Appendix F. Audited health service monitoring of SOP indicators for 2019–20
Click the link below to open a PDF copy of Appendix F: Audited health service monitoring of SOP indicators for 2019–20.
Appendix E. Assessing the impact of actions to address incidents’ root causes
Figure E1 shows a selection of measures out of a sample of 16 serious incident action plans we reviewed across the four audited health services compared to better practice examples. The selection captures a spread of incident and measure types from the sampled action plans. There were two incidents where health services used relevant measures to assess the impact of implemented actions. We denote these measures with a ‘^’.
Click the link below to open a PDF copy of Figure E1: Reported and proposed outcome measures for selected serious incidents.
Appendix D. Initiatives to promote a positive patient safety culture
We briefly discuss the audited health services' initiatives to promote a positive patient safety culture below. PH's placemats and MH's improvement huddles and improvement noticeboards are excluded here as these are covered in Section 2.2.
Appendix C. Scope of this audit
| Who we audited | What we assessed | What the audit cost |
|---|---|---|
|
We assessed whether health services have adequate systems and processes in place to assure the quality and |
Appendix B. Acronyms and abbreviations
| Acronyms | |
|---|---|
| ACSQHC | Australian Commission on Safety and Quality in Health Care |
| BHS | Ballarat Health Services |
| CEO | chief executive officer |
| DH | Department of Health |
| DHHS | Depa |
Appendix A. Submissions and comments
We have consulted with BHS, DjHS, MH, PH and DH, and we considered their views when reaching our audit conclusions. As required by the Audit Act 1994, we gave a draft copy of this report, or relevant extracts, to those agencies and asked for their submissions and comments.
Responsibility for the accuracy, fairness and balance of those comments rests solely with the agency head.
4. Identifying and responding to quality and safety risks
Conclusion
While health services act when they identify underperformance or emerging risks, they do not consistently identify and respond to quality and safety risks in a timely way. Significant delays in completing serious incident investigations and resulting actions to address underlying issues mean that patients remain at risk of known avoidable harm for too long.
3. Establishing and supporting a positive patient safety culture
Conclusion
MH and PH have made greater improvements to their patient safety cultures since Targeting Zero, than BHS and DjHS. They have done this by embedding their clinical governance frameworks in their organisations and supporting staff to actively uphold patient safety.
2. Establishing and embedding clinical governance frameworks
Conclusion
Not all audited health services have embedded their clinical governance frameworks in their organisations. While their frameworks are generally consistent with the VCGF, only MH and PH use their frameworks to identify specific local quality and safety priorities, raise staff awareness and drive changes in organisational practices.
1. Audit context
Health services provide care in complex and high-pressure environments where avoidable harm to patients can occur. Effective clinical governance cultures, systems and processes minimise this risk and reduce the potential for harm.
A health service's clinical governance framework describes the activities it will undertake to minimise harm and maximise the quality of patient care. Health services must meet national and state standards for clinical governance.