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[null,"Closing the Loop "]
[]
["The Closing the Loop Program is focussed on the implementation and enhancement of severity assessment code 1 (SAC 1) clinical incident management, specifically the: "]
[null,"1. Development and implementation of recommendations and\n"]
[null,"2. Evaluation of recommendations.\n"]
["The Closing the Loop Program aims to progress the safety and quality culture within WA Health with regard to the Clinical Incident Management (CIM) process and is an integral part of ensuring that lessons are learnt from clinical incidents so that improvements in health care delivery and patient care are achieved.\n"]
["SAC 1 clinical incidents include all clinical incidents/near misses where serious harm or death is/could be specifically caused by health care rather than the patient’s underlying condition or illness. In WA, SAC 1 also includes the 8 nationally endorsed sentinel event categories.\n"]
["As outlined in the Clinical Incident Management Policy, the key timeframes to "]
[null,"• complete investigations and develop recommendations into SAC1 clinical incidents is 28 working days and "]
[null,"• complete the subsequent implementation and evaluation of recommendations is six months from the submission of the incident investigation report. \n"]
["The Closing the Loop Program includes resources and processes to assist health services with understanding and meeting these SAC1 investigation and evaluation requirements including how to develop strong, sustainable recommendations and methods that can be used to evaluate if these recommendations are working to reduce preventable harm. \n"]
["This spreadsheet tool is designed to assist in the development, implementation and evaluation of the effectiveness of recommendations following the investigation of clinical incidents. This tool is an optional resource that guides users through the development of strong and sustainable recommendations and tracking the implementation and evaluation of these recommendations in line with WA Health CIM Policy requirements. This tool would benefit investigation teams to assist them in developing strong recommendations.\n"]
["Datix CIMS remains the system for clinical incident management in WA Health and all information relating to recommendations arising from a clinical incident investigation should be contained within the incident record in Datix CIMS. This spreadsheet has been drafted as a means of assisting with the identification of system requirements  to inform future configuration of Datix CIMS. Therefore use of the tool and provision of feedback regarding the various components will directly impact future enhancements to the recommendations module in Datix CIMS. Please contact PSSU if you have any queries with regard to this spreadsheet  PSSU@health.wa.gov.au"]

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["Datix CIM Number:",null,"CIMS998234"]
["Hospital/Service:",null,"St Thomas Ward A"]
["Date investigation report submitted to PSSU:",null,"2014-04-14"]
["Date evaluation report due to PSSU:",null,{"$f":"WORKDAY(EDATE(DATE(YEAR(C3),MONTH(C3),DAY(C3)),6)-1,1,'Public holidays'!B2:K11)","v":"2014-10-14"}]
[]
["Steps of system improvement:"]
["1. Identification of contributing factors in clinical incident investigation"]
["2. Development of SMARTA recommendations/actions to address identified contributing factors"]
["3. Executive signoff of recommendations/actions"]
["4. Implementation of recommendations/actions"]
["5. Evaluation of effectiveness of recommendations/actions"]
[]
["Sections:"]
["Develop SMARTA Recommendations"]
["Recommendations should directly address the root causes identified via the investigation process. Recommendations must be implementable, specific, measurable and include who will be accountable for the implementation and timelines for completion and evaluation. If locally appropriate, RCA teams can use this first section to develop strong recommendations and then handover the document to safety and quality teams to complete the remainder of the spreadsheet tool."]
["The steps in this section will help you to develop strong recommendations that will address the identified contributing factors. The appropriate information to be entered in each column is outlined here:"]
["Column A: ","Enter the contributing factors identified in the investigation report. If pasting from another document, double-click in the destination cell and either press Ctrl+V or right click and select Paste. This will ensure there are no formatting issues introduced."]
["Column B:","Select the type of contributing factor from the list."]
["Column C:","Identify aims by answering the question \"What change/improvement are you hoping to achieve?\". Aims should be SMART (Specific, Measurable, Accountable, Realistic, Time related). A strong aim will help to develop stronger recommendations. There may be multiple aims per incident or contributing factor - if there are multiple aims enter one per row."]
["Column D:","Identify recommendations/actions by answering the question \"How are you going to achieve your aims and measure your achievements (outcome measure)?\". Use the criteria in columns H-N to assist in the develop of strong recommendations/actions. Identification of a suitable outcome measure makes the effectiveness of the recommendation/action measurable. There may be multiple recommendations/actions per aim - if so enter one per row."]
["Column E:","Select the action type from the list that aligns to the recommendation.\nRecommendations made from an RCA are a critical component to ensuring that these types of clinical incidents are prevented or minimised in the future. A Recommendations/Actions Hierarchy was developed by the Veterans Affairs National Center for Patient Safety to assist in the development of actions that are more likely to succeed and achieve the desired outcomes.\nThe Recommendations/Actions Hierarchy is a valuable tool that can assist staff in identifying and creating stronger recommendations/actions to ensure effective system change. Recommendations/actions fall into three categories – stronger, intermediate and weaker actions. \nUsing the principles of human factors, stronger recommendations/actions focus on modifying human behaviour to limit or prevent clinical incidents from occurring. For example, eliminating the use of universal adaptors and peripheral devices for medical equipment and use tubing/fittings that can only be connected the correct way.\nThis recommendations/actions hierarchy is available in the CIM Toolkit which is available at:"]
[null,"http://ww2.health.wa.gov.au/Articles/A_E/Clinical-incident-management-system"]
["Column F:","Enter the name and position title of the staff member responsible for the recommendation. This makes the recommendation accountable."]
["Column G:","Enter the target implementation date, i.e. when it is expected that the recommendation will be fully implemented (but does not include evaluating its effectiveness). This makes the recommendation time-related."]
["Column H:","Specific","Assess whether your recommendation is specific. Who are you targeting and what action or activity is being evaluated? (e.g. ward patients, patient having surgery etc.). For example, to reduce pressure injury prevalence by 10% within six months, on all the orthopaedic wards.",null,null,null,null,null,"Possible score of 1"]
["Column I:","Measurable","Assess whether your recommendation is measureable. How much change is expected? The abovementioned example is an easily measurable goal as it outlines the issue, establishes a reduction measure of 10%, identifies a target group and provides a timeline.",null,null,null,null,null,"Possible score of 1"]
["Column J:","Accountable","Assess whether your recommendation is accountable. Having an individual assigned to implement the recommendation makes it accountable. Assigning a group or department to implement the recommendation does not create accountability.",null,null,null,null,null,"Possible score of 1"]
["Column K:","Realistic","Assess whether your recommendation is realistic - for example, can it be implemented within the specified timeframe and within any resource/budget constraints? Recommendations needs to be realistic to ensure that the aims can be achieved.",null,null,null,null,null,"Possible score of 1"]
["Column L:","Time related","Assess whether your recommendation is time related. It is important to state a date by which the recommendation will be implemented.",null,null,null,null,null,"Possible score of 1"]
["Column M:","Action strength","This field will auto-populate based on the action type in column E. ",null,null,null,null,null,"Possible score of 2"]
["Column N:","This field will auto-calculate based on values entered in columns H-M. \nThe SMARTA score provides a means for health services to self-assess the quality of their recommendations/actions. Those recommendations/actions achieving the highest possible score of 7 are considered excellent recommendations/actions that, if  paired with an appropriate evaluation method, are likely to lead to measurable and sustainable system improvement. Recommendations/actions achieving a score of 3 or less in the SMARTA assessment are considered poor recommendations/actions, and are unlikely to deliver sustainable improvement."]
["Column O:","Plan how the recommendation will be evaluated for effectiveness once it is implemented. Check that this evaluation method will provide information relevant to the contributing factor and aim."]
["Column P:","When is it proposed that evaluation of the effectiveness of the recommendation will be conducted? This needs to be later than the target implementation date entered in column G and within 6 months of the investigation report being submitted to PSSU. "]
["Column Q:","Enter whether executive approval has been obtained for the recommendations."]
["Implement Recommendations"]
["Implementation of recommendations should effectively prevent recurrence of the clinical incident and/or minimise the harm that results. Recommendations arising from clinical incidents are to be implemented and evaluated within six months of the finalised investigation. For all SAC 1 clinical incidents hospitals/health services are required to notify the HS Safety, Quality and Performance team and the PSSU when the evaluation of recommendations has been completed. It is important to distinguish between implementation of recommendations and the subsequent evaluation of their effectiveness."]
["The steps in this section will help you track the progress of implementation of recommendations and ensure all recommendations are completed. The appropriate information to be entered in each column is outlined here:"]
["Columns A to E: ","These fields will auto-populate based on the information entered in the Develop SMARTA Recommendations tab. "]
["Column F:","Enter whether the implementation of the recommendation is:\n - Fully completed\n - Partially completed\n - Not yet commenced\n - Rejected\nIf a recommendation has been rejected assess whether a new recommendation is required in its place - if so enter this in the Develop SMARTA Recommendations tab."]
["Column G:","Enter the name and position title of the staff member that has signed off on implementation of the recommendation. Include the date of signoff."]
["Column H:","Summarise the evidence of implementation of the recommendation (further supporting documentation can be uploaded to Datix CIMS). If implementation is partially completed or not yet commenced state why and provide the latest results (if relevant). If the recommendation has been rejected please provide an explanation."]
["Evaluate Effectiveness"]
["The CIM Policy requires all recommendations to be evaluated for effectiveness within six months of the investigation of the incident being completed to ensure that they have effectively reduced the risk of same or similar incidents occurring and/or the harm that results.  For all SAC 1 clinical incidents hospitals/health services are required to notify the HS Safety, Quality and Performance team and the PSSU when the evaluation of recommendations has been completed. Simply stating that implementation is complete is not sufficient evidence of evaluation of the effectiveness of recommendations and the CIM Policy expects that evidence supporting the evaluation activites will be provided via Datix CIMS."]
["The steps in this section will help you track the progress of evaluation of the effectiveness of recommendations. The appropriate information to be entered in each column is outlined here:"]
["Columns A to E: ","These fields will auto-populate based on the information entered in the Develop SMARTA Recommendations tab. "]
["Column F:","Enter the date on which evaluation of the effectiveness of the recommendation took place. If evaluation is not yet completed enter 'Incomplete'."]
["Column G:","Summarise the evaluation of the effectiveness of the recommendation. If evaluation is not yet completed please provide an explanation."]
["Column H:","Has the recommendation been effective so that the intended Quality Improvement (QI) has been achieved? Have you addressed your aim? Provide an explanation if answered Partially achieved or Not achieved. If QI has not been achieved it may be appropriate to develop further recommendations or an ongoing QI activity."]
["Column I:","Enter the name and position title of the staff member that has signed off on evaluation of the recommendation. Include the date of signoff."]
["Evaluation Template - Attach to Datix record"]
["The Evaluation Template tab summarises the key information that the PSSU requires to be assured that the recommendations arising fromSAC 1 clinical incidents have been fully implemented and evaluated for effectiveness. All information is auto-populated from the preceding tabs and no further data entry is required.\nOnce all information has been entered click the \"Create PDF\" button in the top right corner of this tab. A window will open asking you to select a location to save the pdf file and there is the opportunity to change the document name if desired. Attach the pdf document to the relevant Datix CIMS incident record along with the evidence to support the implementation and evaluation activities that have been undertaken."]
["More information regarding the implementation and evaluation of recommendations is available in the CIM Toolkit  which is available from the Safety and Quality website at:"]
["http://ww2.health.wa.gov.au/Articles/A_E/Clinical-incident-management-system"]

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[{"$f":"\"Datix CIM Number: \"&TEXT('Guide for use'!C1,\" \")","v":"Datix CIM Number: CIMS998234"}]
[{"$f":"\"Hospital/Service: \"&TEXT('Guide for use'!C2,\" \")","v":"Hospital/Service: St Thomas Ward A"}]
[{"$f":"\"Date investigation report submitted to PSSU: \"&TEXT('Guide for use'!C3,\"dd/mm/yyyy\")","v":"Date investigation report submitted to PSSU: 14/04/2014"}]
[{"$f":"\"Date evaluation report due: \"&TEXT('Guide for use'!C4,\"dd/mm/yyyy\")","v":"Date evaluation report due: 14/10/2014"}]
[]
["Steps of system improvement:"]
["1. Identification of contributing factors in clinical incident investigation"]
["2. Development of SMARTA recommendations/actions to address identified contributing factors"]
["3. Executive signoff of recommendations"]
["4. Implementation of recommendations"]
["5. Evaluation of effectiveness of recommendations/actions"]
[]
["Contributing/Causative factor as per investigation report","Contributing/Causative factor type","Aim\n\nWhat change are you wanting as a result of QI activity?","Recommendation/Action ",null,null,null,"SMARTA tool",null,null,null,null,null,null,"Evaluation Method \n\nHow are you going to confirm the contributing factor is addressed?","Proposed Evaluation Date \n\nWithin 6 months of investigation report submission to PSSU"]
[null,null,null,"Recommendation/\nAction details\n\nHow are you going to achieve your aim and measure your achievements? (i.e. outcome measure)","Action type ","Name of staff recommendation assigned to","Target implementation date","Specific","Measurable ","Accountable","Realistic","Time Related","Recommendation/Action Strength","SMARTA Scores (possible score of 7) "]
["Signs of clinical deterioration were not recognised and appropriate responses were not actioned ","Knowledge/Skills/Competence","To reduce by 50% the frequency of clinical incidents resulting from failure to recognise and respond to clinical deterioration on ward A within 3 months","Clinical deterioration education refresher given to staff","Training","Staff Development Nurse J Brown","2014-04-30","Met (score of 1)","Met (score of 1)","Met (score of 1)","Met (score of 1)","Met (score of 1)",{"$f":"IF(E15=0,\"\",LOOKUP(E15,Action,Administration!K$2:K$20))","v":"Weak (score of 0)"},{"$f":"IF(A15=0,\"\",LOOKUP((IF(H15=\"Met (score of 1)\",1,0)+IF(I15=\"Met (score of 1)\",1,0)+IF(J15=\"Met (score of 1)\",1,0)+IF(K15=\"Met (score of 1)\",1,0)+IF(L15=\"Met (score of 1)\",1,0)+IF(M15=\"Strong (score of 2)\",2,0)+IF(M15=\"Intermediate (score of 1)\",1,0)),Administration!H$2:H$9,Administration!I$2:I$9))","v":"Good (score of 5)"},"Audit of frequency clinical incidents involving failure to recognise and respond to clinical deterioration","May 2014 and September 2014"]
["The patient monitoring plan was not reviewed during the shift","Policies, Procedures, Guidelines","To ensure that 100% of patient monitoring plans on Ward A are reviewed at least twice during each shift","Shift protocol to be updated to require monitoring plan to be reviewed at least twice during each shift","New procedure/memorandum/policy","Staff Development Nurse J Brown","2014-05-31","Met (score of 1)","Met (score of 1)","Met (score of 1)","Met (score of 1)","Met (score of 1)",{"$f":"IF(E16=0,\"\",LOOKUP(E16,Action,Administration!K$2:K$20))","v":"Weak (score of 0)"},{"$f":"IF(A16=0,\"\",LOOKUP((IF(H16=\"Met (score of 1)\",1,0)+IF(I16=\"Met (score of 1)\",1,0)+IF(J16=\"Met (score of 1)\",1,0)+IF(K16=\"Met (score of 1)\",1,0)+IF(L16=\"Met (score of 1)\",1,0)+IF(M16=\"Strong (score of 2)\",2,0)+IF(M16=\"Intermediate (score of 1)\",1,0)),Administration!H$2:H$9,Administration!I$2:I$9))","v":"Good (score of 5)"},"Audit of patient records to confirm proportion where the monitoring plan was reviewed twice during each shift","June 2014 and September 2014"]
["Inadequate skill mix of senior nursing staff on ward A","Work Environment/Scheduling","To increase the staffing ratio of senior staff to junior staff for each shift within 2 months","Rosters to be reviewed and ratio of junior staff balanced across shifts with monthly survey of nursing rosters to assess adequacy of staffing skill mix","Increase in staffing/decrease in workload","Nurse manager P Lee","2014-05-31","Met (score of 1)","Not met (score of 0) ","Met (score of 1)","Met (score of 1)","Met (score of 1)",{"$f":"IF(E17=0,\"\",LOOKUP(E17,Action,Administration!K$2:K$20))","v":"Intermediate (score of 1)"},{"$f":"IF(A17=0,\"\",LOOKUP((IF(H17=\"Met (score of 1)\",1,0)+IF(I17=\"Met (score of 1)\",1,0)+IF(J17=\"Met (score of 1)\",1,0)+IF(K17=\"Met (score of 1)\",1,0)+IF(L17=\"Met (score of 1)\",1,0)+IF(M17=\"Strong (score of 2)\",2,0)+IF(M17=\"Intermediate (score of 1)\",1,0)),Administration!H$2:H$9,Administration!I$2:I$9))","v":"Good (score of 5)"},"Audit staff rosters to monitor the ratio of senior staff to junior staff each shift","2014-10-01"]
["Lack of senior night duty staff","Work Environment/Scheduling","To increase the ratio of permanent senior nursing night duty staff on ward A within 2 months","Recruit four permanent night duty staff within 2 months","Increase in staffing/decrease in workload","Nurse manager P Lee","2014-07-01","Met (score of 1)","Met (score of 1)","Met (score of 1)","Met (score of 1)","Met (score of 1)",{"$f":"IF(E18=0,\"\",LOOKUP(E18,Action,Administration!K$2:K$20))","v":"Intermediate (score of 1)"},{"$f":"IF(A18=0,\"\",LOOKUP((IF(H18=\"Met (score of 1)\",1,0)+IF(I18=\"Met (score of 1)\",1,0)+IF(J18=\"Met (score of 1)\",1,0)+IF(K18=\"Met (score of 1)\",1,0)+IF(L18=\"Met (score of 1)\",1,0)+IF(M18=\"Strong (score of 2)\",2,0)+IF(M18=\"Intermediate (score of 1)\",1,0)),Administration!H$2:H$9,Administration!I$2:I$9))","v":"Very good (score of 6)"},"Audit staff rosters to monitor the ratio of permanent senior staff on night duty","2014-10-01"]
["EXAMPLE ONLY",null,null,null,null,null,null,"EXAMPLE ONLY"]

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[]
["Steps of system improvement:"]
["1. Identification of contributing factors in clinical incident investigation"]
["2. Development of SMARTA recommendations/actions to address identified contributing factors"]
["3. Executive signoff of recommendations"]
["4. Implementation of recommendations"]
["5. Evaluation of effectiveness of recommendations/actions"]
[]
["Contributing/Causative factor as per investigation report","Recommendation/Action ",null,null,null,"Implementation of recommendations/actions"]
[null,"Recommendation/Action details","Action type ","Name of staff recommendation assigned to","Target implementation date","Has implementation of the recommendation/action been completed?","Sign Off that Achievements Completed (state date)","Evidence of implementation                                  \n(If implementation not complete state why not and provide latest results)"]
[{"$f":"IF('Develop SMARTA Recommendations'!A15=0,\"This field will auto-populate\",'Develop SMARTA Recommendations'!A15)","v":"Signs of clinical deterioration were not recognised and appropriate responses were not actioned "},{"$f":"IF('Develop SMARTA Recommendations'!D15=0,\"This field will auto-populate\",'Develop SMARTA Recommendations'!D15)","v":"Clinical deterioration education refresher given to staff"},{"$f":"IF('Develop SMARTA Recommendations'!E15=0,\"This field will auto-populate\",'Develop SMARTA Recommendations'!E15)","v":"Training"},{"$f":"IF('Develop SMARTA Recommendations'!F15=0,\"This field will auto-populate\",'Develop SMARTA Recommendations'!F15)","v":"Staff Development Nurse J Brown"},{"$f":"IF('Develop SMARTA Recommendations'!A15=0,\"This field will auto-populate\",'Develop SMARTA Recommendations'!G15)","v":"2014-04-30"},"Fully completed","J Brown 4 July 2014","Clinical deterioration module added to mandatory competencies schedule. Staff required to complete within three months of introduction and then annually."]
[{"$f":"IF('Develop SMARTA Recommendations'!A16=0,\"\",'Develop SMARTA Recommendations'!A16)","v":"The patient monitoring plan was not reviewed during the shift"},{"$f":"IF('Develop SMARTA Recommendations'!D16=0,\"\",'Develop SMARTA Recommendations'!D16)","v":"Shift protocol to be updated to require monitoring plan to be reviewed at least twice during each shift"},{"$f":"IF('Develop SMARTA Recommendations'!E16=0,\"\",'Develop SMARTA Recommendations'!E16)","v":"New procedure/memorandum/policy"},{"$f":"IF('Develop SMARTA Recommendations'!F16=0,\"\",'Develop SMARTA Recommendations'!F16)","v":"Staff Development Nurse J Brown"},{"$f":"IF('Develop SMARTA Recommendations'!A16=0,\"\",'Develop SMARTA Recommendations'!G16)","v":"2014-05-31"},"Fully completed","J Brown 4 July 2014","Requirements for two reviews of monitoring plans were included in the shift protocol from 29/5/2014 and Ward A staff informed"]
[{"$f":"IF('Develop SMARTA Recommendations'!A17=0,\"\",'Develop SMARTA Recommendations'!A17)","v":"Inadequate skill mix of senior nursing staff on ward A"},{"$f":"IF('Develop SMARTA Recommendations'!D17=0,\"\",'Develop SMARTA Recommendations'!D17)","v":"Rosters to be reviewed and ratio of junior staff balanced across shifts with monthly survey of nursing rosters to assess adequacy of staffing skill mix"},{"$f":"IF('Develop SMARTA Recommendations'!E17=0,\"\",'Develop SMARTA Recommendations'!E17)","v":"Increase in staffing/decrease in workload"},{"$f":"IF('Develop SMARTA Recommendations'!F17=0,\"\",'Develop SMARTA Recommendations'!F17)","v":"Nurse manager P Lee"},{"$f":"IF('Develop SMARTA Recommendations'!A17=0,\"\",'Develop SMARTA Recommendations'!G17)","v":"2014-05-31"},"Partially completed","P Lee 4 July 2014","Rosters have been reviewed and upper limit of 60% junior staff instigated. Reconfiguration of rosters is planned to be completed by the end of July."]
[{"$f":"IF('Develop SMARTA Recommendations'!A18=0,\"\",'Develop SMARTA Recommendations'!A18)","v":"Lack of senior night duty staff"},{"$f":"IF('Develop SMARTA Recommendations'!D18=0,\"\",'Develop SMARTA Recommendations'!D18)","v":"Recruit four permanent night duty staff within 2 months"},{"$f":"IF('Develop SMARTA Recommendations'!E18=0,\"\",'Develop SMARTA Recommendations'!E18)","v":"Increase in staffing/decrease in workload"},{"$f":"IF('Develop SMARTA Recommendations'!F18=0,\"\",'Develop SMARTA Recommendations'!F18)","v":"Nurse manager P Lee"},{"$f":"IF('Develop SMARTA Recommendations'!A18=0,\"\",'Develop SMARTA Recommendations'!G18)","v":"2014-07-01"},"Fully completed","P Lee 14 July 2014","Three permanent senior night duty staff have commenced work in June and the fourth started in mid-July."]
["EXAMPLE ONLY"]

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[{"$f":"\"Date investigation report submitted to PSSU: \"&TEXT('Guide for use'!C3,\"dd/mm/yyyy\")","v":"Date investigation report submitted to PSSU: 14/04/2014"}]
[{"$f":"\"Date evaluation report due: \"&TEXT('Guide for use'!C4,\"dd/mm/yyyy\")","v":"Date evaluation report due: 14/10/2014"}]
[]
["Steps of system improvement:"]
["1. Identification of contributing factors in clinical incident investigation"]
["2. Development of SMARTA recommendations/actions to address identified contributing factors"]
["3. Executive signoff of recommendations"]
["4. Implementation of recommendations"]
["5. Evaluation of effectiveness of recommendations/actions"]
[]
["Contributing/Causative factor as per investigation report","Recommendation/Action ",null,null,"Evaluation of effectiveness of recommendations/actions"]
[null,"Recommendation/Action details","Action type ","Name of staff recommendation assigned to","Evaluation Method (to confirm contributing factor addressed)","Evaluation Date \n","Evidence of evaluation of effectiveness of recommendations/actions","Has Quality Improvement been achieved?\nYes/No\nIf No, state why not","Sign off that achievements completed (use designation not name)\n\nState date"]
[{"$f":"IF('Develop SMARTA Recommendations'!A15=0,\"This field will auto-populate\",'Develop SMARTA Recommendations'!A15)","v":"Signs of clinical deterioration were not recognised and appropriate responses were not actioned "},{"$f":"IF('Develop SMARTA Recommendations'!D15=0,\"This field will auto-populate\",'Develop SMARTA Recommendations'!D15)","v":"Clinical deterioration education refresher given to staff"},{"$f":"IF('Develop SMARTA Recommendations'!E15=0,\"This field will auto-populate\",'Develop SMARTA Recommendations'!E15)","v":"Training"},{"$f":"IF('Develop SMARTA Recommendations'!F15=0,\"This field will auto-populate\",'Develop SMARTA Recommendations'!F15)","v":"Staff Development Nurse J Brown"},{"$f":"IF('Develop SMARTA Recommendations'!O15=0,\"This field will auto-populate\",'Develop SMARTA Recommendations'!O15)","v":"Audit of frequency clinical incidents involving failure to recognise and respond to clinical deterioration"},"2014-10-10","• During September there were 18 incidents that identified a failure to recognise and respond to clinical deterioration.\n• This is down from 40 incidents notified in the May audit.\n• 10 incidents resulted in unplanned admission to ICU.\n• 12 incidents resulted in delayed escalation to the MER team.\n• 8 incidents resulted from the monitoring plan not being reviewed for every shift in last 24 hours. \n• Nil patient deaths observed.\n• Findings were presented to the ward staff, clinical deterioration education continues to be a ward priority.\n","Yes QI fully achieved with 50% reduction achieved by September 2014","Staff Development Nurse 10/10/2014"]
[{"$f":"IF('Develop SMARTA Recommendations'!A16=0,\"\",'Develop SMARTA Recommendations'!A16)","v":"The patient monitoring plan was not reviewed during the shift"},{"$f":"IF('Develop SMARTA Recommendations'!D16=0,\"\",'Develop SMARTA Recommendations'!D16)","v":"Shift protocol to be updated to require monitoring plan to be reviewed at least twice during each shift"},{"$f":"IF('Develop SMARTA Recommendations'!E16=0,\"\",'Develop SMARTA Recommendations'!E16)","v":"New procedure/memorandum/policy"},{"$f":"IF('Develop SMARTA Recommendations'!F16=0,\"\",'Develop SMARTA Recommendations'!F16)","v":"Staff Development Nurse J Brown"},{"$f":"IF('Develop SMARTA Recommendations'!O16=0,\"\",'Develop SMARTA Recommendations'!O16)","v":"Audit of patient records to confirm proportion where the monitoring plan was reviewed twice during each shift"},"2014-10-10","Audit of patient records in June showed only 45% where monitoring plans were reviewed twice during each shift. The follow-up audit in September showed the level of compliance had increased to 73%, however this is below the target of 100% and 8 incidents resulted.","Yes QI partially achieved with improvement in the proportion of monitoring plans being reviewed. However compliance  remains below the level desired and the Executive have approved an ongoing QI activity around this.","Staff Development Nurse 10/10/2014"]
[{"$f":"IF('Develop SMARTA Recommendations'!A17=0,\"\",'Develop SMARTA Recommendations'!A17)","v":"Inadequate skill mix of senior nursing staff on ward A"},{"$f":"IF('Develop SMARTA Recommendations'!D17=0,\"\",'Develop SMARTA Recommendations'!D17)","v":"Rosters to be reviewed and ratio of junior staff balanced across shifts with monthly survey of nursing rosters to assess adequacy of staffing skill mix"},{"$f":"IF('Develop SMARTA Recommendations'!E17=0,\"\",'Develop SMARTA Recommendations'!E17)","v":"Increase in staffing/decrease in workload"},{"$f":"IF('Develop SMARTA Recommendations'!F17=0,\"\",'Develop SMARTA Recommendations'!F17)","v":"Nurse manager P Lee"},{"$f":"IF('Develop SMARTA Recommendations'!O17=0,\"\",'Develop SMARTA Recommendations'!O17)","v":"Audit staff rosters to monitor the ratio of senior staff to junior staff each shift"},"2014-10-08","• During September 84% of nursing shifts were appropriately staffed.\n• 14 shifts showed 60% or more of the rostered staff for that shift were graduate/junior nursing staff.\n• Lack of senior night duty staff requires senior day staff to be frequently rostered onto nights.\n","Yes","Nurse Manager 8/10/2014"]
[{"$f":"IF('Develop SMARTA Recommendations'!A18=0,\"\",'Develop SMARTA Recommendations'!A18)","v":"Lack of senior night duty staff"},{"$f":"IF('Develop SMARTA Recommendations'!D18=0,\"\",'Develop SMARTA Recommendations'!D18)","v":"Recruit four permanent night duty staff within 2 months"},{"$f":"IF('Develop SMARTA Recommendations'!E18=0,\"\",'Develop SMARTA Recommendations'!E18)","v":"Increase in staffing/decrease in workload"},{"$f":"IF('Develop SMARTA Recommendations'!F18=0,\"\",'Develop SMARTA Recommendations'!F18)","v":"Nurse manager P Lee"},{"$f":"IF('Develop SMARTA Recommendations'!O18=0,\"\",'Develop SMARTA Recommendations'!O18)","v":"Audit staff rosters to monitor the ratio of permanent senior staff on night duty"},"2014-10-08","During September 80% of night duty shifts had at least 40% senior staff ratio","Yes","Nurse Manager 8/10/2014"]
[{"$f":"IF('Develop SMARTA Recommendations'!A19=0,\"\",'Develop SMARTA Recommendations'!A19)","v":"EXAMPLE ONLY"}]

{"sheet":"Evaluation Template","index":5,"n_rows":11,"n_cols":9,"rows_kept":11,"cut":false,"hidden":false,"merged":[[10,0,10,8],[4,5,4,8],[0,0,0,3],[1,0,1,3],[2,0,2,3],[3,0,3,3],[4,0,5,0],[4,2,4,3],[4,1,5,1]]}
[{"$f":"\"Datix CIM Number: \"&TEXT('Guide for use'!C1,\" \")","v":"Datix CIM Number: CIMS998234"}]
[{"$f":"\"Hospital/Service: \"&TEXT('Guide for use'!C2,\" \")","v":"Hospital/Service: St Thomas Ward A"}]
[{"$f":"\"Date investigation report submitted to PSSU: \"&TEXT('Guide for use'!C3,\"dd/mm/yyyy\")","v":"Date investigation report submitted to PSSU: 14/04/2014"}]
[{"$f":"\"Date evaluation report due: \"&TEXT('Guide for use'!C4,\"dd/mm/yyyy\")","v":"Date evaluation report due: 14/10/2014"}]
["Contributing/Causative factor as per investigation report","Aim","Recommendation/Action ",null,"Implementation","Evaluation"]
[null,null,"Recommendation/Action details","Action type ",{"$f":"'Implement Recommendations'!H14","v":"Evidence of implementation                                  \n(If implementation not complete state why not and provide latest results)"},{"$f":"'Evaluate Effectiveness'!F14","v":"Evaluation Date \n"},{"$f":"'Evaluate Effectiveness'!G14","v":"Evidence of evaluation of effectiveness of recommendations/actions"},"Has QI been achieved? \nFully/Partially/Not achieved\n\nIf not fully achieved, state why not","Sign off that achievements completed\n\nState date"]
[{"$f":"IF('Develop SMARTA Recommendations'!A15=0,\"This field will auto-populate\",'Develop SMARTA Recommendations'!A15)","v":"Signs of clinical deterioration were not recognised and appropriate responses were not actioned "},{"$f":"IF('Develop SMARTA Recommendations'!A15=0,\"This field will auto-populate\",'Develop SMARTA Recommendations'!C15)","v":"To reduce by 50% the frequency of clinical incidents resulting from failure to recognise and respond to clinical deterioration on ward A within 3 months"},{"$f":"IF('Develop SMARTA Recommendations'!A15=0,\"This field will auto-populate\",'Develop SMARTA Recommendations'!D15)","v":"Clinical deterioration education refresher given to staff"},{"$f":"IF('Develop SMARTA Recommendations'!A15=0,\"This field will auto-populate\",'Develop SMARTA Recommendations'!E15)","v":"Training"},{"$f":"IF('Develop SMARTA Recommendations'!A15=0,\"This field will auto-populate\",'Implement Recommendations'!H15)","v":"Clinical deterioration module added to mandatory competencies schedule. Staff required to complete within three months of introduction and then annually."},{"$f":"IF('Develop SMARTA Recommendations'!A15=0,\"This field will auto-populate\",'Evaluate Effectiveness'!F15)","v":"2014-10-10"},{"$f":"IF('Develop SMARTA Recommendations'!A15=0,\"This field will auto-populate\",'Evaluate Effectiveness'!G15)","v":"• During September there were 18 incidents that identified a failure to recognise and respond to clinical deterioration.\n• This is down from 40 incidents notified in the May audit.\n• 10 incidents resulted in unplanned admission to ICU.\n• 12 incidents resulted in delayed escalation to the MER team.\n• 8 incidents resulted from the monitoring plan not being reviewed for every shift in last 24 hours. \n• Nil patient deaths observed.\n• Findings were presented to the ward staff, clinical deterioration education continues to be a ward priority.\n"},{"$f":"IF('Develop SMARTA Recommendations'!A15=0,\"This field will auto-populate\",'Evaluate Effectiveness'!H15)","v":"Yes QI fully achieved with 50% reduction achieved by September 2014"},{"$f":"IF('Develop SMARTA Recommendations'!A15=0,\"This field will auto-populate\",'Evaluate Effectiveness'!I15)","v":"Staff Development Nurse 10/10/2014"}]
[{"$f":"IF('Develop SMARTA Recommendations'!A16=0,\"\",'Develop SMARTA Recommendations'!A16)","v":"The patient monitoring plan was not reviewed during the shift"},{"$f":"IF('Develop SMARTA Recommendations'!A16=0,\"\",'Develop SMARTA Recommendations'!C16)","v":"To ensure that 100% of patient monitoring plans on Ward A are reviewed at least twice during each shift"},{"$f":"IF('Develop SMARTA Recommendations'!A16=0,\"\",'Develop SMARTA Recommendations'!D16)","v":"Shift protocol to be updated to require monitoring plan to be reviewed at least twice during each shift"},{"$f":"IF('Develop SMARTA Recommendations'!A16=0,\"\",'Develop SMARTA Recommendations'!E16)","v":"New procedure/memorandum/policy"},{"$f":"IF('Develop SMARTA Recommendations'!A16=0,\"\",'Implement Recommendations'!H16)","v":"Requirements for two reviews of monitoring plans were included in the shift protocol from 29/5/2014 and Ward A staff informed"},{"$f":"IF('Develop SMARTA Recommendations'!A16=0,\"\",'Evaluate Effectiveness'!F16)","v":"2014-10-10"},{"$f":"IF('Develop SMARTA Recommendations'!A16=0,\"\",'Evaluate Effectiveness'!G16)","v":"Audit of patient records in June showed only 45% where monitoring plans were reviewed twice during each shift. The follow-up audit in September showed the level of compliance had increased to 73%, however this is below the target of 100% and 8 incidents resulted."},{"$f":"IF('Develop SMARTA Recommendations'!A16=0,\"\",'Evaluate Effectiveness'!H16)","v":"Yes QI partially achieved with improvement in the proportion of monitoring plans being reviewed. However compliance  remains below the level desired and the Executive have approved an ongoing QI activity around this."},{"$f":"IF('Develop SMARTA Recommendations'!A16=0,\"\",'Evaluate Effectiveness'!I16)","v":"Staff Development Nurse 10/10/2014"}]
[{"$f":"IF('Develop SMARTA Recommendations'!A17=0,\"\",'Develop SMARTA Recommendations'!A17)","v":"Inadequate skill mix of senior nursing staff on ward A"},{"$f":"IF('Develop SMARTA Recommendations'!A17=0,\"\",'Develop SMARTA Recommendations'!C17)","v":"To increase the staffing ratio of senior staff to junior staff for each shift within 2 months"},{"$f":"IF('Develop SMARTA Recommendations'!A17=0,\"\",'Develop SMARTA Recommendations'!D17)","v":"Rosters to be reviewed and ratio of junior staff balanced across shifts with monthly survey of nursing rosters to assess adequacy of staffing skill mix"},{"$f":"IF('Develop SMARTA Recommendations'!A17=0,\"\",'Develop SMARTA Recommendations'!E17)","v":"Increase in staffing/decrease in workload"},{"$f":"IF('Develop SMARTA Recommendations'!A17=0,\"\",'Implement Recommendations'!H17)","v":"Rosters have been reviewed and upper limit of 60% junior staff instigated. Reconfiguration of rosters is planned to be completed by the end of July."},{"$f":"IF('Develop SMARTA Recommendations'!A17=0,\"\",'Evaluate Effectiveness'!F17)","v":"2014-10-08"},{"$f":"IF('Develop SMARTA Recommendations'!A17=0,\"\",'Evaluate Effectiveness'!G17)","v":"• During September 84% of nursing shifts were appropriately staffed.\n• 14 shifts showed 60% or more of the rostered staff for that shift were graduate/junior nursing staff.\n• Lack of senior night duty staff requires senior day staff to be frequently rostered onto nights.\n"},"Fully achieved",{"$f":"IF('Develop SMARTA Recommendations'!A17=0,\"\",'Evaluate Effectiveness'!I17)","v":"Nurse Manager 8/10/2014"}]
[{"$f":"IF('Develop SMARTA Recommendations'!A18=0,\"\",'Develop SMARTA Recommendations'!A18)","v":"Lack of senior night duty staff"},{"$f":"IF('Develop SMARTA Recommendations'!A18=0,\"\",'Develop SMARTA Recommendations'!C18)","v":"To increase the ratio of permanent senior nursing night duty staff on ward A within 2 months"},{"$f":"IF('Develop SMARTA Recommendations'!A18=0,\"\",'Develop SMARTA Recommendations'!D18)","v":"Recruit four permanent night duty staff within 2 months"},{"$f":"IF('Develop SMARTA Recommendations'!A18=0,\"\",'Develop SMARTA Recommendations'!E18)","v":"Increase in staffing/decrease in workload"},{"$f":"IF('Develop SMARTA Recommendations'!A18=0,\"\",'Implement Recommendations'!H18)","v":"Three permanent senior night duty staff have commenced work in June and the fourth started in mid-July."},{"$f":"IF('Develop SMARTA Recommendations'!A18=0,\"\",'Evaluate Effectiveness'!F18)","v":"2014-10-08"},{"$f":"IF('Develop SMARTA Recommendations'!A18=0,\"\",'Evaluate Effectiveness'!G18)","v":"During September 80% of night duty shifts had at least 40% senior staff ratio"},"Fully achieved",{"$f":"IF('Develop SMARTA Recommendations'!A18=0,\"\",'Evaluate Effectiveness'!I18)","v":"Nurse Manager 8/10/2014"}]
[{"$f":"IF('Develop SMARTA Recommendations'!A19=0,\"\",'Develop SMARTA Recommendations'!A19)","v":"EXAMPLE ONLY"}]

{"sheet":"Administration","index":6,"n_rows":19,"n_cols":13,"rows_kept":19,"cut":false,"hidden":true,"merged":[[0,7,0,8]]}
["Contributing factor","Specific","Measurable ","Accountable","Realistic","Time Related","Recommendation/  Action Strength","SMARTA Score",null,"Action type","Action Strength","Executive Concur","Completion"]
["Communication","Not met (score of 0) ","Not met (score of 0) ","Not met (score of 0) ","Not met (score of 0) ","Not met (score of 0) ","Strong (score of 2)",0,"Poor (score of 0)","Architectural/physical plant changes","Strong (score of 2)","Yes","Fully completed"]
["Knowledge/Skills/Competence","Met (score of 1)","Met (score of 1)","Met (score of 1)","Met (score of 1)","Met (score of 1)","Intermediate (score of 1)",1,"Poor (score of 1)","Checklist/cognitive aids","Intermediate (score of 1)","No","Partially completed"]
["Work Environment/Scheduling",null,null,null,null,null,"Weak (score of 0)",2,"Poor (score of 2)","Double checks","Weak (score of 0)",null,"Not yet commenced"]
["Patient Factors",null,null,null,null,null,null,3,"Poor (score of 3)","Education using simulation-based training, with periodic refresher sessions/observations","Intermediate (score of 1)",null,"Rejected"]
["Equipment",null,null,null,null,null,null,4,"Fair (score of 4)","Eliminate look- and sound-alikes","Intermediate (score of 1)"]
["Policies, Procedures, Guidelines",null,null,null,null,null,null,5,"Good (score of 5)","Eliminate/reduce distractions","Intermediate (score of 1)"]
["Safety Mechanisms",null,null,null,null,null,null,6,"Very good (score of 6)","Engineering control (forcing function)","Strong (score of 2)"]
["Other",null,null,null,null,null,null,7,"Excellent (score of 7)","Enhanced documentation, communication","Intermediate (score of 1)"]
[null,null,null,null,null,null,null,null,null,"Increase in staffing/decrease in workload","Intermediate (score of 1)"]
[null,null,null,null,null,null,null,null,null,"New devices with usability testing ","Strong (score of 2)"]
[null,null,null,null,null,null,null,null,null,"New procedure/memorandum/policy","Weak (score of 0)"]
[null,null,null,null,null,null,null,null,null,"Redundancy","Intermediate (score of 1)"]
[null,null,null,null,null,null,null,null,null,"Simplify process","Strong (score of 2)"]
[null,null,null,null,null,null,null,null,null,"Software enhancements, modifications","Intermediate (score of 1)"]
[null,null,null,null,null,null,null,null,null,"Standardised communications tools","Intermediate (score of 1)"]
[null,null,null,null,null,null,null,null,null,"Tangible involvement and action by leadership in support of patient safety","Strong (score of 2)"]
[null,null,null,null,null,null,null,null,null,"Training","Weak (score of 0)"]
[null,null,null,null,null,null,null,null,null,"Warnings","Weak (score of 0)"]

{"sheet":"Public holidays","index":7,"n_rows":11,"n_cols":11,"rows_kept":11,"cut":false,"hidden":true,"merged":[]}
["Public holidays","Public holidays 2014","Public holidays 2015","Public holidays 2016","Public holidays 2017","Public holidays 2018","Public holidays 2019","Public holidays 2020","Public holidays 2021","Public holidays 2022","Public holidays 2023"]
["New Year's Day","2014-01-01","2015-01-01","2016-01-01","2017-01-02","2018-01-01"]
["Australia Day","2014-01-27","2015-01-26","2016-01-26","2017-01-26","2018-01-26"]
["Labour Day","2014-03-03","2015-03-02","2016-03-07","2017-03-06","2018-03-06"]
["Good Friday","2014-04-18","2015-04-03","2016-03-25","2017-04-14","2018-04-14"]
["Easter Monday","2014-04-21","2015-04-06","2016-03-28","2017-04-17","2018-04-17"]
["ANZAC Day","2014-04-25","2015-04-27","2016-04-25","2017-04-25","2018-04-25"]
["Western Australia Day","2014-06-02","2015-06-01","2016-06-06","2017-06-05","2018-06-05"]
["Queen's Birthday","2014-09-29","2015-09-28","2016-09-26","2017-09-25","2018-09-25"]
["Christmas Day","2014-12-25","2015-12-25","2016-12-26","2017-12-25","2018-12-25"]
["Boxing Day","2014-12-26","2015-12-28","2016-12-27","2017-12-26","2018-12-26"]