NADC ACCREDITATION QUALITY IMPROVEMENT FORM
Overview
NADC Diabetes Quality Improvement Accreditation
The NADC accreditation for diabetes centres is the only accreditation of its kind to offer comprehensive diabetes-specific accreditation aimed at the improvement of quality and safety. The accreditation model is focused on a three-pronged approach combining governance, educational and clinical criteria. The objective of the NADC accreditation is to assist diabetes centres to achieve quality patient care through improved governance, centre structure, and improved educational and clinical services.
Accreditation is one tool in a range of strategies that can be used to improve safety and quality in a health based organisation. It is a way of verifying:
•actions are being taken
•system data are being used to informactivity
•improvements are made in safety andquality.
The NADC accreditation also aims to lift the standard of service delivered by centres across Australia, in an effort to meet key goals under the National Diabetes Strategy 2016-2016. Namely, practices and procedures resulting in improved care, improved quality of life among people with diabetes, and a reduction in the prevalence of diabetes-related complications.
Self-assessment against the Standards
To achieve accreditation, you will not need to provide evidence against each criterion, however it is expected that your service could provide this if asked to demonstrate how they have met each relevant indicator of the standards if audited by the NADC.
Quality Improvement Plan
All centres are required to also submit a Quality Improvement Plan outlining key areas for improvement andan action plan.
It is expected that at the completion of the accreditation review, a list of action areas will have arisen that would lead to service improvement. Each centre must complete the Quality Improvement Plan and execute actions documented in the plan within the timeframes outlined on the following page. The action item and stated priority levels will be reviewed by the NADC assessor to ensure that these are appropriate. If they are felt to not be appropriately defined, the organisation will be contacted by the NADC to discuss these further. Where High Priority action items have been identified by either the organisation or the assessor, the NADC will follow up with services to ensure implementation of these has been undertaken. If organisation action items, in consultation with the assessor, are felt to have not been met within an appropriate timeframe, accreditation may be withdrawn.
When prioritising actions, the Risk Matrix on page 12 may be of assistance.
The length and type of planmay vary on the size and staffing of the Centre, but it is expected that even Affiliate Centres will identify areas for improvement.
Quality Improvement plans will only be accepted on the attached NADC template and must be attached to the application following the guidelines outlined in the workbook.
Time Frames for Action Items
When deciding the appropriate timeframe for an action item, consider using the Risk Matrix (Appendix 1)
Centre details
Name of centre: / Diabetes Centre, Bankstown-Lidcombe HospitalCentre type: / Centre of Excellence Tertiary Diabetes Care Centre Affiliate Diabetes Centre
Is yours a multi-site centre? / Yes No
Location of centre being accredited: / Bankstown-Lidcombe Hospital, Eldridge Road Bankstown NSW 2200
Name of contact person for this application: / Prof Jeff Flack AM
Contact person’s email: /
Contact person’s phone number: / +61 2 97228350
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Section 1Healthcare improvement
Standards and criteria
Standard 1.1 / Diagnosis and treatmentCriterion 1.1.1 / Evidence-based care
Criterion 1.1.2 / Multidisciplinary care
Criterion 1.1.3 / Medication management
Criterion 1.1.4 / Patient rights and privacy
Standard 1.2 / Promotion of patient self-management
Criterion 1.2.1 / Contribution of health improvement through patient empowerment
Criterion 1.2.2 / Improved patient health literacy
Standard 1.3 / Improved patient health outcomes
Criterion 1.3.1 / Demonstrated activities to achieve desired health targets
Standard 1.4 / Integrated care
Criterion 1.4.1 / Engagement with other services
Criterion 1.4.1 / Continuity of comprehensive care
Quality Improvement Plan for Section 1
Summary of strengths for Section 1
Strengths / Strengths are:- Comprehensive Diabetes in Pregnancy / GDM Service encompassing prenatal, antenatal and postnatal care;
- Cater for Adult T1DM and T2DM patients with Group and Individual Education including Pump and CGMS;
- Multicultural Ethnically Diverse referral base – we provide CALD sensitive and appropriate services;
- Developing Inpatient Management Guidelines;
- Strong Consumer Engagement.
Key improvements sought for Section 1
Standard/criterion[1.1.2 B.c.] / Criterion 1.1.2 Multidisciplinary CareIdentified issue / More timely referral to current Eye Clinic Service required.
Standard/criterion[1.3.1 B. a.] / Criterion 1.3.1 Demonstrated activities to achieve desired health targets
Identified issue / We have no in-house Eye Assessment capability, but Ophthalmology Dept is adjacent
Quality Improvement Plan
Standard/criteria / What outcome or goal does our centre want to achieve? / Priority (L/M/H/) / How will we achieve this outcome/goal? (Steps) / How will success be measured? / Deadline / Progress notes
1.1.2 B.c. / More Timely Eye Assessments / M / Liaise with Ophthalmology Dept / Development of Referral Pathway including timeframes for service provision
Reduction in Waiting Times / 30-6-2017
1.3.1 B. a. / More individuals receiving Eye Assessments / M / Liaise with Ophthalmology Dept / Development of Referral Pathway including timeframes for service provision
Reduction in Waiting Times / 30-6-2017
Section 2Governance and processes
Standards and criteria
Standard 2.1 / Centre structure and managementCriterion 2.1.1 / Organisational structure
Criterion 2.1.2 / Leadership and accountability
Standard 2.2 / Centre communication
Criterion 2.2.1 / Information about the centre
Quality Improvement Plan for Section 2
Summary of strengths for Section 2
Strengths / Strengths are:- Two staff have completed Diploma of Management Course;
- Standards of Care facilitated through strong audit and research culture;
- All staff trained to follow OH&S and report incidents on facility report system.
Key improvements sought for Section 2
Standard/criterion[2.2.1 A. e.] / Criterion 2.2.1 Information about the centreIdentified issue / Whilst we do have a website, we have no information on or utilisation of Social Media currently
Quality Improvement Plan
Standard/criteria / What outcome or goal does our centre want to achieve? / Priority (L/M/H) / How will we achieve this outcome/goal? (Steps) / How will success be measured? / Deadline / Progress notes
2.2.1 A. e. / Provide information to clients on diabetes and about our services / L / Investigate NSW Ministry of Health and LHD Policy re use of Social Media
Liaise with IT Dept re availability and permission to utilise Social Media in this way, if policies permit / Await outcome of Policy review and discussions with IT Department / 30-6-2017
Section 3Management of quality and safety
Standards and criteria
Standard 3.1 / Risk mitigationCriterion 3.1.1 / Risk mitigation processes
Standard 3.2 / Infection control
Criterion 3.2.1 / Mitigation of infection related incidents
Standard 3.3 / Quality improvement and innovation
Criterion3.3.1 / Quality improvement practices
Criterion3.3.2 / Innovation programs
Criterion3.3.2 / Technology
Standard 3.4 / Education and training
Criterion3.4.1 / Qualifications and professional development of staff
Criterion3.4.2 / HR management of staff qualifications
Criterion 3.4.3 / Participation in knowledge-sharing
Criterion 3.4.4 / Patient education programs
Quality Improvement Plan for Section 3
Summary of strengths for Section 3
Strengths / Strengths are:- Adherence to OH&S and other relevant Policies and Procedures within a Teaching Hospital environment;
- Strong audit and research culture with long standing data management and Database experience;
- Student placement in all disciplines, Mentoring of all staff, Staff undertaking postgraduate studies;
- Senior Advanced Trainee in Endocrinology in Department;
- All staff encouraged and assisted to attend relevant CPD activities.
Key improvements sought for Section 3
Standard/criterion[number] / NO DEFICIENCIES IDENTIFIEDIdentified issue / [Briefly summarise the issue identified during the self-assessment process, then complete the improvement planning table in the following section. Delete rows not required.]
Quality Improvement Plan
Standard/criteria / What outcome or goal does our centre want to achieve? / Priority (L/M/H/) / How will we achieve this outcome/goal? (Steps) / How will success be measured? / Deadline / Progress notes
N/A
Section 4Centre management
Standards and criteria
Standard 4.1 / Safety and welfare of staff, patients and visitorsCriterion 4.1.1 / Occupational health and safety
Criterion 4.1.2 / Management of clinical appointments
Standard 4.2 / Records management
Criterion 4.2.1 / Business records
Criterion 4.2.2 / Clinical records and patient information
Standard 4.3 / Centre maintenance
Criterion 4.3.1 / Cleaning and maintenance
Criterion 4.3.2 / Service and replacement of equipment
Quality Improvement Plan for Section 4
Summary of strengths for Section 4
Strengths / Strengths are:- Centre staff from two Disciplines undertake monthly OH&S audits and report to Quality & Safety Committee;
- All staff trained on Hospital Booking System and in-house Database and eMR;
- Liaison with Referring Health Profession by communication following every Consultation;
- Each patient assessed using Standardised Checklist.
Key improvements sought for Section 4
Standard/criterion[4.3.1. B.] / Criterion 4.3.1 Cleaning and maintenanceIdentified issue / Unit Cleaning and Maintenance undertaken by Hospital Cleaning and Maintenance Depts. Whilst each Professional is responsible under the Hospital Infection Control Policies, there is no in-house Cleaning Roster
Standard/criterion[4.3.2. C.] / Criterion 4.3.2Service and replacement of equipment
Identified issue / Department does not have an Equipment Maintenance Logbook
Quality Improvement Plan
Standard/criteria / What outcome or goal does our centre want to achieve? / Priority (L/M/H/) / How will we achieve this outcome/goal? (Steps) / How will success be measured? / Deadline / Progress notes
Criterion 4.3.1. B. / Department will have a Cleaning Roster / M / CNC to Develop Cleaning Roster / Cleaning RosterDeveloped / 30-6-2017
4.3.2. C. / Department will haveaEquipment Maintenance Logbook / M / CNC to Develop Equipment Maintenance Logbook / Equipment Maintenance LogbookDeveloped / 30-6-2017
APPENDIX 1: RISK MATRIX
1 / 2 / 3 / 4 / 5Consequences / Risk Categories / Tickappropriate boxesunderCONSEQUENCESandLIKELIHOODofRECURRENCEthenascertainlevelofrisk / Rare / Unlikely / Occasionally / Likely / AlmostCertain
Greater than once every 5yrs / (once every2-5years) / (once every1-2years) / (weekly-monthly) / (daily-weekly)
1.Insignificant / Patient/Consumer / Careresultsin inconveniencebut noharm / LowRisk / LowRisk / LowRisk / MediumRisk / MediumRisk
Staff /Visitors / Incident/near miss occurred,noinjury
Resources / Negligibleshorttermdisruptiontonon-essentialservices
Financial / Minor lossresulting in only minimalimpact tolocalareabudget
Reputation/Stakeholder / Short termdisruptiontoservicesnot resulting inlossofbusiness
2.Minor / Patient/Consumer / Careresultsin minor harm with no loss or reduction offunction / LowRisk / LowRisk / MediumRisk / MediumRisk / HighRisk
Staff / Visitors / First aidtreatmentonly
Resources / Short termdisruptiontoservicesnot resulting inlossofbusiness
Financial / Loss that impacts on a s ingle service but does not threaten that service'soverallbudget
Reputation/Stakeholder / Staff and patient groupsin localarealosing trust andconfidence
3.Moderate / Patient/Consumer / Careresultsin harm withtemporary lossor reductionoffunction / LowRisk / MediumRisk / MediumRisk / HighRisk / HighRisk
Staff / Visitors / Injurynecessitatingmedicaltreatment
Resources / Short term disruption to services resulting in short term loss of businesscontinuity
Financial / Loss of more than $500,000 includes losses <$500,000 that threaten theoverallbudget of asingleservice
Reputation/Stakeholder / Staffatanorganisationallevellosingtrustandconfidence,adversemediacoveragelasting upto1month
4.Major / Patient/Consumer / Careresultsin significant harm withpermanent lossor reductionin / MediumRisk / MediumRisk / HighRisk / HighRisk / ExtremeRisk
Staff / Visitors / Injury resulting in serious outcome, impacting on ability to return topreviousworkinthefuture
Resources / Substantial disruption to multiple services resulting in short to mediumtermlossofbusinesscontinuity
Financial / Lossbetween $500,000 to$2M
Reputation/Stakeholder / Staffandpatientsat anorganisationallevel, other stakeholdersandMinister losing trust andconfidence, adversemediacoveragelastingmore
5.Catastrophic / Patient/Consumer / Careresultsinpatient deathor profound impairment / MediumRisk / HighRisk / HighRisk / ExtremeRisk / ExtremeRisk
Staff / Visitors / Injury resulting in permanentsignificant injury or unable to return to anyformor workor preventabledeath
Resources / Substantial disruption to multiple services threatening the survivalor longtermbusinesscontinuity oftheorganisation
Financial / Lossgreater than$2M,representinginsolvency
Reputation/Stakeholder / Substantiallossoftrust andconfidenceby public, regulatoryorparliamentary enquiry withadversefindings, nationalmediacoverage
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