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