Download DPC Quality Report (DOCX 104 KB) - Department of Veterans` Affairs


DAY PROCEDURES CENTRE ANNUAL QUALITY REPORT
Pursuant to Part K and Clause 4 of the Day Procedure Centre Deed of Agreement
Annual Report:
To be submitted by 31 October 2016
Hospital Name:
Name of staff member
completing report:
Director Of Clinical
Services or CEO
signature indicating
approval of report content:
Submission Date:
Queries regarding the
report should be directed to:
/
//
/
/
Section 2 of this template should be used when hospitals do not provide their ACHS clinical
indicator comparison report to DVA, or where they do not report to ACHS on the clinical indicators
outlined below.
If you submit your ACHS clinical indicator comparison report to DVA:


provide two ACHS 6-monthly reports, one for the period 1 July 2015 to 31 December 2015
and another for 1 January 2016 to 30 June 2016; and
customise this template by deleting information that you have already provided.
Any queries in relation to Quality Reporting should be directed to your DVA Contract Manager.
Quality Reports should be submitted to: [email protected].
Page 1
SECTION 1: GENERAL HOSPITAL INFORMATION UPDATE
Accreditation Certification Programme (please underline):
A.

ACHS

ISO

Other (please state)
B.
Date currently accredited to:
C.
Assessment Cycle:

/
/
ACHS: Next survey is (please underline):

Period Review

Organisational Wide Survey
Estimated date (month and year) __________/_____
Or
 ISO: Next Review (please underline):

Annual Review

3 year Certification
Estimated date (month and year) _________/______
D.
Facility Profile:
Provide comment on the introduction or cessation of services or programmes, any change in
licensed bed numbers or use of licensed beds which occurred during the reporting period (1 July
2015 – 30 June 2016). Also provide information on current hospital performance in benchmarking
against peers (if undertaken). If no changes in facility profile please state ‘No Change’.
Page 2
SECTION 2: CLINICAL INDICATOR RESULTS
Clinical Indicators to be reported:







Day Patient Clinical Indicators – Version 5
Infection Control Clinical Indicators – Version 4.1 (including Day Procedure Centres)
Medication Safety Clinical Indicators – Version 4
Anaesthesia and Perioperative Care Clinical Indicators – Version 6 (if applicable)
Ophthalmology Clinical Indicators – Version 5 (if applicable)
Gastrointestinal Endoscopy Clinical Indicators – Version 2 (if applicable)
Specialised facilities (if applicable)
A. ACHS Clinical Indicator Report: Attach the relevant ACHS clinical indicator comparison
reports for the most recent 12 month period; this will involve two ACHS reports.
B. Complete only if the ACHS indicator equivalent has not been reported to ACHS.
Hospitals use internal systems to collect data and monitor results. Please review your
hospital’s clinical/quality report and if the above indicators are not submitted to ACHS,
report hospital collected data on the following pages for the most recent 12 month time
period.
Page 3
SECTION 2B: CLINICAL INDICATORS
ACHS Day Patient Clinical Indicators – Version 5
Previous
Period
Reporting Period
ACHS Day Patient
Clinical Indicators
Indicat
or
Number
Indicator
Description
ACHS
Aggregate
Rates
Numerator
Denominator
(Please replace
description with
your number)
(Please replace
description with
your number)
Your
Rate
%
No. DVA
patients in
numerator
Your
Sector
%
All
Orgs.
%
Your
Rate
%
INDICATOR AREA 2: PROCEDURE NON-ATTENDANCE
2.1
Booked
patients who
fail to arrive
Number of patients
booked into a day
procedure service
who fail to arrive,
as scheduled
during the 12
month reporting
period.
Number of
patients booked
into a day
procedure
service, during
the 12 month
reporting period.
INDICATOR AREA 3: PROCEDURE CANCELLATIONS
3.1
3.2
3.3
Cancellation
after arrival
due to
pre-existing
medical
condition
Number of patients
booked into a day
procedure service,
whose procedure is
cancelled after their
arrival at the facility
due to a preexisting medical
condition, during
the 12 month
reporting period.
Number of
patients who
arrive at the day
procedure
service for a
booked
procedure,
during the 12
reporting time
period.
Cancellation
after arrival
due to an
acute medical
condition
Number of patients
booked into a day
procedure service,
whose procedure is
cancelled after their
arrival at the facility
due to an acute
medical condition,
during the 12
month reporting
period.
Number of
patients who
arrive at the day
procedure
service for a
booked
procedure,
during the 12
month reporting
period.
Cancellation
after arrival
due to
administrative /
organisational
reasons
Number of patients
booked into a day
procedure service,
whose procedure is
cancelled after their
arrival at the facility
for administrative /
organisational
reasons, during the
12 month reporting
period.
Number of
patients who
arrive at the day
procedure
service for a
booked
procedure,
during the 12
month reporting
period.
Page 4
ACHS Day Patient Clinical Indicators (Cont.) – Version 5
Previous
Period
Reporting Period
ACHS Day Patient
Clinical Indicators
Indicator
Number
ACHS
Aggregate
Rates
Indicator
Description
Numerator
Denominator
(Please replace
description with
your number)
(Please replace
description with
your number)
Your
Rate
%
No. DVA
patients in
numerator
Your
Sector
%
All
Orgs.
%
Your
Rate
%
INDICATOR AREA 5: UNPLANNED RETURN TO THE OPERATING THEATRE
5.1
Unplanned
return to the
operating room
on same day
as initial
procedure
Number of
patients having
an unplanned
return to the
operating /
procedure room1
(according to
facility policy)
during the same
admission,
during the 12
month reporting
period.
Number of
patients who
have an
operation /
procedure
performed in the
day procedure
service, during
the 12 month
reporting period.
INDICATOR AREA 6: UNPLANNED TRANSFER/ADMISSION
6.1
6.2
Unplanned
transfer or
overnight
admission
related to
procedure
Unplanned
transfer or
overnight
admission
related to
ongoing
management
Number of
patients who had
an unplanned
transfer or
overnight
admission2
related to the
procedure
performed during
the same
admission,
during the 12
month reporting
period.
Number of
patients who had
an unplanned
transfer or
overnight
admission3
related to
ongoing
management
4
during the same
admission,
during the 12
month reporting
period
Number of
patients
discharged from
the day
procedure
service, during
the 12 month
reporting period.
Number of
patients
discharged from
the day
procedure
service, during
the 12 month
reporting period.
1
Operating room is defined as a room within a complex, which is specifically equipped for the performance of surgery and other
therapeutic / diagnostic / endoscopic procedures.
2
Unplanned transfer or overnight admission refers to those patients who had a discharge intention of one day who were either
transferred to an overnight facility (in the instance of a free standing day procedure centre) or were admitted to a general hospital bed
for an overnight stay (for day patients accommodated in general hospital beds or units or centres within a hospital).
3
Unplanned transfer or overnight admission refers to those patients who had a discharge intention of one day who were either
transferred to an overnight facility (in the instance of a free standing day procedure centre) or were admitted to a general hospital bed
for an overnight stay (for day patients accommodated in general hospital beds or units or centres within a hospital).
4
Ongoing management includes complications unrelated to the procedure performed and may include unplanned issues associated
with regular medications or testing. The most common reasons for an unplanned admission are social, such as a patient failing to have
a suitable escort or the day procedure service ensuring professional supervision for a person with marked anxiety or frailty
Page 5
Previous
Period
Reporting Period
ACHS Day Patient
Clinical Indicators
Indicator
Number
Indicator
Description
ACHS
Aggregate
Rates
Numerator
Denominator
(Please replace
description with
your number)
(Please replace
description with
your number)
Your
Rate
%
No. DVA
patients in
numerator
Your
Sector
%
All
Orgs.
%
Your
Rate
%
INDICATOR AREA 7: DISCHARGE
7.1
7.2
Unplanned
delayed
discharge for
clinical
reasons - >1
hour beyond
expected
Unplanned
delayed
discharge for
non-clinical
reasons - >1
hour beyond
expected
Number of
patients who
have an
unplanned
delayed
discharge of
greater than 1
hour beyond the
expected time
due to clinical
reasons, during
the 12 month
reporting period.
Number of
patients who
have an
unplanned
delayed
discharge of
greater than 1
hour beyond the
expected time
due to nonclinical reasons,
during the 12
month reporting
period.
Number of
patients
discharged from
the day
procedure
service, during
the 12 month
reporting period.
Number of
patients
discharged from
the day
procedure
service, during
the 12 month
reporting period.
ACHS Medication Safety Clinical Indicators – Version 4
Indicator
Number
Indicator
Description
Previous
Period
Reporting Period
ACHS Medication
Safety
Clinical Indicators
ACHS
Aggregate
Rates
Numerator
Denominator
(Please replace
description with
your number)
(Please replace
description with
your number)
Your
Rate
%
No. DVA
patients in
numerator
Your
Sector
%
All
Orgs.
%
Your
Rate
%
INDICATOR AREA 6: MEDICATION ERRORS
6.3
Medication
errors adverse event
requiring
intervention
Number of
medication
errors resulting
in an adverse
event requiring
intervention
beyond routine
observation and
monitoring,
during the 12
month reporting
period.
Number of
occupied bed
days, during the
12 month
reporting period.
Page 6
ACHS Infection Control Clinical Indicators – Version 4.1
Previous
Period
Reporting Period
ACHS Infection Control
Clinical Indicators
Indicator
Number
Indicator
Description
ACHS
Aggregate
Rates
Numerator
Denominator
(Please replace
description with
your number)
(Please replace
description with
your number)
Your
Rate
%
No. DVA
patients in
numerator
Your
Sector
%
All
Orgs.
%
Your
Rate
%
INDICATOR AREA 3: HAEMODIALYSIS-ASSOCIATED BLOODSTREAM INFECTION SURVEILLANCE
3.1
3.2
3.3
3.4
Haemodialysis
- AV-fistula
access associated BSI
Haemodialysis
- synthetic and
native vessel
graft access associated BSI
Haemodialysis
- CI non-cuffed
line access associated BSI
Haemodialysis
- CI cuffed line
access associated BSI
Number of AVfistula access associated blood
stream
infections, during
the 12 month
reporting period.
Number of
synthetic and
native vessel
graft access associated blood
stream
infections, during
the 12 month
reporting period.
Number of
centrally inserted
non-cuffed line
accessassociated blood
stream
infections, during
the12 month
reporting period.
Number of
centrally inserted
cuffed line
accessassociated blood
stream
infections, during
the 12 month
reporting period.
Number of
patient-months
for patients
dialysed through
AV fistula, during
the 12 month
reporting period.
Number of
patient-months
for patients
dialysed through
synthetic and
native vessel
grafts, during the
12 month
reporting period.
Number of
patient-months
for patients
dialysed through
centrally inserted
non-cuffed line,
during the 12
month reporting
period.
Number of
patient-months
for patients
dialysed through
centrally inserted
cuffed line,
during the 12
month reporting
period.
Page 7
ACHS Infection Control Clinical Indicators (cont.) – Version 4.1
Previous
Period
Reporting Period
ACHS Infection Control
Clinical Indicators
Indicator
Number
Indicator
Description
ACHS
Aggregate
Rates
Numerator
Denominator
(Please replace
description with
your number)
(Please replace
description with
your number)
Your
Rate
%
No. DVA
patients in
numerator
Your
Sector
%
All
Orgs.
%
Your
Rate
%
INDICATOR AREA 4: VANCOMYCIN RESISTANT ENTEROCOCCI (VRE)
4.1
4.2
VRE infection
within the ICU
VRE infection
within non-ICU
areas
Number of ICU
associated new
vancomycin
resistant
enterococci
(VRE)
healthcareassociated
infections during
the 12 month
reporting period.
Number of nonICU associated
new vancomycin
resistant
enterococci
(VRE)
healthcareassociated
infections, during
the 12 month
reporting period.
Number of ICU
bed days, during
the 12 month
reporting period.
Number of nonICU overnight
occupied bed
days, during the
12 month
reporting period.
INDICATOR AREA 6: OCCUPATIONAL EXPOSURES TO BLOOD AND/OR BODY FLUIDS
6.1
Reported
parenteral
exposures
sustained by
staff
6.2
Reported nonparenteral
exposures
sustained by
staff
Number of
reported
parenteral
exposures
sustained by
staff, during the
12 month
reporting period.
Number of
reported nonparenteral
exposures
sustained by
staff, during the
12 month
reporting period.
Number of
occupied bed
days, during the
12 month
reporting period.
Number of
occupied bed
days, during the
12 month
reporting period.
Page 8
INFECTION CONTROL: “Hospital Acquired Infections”
DVA recognises that due to a low denominator rate, many facilities do not report to ACHS their
“Hospital Acquired Infections.” If your facility does not submit Infection Control Indicators to ACHS,
please comment below on how Hospital Acquired Infections are monitored and benchmarked, and
any results from this monitoring (attachments are permitted, however please index those
attachments in the box below):
Page 9
ACHS Anaesthesia and Perioperative Care Clinical Indicators – Version 6 (if applicable)
To be provided only where the facility meets minimum denominator requirements for submission of
these indicators to ACHS as specified in ACHS Clinical Indicators User’s Manual and is NOT
providing these as part of the ACHS comparative reports.
Previous
Period
Reporting Period
ACHS Anaesthesia
Clinical Indicators
Indicator
Number
Indicator
Description
ACHS
Aggregate
Rates
Numerator
Denominator
(Please replace
description with
your number)
(Please replace
description with
your number)
Your
Rate
%
No. DVA
patients in
numerator
Your
Sector
%
All
Orgs.
%
Your
Rate
%
INDICATOR AREA 1: PRE-ANAESTHESIA PERIOD
1.1
Preanaesthesia
consultation
completed by
anaesthetist
Number of
patients who
have a
documentation
of risks and
benefits of the
anaesthetic
procedure(s)
completed by an
anaesthetist
prior to transfer
to the operating
suite or
procedure room,
during the 12
month reporting
time period.
Number of
patients who
undergo a
procedure with
an anaesthetist
in attendance,
during the 12
month reporting
period.
INDICATOR AREA 3: PATIENT RECOVERY PERIOD
3.5
Unplanned
stay in
recovery room
>2 hours
Number of
patients
undergoing a
procedure with
an anaesthetist
in attendance
who have an
unplanned stay
in the post
anaesthesia
recovery room
for longer than 2
hours, during the
12 month
reporting period.
Number of
patients
receiving postanaesthesia care
who are
admitted to the
post-anaesthesia
recovery room,
during the 12
month reporting
period.
Page 10
ACHS Ophthalmology Clinical Indicators – Version 5 (if applicable)
To be provided only where the facility meets minimum denominator requirements for submission of
these indicators to ACHS as specified in ACHS Clinical Indicators User’s Manual and is NOT
providing these as part of the ACHS comparative report.
Previous
Period
Reporting Period
ACHS Ophthalmology
Clinical Indicators
Indicator
Number
Indicator
Description
ACHS
Aggregate
Rates
Numerator
Denominator
(Please replace
description with
your number)
(Please replace
description with
your number)
Your
Rate
%
No. DVA
patients in
numerator
Your
Sector
%
All
Orgs.
%
Your
Rate
%
INDICATOR AREA 1: CATARACT SURGERY
1.1
1.2
Cataract
surgery –
readmission
within 28 days
Cataract surgery
– readmission
within 28 days
due to
endophthalmitis
1.3
Cataract
surgery unplanned
overnight
admission
1.4
Cataract
Surgery –
anterior
vitrectomy
Number of
unplanned
readmissions
(related to the
operated eye)
within 28 days of
discharge
following
cataract surgery,
during the 12
month reporting
period.
Number of
patients having a
readmission
within 28 days of
discharge
following
cataract surgery,
due to
endophthalmitis
in the operated
eye, during the
12 month
reporting period.
Number of
patients having a
discharge
intention of 1
day, who had an
overnight
admission
following
cataract surgery,
during the 12
month reporting
period.
Number of
patients having
an anterior
vitrectomy at the
time of cataract
surgery, during
the 12 reporting
time period.
Number of
patients having
cataract surgery,
during the 12
month reporting
period.
Number of
patients having
cataract surgery,
during the 12
month reporting
period.
Number of
patients having
cataract surgery,
during the 12
month reporting
period.
Number of
patients having
cataract surgery,
during the 12
month reporting
period.
Page 11
ACHS Gastrointestinal Endoscopy Clinical Indicators – Version 2 (if applicable)
To be provided only where the facility meets minimum denominator requirements for submission of
these indicators to ACHS as specified in ACHS Clinical Indicators User’s Manual and is NOT
providing these as part of the ACHS comparative reports.
Indicator
Number
Indicator
Description
Previous
Period
Reporting Period
ACHS Gastrointestinal
Endoscopy
Clinical Indicators
ACHS
Aggregate
Rates
Numerator
Denominator
(Please replace
description with
your number)
(Please replace
description with
your number)
Your
Rate
%
No. DVA
patients in
numerator
Your
Sector
%
All
Orgs.
%
Your
Rate
%
INDICATOR AREA 1: FAILURE TO REACH CAECUM
1.1
Failure to
reach caecum
due to
inadequate
bowel
preparation
1.2
Failure to
reach caecum
due to
diseased colon
1.3
1.4
Failure to
reach caecum
due to
instrument
failure
Failure to
reach caecum
for any other
reason
Number of
incomplete
colonoscopies5
as a result of
inadequate bowel
preparation,
during the 12
month reporting
period.
Number of
incomplete
colonoscopies as
a result of
diseased colon,
during the 12
reporting time
period.
Number of
incomplete
colonoscopies as
a result of
instrument failure,
during the 12
month reporting
period.
Number of
incomplete
colonoscopies as
a result of
reasons not
covered by CIs
1.1 to 1.3, during
the 12 month
reporting period.
Number of
colonoscopies,6
during the 12
month reporting
period.
Number of
colonoscopies,
during the 12
month reporting
period.
Number of
colonoscopies,
during the 12
month reporting
period.
Number of
colonoscopies,
during the 12
month reporting
period.
5
Complete colonoscopy is defined as a procedure where completion can be confirmed through intubation of the caecum with
visualisation of caecal identifiers or neoterminal ileum. Note that transillumination is NOT considered to be an acceptable method for
confirming that the caecum has been reached.
6 Number of colonoscopies includes colonoscopy with or without biopsy / polypectomy
Page 12
INDICATOR AREA 2: ADVERSE OUTCOMES - COLONOSCOPY/POLYPECTOMY
2.1
2.2
2.3
Treatment for
possible
perforation
postpolypectomy
Treatment for
possible
perforation not
related to
polypectomy
Postpolypectomy
haemorrhage
Number of
patients treated
for possible
perforation who
have had a
polypectomy
performed, during
the 12 month
reporting period.
Number of
colonoscopies
with
polypectomy,
during the 12
month reporting
period.
Number of
patients treated
for possible
perforation NOT
related to
polypectomy,
during the
12month
reporting period.
Number of
colonoscopies
LESS number of
colonoscopies
with
polypectomy,
during the 12
month reporting
period.
Number of
patients who
have bleeding7,
postpolypectomy,
during the 12
month reporting
period.
Number of
colonoscopies
with
polypectomy,
during the 12
month reporting
period.
INDICATOR AREA 4: OESOPHAGEAL DILATATION - PERFORATION
4.1
Oesophageal
dilatation possible
perforation
Number of
oesophageal
dilatation patients
treated for
possible
perforation8 ,
during the 12
month reporting
period.
Number of
oesophageal
dilations, during
the 12 month
reporting period.
7 Bleeding refers to significant gastrointestinal bleeding post-polypectomy. To be included, the haemorrhage must require repeat
endoscopy or admission to hospital. Intraoperative bleeding managed during the original endoscopy is not included.
8 Perforation: Signs and symptoms suggestive of a perforation of the oesophagus or upper gastrointestinal tract, chest pain, suspected
peritonitis, free intra-abdominal or mediastinal air on radiological imaging.
Page 13
ACHS Gastrointestinal Endoscopy Clinical Indicators – Version 2 (if applicable)
Previous
Period
Reporting Period
ACHS Gastrointestinal
Endoscopy
Clinical Indicators
ACHS
Aggregate
Rates
Numerator
Indicator
Number
Indicator
Description
(Please
replace
description
with your
number)
Denominator
(Please replace
description with
your number)
Your
Rate
%
No. DVA
patients in
numerator
Your
Sector
%
All
Orgs.
%
Your Rate
%
INDICATOR AREA 5: ASPIRATION FOLLOWING GI ENDOSCOPY
5.1
Aspiration
following
endoscopy
Number of GI
endoscopy
patients who
are
transferred or
admitted for
an overnight
stay as a
result of
aspiration
during the 12
month
reporting
period.
Number of
patients who
have a GI
endoscopy
procedure with
sedation, during
the 12 month
reporting period.
Page 14
SECTION 3: SPECIALISED FACILITIES
If you provide specialised services such as dialysis, sleep studies or hyperbaric oxygen, and do not
currently report on any of the clinical indicators above, please provide comment below on the
clinical indicators you do monitor and benchmark and any results available from this monitoring
(attachments are permitted, however please index those attachments below):
Page 15
SECTION 4: COLLECTION, ANALYSIS & REPORTING OF INDICATORS
Provide comment on collection, analysis and any change in the reporting of all clinical indicators. If
relevant, comment on reasons why certain clinical indicators have not been included in your report.
Also, if the ACHS average rate of occurrence is exceeded for any indicator, please explain why
and note any remedial actions undertaken (attachments are permitted, however please index those
attachments below):
Page 16
SECTION 5: COMPLAINTS
Report the complaint by providing information on the issue, action taken and outcome below.
Identify the entitled person by using his/her sex and age, for example, Female 78 years of age.
Include complaints made by an entitled person (or their representative) direct to the facility, as well
as complains made through the Department of Veterans’ Affairs.
Annual Report:
Entitled Person
Details, e.g. Sex, Age
1 July 2015 – 30 June 2016 complaints
Issue
Action
Outcome
Page 17