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Kate is the Service Director of Southern Adelaide Palliative Services (SAPS). Her role is clinical service inpatients, consultation liaison and community. SAPS is a regional level 3 service, inpatient unit of 15 beds - Daw House, provides consultation liaison services to the three hospitals within the Local Health Network, and serves a population of 350,000 with community support. Kate is currently the Acting Chair of the Palliative Care Clinical Network Many thanks Kate for taking time to join our webinar today providing your valuable experience & support to our discussions
Background – national palliative care standards + NSAP
National Standards Assessment Program (NSAP) Continuous quality improvement, performance management & supports
accreditation
Framework to implement national palliative care standards Industry lead mechanism for assessment
Palliative Care Australia (PCA) PCA standards 4th edition (2005) ensure consistent, quality delivery of
palliative care across Australia
Central to PCA policies & policy development
Standards are designed to assist services:
Designing palliative care services Prepare for accreditation by respective bodies Plan, prepare quality activities as part of continuous quality
improvement Conduct research Assist with performance management & agreements Provides data to build evidence for funding
Assist in policy development
Revision of the standards occurs in response to the changing health care environment
Latest edition of the NSAP self assessment workbook
Lets walk through updated version 2…
What’s in your workbook?
Workbook pages 1- 3 provides definitions including what is NSAP, what is a MDAT, audit tool data collection, QI action plans, peer mentorship and linking with accreditation Workbook page 4 the NSAP cycle (Plan, Do, Study, Act) Workbook page 5 Summary of the NSAP cycle Workbook page 6 notes on using this workbook (including using the rating scale) Workbook page 7 notes on understanding the overall priority rating
Latest edition of the NSAP self assessment workbook
Latest edition of the NSAP self assessment workbook
Workbook pages 8 – 33 Defines each standard & includes the intent of the standard, checkbox for evidence sources used and a page to record the results of each assessment Workbook page 35 Appendix 1 – The national palliative care standards, listed Workbook page 36 Appendix 2 – EQuiP5 Standards & Criteria Workbook page 37 Appendix 3 – Summary of Standards, Quality Improvement Council Workbook pages 38 – 39 Appendix 4 - Accreditation Standards (Aged Care Standards & Accreditation Agency Ltd) Workbook pages 40 – 41 for your notes
Latest edition of the NSAP self assessment workbook
How to use your workbook?
Provide the latest version 2 workbook hard copy to each MDAT member (include a photocopy of section 3) During self assessment:
Record as you go (hard copy) Record as you go (electronic copy) Record before (come prepared)
After self assessment – keep copies (hard/electronic) in a safe place
Making an assessment of current achievement for each standard
National palliative care standards set out conditions & practices necessary for provision of high quality services + est. minimum agreed levels of performance
MDAT discuss a rating for each quality element + a single overall improvement priority rating for each standard
What determines a rating for a particular standard MDAT skilled judgement Analysis of available evidence
Quality elements contain multiple aspects…
Rating allocation = service performance against all aspects of the element
only when all aspects of the element are achieved
Aspects of the element are assessed differently?
Overall rating of element reflects lowest rated aspect
Reaching consensus – quality elements Never Rarely < 25%
Sometimes 25-75%
Often > 75%
Always
Reaching consensus – overall rating
Assigning an overall rating indicates the for
for each national palliative care standard
When allocating a priority rating consider:
Patient & family experience (impact)
Organisational strategic plans
Operational plans
Availability of resources
A high priority
B medium priority
C low priority
What does the MDAT record during self assessment
against each quality element Provides a useful summary how the MDAT agreed to the overall rating for the standard (valuable reference for your peer mentor visit)
Record supports your decision & where this is (valuable for ACHS visits & peer mentor visits)
Summarise the key points of your self assessment (valuable reference for prioritising
& planning your quality improvement strategies & peer mentor visit)
x
x
x
x x
x
x
x
x
HR records, agreements & contracts, education / training
X HR records, agreements & contracts
Education / training
X Needs regular identification in annual appraisals
X Difficult for clinical staff to prioritise HR records, education & training X
X
X
X
Describe key points here?
12 Incorporating formal training needs assessment into staff appraisals
Training needs assessments B medium
Why does the MDAT record during self assessment
against each standard
key improvement areas
for areas of improvement
The QI action plan shouldn’t address every area for improvement
but any standard that has been rated as an
an overview of the peer mentor process
what is your strongest evidence + audit tools
making change in the clinical environment