Frequently asked questions around the 2009 QSA activity statement
The Quality Systems Assessment (QSA) is aimed at providing information about the processes, policies and procedures in place which support the delivery of safe patient care. Completing the QSA is compulsory. About the QSA self assessment The QSA consists of a number of self administered surveys which will be completed by different levels of the system. Within Area Health Service (AHS) there will be four surveys: AHS level; Network level; Facility level and Clinical unit level. These self administered surveys are referred to as ‘activity statements’. When completing the activity statements please remember that this not about providing right or wrong answers. What is an Activity Statement? An Activity Statement is a self-assessment tool which asks questions about patient safety and quality systems and processes in place within the workplace. Activity statements are available for viewing and completion online. There is an Activity Statement tailored for each organisational level. How often will I have to complete an Activity Statement? All organisations within the NSW public Health system will be required to complete an activity statement every year. Will the questions asked in the Activity Statement be the same every year? No, the activity statements vary as different elements of safety and quality systems are targeted for assessment. This provides the opportunity to address specific issues that present a high risk to the system or where there is evidence of considerable variation or gaps in systems and processes. 2009 QSA self assessment What are the topics for assessment: The 2009 QSA will be a thematic survey concentrating on the systems, processes and policy frameworks in place around four areas only, those are: Deteriorating patient Communication Clinical handover Medication Safety The activity statements are completed online: Each network, facility and clinical unit will nominate a contact person who will receive an introductory email. If you are the nominated respondent you will receive an email
Frequently asked questions around the 2009 QSA activity statement
providing a link to the online survey site with a username and password to access the site. The information collected in this survey will be processed by the online survey host on a secure server – confidentiality is assured for all data. Who to involve: In developing responses to the activity statement questions, the multidisciplinary team involved in the delivery of services should be included. Due to the complex, multidisciplinary process of patient safety and clinical quality activities in the health system the value and accuracy of the self assessment is significantly reduced if it is completed by a single discipline. Suggested members for each level’s review team will be outlined in the relevant activity statement. What if a specific question or theme doesn’t apply to the services provided in my network/cluster; facility or department/clinical unit? The survey has been set up so that each question must be answered before you can submit the activity statement. A few of the questions list Not Applicable as a choice and you will be able to respond as such if the item doesn't apply to services provided in your particular service. For some smaller hospitals or department/clinical units there will be questions that are difficult to answer where services are not provided and there is no Not Applicable option available. For these items a free text option will be given. Evidence for response: When completing the QSA there are some questions that ask for evidence for the response provided. In these sections you are required to note the source of the information used to answer the question. Sources may include an individual data source, reports and minutes of meetings or policy documents. You are not required to compile this or any additional information as part of the assessment. The online program will have the capacity for documents and other data to be submitted to support the assessment verification process. How long do I have to complete the self assessment? You will have 8 weeks from the initial email to complete and submit the self assessment It is not neccessary to complete the survey in one sitting, as the program saves your answers as you complete each page. If you need to leave the survey at any point, simply close the browser window. When you wish to return to the survey, click on the link provided in the email from Strategic Data, enter your username and password, and you will find the survey with your answers saved up until the last fully completed page. Your answers will not be submitted until you complete the survey and Click the 'submit' button. You can change any of your answers up until you submit the survey. Once you have clicked on the submit button however, you will not be able to access the survey again. Once completed you will be able to download and save a copy of your responses.
Frequently asked questions around the 2009 QSA activity statement
Timeframe of assessment: Unless otherwise specified in the questions please use data or information covering activity from 1 January 2007 to present. Feedback: Feedback around performance will be provided following analysis by the QSA team. This information is expected to be received by the Clinical Governance team 8 to 10 weeks following survey completion and will be utilized in the development of Strategic Improvement Plans which address issues highlighted in the self assessment process. Support available: There are a number of sources of support to assist you. For assistance using the online survey tool, please contact ‘Strategic Data’ who are providing the online environment for this survey – an 1800 number will be available throughout the survey. If you have questions about the survey questions themselves, or the QSA overall, please contact Bernadette King Program Leader, QSA on 02 93827829 or bernadette.king@cec.health.nsw.gov.au If you would like further information or assistance from your AHS on any issue, please contact your AHS QSA coordinator or the Clinical Governance Unit. What are the benefits of completing the QSA? Completing the self assessment at all levels of the organisation will be of significant assistance to managers who seek to identify areas of weakness related to quality and safety policy and process so that improvements can be developed. Also: Aggregate results from a large pool of respondents will provide the AHS and NSW with important information about the status of the system as a whole in relation to the themes assessed each year. Completion of the QSA each year can demonstrate that AHS / facilities and department/clinical units are being proactive in identifying safe practices and will be able to track aggregate progress over time. Will my self-assessment (Activity Statement) be audited and if so will I be audited every year? Each year a sample of respondents will be audited either through site visits, telephone interview or desk-top review of evidence. You will have a one in five change of having an audit of documentation and a one in twenty chance of having an on-site audit of activities. What happens if I have gaps or deficiencies in the safety and quality processes and practices in my organisation/unit? You will be required to develop an action plan to address identified gaps. You will be asked to prioritise actions so that you address those that present the greatest risk to patient care first. The CEC will also make available information on exemplar sites that will assist in identifying ways
Frequently asked questions around the 2009 QSA activity statement
of improving your performance. Where there is a lack of guidance or policy underpinning activities the CEC will be referring this to NSW health.