been reprocessed must be stored
in a way that maintains their level of sterility.
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A traceability system that identifies patients who
have a procedure using sterile reusable medical
instruments and devices is in place.
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Action is taken to maximise coverage of the relevant
workforce trained in a competency –based program
to decontaminate reusable medical devices.
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Healthy Auditors Training – #3/16