JCPSLP Vol 16 no 3 2014_FINAL_WEB

Charissa Zaga is a speech pathologist working within the acute care setting. Charissa has a keen interest in quality and safety in healthcare, specifically, the efficiency of the systems and processes that underpin clinical management. She is currently undertaking a Master of Public Health. Joanne Sweeney is the manager of speech pathology at Austin Health. Joanne has a longstanding interest in safety, quality and risk and concepts of clinical governance as they apply to the speech pathology profession. changes, and use of online menu reporting, etc.) results in reliance upon education and engagement with relevant staff and increasing efficiency and accuracy within existing resources. Reduction in the number of incorrect meals delivered following intervention was observed. The risk of patients receiving the incorrect meal remains at each meal service however, making continued efforts to minimise the risk is essential. References Australian Commission on Safety and Quality in Healthcare. (2012). National safety and quality health standards . Canberra, Australia: Author. Cichero, J. (2006). Conditions commonly associated with dysphagia. In J. Cichero & B. Murdoch (Eds.), Dysphagia: Foundation, theory and practice (pp. 237–298). Chichester, UK: John Wiley and Sons. Garcia, J. M., Chambers, E., & Molander, M. (2005). Thickened liquids: Practice patterns of speech-language pathologists. American Journal of Speech-Language Pathology , 14 (1), 4–13. Langmore, S. E., Terpenning, M. S., Schork, A., Chen, Y., Murray, J. T., Lopatin, D., & Loesche, W. J. (1998). Predictors of aspiration pneumonia: How important is dysphagia? Journal of Dysphagia , 13 , 69–81.

Health was reinforced to stakeholders along with the potential associated risks for patients with incorrect meal provision. This increased knowledge engendered improved compliance with the steps in the process map and highlighted the importance of accurate communication and diet/fluid code matching. Significant differences in the number of meals delivered between audit 1 and audit 2 means the results of this study need to be viewed with caution. It is unknown whether the two interventions applied were directly effective in increasing the overall accuracy of the meal provision system and ultimately minimising the number of incorrect meals delivered. A further larger audit is required to explore this further regarding the local texture modified meal provision at HRH and RTRC sites. Intuitively, an additional supervisor on the plating line and the new allocation of a supervisor to streamline meal tray switching in the re-therm trolley following diet/fluid code changes may increase the accuracy of meal provision. Anecdotal feedback from food services department staff has reported this change was positive as it enabled increased consistency in the process and confidence that the staff were delivering the right meal to the right patient. In future it would also be valuable to continue to embed elements of the National Safety and Quality Health Service Standards (Australian Commission on Safety and Quality in Healthcare, 2012), such as patient identification and procedure matching, clinical governance, partnering with consumers and clinical handover to maximise patient safety, experience of care and minimisation of risk relating to meal provision. Conclusion The meal provision system at the Austin Hospital is complex and relies on up to seven stakeholders’ timely and clear roles within the process to ensure accuracy and safety. With all complex systems, stakeholder engagement and multiple small projects targeting different aspects of the system are necessary to effect meaningful change and improve outcomes. Limited funding availability for large- scale change in this area (e.g., technology software

Correspondence to: Charissa Zaga The Austin Hospital, Austin Health 145 Studley Rd, Heidelberg, Melbourne VIC 3084 phone: +61 (0)3 9496 5000

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JCPSLP Volume 16, Number 3 2014

Journal of Clinical Practice in Speech-Language Pathology