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The Clinical Excellence Commission The eChartbook


QUALITY SYSTEMS ASSESSMENT - 2013 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 mean 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 eChartbook, the QSA charts reflect data based on the perceptions of managers and clinical staff working in local health districts (LHDs). Unless stated otherwise, the results provided here reflect data provided at the department/clinical unit level for the LHDs and networks.


Findings


The QSA self-assessment in 2013 (QSA 2013) focused on Transitions of Care, Medication Safety, and Falls. There were 1,745 responses to the self-assessment between August and October 2013 (97.6 per cent response rate), from right across the NSW health system. For the first time, community health units were included [1].


Only responses from unit level participants were included in this analysis. The questions of QSA 2013 were analysed by LHDs/SNs and additionally at times by four domains of: i) Acute; ii) Community; iii) Justice Health and Forensic Mental Health Network (JH&FMHN); and iv) Ambulance Service NSW (ASNSW). Some questions required the LHDs/SNs analysis by one or more of these domains. Responses 'Not applicable' or blanks / missing cells were excluded from the analysis.


Clinical governance, Patient based care and Safety & Quality (Charts QS01 to QS05):

A healthy patient safety culture is the foundation for high quality health care. This Safety & Quality component of QSA 2013 was analysed by LHDs/SNs, all four domains were included in the analysis. In NSW, 96 per cent of respondents 'Strongly agreed' or 'Agreed' that there was a positive patient safety and quality culture in their departments or clinical units. Responses from LHDs/SNs ranged from 87 to 97 per cent (Chart QS01).


QSA 2013 demonstrated that mechanisms required for clinical governance were in place in majority of LHDs/SNs as well as NSW. In NSW, 89% of respondents 'Strongly agreed' or 'Agreed' that the organisation had 'clear, integrated and effective processes for safety and quality, including risk management and clinical incident management systems'. Responses from LHDs/SNs ranged from 66 to 100 per cent (Chart QS02). In NSW, 76 per cent of respondents 'Strongly agreed' or 'Agreed' that 'All staff are provided with adequate information, resources, training and professional development to support the organisation's quality & safety processes'. Responses from LHDs/SNs ranged from 56 to 90 per cent (Chart QS03).


This Patient based care component of QSA 2013 was analysed by LHDs/SNs, all domains except for ASNSW were included in the analysis. In NSW, 92 per cent of respondents 'Strongly agreed' or 'Agreed' that 'Patients and their families and/or carers are viewed as integral members of the health care team'. Responses from LHDs/SNs ranged from 65 to 100 per cent (Chart QS04). The following question related to Patient based care in acute services only. In NSW, 26 per cent of respondents indicated that they fully implemented 'a process for patients, families or carers to escalate care and to request a clinical review or rapid response if they are worried or concerned about any change in the patient's condition'. Responses from LHDs/SNs ranged from 16 to 46 per cent (Chart QS05).


Transition of Care (Charts QS06 to QS11):

In this section, questions related to the Transition of Care component of QSA 2013 were applicable to acute services only. The other three domains were not included in the analysis. On admission in NSW, 90 per cent of respondents indicated that they used 'a standardised process to guide the patient's care coordination from admission (includes day only, planned and emergency admissions)'. Responses from LHDs/SNs ranged from 67 to 100 per cent (Chart QS06). At discharge in NSW, 82 per cent of respondents indicated that they used 'a standardised process or tool to direct the care plan for a patient's discharge (this question includes day only, planned and emergency admissions)'. Responses from LHDs/SNs ranged from 53 to 95 per cent (Chart QS07).


In NSW, 63 per cent of respondents reported that 'Patients who require ongoing nutrition support on transfer of care have a formalised nutrition care plan which is provided to the patient and carer and forwarded to the receiving facility or service' 'Always' or 'Often' occurred. Responses from LHDs/SNs varied, majority of LHDs/SNs in metropolitan and urban areas had higher percentage than NSW overall. The reverse was true for regional and remote areas (Chart QS08). Regarding the transfer of patients' medication, 66 per cent of respondents in NSW indicated that they used 'a standardised process for reconciling a patient's medication on transfer between care teams or institutions'. Responses from LHDs/SNs ranged from 58 to 79 per cent (Chart QS09).


Issues related to patients' inter-facility transfer were surveyed. In NSW overall, 89 per cent of respondents indicated that they had 'a policy or guidelines in place for inter-facility transfer of patients'. A majority of LHDs/SNs in regional areas had higher percentage than NSW average while metropolitan LHDs/SNs displayed a wide variation between 59 and 97 per cent (Chart QS10). For respondents who indicated their units had a policy in place for inter-facility transfer of patients, a further question 'whether they used a standardised inter-facility transfer form' was asked. In NSW, 76 per cent of respondents indicated that they used the form. Responses from urban LHDs/SNs ranged from 58 to 97 per cent. A majority of regional LHDs had higher percentage than the NSW average (Chart QS11).


Antimicrobial Stewardship (Charts QS12 to QS13):

In this section, questions related to Antimicrobial Stewardship were applicable to acute services only. The other three domains were not included in the analysis. In NSW, 67 per cent of respondents indicated that they had 'a standardised approach for antimicrobial prescribing and review'. Responses from LHDs/SNs ranged from 9.1 to 89 per cent (Chart QS12). In NSW, 34 per cent of respondents indicated that they undertook 'audit of compliance with antimicrobial prescribing guidelines to monitor and assess outcomes of antimicrobial stewardship initiative'. Responses from LHDs/SNs ranged from 15 to55 per cent (Chart QS13).


Venous Thromboembolism (VTE) Prevention (Charts QS14 to QS15):

Prevention of VTE is an important ongoing initiative to reduce iatrogenic harm and maximise efficiency in health care. The presence or absence of a mechanism for preventing VTE events was assessed in QSA 2013. Questions in this section were applicable to acute services only. In NSW, 71 per cent of respondents indicated that they had 'a standardised approach for venous thromboembolism (VTE) assessment and management'. Responses from LHDs/SNs ranged from 44 to 88 per cent (Chart QS14). The use of VTE prophylaxis is one of the mechanisms for preventing VTE events. In NSW, 74 per cent of respondents indicated that their patients identified as at risk of VTE were offered 'VTE prophylaxis based on their level of risk assessment'. Responses from LHDs/SNs ranged from 44 to 90 per cent (Chart QS15).


High Risk Medications (Charts QS16 to QS18):

Errors caused in the administration of high-risk medications may not be common but their consequences can potentially be devastating. High-risk medications should be targeted for specific error-reduction interventions. Questions related to high-risk medications in this section were applicable to acute services and JH&FMHN only, the other two domains were not included in the analysis.


In NSW, 77 per cent of respondents indicated that their departments or clinical units 'prescribed or managed patients with high-risk medications'. Responses from LHDs/SNs ranged from 57 to 100 per cent (Chart QS16). Respondents who reported prescribing or managing patients with high-risk medications were asked a series of further questions. Firstly, they were asked to identify top three high-risk medications used in their departments and/or clinical units. Those results are not reported here. Secondly, the question 'Has the department or clinical unit developed and implemented a standardised processor protocol to manage use of the above identified medications?' was asked after the high-risk medications were identified. In NSW, 81 per cent of respondents answered 'Yes' to this question. Responses from LHDs/SNs ranged from 67 to 95 per cent (Chart QS17). Thirdly, respondents were asked if there was 'an audit program undertaken to assess and monitor the use of high-risk medications (either by the department or as part of facility or district audit program)'. In NSW, 47 per cent of respondents indicated that they undertook the audit program. Responses from LHDs/SNs ranged from 33 to 58 per cent (ChartQS18).


Falls (Charts QS19 to QS20):

Questions related to Falls in this section were applicable to acute services only. In NSW, 90 per cent of respondents indicated that they had 'a standardised approach for management of patients at risk of falls'. Responses from LHDs/SNs ranged from 72 to 100 per cent (Chart QS19). In NSW, 15 per cent of respondents reported that there was 'a formal protocol or business rule for the use of night sedation for patients identified as at risk of falling' in their departments or clinical units. Responses widely varied across LHDs/SNs, ranging from 4.1 per cent (2 out of 49 units) to 28 per cent (15 outof 53 units) (Chart QS20).


QSA Evaluation (Charts QS21 to QS22):

Questions related to QSA Evaluation in this section were applicable to respondents from all levels (LHD, Division, Facility and Unit levels) (N=1,745). In NSW, 65 per cent of all respondents 'Strongly agreed' or 'Agreed' that 'The QSA self-assessment is a valuable process that assists our Department or Clinical Unit to improve our quality and safety systems'. Responses from LHDs/SNs ranged from 31 to 89 per cent (Chart QS21). In NSW, 68 per cent of all respondents 'Strongly agreed' or 'Agreed' that 'The information from this self-assessment will be used in developing our quality and safety improvement plans'. Responses from LHDs/SNs ranged from 37 to 89 per cent (Chart QS22).



References

[1] Clinical Excellence Commission, 2014, Safer Systems Better Care - Quality Systems Assessment Statewide Report (2013), Sydney: Clinical Excellence Commission.


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 QSA 2013 indicate that:

  • Perceptions have improved regarding the alignment of clinical governance structures and processes, while the perceptions of a positive patient safety culture remain strong across NSW.
  • While implementation of standards and protocols for transition of care are generally high across NSW, there is considerable variability between organisations, particularly with regard to the use of a standardised inter-facility transfer form.
  • Governance for anti-microbial stewardship is maturing, in the context of highly variable current implementation of a standardised approach for prescribing and reviewing between organisations.
  • A high proportion of units across NSW have standardised approach for venous thromboembolism assessment and management, yet there are further improvements available in the alignment of VTE risk with prophylaxis.
  • Most units across NSW are identifying their use of high-risk medications. There are further improvements available to ensure that standard protocols and audit processes are implemented to manage the use of these medicines.
  • Falls related processes and protocols are generally embedded across NSW. There is opportunity to spread the implementation of targeted risk assessments and protocols, e.g. Dementia, nutrition and night sedation.


What we don't know


The responses given by participants may reflect a practice and/or perception gap.


It is impossible for the system level analysis of QSA data to comprehend the specific local context around clinical practice as it happens. For this reason, QSA data needs to be reviewed by local teams at the local level to assign true meaning and to understand the root causes for clinical practice as it happens.


Local teams develop and implement their own action plans, aligned with their identified local priorities from the QSA data. The detail, implementation status or impact of local action plans is not known.


Chart QS01 - Quality and Safety culture by LHD/SN, NSW, 2013

Agreement of unit level respondents (%) for "There is a positive patient safety and quality culture in our department or clinical unit" (n=1,599)


eChartbook
Source: Quality Systems Assessment, Clinical Excellence Commission.


Chart QS02 - Clinical Governance by LHD/SN, NSW, 2013
 
Agreement of unit level respondents (%) for "The organisation has clear, integrated and effective processes for safety and quality, including risk management and clinical incident management system" (n=1,599)

eChartbook
Source: Quality Systems Assessment, Clinical Excellence Commission.


Chart QS03 - Clinical Governance by LHD/SN, NSW, 2013
 
Agreement of unit level respondents (%) for "All staff are provided with adequate information, resources, training and professional development to support the organisation's quality & safety processes" (n=1,599)

eChartbook
Source: Quality Systems Assessment, Clinical Excellence Commission.


Chart QS04 - Patient Based Care by LHD/SN, NSW, 2013
 
Agreement of unit level respondents (%) for "Patients and their families and / or carers are viewed as integral members of the health care team" (n=1,370)*

eChartbook
Note: *This assessment is not applicable to ASNSW, it is not presented in the chart.
Source: Quality Systems Assessment, Clinical Excellence Commission.



Chart QS05 - Patient Based Care by LHD/SN, NSW, 2013
 
Implementation of unit level respondents (%) for "Our clinical unit has a process for patients, families or carers to escalate care and to request a clinical review or rapid response if they are worried or concerned about any change in the patient's condition"(n=1,064)*

eChartbook
Note: * Unit level respondents in acute services only. 'Not applicable' responses were excluded from the analysis.
Source: Quality Systems Assessment, Clinical Excellence Commission.



Chart QS06 - Transition of Care by LHD/SN, NSW, 2013
 
Per cent of unit level respondents using "a standardised process to guide the patient's care coordination from admission (includes day only, planned and emergency admissions)" (n=1,022)*

eChartbook
Note: * Unit level respondents in acute services only. 'Not applicable' responses were excluded from the analysis.
Source: Quality Systems Assessment, Clinical Excellence Commission.



Chart QS07 - Transition of Care by LHD/SN, NSW, 2013
 
Per cent of unit level respondents using "a standardised process or tool to direct the care plan for a patient's discharge (this question includes day only, planned and emergency admissions)" (n=1,010)*

eChartbook
Note: * Unit level respondents in acute services only. 'Not applicable' or blanks were excluded from the analysis.
Source: Quality Systems Assessment, Clinical Excellence Commission.



Chart QS08 - Transition of Care by LHD/SN, NSW, 2013
 
Consistency of unit level respondents (%) for "Patients who require ongoing nutrition support on transfer of care have a formalised nutrition care plan which is provided to the patient and carer and forwarded to the receiving facility or service". (n=796)*

eChartbook
Note: * Unit level respondents in acute services only. 'Not applicable' or blanks were excluded from the analysis.
Source: Quality Systems Assessment, Clinical Excellence Commission.



Chart QS09 - Transition of Care by LHD/SN, NSW, 2013
 
Per cent of unit level respondents having "a standardised process for reconciling a patient's medication on transfer between care teams or institution". (n=1,010)*

eChartbook
Note: * Unit level respondents in acute services only.
Source: Quality Systems Assessment, Clinical Excellence Commission.



Chart QS10 - Transition of Care by LHD/SN, NSW, 2013
 
Per cent of unit level respondents having "a policy or guidelines in place for inter-facility transfer of patients" (n=954)*

eChartbook
Note: * Unit level respondents in acute services only. 'Not applicable' or blanks were excluded from the analysis.
Source: Quality Systems Assessment, Clinical Excellence Commission.



Chart QS11 - Transition of Care by LHD/SN, NSW, 2013
 
Per cent of unit level respondents using "a standardised inter-facility transfer form" (n=846)*

eChartbook
Note: * Unit level respondents in acute services that had policy or guidelines for inter-facility patients' transfer.
Source: Quality Systems Assessment, Clinical Excellence Commission.



Chart QS12 - Antimicrobial Stewardship by LHD/SN, NSW, 2013
 
Per cent of unit level respondents having "a standardised approach for antimicrobial prescribing and review" (n=1,004)*

eChartbook
Note: * Unit level respondents in acute services only. 'Not applicable' or blanks were excluded from the analysis.
Source: Quality Systems Assessment, Clinical Excellence Commission.



Chart QS13 - Antimicrobial Stewardship by LHD/SN, NSW, 2013
 
Per cent of unit level respondents indicated "The department or clinical unit undertakes audit of compliance with antimicrobial prescribing guidelines to monitor and assess outcomes of antimicrobial stewardship initiative" (n=1,004)*

eChartbook
Note: * Unit level respondents in acute services only. 'Not applicable' responses were excluded from the analysis.
Source: Quality Systems Assessment, Clinical Excellence Commission.



Chart QS14 - Venous Thromboembolism (VTE) Prevention by LHD/SN, NSW, 2013
 
Per cent of unit level respondents having "a standardised approach for venous thromboembolism (VTE) assessment and management" (n=848)*

eChartbook
Note: * Unit level respondents in acute services only. 'Not applicable' or blanks were excluded from the analysis.
Source: Quality Systems Assessment, Clinical Excellence Commission.



Chart QS15 - Venous Thromboembolism (VTE) Prevention by LHD/SN, NSW, 2013
 
Per cent of unit level respondents indicated "Patients assessed at risk of VTE are offered VTE prophylaxis based on their level of risk assessment" (n=848)*

eChartbook
Note: * Unit level respondents in acute services only. 'Not applicable' or blanks were excluded from the analysis.
Source: Quality Systems Assessment, Clinical Excellence Commission.



Chart QS16 - High Risk Medications by LHD/SN, NSW, 2013
 
Per cent of unit level respondents prescribing or managing patients with high risk medications (n=1,217)*

eChartbook
Note: * Unit level respondents (acute & Justice Health & Forensic Mental Health Network (JH&FMHN) services only).
Source: Quality Systems Assessment, Clinical Excellence Commission.



Chart QS17 - High Risk Medications by LHD/SN, NSW, 2013
 
Per cent of unit level respondents having developed and implemented a standardised process or protocol to manage use of the medications identified in the previous question(n=930)*

eChartbook
Note: * Unit level respondents in acute and JH & FMHN services that prescribed or managed patients with high-risk medications.
Source: Quality Systems Assessment, Clinical Excellence Commission.



Chart QS18 - High Risk Medications by LHD/SN, NSW, 2013
 
Per cent of unit level respondents reported that "There is an audit program undertaken to assess and monitor the use of high risk medications" (n=887)

eChartbook
Note: * Unit level respondents in acute services that prescribed or managed patients with high-risk medications.
Source: Quality Systems Assessment, Clinical Excellence Commission.



QS19 - Falls by LHD/SN, NSW, 2013
 
Per cent of unit level respondents having "a standardised approach for management of patients at risk of falls" (n=969)*

eChartbook
Note: * Unit level respondents in acute services only. 'Not applicable' responses were excluded from the analysis.
Source: Quality Systems Assessment, Clinical Excellence Commission.



QS20 - Falls by LHD/SN, NSW, 2013
 
Per cent of unit level respondents indicated that "There is a formal protocol or business rule for the use of night sedation for patients identified as at risk of falling in the department or clinical unit" (n=957)*

eChartbook
Note: * Unit level respondents in acute services only. 'Not applicable' or blanks were excluded from the analysis.
Source: Quality Systems Assessment, Clinical Excellence Commission.



QS21 - QSA Evaluation by LHD/SN, NSW, 2013
 
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" (n=1,744)*

eChartbook
Note: *Only respondents completed the self-assessment were included in the analysis.
Source: Quality Systems Assessment, Clinical Excellence Commission.



QS22 - QSA Evaluation by LHD/SN, NSW, 2013
 
Agreement of all respondents for "The information from this self-assessment will be used in developing our quality and safety improvement plans" (n=1,743)*

eChartbook
Note: *Only respondents completed the self-assessment were included in the analysis.
Source: Quality Systems Assessment, Clinical Excellence Commission.


End Matter


Contributors
Drafted by: CEC Quality Systems Assessment team and eChartbook 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-2013. 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: QS01-QS03

Admin Status: Current, 2013

Indicator Name: QSA 2013: Quality & Safety culture and Clinical Governance

Description: QSA 2013: Responses to self-administered survey questions related to the Quality & Safety culture and Clinical Governance by LHD/SN

Dimension: Patient safety

Clinical Area: Initiatives in safety and quality health care

Data Inclusions: Responses from Unit level respondents in all domains (acute, community, JH&FMHN and ASNSW).

Data Exclusions: Responses from the following levels; District, Division and Facility.

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 2013 data, Clinical Excellence Commission, NSW Ministry of Health

Comments: Not Applicable
 
Chart: QS04

Admin Status: Current, 2013

Indicator Name: QSA 2013: Patient Based Care

Description: QSA 2013: Responses to self-administered survey questions related to the Patient Based Care by LHD/SN

Dimension: Patient safety

Clinical Area: Initiatives in safety and quality health care

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

Data Exclusions: Responses from the following levels; District, Division and Facility.

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 2013 data, Clinical Excellence Commission, NSW Ministry of Health

Comments: Not Applicable
 
Chart: QS05

Admin Status: Current, 2013

Indicator Name: QSA 2013: Patient Based Care

Description: QSA 2013: Responses to self-administered survey questions related to the Patient Based Care by LHD/SN

Dimension: Patient safety

Clinical Area: Initiatives in safety and quality health care

Data Inclusions: Responses from Unit level respondents for acute services only

Data Exclusions: Responses from the following levels; District, Division and Facility.

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 2013 data, Clinical Excellence Commission, NSW Ministry of Health

Comments: Not Applicable
 
Chart: QS06-QS11

Admin Status: Current, 2013

Indicator Name: QSA 2013: Transition of Care

Description: QSA 2013: Responses to self-administered survey questions related to the Transition of Care by LHD/SN

Dimension: Patient safety

Clinical Area: Initiatives in safety and quality health care

Data Inclusions: Responses from Unit level respondents for acute services only

Data Exclusions: Responses from the following levels; District, Division and Facility.

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 2013 data, Clinical Excellence Commission, NSW Ministry of Health

Comments: Not Applicable
 
Chart: QS12-QS13

Admin Status: Current, 2013

Indicator Name: QSA 2013: Transition of Care

Description: QSA 2013: Responses to self-administered survey questions related to Antimicrobial Stewardship by LHD/SN

Dimension: Patient safety

Clinical Area: Initiatives in safety and quality health care

Data Inclusions: Responses from Unit level respondents for acute services and JH&FMHN

Data Exclusions: Responses from the following levels; District, Division and Facility.

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 2013 data, Clinical Excellence Commission, NSW Ministry of Health

Comments: Not Applicable
 
Chart: QS15

Admin Status: Current, 2013

Indicator Name: QSA 2013: Venous Thromboembolism (VTE) Prevention

Description: QSA 2013: Responses to self-administered survey questions related to the VTE Prevention by LHD/SN

Dimension: Patient safety

Clinical Area: Initiatives in safety and quality health care

Data Inclusions: Responses from Unit level respondents for acute services only

Data Exclusions: Responses from the following levels; District, Division and Facility.

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 2013 data, Clinical Excellence Commission, NSW Ministry of Health

Comments: Not Applicable
 
Chart: QS16-QS17

Admin Status: Current, 2013

Indicator Name: QSA 2013: High Risk Medications

Description: QSA 2013: Responses to self-administered survey questions related to the Quality & Safety culture and Clinical Governance by LHD/SN

Dimension: Patient safety

Clinical Area: Initiatives in safety and quality health care

Data Inclusions: Responses from Unit level respondents for acute services and JH&FMHN

Data Exclusions: Responses from the following levels; District, Division and Facility.

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 2013 data, Clinical Excellence Commission, NSW Ministry of Health

Comments: Not Applicable
 
Chart: QS18

Admin Status: Current, 2013

Indicator Name: QSA 2013: High Risk Medications

Description: QSA 2013: Responses to self-administered survey questions related to the high-risk medications by LHD/SN

Dimension: Patient safety

Clinical Area: Initiatives in safety and quality health care

Data Inclusions: Responses from Unit level respondents for acute services only

Data Exclusions: Responses from the following levels; District, Division and Facility.

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 2013 data, Clinical Excellence Commission, NSW Ministry of Health

Comments: Not Applicable
 
Chart: QS19-QS20

Admin Status: Current, 2013

Indicator Name: QSA 2013: Falls

Description: QSA 2013: Responses to self-administered survey questions related to Falls by LHD/SN

Dimension: Patient safety

Clinical Area: Initiatives in safety and quality health care

Data Inclusions: Responses from Unit level respondents for acute services only

Data Exclusions: Responses from the following levels; District, Division and Facility.

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 2013 data, Clinical Excellence Commission, NSW Ministry of Health

Comments: Not Applicable
 
Chart: QS21-QS22

Admin Status: Current, 2013

Indicator Name: QSA 2013: QSA 2013 Evaluation

Description: QSA 2013: Responses to self-administered survey questions related to the QSA 2013 Evaluation by LHD/SN

Dimension: Patient safety

Clinical Area: Initiatives in safety and quality health care

Data Inclusions: All respondents participated in the QSA self-assessment 2013 survey

Data Exclusions: None

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 2013 data, Clinical Excellence Commission, NSW Ministry of Health

Comments: Not Applicable