Chief Psychiatrist's annual report 2008-09 - Department of Health

Chief Psychiatrist’s annual report 2008–09 31
6 Improving service quality
The Office of the Chief Psychiatrist undertakes a range of ongoing and time-limited activities to
monitor and promote continuous improvement in clinical standards across the mental health
service system, in addition to responding to identified concerns or problems. Improved service
quality leads to improved consumer outcomes.
6.1 Quality Assurance Committee
The Chief Psychiatrist chairs the Quality Assurance Committee (QAC), which was established under
section 106AC of the Mental Health Act and proclaimed a consultative council under the Health
Act 1958. The function of the QAC is to assist the Chief Psychiatrist in overseeing and monitoring
standards of treatment and care in Victorian public mental health services. The QAC meets
quarterly and membership consists of senior psychiatrists and mental health clinicians from across
the clinical mental health service system. Members are appointed as authorised officers under
the Mental Health Act for their work with the QAC and are subject to the confidentiality provisions
relating to authorised officers and consultative councils.
Membership of the QAC in 2008–09 is provided in the appendix. Further information about the QAC
is available at www.health.vic.gov.au/chiefpsychiatrist/qac.htm
The following key activities were undertaken by the QAC in 2008–09:
• The QAC reviewed sentinel events referred from the department’s Sentinel Event Program. 13
Sentinel events referred to the Chief Psychiatrist are de-identified (by patient and by service) and
include suicide (and near-miss suicide) in an inpatient unit (general hospital or specialist mental
health unit) and any other catastrophic event relating to a mental health consumer in an inpatient
service. The Chief Psychiatrist provides advice on any service system and quality issues arising
from these reviews to the Sentinel Event Program which, in turn, provides feedback to the relevant
services. During the reporting period 15 sentinel events were reviewed by QAC.
• The QAC provided joint oversight together with the Victorian Quality Council of the Creating
Safety: Addressing Restraint and Seclusion Practices project and its activities during the
reporting period (see 6.1.1)
• The QAC reviewed data reports about statutory functions and thematic summaries from coronial
reports 14 .
• The ECT subcommittee of the Quality Assurance Committee continued to meet in 2008–09. The
sub-committee monitors ECT practice, oversees ECT training and in January 2009 produced the
revised Electroconvulsive therapy manual. Licensing, legal requirements and clinical guidelines.
In 2009–10 the QAC is expected to auspice a new round of clinical reviews of public mental health
services.
6.1.1 Creating Safety: Addressing Restraint and Seclusion Practices
The Creating Safety project was launched in 2007–08 as a partnership initiative of the Chief
Psychiatrist, the Quality Assurance Committee and the Victorian Quality Council. The project
aimed to strengthen and support safety in acute mental health services using an evidence-based
13 Further information on the Sentinel Event Program can be found at
www.health.vic.gov.au/clinrisk/sentinel/ser.htm
14 These summaries an be accessed online at www.health.vic.gov.au/chiefpsychiatrist/corep