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Problem Statement

Care Compass is CM Health’s point of care survey instrument. It provides a view on harm, which can be used alongside other measures of harm, to measure local and system progress in providing the safest care we can. Care Compass keeps us on track on our journey to safer care by collecting and reporting process, outcome and balancing measures.

Care Compass also helps identify safety concerns while the patient is on the ward, enabling staff to intervene quickly and make improvements. Using Care Compass, staff will know where and how to make a difference in patient safety, in key areas such as falls, pressure injuries, healthcare associated infection, patient identification and documentation, thereby building reliability and resilience into our system.

The clinical areas have been collecting data for Care Compass since November 2017, usually on five patients per month. Currently, there are 40 participating wards and units that complete a combination of the different 15 Care Compass audits. These audits are: blood and blood products; delirium; documentation; falls; infection prevention surveillance; medication chart; nutrition; pain; patient identification; peripheral intravenous line maintenance; pressure injury; protected mealtimes; recognising and responding to clinical deterioration; safe sleep; and venous thromboembolism.

An initial survey and analysis of compliance with Care Compass and survey has identified inconsistencies across CM Health. These inconsistencies relate to completing audits in accordance with the proposed schedule and a general lack of engagement with the initiative.

What are we trying to achieve?

Our goal is to improve the engagement of frontline staff with Care Compass, and build understanding of the relevance of Care Compass audits to patient care. We are aiming for 80% compliance in audit completion, and will put in place a structure to help wards to implement quality improvement initiatives based on their audit results.

What have we done?

The Patient Safety Measures database was decommissioned in 2019, so that all point-of-care safety measures can be centrally located within Care Compass, DHB-wide.

We have engaged frontline staff and key stakeholders in Care Compass, and:

  • updated the audit schedule
  • reviewed and updated the audit forms
  • reviewed and updated the ward-level dashboard reports.

Where to from here?

Our next steps will be to explore options for an alternative audit platform, and the feasibility of adopting a multidisciplinary team approach to audits.

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