Summary of Quarter 2 report against the 2014/15 Statement of

Summary of Quarter 2 report against the 2014/15 Statement of Performance Expectations
Health Quality & Safety Commission
1 October 2014 to 31 December 2014
Performance expectation
Four quality and safety
markers reports provided
At least one quality and
safety indicators report
At least four atlas of
healthcare variation domains
Patient experience survey
reports will be published
quarterly, from October 2014
At least one serious adverse
events report published
At least two articles published
in peer-reviewed journals
On track?
Progress report
The most recent report for the 2014/15 year was issued on the Commission website on 15
December 2014, covering the July to September 2014 quarter.
A first draft of the Commission’s new ‘State of the Nation’ report was reviewed by the Commission
Board in November 2014 and work continues towards an expected publication in March or April
2015 to meet the deliverable.
The established QSI report will also be updated with new data when this becomes available in the
first half of 2015.
The opioids domain was published on 19 December 2014.
The falls domain is on track and publication will be aligned with plans for the April Falls 2015
At least two further domains will be completed by 30 June 2015. The topics for these have been
confirmed as cancer and anti-microbial resistance, and work is underway with the Ministry of
Health and other stakeholders.
The second quarterly survey has been proceeding well and is on track for publication by the end
of January 2015. The response rate is improving on the first quarter results in line with a stronger
push for email-based responses, although there is still room for further improvement.
The report, Making health & disability services safer: Serious adverse events reported to the
Health Quality & Safety Commission, 1 July 2013 to 30 June 2014, was published as planned.
The 2013/14 mental health and addictions report, previously published as part of the
Commission’s serious adverse events report, was published as part of the Director of Mental
Health’s annual report on 4 December 2014.1
Two draft articles have been completed (on the Commission’s overall role and its measurement
and evaluation work) and during the second quarter were being considered for publication by the
Performance expectation
On track?
At least two opinion papers
At least two workshops
featuring international
speakers arranged
At least one report on child
and youth mortality published
At least one report on
perinatal and maternal
mortality published
At least one report on family
violence deaths published
At least one report on
perioperative deaths
At least two mortality review
conferences held
Deliver a nationally
coordinated programme to
reduce harm from falls in
care settings
Progress report
editor of the New Zealand Medical Journal. (They have both since been accepted). Article titles:
 ‘The Health Quality & Safety Commission: making good health care better’
 ‘Measurement of New Zealand health care’.
A third article arising from the perioperative harm programme has been accepted for publication in
the Australia New Zealand Journal of Surgery: ‘Briefings and debriefings in one surgeon’s
practice’. The publication date has yet to be confirmed.
A draft article on Central Line Associated Bacteraemia (CLAB) has been accepted for publication
by North & South magazine (circulation approx. 26,000), at a date yet to be determined.
A second article will be prepared by 30 June 2015.
Prof James P Bagian, a US expert in human factors and a former astronaut, was the focus of a
successful week of quality and safety events during Patient Safety Week (3-7 November 2014) in
Auckland, Wellington and Dunedin.
An event with a renowned international quality and safety expert will be announced shortly.
CYMRC published its report on child and youth mortality involving quad bikes and other off-road
vehicles on 17 December 2014.
Data collection and analysis is underway. This year’s report will contain analysis of ‘small for
gestational age’ mortality. The report will be issued before the PMMRC national conference on 23
June 2015.
An Activities Report from the Family Violence Death Review Committee will be prepared during
the first half of 2015, for publication by 30 June 2015. Drafting will commence in the third quarter.
Draft statistics to inform the report have been prepared by the Otago Data Group and are being
considered by the committee as report drafting proceeds. A first draft will be prepared in the first
quarter of 2015.
The POMRC conference will be held at the Heritage Hotel in Auckland on 15 June 2015.
The PMMRC conference will be held at Te Papa in Wellington on 23 June 2015.
A falls prevention toolkit for primary care and consumers is near completion.
Work has started on the April Falls quiz, which is the main promotional tool for raising sector
Performance expectation
On track?
Deliver a nationally
coordinated programme to
reduce surgical site infections
A nationally coordinated
programme to reduce
perioperative harm
Deliver a nationally
coordinated programme to
reduce harm from high-risk
Topics four and five of the
‘Open for better care’ national
patient safety campaign are
All DHBs receive national
guidance to assist DHBs to
engage with consumers at
governance, policy and
service delivery levels
Progress report
A programme of engagement is underway involving visits across DHBs and aged care facilities by
falls clinical lead Sandy Blake to promote the falls 10 Topics and guidance documents on risk
assessment and care planning.
Hip and knee SSI guidelines were released from December 2013 to March 2014. The programme,
in collaboration with DHBs, has developed and implemented a consistent, evidence-based
approach to collecting and reporting hip and knee and cardiothoracic SSIs. All 20 DHBs are
submitting data to ICNet on SSIs in hip and knee operations.
Work during the second quarter included:
 completing the proof of concept project with pilot sites, Lakes and Waikato DHBs and
Southern Cross Auckland.
 the outcome report from the project was received in December 2014, with results presented to
the programme’s advisory group.
 a real-time observational data collection application was trialled as part of the proof of concept,
aimed at reducing the reporting burden on DHBs.
Work during the second quarter included:
 developing the Open for better care campaign topic, which was launched at a national forum
on 16 October 2014 and will run until March 2015.
 launching the ‘Safe use of opioids collaborative’, which will run from October 2014 to May
 four regional ‘learning session zero’ events, which were held in October and November 2014
to start the collaborative learning process.
Open topic 4, a medication safety focus on high-risk medicines, was launched on 16 October
2014 at the Medication Safety Forum at Westpac Stadium in Wellington, and will run until March
2015. Open topic 5 will focus on falls in care settings, and will run from April to September 2015.
Commenced a regional stocktake of consumer activities to inform the project, with results
expected by the end of February 2015. Also presented to DHB Quality & Risk Managers and
South Island Alliance to advise and consult on guidance, and received useful feedback.
The main priority for the next quarter will be preparing guidance content.