title: Between the flags: implementing a safety-net system at scale to recognise and manage deteriorating patients in the New South Wales Public Health System.
abstract: OBJECTIVE
  In 2005, the Clinical Excellence Commission (CEC) found that unrecognised patient deterioration remained an important problem in New South Wales (NSW) public hospitals.
  
  
  METHODS
  The challenge was to design and implement an effective and sustainable safety-net system in all 225 NSW public hospitals.
  The CEC's system was designed in collaboration with a broad coalition of partners, including clinicians, managers, system administrators and collaborating agencies. A five-element system comprising governance, standard calling criteria in standard observation charts, two-level clinical emergency response systems (CERS) in each facility, an education programme and evaluation, was designed for state-wide implementation. This system was called 'Between the Flags' (BTF).
  
  
  METHODS
  Implementation was led by the CEC on behalf of a NSW coalition, and commenced in January 2010 with the implementation of the Standard Adult General Observation Chart, awareness training for all staff and a CERS in each facility.
  
  
  RESULTS
  Since the introduction of BTF, the cardiac arrest rate has declined by 42% (P < 0.05) and the Rapid Response rate has increased by 135.9% (P < 0.05) in NSW. The strength of staff support for BTF has grown with the proportion of respondents strongly agreeing that BTF has benefitted patient safety more than doubling from 21% to 44%, and overall agreement rising from 68% to 82% between 2010 and 2012.
  
  
  CONCLUSIONS
  Key success factors are a focus on governance, standardisation of observation charts and striking the right balance between a rule-based approach and individual clinical judgement.
authors.affiliation: Top End Health Service, Department of Health, Rocklands Drive, Tiwi 0810, Northern Territory.
authors.forename: Charles
authors.initials: C
authors.lastname: Pain
authors.affiliation: Systems Improvement, Clinical Excellence Commission, Level 17 McKell Building, 2-24 Rawson Place Sydney 2000, NSW, Australia.
authors.forename: Malcolm
authors.initials: M
authors.lastname: Green
authors.affiliation: Clinical Governance, South Western Sydney Local Health District, Liverpool Hospital, Corner of Elizabeth and Goulburn Streets, Liverpool NSW 2170, Australia.
authors.forename: Colette
authors.initials: C
authors.lastname: Duff
authors.affiliation: Strategic Relations and Communications, NSW Ministry of Health, 73 Miller Street North Sydney, NSW 2059, Australia.
authors.forename: Deborah
authors.initials: D
authors.lastname: Hyland
authors.affiliation: Patient Safety, Tasmania Department of Health, Tasmanian Health Service, Tasmania, Level 1, Northern Integrated Care Service, 41 Frankland Street Launceston 7250, Tasmania, Australia.
authors.forename: Annette
authors.initials: A
authors.lastname: Pantle
authors.affiliation: Service Development, South Eastern Sydney Local Health District, The Sutherland Hospital, Corner The Kingsway & Kareena Road, Caringbah NSW 2229, Australia.
authors.forename: Kimberley
authors.initials: K
authors.lastname: Fitzpatrick
authors.affiliation: Clinical Excellence Commission, Level 17 McKell Building, 2-24 Rawson Place, Sydney 2000, NSW, Australia.
authors.forename: Cliff
authors.initials: C
authors.lastname: Hughes
mesh_terms: D000328:Adult; D018450:Disease Progression; D006323:Heart Arrest / Q000517:prevention & control; D057209:Hospital Rapid Response Team / Q000458:organization & administration*; D006779:Hospitals, Public / Q000458:organization & administration*; D006801:Humans; D008499:Medical Records / Q000592:standards; D009517:New South Wales; D061214:Patient Safety / Q000592:standards*; D016730:Program Development; D015397:Program Evaluation
keywords: adverse events < patient safety; health policy < healthcare system; hospital care < setting of care; quality culture < quality management; quality improvement < quality management