Category: Health Quality and Safety Commission

Source: Health Quality and Safety Commission – Press Release/Statement:

Headline: National event marks ‘the beginning of the end’ for seclusion

Mental Health & Addiction Quality Improvement

District health board (DHB) teams from across the country joined mental health and addiction service consumers, the Health Quality & Safety Commission and Te Pou o te Whakaaro Nui (Te Pou), in Wellington this month, to begin the important work of the national collaborative, Zero Seclusion: towards the elimination of seclusion by 2020.

The national workshop held on 7 March was the first meeting for the collaborative, providing an important opportunity to start planning the steps towards ending the use of seclusion. It featured presentations from key individuals within the mental health and addition sector, who helped to set the context for this area of work, providing a national and international perspective on the elimination of seclusion.

There was a strong focus on the role of consumers and families/whānau in supporting long term change, as well as an explanation of the quality improvement methodology that will drive the project. Attendees worked in groups looking at local implementation of the initiative and then provided feedback.

Clinical lead for the Commission’s mental health and addiction quality improvement programme, Dr Clive Bensemann, says the workshop meant everyone could hear and see first-hand what a quality improvement approach to eliminating seclusion looks and sounds like, and what needs to be done to scale up programmes and further improve the health system to achieve this goal.

The event also saw the introduction of the Commission’s new mental health and addiction Māori advisory group, who will work alongside the Commission, Te Pou, DHBs and consumers to improve the quality of mental health and addiction services in New Zealand.

Their involvement in this initiative is particularly important, said Wi Keelan, Māori Kaumatua and cultural advisor to the Commission’s mental health and addiction programme.

‘It is important that Māori, who experience the highest rates of seclusion in New Zealand, feature effectively in the aspiration of the sector to eliminate seclusion by 2020. Setting this deadline brings greater hope for Māori who are particularly impacted by current restrictive practices. This will be imperative to achieving health equity, by eliminating disparities in their care.’

Te Pou chief executive Robyn Shearer says that New Zealand has made good progress towards reducing seclusion and restraint.

‘We look forward to supporting the mental health and addiction Māori advisory group with this work so that this progress can continue.’

Roz Sorenson, project manager for the Commission’s mental health and addiction quality improvement programme says feedback from participants on the day was positive.

‘There was a really strong sense of commitment expressed on the day, as to the importance of achieving this aspirational goal, and a clear understanding that eliminating seclusion means improving safety and reducing harm, across our wider services.’

Participants from the workshop also shared their thoughts on the day (click the images below to go to the videos).

Simon Phillips, chief executive of the Maraeroa Marae Health Clinic reflects on the day and discusses the importance of making mental health a priority to achieve change.

Claudine Nepia-Tule, portfolio manager – mental health & addictions, MidCentral DHB talks about how the day has provided frameworks for improvement through improved collaboration.

Heather Casey, director of nursing, Southern DHB talks about how the team-approach is important for success in achieving the goal of zero seclusion.

For more information about the zero seclusion project visit www.hqsc.govt.nz/our-programmes/mental-health-and-addiction-quality-improvement.

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Source: Health Quality and Safety Commission – Press Release/Statement:

Headline: Perinatal and Maternal Mortality Review Committee annual conference: Coming together to be better

Perinatal & Maternal Mortality Review Committee

Nou te rourou, Nāku te rourou ka ora ai te iwi katoa.

With my food basket and your food basket the iwi shall be fed.

On June 26, the Perinatal and Maternal Mortality Review Committee (PMMRC) will host its annual conference, Coming together to be better, and will launch its 12^th Annual Report.

PMMRC annual conferences present national perinatal and maternal mortality and morbidity data and findings, and discuss learnings for improving the quality of care for mothers and babies. 

We hear from keynote speakers on neonatal deaths in this country over the past ten years, persistent inequities in perinatal and maternal outcomes for Māori, paediatric heart obstruction and, the power of combing data with whānau/family voices. 

Programme

This year’s programme includes two concurrent sessions: one focusing on serious maternal morbidity and perinatal mortality related to fetal growth restriction and maternal sleep practices; the second, looking at maternal mortality and whānau/family views on postmortems. 

View the draft conference programme here.

Networking function 

A networking function will be held after the conference, to bring our guest speakers and delegates together. This is a great opportunity to catch up and meet new colleagues. Attendance is included in your registration and is open to all registered delegates.

When: 5.00pm – 6.30pm, 26 June 2018
Where: Te papa Tongarewa (Icon room), 55 Cable St, Wellington

Canapés are provided and a cash bar will be available.  

Registration

Early bird registration (closes midnight, Sunday 13 May 2018)	$210 + GST
Regular registration (if received on or after Monday, 14 May 2018)	$275 + GST
Student registration (ID required on day of workshop)	$60 + GST

To register go to http://www.etouches.com/pmmrc2017.

CME points will be available for this meeting.

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Source: Health Quality and Safety Commission – Press Release/Statement:

Headline: Health Quality & Safety Commission e-digest – Issue 80 online now

Health Quality & Safety Commission

In this issue

Quality and safety improvement

• Presentations from Let’s Talk: our communities, our health
• A day in the life of the Toiora exercise class
• What cancer taught me
• Dr Lynne Maher on co-design
• The ripple effect
• Advance Care Planning Day, 5 April 2018
• Advance care planning brochure

Reducing harm

• Blog: Zero seclusion: It’s about teamwork
• Zero seclusion infographic
• April Falls 2018 update
• Live Stronger for Longer
• Pressure injury measurement frequently asked questions
• Patient Safety Week 2017 evaluation

Reporting and commentary

• Call for nominations for four mortality review committees
• Vacancy for a communications coordinator

Events

• Putting prevention first: Leadership and action on preventing healthcare associated infections
• BMJ International Forum on Quality & Safety in Healthcare
• Eighth biennial Australian and New Zealand falls prevention conference

 

 

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Source: Health Quality and Safety Commission – Press Release/Statement:

Headline: Advance Care Planning Day, 5 April 2018

Advance Care Planning

Advance Care Planning Day is an opportunity for each region to connect with their communities to enhance the profile and knowledge of advance care planning. Advance Care Planning Day was previously known as Conversations that Count Day.

The Health Quality & Safety Commission is overseeing the national advance care planning programme, with funding from district health boards (DHBs).

Advisory and steering groups have been established to support and guide the programme.

About two weeks before Advance Care Planning Day, key messages and tweets will be sent to DHB communication managers and ACP contacts; and a national media release will be sent out on 4 April.

Over 60,000 resources have been dispatched to DHBs and others. A new resource entitled What matters most for your future care is available in hard copy, or can be downloaded from our website.

For further information please email Clare O’Leary.

We look forward to hearing more about your events across the regions.

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Source: Health Quality and Safety Commission – Press Release/Statement:

Headline: Call for Nominations for one member to join the Family Violence Death Review Committee

Family Violence Death Review Committee

Nominations close at 5pm on Monday 2 April, 2018. 

The Health Quality & Safety Commission’s Board is seeking one member to join the Family Violence Death Review Committee.

The Family Violence Death Review Committee (the Committee) is a mortality review committee established under Section 59e of the New Zealand Public Health and Disability Act 2000. The Committee will consider self-selected mortality subgroups.

Collectively, the Committee will have:

• one member with relevant consumer experience and well-established connections to consumer groups, to provide a consumer perspective.

The other members include people:

• with expertise in mortality review systems
• with expertise in legal (criminal and family), medical, indigenous, social science and/or health research and practice
• who are experts in the field of intimate partner violence
• who are experts in the field of child abuse and protection issues
• with knowledge of, or experience in, service provision or operational policy in the social sector, including family violence services
• with knowledge of family violence issues from a service user/family perspective
• of Māori descent, with knowledge of family violence issues, or experience in working with Māori whānau affected by family violence
• of other ethnic groups, with knowledge of family violence issues, or experience in working with families affected by family violence.

The Commission welcomes all applications, particularly from candidates who offer independent academic and sector expertise in the following areas:

• legal jurisprudence (criminal and family)
• child protection
• Māori and/or Pasifika conceptual frameworks for preventing violence within whānau.

The Committee will be assisted by advisors from the following agencies and organisations:

• Ministry of Social Development and Oranga Tamariki
• Ministry of Justice
• New Zealand Police
• Department of Corrections 
• Ministry of Education
• Ministry of Health
• key non-government organisation family violence representatives
• Chief Coroner’s Office
• Office of the Children’s Commissioner.

Members will:

• have the ability to work strategically and operate effectively in the national policy space
• have credibility in relevant communities 
• be drawn from a range of disciplines and contexts such as legal (criminal and family), medical, indigenous, social science and/or health research and practice, providers, consumer representatives such as advocacy groups, and people representing Māori and Pacific peoples’ interests
• be able to communicate effectively with practitioners, as well as government ministers and media commentators, individually and in group contexts.

All members will also have:

• wide professional or cultural networks
• strong personal integrity and ethical behaviour
• commitment to the issues at the heart of the Committee’s business
• critical appraisal skills
• highly developed written and oral skills
• wide life experience
• respect of peers
• appropriate clinical or professional experience 
• ability to engage with the other members of the committee and contribute constructively.

If you would like to nominate suitable candidates, please complete the nomination form below and email it to Dez McCormack.

If you would like to apply directly, without nomination, please complete the application for appointment form below and provide your current curriculum vitae, and a cover letter outlining your interest in the position, by email to Dez McCormack.

Nominations close on Monday 2 April, 2018 at 5pm

Downloadable documents

Application for appointment (472 KB, doc)
Nomination form (435 KB, doc)

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Source: Health Quality and Safety Commission – Press Release/Statement:

Headline: Counties Manukau Health seeks part-time experience engagement advisor

Partners in Care

Counties Manukau Health is recruiting for a part-time experience engagement advisor. This position works in partnership with patients and staff to deliver exceptional care and experiences at Counties Manukau Health.

More information about the role is available in the document below or visit the Counties Manukau Health recruitment website.

Applications close on 28 March 2018.

Downloadable documents

• Experience engagement advisor (37kb, PDF)

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Source: Health Quality and Safety Commission – Press Release/Statement:

Headline: Call for nominations for three positions on the Perinatal and Maternal Mortality Review Committee

Perinatal & Maternal Mortality Review Committee

Applications close Monday, 9 April 2018

The Health Quality & Safety Commission’s Board is seeking three new members to join the Perinatal and Maternal Mortality Review Committee. The members will be from perinatal and maternal related disciplines of midwifery, obstetrics, neonatology, or primary care; and those with knowledge and experience in health service provision to Māori. 

The Perinatal and Maternal Mortality Review Committee is a mortality review committee established under Section 59e of the New Zealand Public Health and Disability Act 2000. The Committee is required to review and report on infant (up to 28 days) and maternal mortality and morbidity, as directed by the Board, for the purposes of improving care, quality and safety, and saving lives.

There are three positions available. We are requesting nominations for, and applications from, practitioners with expertise in the areas of maternal and perinatal care, midwifery, and primary care, and with knowledge and experience in health service provision to Māori.

All applicants are required to have the following:

• wide professional or cultural networks
• credibility in relevant communities and respect of peers
• strong personal integrity and ethical behaviour
• commitment to the issues at the heart of the Committee’s business
• critical appraisal skills, highly developed written and oral skills, strategic thinking
• experience in working with Māori and Pacific peoples
• broad life experience
• appropriate clinical or professional experience
• ability to engage with the other members of the committee and contribute constructively.

Collectively, the committee must have the following expertise:

• quality improvement and risk management; quality assurance in the health sector
• data and information gathering systems and analysis
• clinical epidemiology
• DHB service provision and management
• clinical experience in neonatal paediatrics, perinatal pathology, obstetrics, midwifery and other clinical expertise relevant to the PMMRC’s function
• Māori health
• knowledge of the health of other ethnicities, particularly those at higher risk
• consumer participation and representation.

If you would like to nominate suitable candidates, please complete the nomination form below and email it to Dez McCormack.

If you would like to apply directly, without nomination, please complete the application form below and provide your current curriculum vitae, by email to Dez McCormack.

Downloadable documents

Application for appointment (472 KB, doc)
Nomination form (435 KB, doc)

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Source: Health Quality and Safety Commission – Press Release/Statement:

Headline: Eighth biennial Australian and New Zealand falls prevention conference

Reducing Harm from Falls

The eighth biennial Australian and New Zealand falls prevention conference is being held on 18–20 November 2018 in Hobart, Tasmania. 

The programme includes plenary lectures by speakers from the UK, USA, Australia and New Zealand. Topics are related to falls prevention in the community, hospital and aged care settings (and much more). 

For more information download the conference brochure or visit the conference website.

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Source: Health Quality and Safety Commission – Press Release/Statement:

Headline: What cancer taught me

Partners in Care

Author and young cancer survivor Jake Bailey made international headlines when he delivered his end-of-year prizegiving speech as head boy of Christchurch Boys’ High School in December 2015, just one week after being diagnosed with Burkitt’s non-Hodgkin’s lymphoma.

Jake, who has been in remission since 2016, shared the story of his diagnosis and subsequent treatment at the Health Quality & Safety Commission’s Let’s Talk forum. He discussed the highs and lows – from delays in diagnosis, to the incredible team of health care professionals he considers himself lucky to have worked alongside during his treatment.

While he was invited to speak at the forum about the areas of his treatment which could have been improved, Jake is quick to reiterate how grateful he is for everything his health care team has done for him, and how his experiences within the system were overwhelmingly positive. He noted that, while it’s confronting for patients and professionals to look at the times where things went wrong, it’s important to do so, particularly for the benefit of the patients who will come after him.

A series of system failures meant Jake wasn’t diagnosed as early as he could have been. Scans which could have helped diagnose his condition weren’t looked at by his doctors or dentists, his pain was put down to his wisdom teeth which were subsequently extracted and his pain levels were downplayed.

The type of cancer Jake had is incredibly fast growing and can double in size every 24-48 hours. By the time he was diagnosed, his body was riddled with tumours and the tumour in his jaw was sticking out through the holes left by the removal of his wisdom teeth. The delay in diagnosis bought him within two weeks of death.

“When you’re 18 years old, that’s far closer to death than you are comfortable being,” he noted with a laugh.

He has several examples of ways the system failed while having treatment, and recalls an experience where he was transferred through the hospital for a scan without a face mask, and picked up a bug.

Jake spent 50 days straight in Christchurch Hospital’s bone marrow transplant unit leaving only once to make the speech which thrust him into the spotlight. That time was spent in an isolation room where visitors had to go through two airlocks and two hand washing stations before even making it onto the ward.

“I genuinely believe that through sharing the details of my story, I have the ability to positively influence the consumer experiences of future patients. It’s important to me to be part of the change I want to see.”

While he looks back on his time in hospital with positivity, Jake says he was lucky to have a strong and confident advocate – his mum Janine – but he realises that many consumers may not have such strong family support.

“While my outcome may not have been different, had I not had my family there to advocate for me, it would have been a much longer and slower process to be diagnosed and treated.

“It was them who pushed for me to be seen by specialists, it was them who took me to appointments, it was them who pushed for answers when we felt like we weren’t getting any.”

Jake sees the dedicated health care professionals as the biggest asset of our health care system.

“The most important part of my experience with our health care system was the people who stood beside me throughout it. And that wasn’t just my family – it was a team of truly incredible medical professionals, who I will forever be connected to.

“The staff that made the biggest impact for my family and I were those that saw us as part of the health care team. They understood the psychological impact that isolation can have and made allowances to minimise this.

“They approached their job in a holistic way and gave support on a real and personal level. They made an effort to get to know us as real people– they were humble, hugged me when I cried, talked to me when I was lonely, laughed with me and ultimately saved my life.”

Jake will remain forever grateful to the amazing health care workers who supported him and says that the points he makes should be seen as the failures of a system, not the individuals who work within it.

Jake has written a bestselling book about his experiences called Jake Bailey: What Cancer Taught Me.

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Source: Health Quality and Safety Commission – Press Release/Statement:

Headline: Dr Lynne Maher on co-design

Partners in Care

Dr Lynne Maher presented at the Health Quality & Safety Commission’s Let’s talk forum on 8 March 2018. Lynne is the Director of Innovation at Ko Awatea, Counties Manukau Health, Honorary Associate Professor of Nursing at the University of Auckland, and has led the co-design movement across New Zealand.

She began by asking the audience how many people had ever accessed the health service for themselves or their families – not surprisingly, everybody in the room had. She then asked how many people would describe their experiences as ‘excellent service’? Only about ten people in the room put their hands up. Lynne saw this as an opportunity to learn about integrating the voice of consumers into the design of improved services.

“The response of consumers is a key component of co-design, to create a feedback loop for the design and development of health services,” she said.

“Generally, when consumer voices are integrated into the design of health services, research has shown a number of benefits. For example, patients are more able to take their medications correctly and feel more confident and empowered in their own health care management, which can reduce access to health care services.”

She said that when considering co-design, many mainly focus on working with patients and families. However, co-design is actually about working with everybody who is involved in or impacted by the health care process.

“It is important to understand staff perspective and there is a significant amount of research that demonstrates when staff feel fulfilled and able to work in a positive way, this translates into patients and family/whānau having a more positive experience.”

What is co-design?

Co-design is a process where a challenge or an opportunity is identified. A range of people who have experience and expertise in delivering or receiving services are engaged. The experiences they have are shared and captured with specific attention to how they feel at each step and any ideas they may have for improvement.

We are also capturing consumer experiences that may not have been good. We are gathering ideas for improvement, asking those intricately involved in the care: “How did it make you feel?” and also what ideas they have to improve the service.

Co-design enables us to:

• explore experiences, which helps us to better understand the root cause of the problem – people feel more engaged with the solution if they understand the problem
• engage and build partnerships between staff and consumers from the start
• better utilise all of the expertise available to us, especially from consumers and staff.

Lynne emphasised the importance of considering appropriate combinations of tools to capture experiences. Surveys provide excellent high-level understanding. This can be enhanced by even a short face-to-face discussion which provides much more depth about the experience.

“This storytelling also be very cathartic – people like to feel listened to – it can be therapeutic for patients to tell their story to get it off their chest and feel heard.”

She said capturing the evocative emotions from interviews with patients was key and could reveal subtexts.

In co-design, we are particularly listening for words that depict emotion: ‘In reception I was scared, but by the time the nurse came to talk to me I felt more comfortable’.

The data we capture helps us to map the care journey from multiple perspectives.

“The maps visually represent the story.

“Co-design is about turning experience into action and this results in improvement. It helps to draw out what is happening.”

She said this is a positive way to enable healing and build confidence and competence in health care services.

“Co-design helps to create a health service that can truly be known as world class.”

The Commission is committed to using co-design; a tool which is integral to its programmes.

You can find out more about co-design here: www.hqsc.govt.nz/partners-in-care/work-programmes/co-design/.

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