Year in Review

The Clinical Excellence Commission is committed to improving patient safety and health outcomes across the NSW Health system and this includes closing the gap and addressing cultural safety of health care for Aboriginal people.

With this ambitious target in mind, our work across 2023-24 has been broad, partnered with local health districts and specialty networks and deeply engaged with our pillar colleagues.

Across health the notion of safety has matured and while we are always committed to the goal of improved patient safety we are now also focused on embedding safety into all levels of health, including for staff. Humanising the work of health is a significant step forward and realised through our reflective practice work.

Our work this year has included leadership on clinical governance, processes and functions across NSW healthcare organisations and we are particularly proud of the NSW Medicines Formulary which has been fully implemented and adopted. The formulary promotes efficient healthcare delivery, improves equitable access to medications and delivered $100 million in saving in 2023-24.

We are indebted as always to the thoughtful and dedicated work of the CEC team whose expertise and passion for improving health safety and outcomes drives our significant achievements.

We continue to develop a tailored Reflective Practice Program that humanises the healthcare work experience by recognising and supporting NSW Health healthcare workers to manage the emotional demands placed on them. Over the last year, this work has evolved by implementing evaluation findings from the initial 2022 pilots. This includes partnering with Murrumbidgee Local Health District’s First Australians mental health and patient safety teams to co-design an experiential workshop, integrating reflective practice skills and unconscious bias training. These workshops are grounded in Aboriginal cultural principles to enhance cultural safety among staff and improve patient care. We are supporting an Aboriginal and Torres Strait Islander Advisory Group in developing tailored resources to facilitate the meaningful adoption and application of these practices among First Australian’s staff across the NSW Health system.

This collaboration deepens our understanding of our work with First Australians people, including an awareness of our biases and how they impact our practices and, ultimately, NSW Health patients. As with the initial evaluation, this redesign and inclusion of unconscious bias demonstrates the value of reflective practice as an integral component of staff wellbeing and enables a deeper connection and understanding of self and others. Ongoing evaluation shows a strong need to embrace reflective practice and prioritise the health and wellbeing of NSW Health staff to deliver safe and high-quality healthcare across the state.

Case study: Building a culture of reflective practice

We are building a roadmap to expand reflective practice skill-building across NSW Health to enhance workforce capability and create a culture of reflective practice. In partnership with Murrumbidgee Local Health District (MLHD), we have co-designed a reflective practice workshop integrating unconscious bias training to deepen awareness of and support the management of emotional wellbeing across the NSW Health healthcare workforce.

The Reflective Practice program builds a culture of reflective practice and improves the capability of healthcare workers to integrate their experiences using these skills. It aims to deepen people’s knowledge of quality reflective practice and why it is essential to maintain wellbeing in the workplace. However, building a culture of reflective practice that is meaningful and accessible to healthcare workers across the state is challenging. By partnering with local health districts, we can identify and create opportunities to embed reflective practices and humanise work experiences for healthcare professionals.

As we shared reflective practice resources and workshops, MLHD’s First Australians mental health and patient safety teams shared their interest in tailoring the workshop to local needs, including integrating unconscious bias training to support better patient health outcomes.

We worked together to co-design and successfully pilot a reflective practice workshop to increase awareness of unconscious biases and identify strategies and tools to mitigate them. By making the ‘unconscious conscious’, participant feedback showed they developed deeper insights into their interactions and decision-making, including actively questioning assumptions, scrutinising interpretations and seeking alternative perspectives. We are now developing this workshop for rollout to all NSW Health staff. Our collaboration with MLHD has demonstrated how we can embed reflective practice into healthcare delivery and emphasised its value as a practical tool for building a better understanding of ourselves and each other.

CEC team
Capability and Culture

Our partners
Murrumbidgee Local Health District

Future Health priorities

• Patients and carers have positive experiences and outcomes that matter.
• Safe care is delivered across all settings.

CEC 2021-24 Strategic Plan priorities

• Embedded safety systems
• Safety culture with accountability
• Safety priorities and programs

We partnered with the NSW Ministry of Health to deliver a statewide medicines formulary, associated governance and procurement processes to improve equity of access and patient safety across NSW public hospitals. In 2024, the NSW Medicines Formulary was fully implemented and adopted by all 18 local health districts and specialty health networks.

The statewide rollout included policy updates, clinician resources and a custom online platform to host and share formulary information. We established a Benefits Realisation Plan and a Benefits Register for ongoing monitoring, and our initial Baseline Benefits report in 2024 shows improvements and efficiencies in medicines evaluation, access and value.

Clinicians and medication experts appropriately rationalised medications which significantly saved costs while promoting consistent, efficient healthcare delivery. The formulary has enabled clinical decisions to inform medicine procurement, delivering almost $100 million in savings in 2023-24. The NSW Medicines Formulary won the Patient safety first category at the 2024 NSW Health Awards.

Case study: Implementing the NSW Medicines Formulary for statewide patient care and cost savings

In 2023-24, we collaborated with NSW Health partners to implement the NSW Medicines Formulary across all 18 local health districts and specialty health networks after a 4-year project phase. The integrated approach to the governance and evaluation of medicines informed statewide procurement processes to achieve $100 million in cost savings and promote consistent, equitable and efficient healthcare delivery.

The NSW Medicines Formulary is a centralised list of medicines approved for initiation and use in NSW public hospitals. It promotes evidence-based and quality use of medicine principles in all decision-making, and medicines are re-evaluated regularly to ensure the formulary remains accurate and current. Health facilities, particularly in rural and regional areas, previously may not have stocked some medicines. This could be due to their high cost or a lack of specialty expertise to advocate for a medicine to be added to a local formulary.

Available medications differed between hospitals, leading to inconsistent treatment availabilities between metropolitan, regional and rural areas.

Health facilities previously negotiated medicine costs independently with suppliers, and not all facilities could navigate these negotiations or purchase enough medicine to secure lower prices. We introduced a statewide governance framework for medicines to rationalise the list of medicines for use in NSW Health facilities and develop an agreed list of medicines based on evidence for effectiveness and safety. Clinical decision-making informed statewide procurement processes, which enabled HealthShare NSW to negotiate the best price for medicines that were aligned with the system’s needs.

The CEC led the implementation and transition from local formularies to a single statewide formulary in over 200 NSW Health facilities and partnered with HealthShare NSW to support the adoption of new pharmaceutical contracts. Medicines that previously had significant price variations between facilities are now procured at a single contracted price, improving equity of access across metropolitan, regional and rural hospitals. For example, medicines that were not regularly stocked in regional and remote healthcare facilities are now available. The statewide formulary has improved care for patients in NSW hospitals by utilising centralised governance to support decision-making and equitable medicine access and reducing the cost of medicines to support better value care, resulting in $100 million in cost savings.

CEC team
Dr Harvey Lander
Professor Jennifer Martin
Nina Muscillo
Lucy Nair
Carly Wills
Medication Safety team

Our partners
NSW Ministry of Health
HealthShare NSW
eHealth NSW
Local health districts/Specialty health networks

Future Health priorities

• Patients and carers have positive experiences and outcomes that matter.
• Safe care is delivered across all settings.
• The health system is managed sustainably.

CEC 2021-24 Strategic Plan priorities

• Safety priorities and programs
• Embedded safety systems
• Safety intelligence.

In 2024, our Quality Audit Reporting System (QARS) celebrated its tenth anniversary. Established in 2014, QARS is an electronic tool to help improve the quality and safety of health care delivery. In July, more than 90,000 registered QARS users conducted more than 50,000 audits and surveys monthly. A recent pilot project initiated by the NSW Ministry of Health uses QARS to automate the patient experience survey, significantly improving the effectiveness and efficiency of the rapid patient survey process.

Zero Suicides in Care is part of NSW Health’s Towards Zero Suicides initiative to reduce the state’s suicide rate. Addressing suicide in care in NSW Health is complex, requiring a multi-strategy approach and collaborative implementation between local health districts, speciality health networks and NSW Health pillar agencies.

The Mental Health Branch of the NSW Ministry of Health commissioned our Mental Health Patient Safety Program to implement the Transforming Safety Culture Partnership Program. The program enhances the safety culture in public healthcare facilities, particularly in creating a restorative just and learning culture (RJLC) in mental health services by engaging executives, managers, and clinical teams. The approach is informed by the NSW Health Safety System Model, which consists of six levers designed to build reliable and resilient safety systems.

The RJLC pilot involved four local health districts and speciality health networks partnering in safety culture workshops and developing action plans. Evaluation showed improvement in engagement, trust, psychological safety, and an overall commitment to implementing safety culture action plans. All participating districts and networks demonstrated their commitment to developing an RJLC through participation in masterclasses, symposiums, workshops and the community of practice. Future recommendations include strengthening safety culture through leadership, integrating restorative practices into the incident management policy review, and further capacity building through partnership with the Health, Education, and Training Institute.

As part of NSW Health’s Aboriginal Health Transformation agenda, we have enacted a strategic plan to improve safety for Aboriginal and Torres Strait Islander patients, their families and carers. The plan outlines specific actions to ensure that we, as an organisation, connect, listen and respond to Aboriginal patient safety issues through collaboration with Aboriginal patients and families, building capability, capacity and cultural awareness with NSW Health staff, addressing patient safety issues and ensuring Aboriginal patient safety data is visible and actionable to clinicians and patients. Our plan will ensure NSW Health is equipped to provide safer healthcare and experiences for Aboriginal and Torres Strait Islander patients, their families and carers.

We have created Aboriginal-identified patient safety positions in our workforce and initiated a review of key policies to ensure cultural appropriateness and support for Aboriginal people. Additionally, key patient safety data is now being disaggregated to better understand and respond appropriately to the factors contributing to patient harm among Aboriginal people. The contributions of our Aboriginal Patient Safety Project Officers, integrated into our core patient safety team, have significantly enhanced our approach to patient safety and cultural competency.

Our Healthcare Safety Culture Framework supports and connects safety and quality capability development across NSW Health, promoting a psychologically safe work environment for staff and better health outcomes and experiences for patients, families and carers. In 2023-24, a key focus was socialising and integrating the framework into our established programs to support effective leadership and teamwork.

Targeting the NSW Health workforce, the framework promotes a shared mental model of the interconnected components of healthcare safety culture, which is now embedded across all CEC programs. The framework supports the Mental Health Patient Safety program in developing leadership capabilities that enhance workplace culture and promote learning for safety. The framework has helped to define what a safety culture looks like in healthcare delivery across the NSW Health system and what it feels like from the perspective of staff, patients, their families and carers. This outcome has encouraged NSW Health healthcare workers to integrate safety values and governance in their everyday work. Operationalising the framework is a non-linear and iterative process with learnings from each engagement shaping an innovative approach to building a safe, positive workplace culture across the NSW Health system.

Case study: Strengthening rural health Outcomes through the Safety & Quality Essentials Pathway

We partner with local health districts and specialty health networks across NSW to support their implementation of the Safety & Quality Essentials Pathway. This pathway equips healthcare workers with knowledge, tools and skills to deliver and influence safe, high-quality healthcare. In 2023-24, we worked closely with districts and networks in rural areas to identify and understand their Safety and Quality Essentials Pathway implementation successes and challenges, to tailor our support to meet their needs.

Rural entities face significant and nuanced workforce challenges. As a result, Safety & Quality Essentials Pathway program uptake and implementation sustainability vary significantly by program. In April 2024, three in every four Applied Safety & Quality Program graduates were from rural areas. However, rural healthcare workers comprised just one in 20 who completed the foundation-level training. This demonstrates the need to focus our support on rural districts and networks to meet their specific implementation needs.

We have promoted collaboration between districts and networks across the state to support implementing the Safety and Quality Essentials Pathway. Cooperation between Western NSW Local Health District and Far West Local Health to implement the Applied Safety and Quality Program and multiple districts providing space in their programs for participants from other districts to join are examples of success.

NSW Ambulance sought collaborative relationships with districts statewide to increase workforce engagement with the Applied Safety & Quality Program. In collaboration between NSW Ambulance and Central Coast LHD (CCLHD), program participants shared knowledge and stories, broadening their understanding of the patient journey, enhancing their learning experience and challenging their thinking. It also established networks between managers and healthcare workers with limited opportunities to connect with colleagues, demonstrating how collaboration supports problem-solving and improves patient outcomes.

As a result of the collaboration, NSW Ambulance and CCLHD have established a paramedic referral pathway enabling referrals of low acuity patients from the community to CCLHD programs. This allows patients to access appropriate treatment at home, reducing local emergency department presentations. Establishing a local paramedic referral pathway will positively impact patients and healthcare facilities by reducing unnecessary hospital visits, improving patient experiences, promoting faster recoveries, reducing pressure on CCLHD emergency departments, and freeing up resources for more critical cases. The project is nearing completion and will provide valuable insights into the care options for local clinicians in managing low-acuity patients.

CEC team
CEC Academy

Our partners
NSW Ambulance
Central Coast Local Health District
Western New South Wales Local Health District
Far West News South Wales Local Health District

Future Health priorities

• Patients and carers have positive experiences and outcomes that matter,
• Safe care is delivered across all settings,
• Our staff are engaged and well supported.

CEC 2021-24 Strategic Plan priorities

• Embed and mature a safety system model.

In 2024, we updated the NSW sepsis pathways to improve sepsis recognition and rapid treatment for adult, maternal, paediatric and neonatal patients. Sepsis is a life-threatening response to infection and a medical emergency. The pathways support clinicians in identifying sepsis risk factors, signs and symptoms, escalation to a senior clinician, and commencing treatment rapidly. The pathways incorporate advice from expert clinicians and align with the national Sepsis Clinical Care Standard, directing clinicians, patients, families and carers to ask, ‘Could it be sepsis?’ This question is a key feature of the pathways and the NSW public sepsis awareness campaign.

The CEC took a patient-centred design approach to ensure the updated pathways would support clinicians practically at the bedside. Clinician feedback on the streamlined and easy-to-follow pathways has been overwhelmingly positive. In addition to an increase in sepsis awareness and pathway use, the pathways have attracted considerable interest from health services nationally and internationally, seeking to adopt the updated tools. The sepsis pathways are a critical bedside tool to help clinicians recognise and respond to sepsis. Asking ‘Could it be sepsis?’ and picking up a sepsis pathway is the first step in saving lives.

• We defined and promoted a proactive and predictive safety system model for NSW Health outlined in the Clinical Governance in NSW policy PD2024_10, facilitating a consistent and reliable approach to safety.
• To embed these safety systems, we strengthened statewide and external partnerships across NSW Health, collaborating with local health districts to advance the Deteriorating Patient Dashboard and explore predictive analytics models.
• Ongoing collaborations with the Agency for Clinical Innovation using the Quality Improvement Data System to improve neonatal data and harm reporting.
• Our Maternal and Neonatal Safety Program supports district and specialty health network maternity and neonatal safety teams by providing clinical governance support and evidence-based guidelines and standards. Our efforts also enhanced the visibility of key mental health data, with work continuing to develop local safety dashboards in collaboration with districts.

We significantly improved system-wide safety capabilities across NSW Health in 2023-24. Through integrated data reporting systems and innovative safety frameworks, we are now better positioned to identify and address safety concerns more effectively. Key initiatives include:

• Completing the QIDS Maternity Intelligence System, which gives clinicians maternal and newborn data insights in near real-time,
• Establishing the Medical Device Governance Program to strengthen medical device regulations across the state on behalf of the Therapeutic Goods Administration,
• Strengthening Incident Management System reporting.

These efforts have increased engagement with clinicians and stakeholders, improved mental health data visibility and developed new, effective reporting tools. These initiatives have led to enhanced predictive capabilities, improved maternal and neonatal outcomes, and a stronger safety culture within NSW Health healthcare facilities. Collaboration with academic institutions and the NSW Ministry of Health has further reinforced our commitment to integrating data-driven approaches in safety practices.

Our Capability and Culture team has led reflective practice workshops with local health districts to build a reflection culture among NSW Health healthcare workers and collaborated with patients, families, and carers to integrate their perspectives in program design, such as co-designing resources and developing consumer remuneration guidelines.

We promoted compassionate leadership in various forums and strengthened capabilities within local health districts using the Team Stripes framework to support culture change in healthcare settings. We continue to provide expert safety culture advice, support a new Mortality and Morbidity meeting practice, and promote co-leadership models.

Safety priorities and programs

We developed resources like the Safer Baby Bundle Program and the Haemovigilance tools and implemented the Infection Prevention and Control Safety Program to support local health districts, specialty health networks, and NSW Health agencies. These actions strengthened stakeholder relationships, improved recognition and management of deteriorating patients, adherence to medication safety protocols, and enhanced clinical governance across NSW. Collaborations with universities have further strengthened educational pathways, embedding human factors into patient safety programs.