Quality and Safety Unit

Safety and quality of care are core elements in the provision of health services. The Quality and Safety Unit (QSU) takes a lead role in planning, managing and evaluating patient safety and quality for the ACT Health Directorate. The QSU focuses on quality improvement, evaluation and review, clinical management systems and measurement, consumer engagement, clinical performance related to patient safety and quality, and risk management. The Workplace Safety section within the QSU has overarching responsibility for keeping Health Directorate staff healthy and safe.

The Business Plan for the QSU highlights three themes which underpin the functions of the unit. These themes are that care provided to consumers will be:

  • consumer-centred
  • driven by information
  • organised for safety.

These themes have been compiled using:

  • recommendations and information from reviews and monitoring processes carried out within the Health Directorate
  • national and international health improvement methods
  • national priority and reform processes.

National Safety and Quality Health Service Standards

QSU is committed to advancing the national agenda on patient safety and is working closely with the Australian Commission on Safety and Quality in Health Care to progress implementation of the 10 National Safety and Quality Health Service Standards.

The QSU also coordinates the accreditation process for the organisation. The Accreditation and Evaluation team is currently managing changes in accreditation practice to ensure that the Health Directorate is ready for its assessment against the 10 National Safety and Quality Health Service Standards in 2014.


In 2012‑13, the QSU carried out the following activities.

Policies and procedures

  • Developed clear policy documents on important safety and quality issues such as:
  • – consent and Treatment Policy and Standard Operating Procedures
  • – responding to the use of non-prescription alcohol and other drugs in health settings
  • – open disclosure
  • – work health and safety, and the safety management system
  • – dangerous substance management.
  • Issued a Respiratory Policy to ensure appropriate respiratory protection is maintained for all relevant staff.
  • Supported and monitored the quality of policy documents through the Policy Advisory Committee and staff training sessions on policy governance and policy writing.
  • Completed the updated Work Health and Safety Management System and revised Work Health and Safety Policy to:
  • – ensure the Health Directorate meets the Work Health and Safety Act 2011 and associated regulations, codes of practice
  • – provide appropriate guidance to staff in relation to best practice safety management.

Developed two new RiskMan registers for Occupational Medicine and Workplace Safety Physiotherapy management and enhanced a number of RiskMan modules to meet changed needs and user requirements.


  • Supported the Health Directorate through the Australian Council on Healthcare Standards (ACHS) Organisation Wide Survey to retain its accreditation status. The Health Directorate met all criteria to achieve accreditation for another four years with 28 marked achievements, 18 extensive achievements and 1 outstanding achievement.
  • Updated the Safety and Quality Framework to include the new National Safety and Quality Health Service Standards. A consultation draft will be issued in early 2013‑14.
  • Supported the establishment of the 10 National Safety and Quality Health Service Standards Groups to provide strategic direction for the implementation of these standards and monitor progress on key activities.
  • Developed a Health Directorate Quality Improvement and National Safety and Quality Health Service Standards (NSQHSS) Education strategy to improve understanding of change management and quality improvement methodology to support improvements in quality and safety practices.

Projects and programs

  • Completed a project on behalf of the Local Hospital Network (LHN) Council to collect patient stories particularly related to bedside handover and discharge planning, to allow the LHN to make recommendations for improvements.
  • Negotiated a budget bid to allow increased resourcing for the Respecting Patient Choices Program to increase community awareness and uptake of advance care plans.
  • The Respecting Patient Choices program negotiated a successful partnership arrangement with Medicare Local ACT to support and promote Advance Care Planning to the wider ACT community and health professionals.
  • Facilitated the ACT Quality in Healthcare Awards which showcase patient safety and quality initiatives across the territory; and the Health Directorate Better Practice Awards which celebrate local quality improvement activities.


  • Developed a toolkit to support Chairs and Secretariats of committees who have consumer representatives on committees.
  • Planning for future implementation of core standards for forms outlined in ‘A National Framework for Advanced Care Directives’ through working with the Medicare Local Aged Care Forums and Council on the Ageing ACT.
  • Revised The Dangerous Substances Manual to meet updated legislation.
  • Amended the Safety Management System document to reflect the changes to workplace legislation, in particular, the responsibilities of managers.


  • Made an appointment to the Patient Experience Team Leader position.

Training and education

  • Implemented and evaluated training in bedside handover as part of the Effective Communication in Clinical Handover (ECCHO) Project, a national Australian Research Council Funding project in collaboration with the University of Technology Sydney and three other jurisdictions. Training is now being piloted in another ward. The project team presented at the International Council of Nurses Conference in May 2012. Held ‘Open Disclosure Master Classes’ for senior clinical and executive staff. These classes provide targeted skills to support staff when open disclosure discussions with patients and families are required. Partnered with the Healthcare Consumers Association ACT to provide forums on ‘How to complain properly’, consumer representative training and advocacy training.
  • Participated in the Rural Health Education Foundation DVD and toolkit titled ‘The Patient’s Choice: Quality at the End of Life’.
  • Provided education and training to staff on implementing the 10 National Safety and Quality Health Service Standards.

Issues and analysis

Transitioning to the 10 National Safety and Quality Health Service Standards from the Australian Council on Health Services Standards (ACHS) accreditation program is a significant change for the organisation. Implementation of the standards provides an opportunity to embed these standards in the organisation and further improve the safety and quality of our services.