Clinical Excellence Commission Year in
Review 2020-2021

Portrait of Carrie Marr and Associate Professor Brian McCaughan, AM


This year has been marked by significant and ongoing challenges as health systems around the world continue to respond to the COVID-19 pandemic. We are proud of the Clinical Excellence Commission's (CEC) response to this global health emergency and the important role we have played supporting health workers, patients and families.

As the lead agency for Infection Prevention and Control, the CEC played a critical role through 2020-21 keeping frontline staff, patients and visitors safe through the COVID-19 pandemic and supporting the system with strategic guidance, expert advice, resources, and education.

At the same time, it has been imperative for us to maintain focus on our core work ensuring patient safety and clinical quality for patients in NSW public hospitals.

This year in review sets out examples of our key achievements and collaborations with Local Health Districts and Speciality Health Networks to create safer care and improved experiences for patients and their carers.

Ensuring this strong focus on safety is embedded across the health system, in every ward and every health worker’s role is critical to our overall goal of making patient safety everyone's business. Our Safety Culture Measurement Toolkit and Safety Fundamentals for Teams and for Person Centred Communication are resources developed to assist teams to focus on safety every day.

The support of other health agencies and the crucial collaboration across teams has been fundamental to much of our work this year to help health services measure, promote and support improved clinical care, safety and quality across the NSW public health system. Implementation of the revised NSW Health Incident Management Policy is one such example where our work with eHealth NSW, local health districts and specialty networks has developed an improved system to respond to, and learn from, safety issues in hospitals.

Continuous learning is fundamental to our safety and quality improvement efforts, and I am delighted that this year the CEC has been able to develop and deliver the updated Safety and Quality Essentials Pathway while also partnering on 15 research projects across priority areas including stillbirth, falls and medication safety.

Finally, I would encourage you to take the time to review the case studies which offer practical examples on how our collective work is impacting and realising a safety culture in healthcare. These case studies highlight new developments and improvement in our safety work as well as our ongoing contribution to the COVID-19 response.

We trust you find this review a valuable resource and helpful and supportive of your own healthcare improvement and safety pursuits. Realising safe and effective care for patients which is of the highest quality is an ongoing goal for all of us and we are thankful for the continued support and co-operation of colleagues across NSW Health who support our safety endeavours.

CEC Strategic Plan

This was an important year for the CEC, as we embarked on the journey to develop of our strategic plan and vision for the next three years.

The CEC worked with consultants from Nous group to learn from people across the system, including consumers, carers, and clinical, management and executive staff from a wide variety of disciplines and backgrounds. We were keen to use insights from across the system, including looking at best practice models from similar agencies internationally, to shape our strategic direction for 2021 - 2024.

Through these conversations, we learned that there was a strong commitment to clinical quality and safety across the system, with four key themes emerging, which have informed the CEC's strategic priorities for 2021 – 2024:

  • Embedded safety systems: A safety model where the whole care system is strategically enabled through governance, partnerships, roles and responsibilities, and capability and capacity.
  • Safety culture with accountability: The whole care system including patients, clinical and support staff, management and boards, are equipped to lead positive safety cultures and improve performance in all settings.
  • Safety intelligence: Triangulated data, connected technologies and real-time insights enable a predictive and proactive approach to safety.
  • Safety priorities and programs: Targeting patient populations and key focus areas with programs, tools, resources, and safety expertise, while maintaining flexibility and agility to respond to urgent needs.

These four strategic priorities are reflective of the growing importance of predictive, data-driven decision making as being fundamental to patient safety, the shift toward population-based approaches to safety and quality improvement, and the key role that staff at all levels of the system - from board to bedside - have in the CEC's vision for 2021 - 2024, 'Safety is everyone's business'.

This focus is reflected in the CEC's new Safety and Quality Essentials Pathway, our patient safety programs in key areas, and the innovative resources we offer to the system, including QIDS, QARS and our quality improvement toolkits.

The year in numbers - COVID-19

  • 1.5 million Pageviews on the CEC website
  • 250,000 Downloads of COVID-19 resources
  • 106,520 episodes of health workers participated in the statewide Respiratory Protection Program
  • 3160 Requests for expert COVID-19 advice and support
  • 37 Serious Adverse Event Reviews (SAERs) with COVID-19 as risk factor
  • 4108 ims+ COVID-19 incidents
  • 27 QARS PPE audit cycles for LHDs
  • 10 COVID-19 Communities of Practice supported by the CEC
  • 15,826 HETI PPE modules completed since 1 January 2021
  • 197 PPE reviews
  • 76 Website resources developed
  • 469 Hotel Quarantine recommendations
  • 13 PPE videos
  • 70 Medication safety investigations
  • 50 Supply issues requiring local mitigation
  • 13 Safety communications
  • 7 Medication-related Safety Alert Broadcast Systems (SABS).

Key Achievements

In 2020-21, the Clinical Excellence Commission:

  • Supported 1.5 million webpage views and over 250,000 downloads of COVID-19 resources in 2020-21. .
  • Collaborated with HealthShare NSW to conduct 197 personal protective equipment (PPE) reviews, totalling 430 PPE product assessments, and delivered weekly PPE audits via the Quality Audit Reporting System for local health districts and specialty health networks. .
  • Responded to 968 notifications regarding issues with medical devices, medicines and biological agents with our Critical Response Unit conducting risk assessments. Of these, 18 required system-wide critical responses related to product issues and shortages to ensure the safe delivery of care and continued service delivery. We issued 25 urgent safety alert broadcasts, including 12 related to clinical issues and 13 related to medicines and vaccines. These were in addition to 19 medication safety updates and 10 medication safety communications as part of our primary function to minimise potential harm. .
  • Developed and led implementation of a statewide Respiratory Protection Program with participation by more than 106,520 health workers; and coordinated a whole-of-health approach to developing standardised resources for fit checking, fit testing, reporting and training. .
  • Developed new Morbidity and Mortality meeting guidelines in conjunction with clinicians and established these on the Quality Improvement Data System platform for clinical teams to access near real-time data and generate insights for meetings. The new Morbidity and Mortality guidelines identify six core principles that reflect contemporary safety and quality principles, which are guided by Human Factors science to support robust processes that improve learning and system improvement. .
  • Developed, tested and released a Safety Culture Measurement Toolkit to serve as a self-contained set of instructions and templates to enable health services to administer a safety culture survey effectively and adapt for local conditions. .
  • Developed the Safety Fundamentals for Person Centred Communication tools to support staff in building relationships and partnering with patients, their families and carers in decision making. They include Teach Back, What Matters to You? and the Patient Delivered Handover. .
  • Implemented the revised NSW Health Incident Management Policy following the commencement of legislative changes for serious incident management in December 2020. Collaborated with eHealth NSW to align the use of the incident management system platform through refocusing process aims to improve reliability, quality, timeliness, strength of incident management, responses to review recommendations and system learning. Supported local health districts and specialty health networks to implement the use of the Preliminary Risk Assessment and serious adverse event review methodologies by hosting 36 masterclass sessions for 1507 participants prior to commencement of legislation; developing 80 resources including templates, toolkits, workbooks, fact sheets and explainer videos; and hosting two Patient Safety Manager Forums following implementation attended by 195 staff. .
  • Developed the updated Safety & Quality Essentials Pathway that learns from and replaces the Foundational Clinical Leadership and Executive Clinical Leadership Programs. The pathways aim to build the skills and knowledge needed of effective leaders for safety and quality improvement in daily practice. The CEC Academy works with health entities through partnership agreements to support sustainable local implementation. .
  • Partnered on 15 research projects to support innovation and translation in a range of quality and safety priorities, including stillbirth prevention, falls prevention, antimicrobial stewardship and virtual clinical pharmacy services. .

New CEC Academy

Learning together for safety and quality

The CEC Academy brings people together to learn, share and apply the principles of safety and quality improvement in clinical practice.

In 2020/21, the Academy made substantial progress by working with local health entities to review and update its safety and quality capability development programs.

The goal is to establish a pathway for all staff that grows their awareness, understanding and practical application of safety and quality improvement in daily practice.

Working with local health entities, the CEC developed the Safety & Quality Essentials Pathway as one strategy to build capability across the NSW Health workforce in patient safety and quality improvement. 

The Pathway contributes to reducing harm by offering tailored development through programs aligned to the Healthcare Safety and Quality Capabilities set.

Foundational is the first level of the Pathway and is designed for all NSW Health employees. From January to June 2021, 6,586 NSW Health staff have already completed all Foundational modules, and 8,230 had completed the 6 Dimensions of Healthcare Safety & Quality video.

Leading from the Chief Executive's office, South Western Sydney Local Health District (SWSLHD) has been a key driver to the impressive uptake of the Foundational programs within the Pathway.

Amanda Larkin (Chief Executive) and Ken Hampson (former Director of Clinical Governance) were among the first people to complete the Foundational program and have made it a requirement for all SWSLHD employees.

At the opposite end of the pathway, the Academy continued to partner with SWSLHD for the first test of the Applied Safety & Quality Program with 12 local leaders in safety and quality.

The Applied Safety & Quality Program is a 12-month development opportunity designed for local leaders of safety and quality with a focus on workplace application to build local capability and lead continuous improvement.

Quotes from SWSLHD Applied SQ Program participants:

"My most valuable learning was that Improvement Science is adaptable to the dynamic nature of organisational and patient safety requirements. My own thinking also needs to be adaptable and dynamic."

"I now have a lot of resources to build my repertoire of change management, and hopefully I can support more staff through driving their own change projects."

Reflecting on learnings so far, the CEC has committed to work with local health entities through implementation partnerships over the next two years. The goal is to build from the foundations up, to the point where all pathway programs can be sustainably locally delivered and integrated with local strategic priorities.

Morbidity & Mortality

M&Ms - New Guidelines

Traditionally Morbidity & Mortality (M&M) meetings have not focussed on education or felt like a 'safe space' to share information from which to learn, improve care and build team cohesion.

To provide guidance on how to lead and facilitate safe and meaningful discussions within the M&M, the CEC consulted and collaborated with clinicians to develop the new M&M meeting guidelines.

The new M&M guidelines identify six core principles that reflect contemporary safety and quality principles, which are guided by Human Factors science to support robust processes that improve learning and system improvement. These principles allow health agencies to review the quality of the care that is being provided to their patients and to identify any opportunities for improvement.

A key aspect of effective M&M meetings is having access to meaningful patient level data to support the M&M process. The CEC has developed an M&M Module in the Quality Improvement Data System (QIDS) that provides clinicians with access to local Hospital Acquired Complication (HAC) data from the Health Information Exchange (HIE), ims+, and other sources. By making it easy to review this data at the Local Health District, hospital and ward levels, opportunities for improvement can be identified.

To enable LHDs to run effective M&M meetings, supporting resources developed by the CEC include cue cards for presenters and a checklist for M&M meeting chairs.

The CEC has also collaborated with clinicians in publishing its first educational podcast series on M&Ms, further raising awareness of the important change in how M&M meetings are being approached. Described by some as a masterclass in how to undertake M&M discussions in a safe space for learning and improvement, these podcasts set the bar for how best to manage these vital meetings.

Quotes from the podcast participants:

"Using the structure of the CEC guidelines for the M&Ms, we've actually developed a very structured way in which we approach every meeting….. And then we use the CEC M&M template for reporting and everyone's used to seeing that."

Dr Andrea Christoff, Medical Co-Director, MD FCICM FRACP

"...the number one thing is - and it's beautiful to see it on the guidelines from the CEC - the safety of the people who are actually at the meeting…… We're missing the opportunity of focusing on learning from what we did well. It is so important….I was so happy to see the CEC's guidelines talking a lot more about Safety II introducing those ideas."

Dr Dane Chalkley, Deputy Director WellMD Centre, SLHD Emergency Department, Senior Staff Specialist in Emergency Medicine, RPAH BSc. (Hons) MBBS FRCEM FACEM

"...really important to me to choose the cases that we talked about really carefully. So, only choose the cases where you're actually going to learn from them, not where you're just going to embarrass or shame someone…. You don't learn if you're feeling ashamed and you don't learn if you're feeling frightened…"

Dr Clare Skinner, Staff Specialist in Emergency Medicine, Hornsby Ku-ring-gai Hospital BSc BA(Hons) MBBS MPH FACEM.


COVID-19 Infection Prevention and Control response

With the declaration of a pandemic on 11 March 2020, under NSW legislation, the CEC became the lead agency for Infection Prevention and Control (IPAC) in NSW.

Under the leadership of Chief Advisor Kathy Dempsey, CEC's Healthcare Associated Infection (HAI) and Infection Prevention and Control (IPC) team developed a comprehensive range of COVID-19 IPAC resources setting clear clinical guidelines for the NSW Health community.

The IPAC team influenced IPAC compliant behaviour across the health system through webinars, support sessions, and educational videos. The cornerstone of the HAI team's approach was the creation of the COVID-19 IPAC Manual, a consolidated 215-page guide for acute and non-acute healthcare settings. The manual is regularly updated and provides healthcare workers with guidance on COVID-19 infection prevention and control requirements for the management of patients or clients with suspected, probable or confirmed COVID-19.

To ensure the consistent application of processes and procedures, the team initiated new channels of communication to share knowledge with NSW clinical Communities of Practice and to Infection Control Practitioners networks across the NSW Health system, LHDs, enabling them to respond to the pandemic challenge. The team also developed and led implementation of a state-wide Respiratory Protection Program (RPP) with participation by more than 100,000 health workers.

The team also coordinated a whole of health approach to developing standardised resources for fit checking, fit testing, reporting and training. In addition, the team implemented robust governance processes for Personal Protective Equipment (PPE) and developed a range of downloadable PPE instructional videos to embed safety protocols.

The success of the team's COVID-19 response strategy was evident in the 1.5 million webpage views and 250,000 downloads of CEC's COVID-19 infection prevention and control resources.

As new needs emerged, the team assisted Residential Aged Care Facilities, educational facilities, multi-purpose services, private hospitals, community residential care group homes, hostels and refuges.

The team's vital work with NSW Hotel Quarantine and Airport Program Quality Assurance Program contributed substantially to key outcomes in the successful control of COVID-19 in NSW by helping prevent the spread of the virus into the wider community from any arriving travellers.

Maintaining medication supply during COVID-19

A significant challenge for NSW Health during the COVID-19 pandemic has been ensuring adequate supply of essential medications for all facilities due to global medication shortages and supply chain constraints. As the lead agency for critical response to all COVID-19 medication supply and safety issues, the CEC Medication Safety Team (MST) has focused on ensuring that medicines are available to treat all patients and when alternatives are recommended for use in our facilities, that they do not introduce safety concerns.

The CEC MST have liaised with other NSW Health agencies to ensure safety in the continuous supply of medication being used in our facilities. All alternative products undergo rigorous review to ensure they do not introduce risks that could lead to prescribing, dispensing or administration errors e.g., packaging variations and/or differing storage requirements.

In the 2020-2021 financial year,

  • 571 supply issues were made apparent to the CEC requiring investigation for potential safety issues
  • 123 of these were reported to frontline staff due to safety risk(s) requiring local mitigation
  • 17 resulted in a formal safety communication (including a Safety Alert Broadcasts in some instances)

To summarise the emerging safety risks requiring local mitigation, the CEC MST created a Medication Safety Update document that was disseminated to the system regularly (weekly initially and then fortnightly) until early November 2020 when it was transitioned to a webpage hosted on the CEC website.

To understand the utility and timeliness of the initial updates, consultation was undertaken through interviews with six Pharmacy departments and an electronic survey was disseminated to NSW Health employees. Overall, the feedback was positive with respondents agreeing that the updates contained valuable and relevant information. Comments regarding the timeliness and format of the update led to a transition to a dynamic online format with the ability to filter and sort entries. Up-to-date information is now added as it becomes available, and clinicians are alerted to changes via email (if they choose to join the subscriber list). Additionally, a document summarising the last month's medication safety and supply related issues is now released at the beginning of each month (e.g. June 2021 update) and can be used by frontline clinicians to table at relevant committee meetings, such as Drug and Therapeutics Committee meetings.

The CEC has demonstrated agility in their response to medication supply and safety during the pandemic to meet frontline needs. Collaboration across NSW Health agencies resulted in a central reference point which could be relied upon as the 'source of truth' for up to date information. This is unprecedented and has broken down barriers to allow for a more efficient and effective process.

Redesigning Quality Improvement Toolkits

The CEC Quality Improvement Toolkits support local healthcare teams to start and sustain a quality improvement (QI) project focusing on clinical areas where the risk of harm is well recognised.

Design, consultation phase and improvements to the toolkits

The redevelopment and standardisation of the CEC toolkits consisted of two rounds of consultation via the Quality Audit Reporting System (QARS) survey and email correspondence targeting a wide range of clinicians and managers across NSW. Over 50 survey responses and 15 individual experts' feedback were received. As a result, the following improvements to the design of the toolkits were implemented:

  • Human centered design with interactive layout and resources specific to each clinical area
  • Step by step approach to Improvement Science allowing anyone to conduct a project with ease
  • Initiation of Communities of Practice (CoPs) providing a channel for clinicians to reach out for advice and to share their own learning across NSW health facilities
  • Formation of the CEC toolkit working group to guide standardised toolkit development and maintenance.

Official launch and introducing the Communities of Practice (CoPs)

The CEC launched six QI toolkits in June 2021 (with plans to launch at least another six in the coming year). Communication strategies included an introduction video by Chief Executive Carrie Marr, a series of webinars and advertisements through specific clinical networks. The strategies were well received by our colleagues, with over 500 staff across NSW registering for three webinars.

Within three months of the launch, the toolkit webpages had over 4,500 views and 100 individual CoP registrations. This includes enquiries from other States finding the toolkits very useful.

Positive feedback from clinicians

Here are some specific feedbacks from clinicians who have reviewed and/or used the toolkits.

"Thanks CEC for developing a practical and useful toolkit which is simple to follow and step-by-step guide. I love the examples to illustrate the point and helps my understanding."

Angela Wai, Senior Pharmacist Medication Safety, SLHD.

"I found the information very helpful, VTE Prevention and improving the use of the VTE risk assessment has been a project we have been looking at for a number of years. The driver diagram was useful to compare with our project's driver diagram."

Maria Pron, Quality and Accreditation Manager, Fairfield Hospital.

Our thanks

In the preparation of this document we would like to thank management, clinical staff and communications teams in the following local health districts: Nepean Blue Mountains, Northern NSW, Northern Sydney, Sydney, and South West Sydney.