PDF ~1.6mb - Clinical Excellence Commission

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Excellence
Excellence
Clinical Leadership Program Projects 2008
in Clinical Leadership
ACCOct09cover1.indd 3-4
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The Clinical Excellence Commission_ _______ 1
Clinical Leadership Program______________ 2
Selected Project Summaries______________ 6
Past Participant Testimonials_ ___________ 33
List of 2008 CLP Projects_ _____________ 34
Acknowledgements___________________ 44
Clinical Excellence Commission
PO Box 1614
Sydney NSW 2001
Tel: (02) 9382 7600
Fax: (02) 9382 7615
www.cec.health.nsw.gov.au
This work is copyright. It may be reproduced in whole
or part for study or training purposes subject to the
inclusion of an acknowledgement of the source.
It may not be reproduced for commercial usage or sale.
If you would like more information about the Clinical
Leadership Program or would like further details about
any of the projects please contact:
Reproduction for purposes other then those indicated
above require permission from the Clinical Excellence
Commission.
GPO Box 1614
Sydney NSW 2001
The CEC Clinical Leadership Program has no association
with the Royal College of Nursing, United Kingdom (RCN,
UK) Clinical Leadership Programme, represented in
Australia by the Royal Adelaide Hospital.
Ph: 02 9382 7600
Fax: 02 9382 7615
Email:[email protected]
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Clinical Leadership Program
I
The Clinical Excellence Commission
The Clinical Excellence Commission (CEC)
is committed to making healthcare in
NSW demonstrably better and safer for
patients and a more rewarding workplace
for healthcare workers. To achieve this will
require effective and supportive clinical
leadership at all levels of the system, where
those in positions of leadership have both the
skills and support to carry out their roles in a
compassionate, safe and effective manner.
The CEC Clinical Leadership Program was
initiated in 2006, and this booklet reports
on the continuation of the process with the
results of the 2008 program. The importance
of investing in clinical leadership programs
has been noted in recent reports, both the
statewide Garling report and the National
Health and Hospitals Reform Commission
report. Recognition of the link between
ACCOct09content2.indd 1
leadership, patient safety and governance
is also supported, where it is recognised
that patients and staff are at the heart of
healthcare.
I am pleased to commend this booklet to
wide use, in the hope that, in addition to
highlighting the benefits of the Clinical
Leadership Program to the NSW health
system, the projects detailed herein will
encourage others to apply the findings or
develop them further.
Professor Clifford Hughes AO
Clinical Professor
Chief Executive Officer
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I Clinical Excellence Commission
The continuation into 2008/09 of the
successful Clinical Leadership Program
(CLP), initiated in 2006, is marked again with
the publication of this booklet.
The aim of the program remains to build
a cohort of effective clinical leaders who
progressively become the ‘critical mass’
needed for patient-centred system change.
The Clinical Leadership Program is offered in
two different modes: statewide and modular.
The statewide program is a multidisciplinary
program, targeting clinicians at a middle
management level. It is delivered by local
area facilitators within an area health service.
The modular program targets senior clinician
managers, and is delivered as five intensive
modules in Sydney. Participants attend
modules which focus on the personal and
professional attributes of effective leaders.
Both programs require the completion of
a clinical service challenge which provides
the opportunity for participants to apply the
skills and learning they have gained from
the program. The challenge also enables
the strengthening of links between effective
governance, core leadership competencies, a
culture of safety and quality and continuous
improvement.
Clinical Practice Improvement (CPI)
methodology is a key learning area of the
program as it provides the model upon which
the clinical service challenge can be based.
This methodology requires the participants to
identify a problem in their clinical area which
directly impacts on patient care.
Publication of this booklet has a twofold
purpose. One is to present some of
the clinical projects, their methods and
outcomes; the other is to encourage the
sharing and application of the projects more
broadly throughout the health system.
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I
Overview of CPI methodology
Problem Identification
Aims statement
Project team
Ongoing monitoring
Outcomes
Future plans
Conceptual Flow of process
Customer Grid
Data
- Fishbone
- Pareto chart
- Run charts
- SPC charts
Annotated run
chart
SPC charts
Plan a change
Do it in a small test
Study its effects
Act on the results
There is a list of all projects undertaken by
the 2008 cohort of both the statewide and
modular CLP participants in this booklet. All
participants are to be congratulated on their
achievements; there was a broad scope of
issues addressed. The projects chosen for
inclusion in this booklet were selected due to
the quality of the participants’ submissions
to the CEC.
The CEC acknowledges the contribution
and cooperation of the participants,
their facilitators, managers, the Clinical
Governance and Clinical Redesign Units
within area health services, and the
considerable expertise provided by an
extensive external faculty of trainers. Our
thanks go to all for their involvement.
Ms Bernie Harrison
Director, Organisation Development & Education
If you would like more information about the Clinical Leadership Program or would like further details about
any of the projects please contact: Clinical Excellence Commission, GPO Box 1614, Sydney NSW 2001;
Ph: 02 9382 7600; Fax: 02 9382 7615; Email:[email protected]; ww.cec.health.nsw.gov.au
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The Modular program
Thirty senior clinician managers successfully
completed the Modular program in 2008.
A clinical service challenge was completed
by each participant as part of the program
and this has served to equip them as
advocates for patient safety along with
assisting them to integrate health system
improvement into their everyday clinical
practice.
The clinical service challenge areas
encompassed a broad array of topics,
ranging from improving clinical treatment
(in areas such as psoriasis, transfusion
medicine, pregnancy, delirium, alcohol
withdrawal) to system-wide enhancements
including clinical governance teams,
workforce flexibility, models of care, strategic
planning and Junior Medical Officer (JMO)
rotation periods.
Participants presented a summary of their
projects to fellow participants and CEC
representatives prior to graduation.
2008 Modular Clinical Leadership Program - Presentation Day, 8th November 2008.
Back row L-R: Greg Hugh (GWAHS), Frank Moloney (GWAHS), Michael Golding (SESIAHS), James Donnelly (SESIAHS),
Doug Andrews (NCAHS), Stuart Turner (HNEAHS), Pablo Fernandez-Penas (SWAHS).
Middle row L-R: Christine Packer (GSAHS), Liz Mullins (Program Facilitator), Katherine Brown (SESIAHS),
Wendy Cox (Director CGU SESIAHS), Leonie Watterson (NSCCAHS), Joanne Ging (NSCCAHS), Frances Monypenny
(NSCCAHS), Kathryn Carmo (CHW), Mark Cross (SSWAHS), Helen Gillespie (NSCCAHS), Kevin Quan (GWAHS).
Front row L-R: Wolfgang Weninger (SSWAHS), Michael Peregrina (NSCCAHS), Patricia Saccasan-Whelan (GSAHS),
Mark Dexter (SWAHS), Bernie Harrison (CEC), Bruce Barraclough (CEC Board), Teresa Pudo (CEC), Kay Wright (CEC).
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I
The Statewide program
Over 170 people successfully completed the
program in 2008.
The Statewide program is delivered at
an area health service level by local
facilitators. As a part of the program,
participants undertake a Clinical Practice
Improvement project and present this to
area management, sponsors and CEC
representatives at the end of the program.
The range of projects undertaken by the
2008 cohort represented a broad range
of topics, from specific clinical areas to
broader system and workforce development
initiatives.
A list of all projects undertaken by the
Statewide and Modular cohorts is provided
in the back section of this booklet, with
a selection of projects showcased in the
following pages.
Projects undertaken in the statewide CLP
involve working with a project team to
develop an improvement initiative at the
local level.
The Children’s Hospital Westmead, 2008
CLP participants and program leaders.
Front row: Colleen Leathley (CEC Statewide Coordinator),
Helen O’Grady CHW CLP Program Manager, Bernie
Harrison (CEC Director), Sonya Bubnij (CHW CLP
Facilitator). Middle Row: Sarah Clarke, Tracey Marshall,
Margaret Kelly, Chrissy Ceeley, Claire Blackburn, Gloria
Tzannes, Erin Sheehan. Back Row: Jan Hancock,
Amy Walker, Frank Horn (CHW Director of Workforce
Development / CLP Program Sponsor).
South Eastern Sydney Illawarra Area Health
Service - Southern Network, Statewide
2008 CLP participants (TRACS Project).
Left to Right: Sarah Foulstone, Susan Dileva, Rebekah
Reurich, Maren Jones, Coral Levett (CLP facilitator),
Helen Troy, Anthony Arnold, Anne Lees, Verica Marin,
Sue-Ellen Hogg.
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Getting on TRACS: Investigating issues affecting the
occupancy levels of the Illawarra Transitional Aged Care
Service (TRACS)
______________________________________ 7
Youth Mental Health – Getting It Right
_____________________________________ 10
Paediatric Pain Management: No Laughing Matter Nitrous Oxide (N2O) administration to Paediatric Patients
_____________________________________ 12
Improving client attendance rates at the Brain Injury
Clinic (BIC)
_____________________________________ 15
Selected
Project Summaries
Clinical Leadership
Program - 2008
One Step at a Time
- Improving access to podiatry services
_____________________________________ 16
Drying out with Dignity: medically supervised alcohol
withdrawal in the Shoalhaven, an Aboriginal Health
solution
_____________________________________ 19
Paediatric Ambulatory Care Service
_____________________________________ 21
Following Up: To call or not to call? Streamlining followup calls to parents and carers of children with asthma
_____________________________________ 24
Palliative Care Pathway for
End of Life Care
_____________________________________ 26
Tweed Valley Aged Care Assessment Team (ACAT)
Waiting Times Project
_____________________________________ 28
Nutrition Assistant in a Rural Health Service: optimising
nutrition
_____________________________________ 31
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Clinical Leadership Program - Project Summaries
Getting on TRACS: Investigating
issues affecting the occupancy
levels of the Illawarra
Transitional Aged Care Service
(TRACS)
Verica Marin RN TRACS, Anthony Arnold
Chief Radiation Therapist, Sue Ellen Hogg
Speech Pathologist, Susan Dileva Regional
Operations Manager, Sarah Foulstone Social
Work, Anne Lees CNC, Rebekah Reurich
Social Work, Helen Troy Physiotherapist,
Maren Jones Physiotherapist, Coral Levett
Facilitator
South Eastern Sydney Illawarra Area Health
Service (SESIAHS)
Problem/Background
In 2007 the Illawarra Transitional Aged Care
Service (TRACS) had a bed occupancy rate of
59%. This compared poorly with an average
of 79% occupancy across similar programs
throughout NSW. The Southern Hospital
Network (SHN) participants of the Clinical
Excellence Commission’s Clinical Leadership
Program selected TRACS as the team project
for 2008.
I
Problem identified
The TRACS program provides clients aged
65 and older with individually tailored therapy
in their own homes from six to twelve
weeks. Statistical data for 2007 showed
that TRACS operated at 59% utilisation that
year. This compared poorly with an average
of 79% usage across similar programs
throughout NSW (SESIAHS Transitional Care
KPI Occupancy data). Due to the low level
usage, no additional funded places were
provided for TRACS in 2008.
Investigation of the extent of the insufficient
utilisation problem was done through surveys
of clinical staff and referrers; discussions
with stakeholders; and a fishbone analysis
of issues identified by the project team. The
findings assisted the project team to direct
their strategies and make recommendations.
Valuable guidance and support was obtained
from the SHN executive and the Clinical
Practice Improvement unit. Issues identified
were prioritised by the project team using a
Pareto analysis.
Aim
The aim was to achieve and maintain a
100% usage rate of the community based
TRACS based in the Illawarra, within six
months.
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Changes made
The following table shows the problems identified in the areas of systems, communication and
process, with the solution implemented to redress the deficit in each case.
Systems Issues
1. Lack of program data available
Implemented Solutions
a. Reconfiguration of the Community Health
Information Management Enterprise (CHIME)
data system enabling access to relevant
statistical information
2. Lack of clear referral criteria
a. Clear referral criteria determined and
approved by key stakeholders
b. Referral criteria clearly documented with
a supporting flowchart.
Communications Issues
3. Confusion and lack of information
available to staff
Implemented Solutions
a. Education strategy developed
4. Information pamphlets were outdated
and not readily available
a. Existing pamphlet updated
5. Need to increase TRACS profile a. Inclusion in the SHN daily bed
management teleconference
b. Promotion of TRACS as a patient pathway
at case management meetings
6. Feedback mechanism issues following
the referral process
a. Standard template and system for
providing feedback to referrers developed
Process Issue
7. Intra-team and stream reporting issues
Implemented Solution
a. Scheduled meetings between
TRACS team leader and management
communicating program outcomes and
initiatives.
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I
Measurement / process measures
The outcomes of the project were immediate
and evident, with data confirming the
increased profile of the TRACS among staff
and stakeholders. The project culminated
in an occupancy rate of 94.5% for June–
November 2008. This represents a 35%
improvement from the previous 12-month
period, and is well above the state average
of 79%.
Furthermore, TRACS has recently been
offered additional funded places to expand
the service.
Through identifying causal and systemic
issues that had been impacting on the
TRACS program, improvements in access
to this service were obtained. These
resulted in improved primary health care
in the community and optimal utilisation of
resources.
• Dissemination of a quarterly report to
stakeholders
• Ongoing benchmarking of project
outcomes.
These strategies have been incorporated into
the TRACS current business plan.
Plans to sustain change
Strategies for sustaining the change
achieved through this project include:
• A four-tiered strategy for ongoing
education involving:
o Scheduled TRACS education sessions
o Provision of resource packs about TRACS
to referral hospitals
o Circulation of TRACS occupancy rates on
a daily basis
o Establishment of a TRACS intranet site
“You begin with the end in mind,
by knowing what you dream about
accomplishing, and then figure out how to
make it happen”
Jim Pitts, Northrop Grumman Corporation.
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10 I Clinical Excellence Commission
Youth Mental Health
– Getting It Right
Mr Adrian Cobbold Clinical Nurse Consultant
- Children & Young People’s Mental Health,
Central Coast Children and Young People’s
Mental Health (CC CYPMH)
Northern Sydney Central Coast Area Health
Service (NSCCAHS)
Problem/Background
In 2007 NSW Health allocated funding
to NSCCAHS to establish and evaluate a
prototype Youth Mental Health (YMH) model
on the Central Coast (CC). This model was
aimed at improving access to mental health
services for 12–24 year olds experiencing
moderate to severe mental health disorders
or problems, and extending the existing
services within CC CYPMH.
Given that this was a pilot project, the CC
YMH model was formally evaluated in order
to make recommendations to other area
health services for the reorientation of their
current service provisions in line with the
YMH approach. However, data collection
during the first six months of the CC pilot
indicated that referrals in the 18–24 year
age group remained relatively low (despite
high levels of referrals in the 12–17 year age
group) and the potential of the project was
not being fully reached.
Aim
The aim of the CC YMH pilot was to increase
the number of early intervention referrals
of young people (aged 18–24yrs) by 75%
(from the initial six month referral date) by
December 2008.
Problem identified
The mechanisms used to identify the
problem were as follows:
• A planning session with YMH staff
after six months of the initial CC YMH pilot
project being implemented. This supported
the previous evidence of low referral rates,
and staff were keen to contribute ideas for
increasing access to the services.
• Through evaluation questionnaires, users
and potential users of the service reported
dissatisfaction with and limitations to the
existing service model.
• Feedback from CC Adult Mental Health
services indicated that the existing model
was restricted and the referral criteria were
unclear and confusing.
Changes made
In February 2008 some of the recommended
changes from the planning session were
started within the CC YMH team. A decision
was made to focus more on an intensive
case management and assertive outreach
model. Despite this shift, the original criteria
remained unchanged.
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I 11
In June 2008 it remained apparent that there
were still low referrals rates (in the 18–24
year age group) and inappropriate referrals,
which led to the clinical improvement project
team meeting over June and July 2008 to
complete a Cause & Effect Diagram, Pareto
Chart and Intervention Action Plan.
Outcomes from this stage of the clinical
improvement process resulted in prioritising
the areas highlighted for change and setting
out actions required to address the identified
issues. Two of the main changes centred on:
• Conducting a major collaborative review
with internal and external key stakeholders
before amending the CC YMH inclusion
criteria and clearly defining the early
intervention focus
• Developing and implementing a
structured communication strategy aimed
at effectively promoting the service with
stakeholders.
Measurement/ process measures
Amendments to the CC YMH criteria
have resulted in the desired outcome
of substantially increasing the number
of suitable referrals into the project and
improving outcomes beyond expected
targets.
The quantitative data collected to
date provides evidence of sustained
improvements, showing:
Adrian Cobbold and Sue Leonard - Project ‘Youth
mental health - getting it right’
• A dramatic increase of over 150% in
the number of referrals of 18–24 year olds
accepted into the CC YMH model
• A significant downward slide of over
150% in inappropriate referrals
• Clients remaining engaged for longer,
with a 75% increase in the average episode
of care.
These findings were reinforced by the
qualitative evidence of positive change
including:
• Increased job satisfaction and retention
rates for CC YMH staff following clarification
to teams of the CC YMH model and the
staff’s roles and responsibilities, thus
assisting team cohesion and functioning
• Improved partnerships and awareness of
pathways through hospital departments and
other agencies, following the establishment
of clearer expectations and guidelines.
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In order to promote the CC YMH service
criteria and pathways, and sustain project
reporting key performance indicators, it
is recognised that regular and ongoing
in-service education to identified referral
sources is required.
Other required action has also been
identified and begun, to assist with the CC
YMH model progression, i.e. file audits to
determine typical client intervention profiles
and standardised client/carer satisfaction
surveys.
It is hoped that the formal evaluation of the
process used to develop an effective CC YMH
clinical model will be used to inform other
health services planning to engage this ‘at
risk’ population.
“Don’t let anyone tell you that you can’t
make a difference. If we all work on our little
parts of the planet we will change the world.”
Tara Church, Quin Emanuel Urquhart Oliver
& Hedges LLP
Paediatric Pain Management:
No Laughing Matter - Nitrous
Oxide (N2O) administration to
Paediatric Patients
Belinda Porter RN/CNE Emergency
Department, Port Macquarie Base Hospital
Emergency Department
North Coast Area Health Service (NCAHS)
Problem/Background
There are many misconceptions surrounding
the management of pain and anxiety
in paediatric patients which has led to
inadequate pain relief being delivered during
a diagnostic or therapeutic procedure.
Nitrous Oxide (N2O), is commonly used in
Emergency Departments (ED) as a safe
form of analgesia as it produces rapid, short
duration analgesia without complete loss of
consciousness in most cases (Harrop, 2007).
Various paediatric studies have been
conducted which conclude that the
performance of minor invasive procedures
using N2O leads to a less distressing
experience along with fewer adverse effects
and shorter recovery times than that for
those children who receive other parenteral
forms of sedation (Hsu, 2008).
Aim
The aim of this project was that within
two months, 100% of ‘eligible’ paediatric
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patients would receive non-parenteral
sedation (specifically N2O) during minor
laceration repair in Port Macquarie Base
Hospital (PMBH) ED in order to improve their
experience.
Problem identified
Retrospective data on paediatric patients,
who had required a minor invasive procedure
and presented to the ED in PMBH, was
collected for the month of March 2008.
Benchmarking with other EDs within NSW
showed that N2O is used regularly for
children presenting with similar injuries.
The data for PMBH showed that 0% of their
patients received N2O as a form of sedation
or analgesia. Therefore, a change in practice
was required.
A multi-disciplinary team was assembled
comprising: the ED nursing unit manager (the
project team leader or change agent); the
ED medical director; the ED nurse educator,
PMBH paediatric clinical nurse consultant
and two ED registered nurses who have a
paediatric background and an interest in
improving the care of paediatric patients. A
literature review revealed that administration
of N2O is a safe and effective method of pain
relief in paediatric patients.
Clinical Practice Improvement methodology
was used to identify the causes of non
administration of analgesia in paediatric
patients. The team also decided that the
most appropriate measure would be to
I 13
collect information about the administration
of N2O to appropriate clients.
The team constructed a flow diagram
of the process of pain management in
place for paediatric patients presenting to
the ED with conditions requiring a minor
invasive procedure. Next, the team held
a brainstorming session on issues arising
from paediatric pain management. From
this process, a cause and effect diagram
was constructed and it appeared that
there had been previous failed attempts
to implement the administration of N2O as
common practice. It was also noted that the
N2O delivery device was not available on a
permanent basis in the ED. This had led to
difficulties in accessing it when needed. As
a result, it was not used regularly and staff’s
knowledge of the use of N2O and the delivery
device had diminished.
Staff also thought, incorrectly, that patients
needed cardiac monitoring during the
administration procedure and this led to
the problem of these beds often being
inaccessible when needed. Therefore
N2O was not seen as a simple solution
to analgesia in the paediatric group of
ED patients, and was thus omitted from
paediatric pain management.
A Pareto chart was then constructed which
emphasised that two major changes needed
to occur in order to initiate a change and
introduce the use of N2O into common
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practice of managing paediatric pain. The
two changes identified were:
• education and accreditation in the
administration of N2O and the use of the
delivery device
• the permanent relocation of the N2O
delivery device to the ED.
It was also concluded that ongoing education
for nurses and doctors would help improve
the usage of N2O, and the purchase of a
N2O machine for the ED would increase the
likelihood of paediatric patients receiving
adequate pain management during a minor
laceration repair.
Changes made
In response to the findings of the project
team’s investigations, the following changes
were made:
• Negotiation with the Paediatric ward staff
occurred to ensure that the N2O machine is
located in the ED on a permanent basis for
improved access
• Information about the use of N2O was
posted around the ED. This included the
criteria for use in paediatric patients, and a
brief outline of the policy. A photo of the N2O
tubing and set up was also placed on the
delivery device
• Education sessions were provided to
doctors and nurses in August, one month
before the “go live” date of the project.
The planned actions to be taken to sustain
the change achieved by this project are:
• Purchase of a nitrous oxide machine for
the ED and the ECCC
• Ongoing education for nurses and doctors
• Usage of N2O in the ED to be included in
the orientation process for new staff.
Monitoring of the change in practice showed
that initiating education and implementing
the use of N2O into the management of
laceration repair in the Express Community
Care Centre (ECCC) would also be of major
benefit to the paediatric patients who attend
PMBH with a minor laceration.
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Improving client attendance
rates at the Brain Injury Clinic
(BIC)
Janice Hancock Brain Injury Service
Coordinator, Brain Injury Unit
The Children’s Hospital Westmead (CHW)
Problem/Background
Attendance at Brain Injury Clinic (BIC) is
essential for multiple reasons, including
monitoring of the client’s condition,
evaluation of the client’s progress, evaluation
of the family’s coping mechanisms,
identifying new issues, and ensuring optimal
care for the client. Non-attendance at BIC
can therefore jeopardise optimal care for
the client and the family. Brain Injury Service
(BIS) staff identified non-attendance at BIC
as an issue for further investigation. The rate
of non-attendance was 33% for the first
three months of 2008. Staff were concerned
that patients who need assessment and
intervention, and their families, were not
receiving adequate care.
In order to increase attendance rate at BIC
two main issues required review. These were:
• The process for making appointments,
including communication between clients
and their families and the BIS
• Clients’ and their families’ beliefs and
opinions about the importance of the clinic
and why they do or do not attend clinic.
I 15
Aim
The aim of the project was to increase
attendance of clients and families at
scheduled appointments at the BIC of The
Children’s Hospital at Westmead to 90% by
December 2008.
Problem identified
Surveys of families who attended clinic
and of those who failed to attend clinic
were conducted using a paper survey for
attendees and phone call enquiries for
non-attendees. The surveys were developed
in consultation with the Rehabilitation
Department Parent Advisory Committee.
The data collected enabled the project team
to identify issues related to non-attendance,
and identify strategies to increase attendance.
Rates of attendance were monitored using
existing outcome clinic reports.
Changes made
Strategies used to implement necessary
changes to redress the identified problems
included reviewing the content of the
current clinic letters and information sent to
parents and developing a plan for changes
to signage and maps directing clients and
visitors to the Rehabilitation Department.
In addition, to promote ongoing monitoring
of the use of the clinic, the procedures for
collecting demographic information during
outpatient appointments were modified.
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A positive change in attendance rates to BIC
was recorded with the rate of attendance at
the end of the project at 90.4% compared
with 67% at the beginning of the year.
Feedback from families surveyed, which was
primarily positive, was provided to staff of the
BIS and wider Rehabilitation Department.
The plan for sustaining the positive
increase in attendance at BIC includes the
implementation of procedures to:
• Regularly monitor the attendance rates
at BIC
• Continue to review the levels of
satisfaction of clients and families who
attend BIC. This will include surveying
attendees’ satisfaction with the service and
reviewing communication procedures for
arranging appointments.
This implementation will continue in
2009/2010 as part of reviewing the
Department’s family-centred practice.
One Step at a Time
David Cooper Podiatrist,
Hastings / Macleay Podiatry services
North Coast Area Health Service (NCAHS)
Problem/Background
Clients with foot ulcers or infections were
waiting up to four weeks to receive what
should have been urgent podiatry treatment.
The improved ‘Podiatry Practice Guidelines’
state that treatment for such conditions
should be initiated within two working days
from referral.
This problem is an issue for:
• All professions involved in the treatment
of these clients
• The clients themselves, who are at risk of
developing chronic conditions
• The Health Department, due to the
financial management implications of chronic
health conditions.
Aim
The aim of the project was that within 4
months, 80% of podiatry clients referred
with a foot ulcer or infection would be able to
access Hastings / Macleay Podiatry services
within two working days from referral.
Problem identified
The investigation and analysis stages of the
project involved a multi-disciplinary team
in conjunction with Podiatry services which
19/10/2009 1:44:54 PM
I 17
included Community Nursing, Wound Clinic
and administration staff.
Waiting times of very high risk clients and
patients with ulcers were measured and
compared to the benchmarks set out in the
‘Better practice guidelines for managing
appointments in podiatry services’. Analysis
showed that only 17% of clients with an
active ulcer or infection, and only 9% of very
high risk clients, were being seen within
benchmark waiting times.
The main factors identified as causing the
access block were (in order):
• Administration procedures not being
clearly defined
• Podiatry staffing levels
• No podiatry intake forms
• Limited podiatry clinical hours
• Poor appointment book management.
As improving podiatry staffing levels was
deemed to be outside the scope of this
project, the first focus was to measure the
number of work hours allocated to direct
clinical contact. The number was determined
to be the maximum that could be achieved
without:
• An increase in podiatry staffing levels
• Ceasing outreach clinical services to
allow travelling time to be reallocated to
extended clinical hours at major centres
• Ceasing other vital clinical services
such as community education sessions and
orthotic therapies.
Given this, the other aspects of the problem
regarding administration and bookings
became the issues for redress in attempting
to fulfil the project aim.
Changes made
An intervention plan was implemented
that involved three components of process
alteration to redress issues identified in the
problem analysis.
The first was a review of administration
procedures comprising:
• Consultation with administration staff to
identify the specific current problems
• Involvement of administration staff in the
development of new intake procedures
• Implementation of a flow chart for
19/10/2009 1:44:56 PM
administration staff to follow to assess the
urgency of referrals
• Individual training of administration staff
in the new procedures.
The second was in relation to the lack of
intake forms, wherein two steps were taken:
• A review of other services’ intake forms
was conducted
• Consultation was undertaken with
administration staff in the development of an
appropriate intake form for podiatry services
at Hastings / Macleay.
The third process undergoing alteration was
the appointment book management. The
review here identified:
• An increase in the number of urgent
appointments available on each clinical day
• Longer waiting times for assessment of
low risk diabetic clients
• The establishment of a waiting list for
all assessments not deemed an “Active
Problem”, a “Very High Risk” or a “Low Risk”
or “Diabetic”.
The new procedures resulting from these
reviews were instrumental in achieving an
increase in Active Problem clients seen by
the Podiatry service within benchmarks from
17% to 47%. This increase was obtained
even with an increase of 250% in the
number of referrals. The average length of
waiting time fell from 8.7 to 3.3 working
days.
There was an increase in Very High Risk
clients seen by the Podiatry service within
benchmarks from 9% to 62.5%. The average
length of waiting time fell from 46.2 to 12.4
days.
The greatly decreased length of delay in
receiving treatment from referral means
that clients that are requiring urgent care
are receiving this on more occasions than
not. This results in quicker healing times,
with less development of chronic conditions,
both of which are of cost benefit to the
Health Service. Clients are receiving a better
standard of health care with higher levels of
client satisfaction.
The improvements made continue to be
maintained through:
• The development of clearly defined intake
procedure flow charts and intake forms
• Training of all new and casual
administration staff in the intake procedures
• Continual education of staff in the major
referral sources.
In addition, the podiatry service’s waiting
times are continually monitored with incident
reporting measures taken when breaches of
benchmarks occur.
19/10/2009 1:44:56 PM
I 19
Drying out with Dignity:
medically supervised alcohol
withdrawal in the Shoalhaven,
an Aboriginal Health solution
Clinical Associate Professor Katherine
Brown Clinical Stream Director, Population
Health & Primary Care
South Eastern Sydney Illawarra Health
Service (SESIAHS)
Problem/Background
Aboriginal people with co-morbidities in
Shoalhaven need to access a medical
withdrawal service locally. Health
professionals and advocates for Aboriginal
health considered that a new facility was
needed for this purpose.
Australian data indicates that:
• Alcoholism is 11 times higher in
Aboriginal people
• 45% of Aboriginal people who drink do
so at risky levels compared with 12% of the
general population
• Aboriginal male drinkers are five times
more likely to die and nine times more likely
to be hospitalised than non-Aboriginal male
drinkers
• Aboriginal female drinkers are four times
more likely to die and 13 times more likely to
be hospitalised than non-Aboriginal female
drinkers.
A/Prof Katherine Brown and Prof Bruce Barraclough,
CEC Board Chairman at the CLP Modular presentation,
November 2008.
Aim
The aim of the project is that SESIAHS
Southern Hospital network will provide a
functioning sustainable system for medically
supervised withdrawal from alcohol for
clients with co-morbidities.
Problem Identified
Aboriginal people comprise 3.8% of
Shoalhaven’s population. Shoalhaven has
the highest death rate in SESIAHS. Aboriginal
deaths are 1.6 times higher than the
SESIAHS average, with avoidable deaths
being 2.4 times higher. Alcohol causes 13%
of drug related deaths.
There were 149 Aboriginal people admitted
to Shoalhaven District Memorial Hospital
for alcohol related problems in 2007. 84
admissions related to mental & behavioural
disorders associated with alcohol, while 27
related to withdrawal from alcohol.
19/10/2009 1:44:56 PM
There were 67 presentations to Shoalhaven
Hospital by Aboriginal clients needing
alcohol withdrawal treatment. Co-morbidities
included cardiovascular, respiratory and renal
diseases.
Many Aboriginal people prefer to receive care
close to land and family. Access to skilled
medical staff who can provide hospital-based
care is problematic, and separate access to
a community facility is required for clients
with social rather than medical problems.
Aboriginal service providers and community
members had identified the problem
and sought assistance in meeting their
communities’ needs.
Changes made
In the absence of a specialist in Addiction
Medicine, the Clinical Stream Director for
Population Health and Primary Health Care
suggested appointment of a lead clinician
to take responsibility for medical withdrawal
from alcohol for patients with co-morbidities.
The local infectious disease physician
was approached, as he already treated
marginalised populations for hepatitis C.
Protocols for medical withdrawal from
alcohol were obtained from Langton Centre
in Sydney. All patients requiring admission for
medically supervised withdrawal from alcohol
are assessed by the Shoalhaven Drug and
Alcohol team. Admissions are planned and
discussed with the admitting medical team.
Clients needing social support in addition to
treatment are not admitted to prevent such
social support requirements becoming the
focus for hospital staff. Clinical backup is
provided from the Langton Centre’s Addiction
Medicine physicians. Local support during
the admission is provided by a CNS in
Addiction Medicine. Outpatient follow-up is
provided by the Drug and Alcohol service on
discharge.
Measurement/process measures
Establishment of the program has resulted
in improvements in the local management
of alcohol withdrawal clients, measured in
terms of the reported progress from the
various service representatives involved.
The lead clinician reports the following:
• elective admission means the
detoxification process is smoother for the
client
• unnecessary admissions have been
avoided
• clients have benefited from involvement
of the Drug and Alcohol service throughout
the process
• other physicians are now willing to
undertake these admissions if the lead
clinician is unavailable.
Aboriginal Health services report that:
• the lead clinician is very supportive
• planned intake has increased acceptance
from staff and clients
19/10/2009 1:44:57 PM
I 21
• withdrawal is now seen as a health issue,
not a nuisance.
Southern Network Drug and Alcohol Service
reports that this process has improved their
relationship with Shoalhaven Hospital.
The implemented change is planned to be
sustained through:
• Maintenance of intensive support from
the local Drug and Alcohol services
• Maintenance of links with the specialist
Addiction Medicine service in Sydney until
local specialist support is available south of
Sydney.
Dr. Joanne Ging - Paediatrician / Nicole Page- Clinical Nurse Specialist / Debbie Skinner- NUM Paediatric
Ward / Dr. Anna Gill- Paedaitrician / Michael PeregrinaDivisional Manager
Paediatric Ambulatory Care
Service
Mr Michael Peregrina Divisional Manager &
Dr. Joanne Ging Clinical Director,
Division of Women’s & Children’s & Family
Health, Hornsby Ku-ring-gai Health Service
North Sydney Central Coast Area Health
Service (NSCCAHS)
Problem/Background
The capacity of the paediatric inpatient unit
at Hornsby Ku-ring-gai Health Service (HKHS)
was reduced from 18 beds to 12 beds with
the opening of the new ward in November
2006.
This created potential for access block, long
waits in the Emergency Department (ED)
and reduced capacity for elective surgery.
19/10/2009 1:44:57 PM
Furthermore,
• Paediatric ED presentations have
increased since 2005 (4965) to 2007 (6978)
by 28%
• Paediatric separations increased by 23%
in the same period
• Paediatric patients who did not wait
increased by 24%
• With reduction of inpatient beds from
2005 to 2007, access block of paediatric
beds has increased from 2.8% to 6.7%.
Aim
The aim of the project was to reduce access
block in the Paediatric Ward within 18
months to ensure that all children and their
families are able to access and be supported
by a model of care that is appropriate to their
needs using existing resources.
Problem identified
With a 10% increase in paediatric
presentations to ED and the reduction of bed
numbers at Hornsby Ku-ring-gai Hospital
(HKH) Paediatric Ward, a potential for access
block was identified, particularly during the
winter peak. A small working party was
formed to develop strategies to minimise
access block during winter. In order to use
existing resources to develop new paediatric
models of care a project team was formed,
and using CPI methodology, a cause and
effect diagram and a Pareto chart were
developed.
Two possible interventions were identified.
These were: (a) introduction of a Paediatric
Ambulatory Care Service and (b) changing
the theatre admission times for surgical
patients. It was determined that the first of
these would be the target for this project.
Changes made
The HKH PACS opened in July 2007. PACS
was implemented at neutral cost. The model
of care currently incorporates:
• daily acute review clinics
• telephone support.
Planning for service implementation
included:
• Development of a “dashboard” to capture
the service-related data
• Consultation with Wyong Hospital PACS
staff prior to implementation at HKHS.
Ideas were shared between Wyong PACS
and HKHS wherever possible and the units
worked together to develop shared forms,
guidelines, referral criteria and policies.
The HKHS PACS clinic is run by a
paediatrician and a registered nurse five
days per week. Children are referred to the
service by the ED, GPs, paediatricians and
the children’s hospitals. Children who are
on the borderline for admission, especially
overnight, can have treatment started
including intravenous antibiotics which can
be continued at home and reviewed the next
day. Children can also be discharged earlier
from the ward with treatment completed as
outpatients.
19/10/2009 1:44:57 PM
In the 10 months since HKHS PACS
commenced operation there has been:
• 1890 non-admitted patient occasions of
service (phone calls and clinic visits)
• Parent satisfaction surveys conducted
showing very positive results with high levels
of praise and satisfaction with the care given,
i.e.,
• 100% of parents reported that PACS
met their child’s needs
• Parents commented that follow up
phone calls were good as it gave them an
opportunity to ask questions
• Reports received stated that staff
were friendly, calm, efficient
• 100% of respondents reported they
would recommend this service
• Simplifications of the clinic, allowing
quick and easy access to a personalised service
• Coordination of services
• At least two bed days saved per day
• Thursday access block improvements.
I 23
There is ongoing collaboration between
Wyong and HKHS in the development of
services. This collaborative approach in
developing standard forms, guidelines and
procedures shows potential for collaboration
and support for similar service development
on a wider scale across NSW. Consideration
should be given to developing PACS (short
stay units, outreach care and telephone
support) to complement traditional inpatient
models of care.
This project, together with PACS (Wyong
Hospital), was a finalist in NSW 2008
Quality Health Awards for the “Create better
experiences for people using health services”
category.
The HKHS PACS was established and is
operating within existing resources and
demonstrates a cost-effective, sustainable
model of care.
19/10/2009 1:44:58 PM
Following Up: To call or not to
call? Streamlining follow-up
calls to parents and carers of
children with asthma
Tracey Marshall CNC Asthma Education
Respiratory Function Unit
The Children’s Hospital Westmead (CHW)
Problem/Background
The Asthma Education Service (AES) provides
a Monday to Friday Service from 7.30am to
5pm and is primarily responsible for followup calls regarding children with a diagnosis
of asthma. The purpose of the follow-up
call is to ensure that the families of children
who are discharged outside business hours
receive an offer of educational support.
Aim
The aim of the project was to develop the
criteria for which children’s families should
receive a follow-up phone call in regards
to asthma education and management
issues. The follow-up calls are for children
whose asthma management is complex or
where asthma education issues have been
identified.
Problem identified
In past years the AES has provided follow-up
phone calls for children with asthma who
have been discharged outside business
hours. The follow-up call is based on clinical
judgment, but in order to ensure safety,
quality and equality the aim of the project
was to establish the set criteria for making
follow-up calls. In order to achieve this,
a multi-disciplinary team approach was
adopted to develop the criteria that would
guide the process of performing follow-up
calls.
Changes made
There were two main changes adopted as a
result of this project:
• the development of AES criteria for
follow-up calls
• the development of a new template to
provide consistency in the type of questions
that parents are asked in follow-up calls.
The ‘discharge asthma patient’s follow-up’
template was developed and implemented.
All calls are now documented in a software
system using Powerchart which allows other
health professionals to document follow-up
calls for this group of children.
Key stakeholders were engaged using a
variety of strategies such as team meetings,
progress reports and updates on the
dedicated CHW Asthma webpage.
Changes were implemented over a six month
period.
The utility and efficacy of follow-up calls was
evaluated by a parent survey in June 2009.
19/10/2009 1:44:58 PM
For May to July 2007, the AES performed
99 follow-up calls. The results from May to
July 2008 showed there were 71 follow-up
calls during this time. Eight children did
not meet the draft criteria, mainly due to a
diagnosis of wheeze, and one return call was
made to a parent from a past admission. The
follow-up calls were made within 72 hours of
discharge of the patient.
In addition, due to the revised procedure,
all follow-up calls were documented. 69
of the calls were documented either in the
phone consult or in the ‘Discharged asthma
patients’ follow-up’ template.
The remaining two of the total 71 calls were
only documented in the patient diary. This
was because no Medical Record Number
was available at the time of the call.
The length of calls ranged from five to 30
minutes.
The Clinical Indicator Comparative Report
(CHW) for 2002 to 2008, in September 2008
showed that:
• The re-admission rate for children with
asthma from January to June 2008 is down
to 2.1% as compared with the rate for the
same period in 2007 of 5.8%
• The development of the criteria for followup calls resulted in no harm or increase in
re-admissions even though fewer follow-up
I 25
Tracey Marshall, CNC Asthma Education
Respiratory Function Unit
calls were made from mid-May to mid-July
as compared with the same period in 2007.
The CHW is investigating implementing the
criteria in other paediatric services such as
the Asthma Education Service at Sydney
Children’s Hospital. The “follow-up phone
criteria” will form the basis for development
of inpatient consultation criteria.
” Leaders are people who model
good practice, challenge poor practice
and inspire others.”
Health Foundation
19/10/2009 1:44:58 PM
Palliative Care Pathway for
End of Life Care
Caroline Short CNC Palliative Care,
Cessnock Community Health
Hunter New England Area Health Service
(HNEAHS)
Problem/Background
Care for the dying is important and, from
the palliative care perspective in particular,
how that care is delivered is a measure
of the success, not failure of health care
professionals.
According to Costello (2001), a culture of
death avoidance has led to care that is
often unplanned, sub-standard, and which
excludes patients, carers and families from
end of life discussions and decision-making.
This occurs despite the public’s reliance
on health professionals to care at this most
significant time in patients’ and carers’ lives.
This may have far reaching consequences
for health teams, as well as families and
society generally (Ellershaw & Ward 2003).
Evidence suggests that this problem is
extensive throughout hospitals in the
developed world (Costello 2006; Gomes
& Higginson 2006). These problems are
attributed to reliance on medical models of
care amid the complexity of a death-denying
society.
Aim
The aim of this project was to improve end
of life care for dying people by increasing the
ability of hospital nurses to diagnose dying in
80% of expected deaths in the last few days
of life. The timeline for meeting the project
aim was within three months.
Problem identified
Inability to recognise the signs of imminent
death in palliative care patients resulted
in formal and informal complaints from
relatives. This problem was also identified
through anecdotal evidence and requests
for further education from hospital nurses,
and through bereavement visit feedback
from carers. In 2002, a Palliative Care ‘carer
satisfaction survey’ also demonstrated that
there was an opportunity for improvement.
A pre-project file audit was conducted in
Cessnock District Hospital to establish the
extent of the problem using the Liverpool
Care Pathway (LCP). This tool recognises the
challenges of the prevailing ‘death-denying
attitudes’ and promotes excellence in end of
life care in any setting.
Changes made
The project implemented an end of life
pathway and associated education and
procedures suited to the lower Hunter
environment. This strategy had the potential
to increase nurses’ abilities to diagnose
dying and enable the implementation of
improved end of life care for dying people.
19/10/2009 1:44:59 PM
I 27
Evaluation of the end of life pathway project
clearly showed that the end of life care
for dying people had improved. This was
demonstrated by an increase in the ability of
hospital nurses to diagnose dying in 85% of
expected deaths in the last few days of life,
up from 45% in the pre-project audit.
End of life pathway commencement is
dependent on recognising the determinants
that are indicative of terminal status. The
greatest improvement was in the ability
to recognise patients’ inability to swallow
tablets.
Community and hospital nurses working together to
improve end of life care. NSW Rural Nurse Workshop
March 2009. Trish Ling; Caroline Short; Michelle Wiehe;
Anne Scott; Louise Ball; Emma Wesseling; Debborah
Olsen; Kate Stuart.
The following results were also achieved:
• A 30% improvement in cessation of
inappropriate interventions
• Improved referral to palliative care
services for people with chronic disease
• Improved documentary evidence of good
practice and symptom control, e.g., a 20%
improvement in pain management and
appropriate use of analgesia and a 15%
reduction in nausea and vomiting through
improved anticipatory use of antiemetic
• Nursing staff utilised the end of life
pathway to address the ‘plan of care of
the dying’ with carers and families. They
were able to reassure relatives of the best
practice, evidence-based care contained in
the pathway.
• Nursing staff developed skills in an area
where they were previously anxious
• The end of life pathway prompted staff to
provide grief brochures and to discuss the
grieving process. This has initiated further
requests for education and skill development
in the area of grief and bereavement, to
assist in ‘normalising’ the process.
Following the success of the pilot project
at Cessnock district hospital, the end of
life pathway project has been extended to
Singleton and Kurri Kurri hospitals within the
lower Hunter cluster.
The palliative care team continues to
provide ongoing support and developmental
education to the hospital resource nurses
and other nurses. Auditing and variance
analysis has continued.
19/10/2009 1:44:59 PM
The project materials have been developed
so that they can be used in other facilities of
the HNEAHS.
Ongoing evaluation and variance analysis
is occurring in conjunction with the UK‘s
Liverpool Care Pathway Collaborative, and
this will allow for international benchmarking.
Tweed Valley Aged Care
Assessment Team (ACAT)
Waiting Times Project
Siobhan Laffey Integrated Care Coordinator,
Tweed Valley Aged Care Assessment Team
North Coast Health Service (NCAHS
Problem/Background
The Aged Care Assessment Program Operational Guidelines from the Commonwealth
Department of Health and Aging recommend
that: Category 3 clients (in the community)
are to be assessed within 3 months of referral to the Aged Care Assessment Team.
data indicated 66.3% of Category 3 clients
in the community setting were assessed
according to these guidelines.
“Leadership is ultimately about
creating a way for people to contribute to
making something extraordinary happen.”
Alan Keith, Genetech
Prior to undertaking the project, the
prioritising of ACAT clients was conducted
by the clinical team members rostered onto
the daily intake roster. Anecdotally, when
a person contacted the administration
officers at ACAT they were ready to give
all the information required for referral for
service. This information was held by the
administration staff pending the availability
of a clinician to progress the intake and
allocate a suitable category. In some
instances it could take several weeks for the
clinician to make contact with the client for
categorisation to occur.
19/10/2009 1:44:59 PM
I 29
From the initial contact with the ACAT the
client data was recorded on the minimum
data set (MDS) indicating they had been
referred to the service and were awaiting
assessment. This data reflected a lengthy
timeframe between initial contact with
the service and subsequent conduct of
assessment.
Aim
The aim of the project was to reduce the
average waiting time for assessment by
(ACAT) by 30% for community based clients,
within six months.
Problem identified
Utilising the principles of Clinical Practice
Improvement, the team set about identifying
the components that influence an efficient
prioritisation of an ACAT Client. The Pareto
chart identified the two key areas for
improvement, i.e. the referral tool for ACAT
assessment and the intake process.
To check the accuracy of the waiting list
at the starting point of the project, 120 of
the 183 existing referrals were contacted
for updates on their requests and need
for assessment. As a result, 52 referrals
withdrew, leaving 132 referrals remaining.
A workload tool was provided by an external
consultant and used to equitably distribute
the referrals among the team members.
Siobhan Laffey, Integrated Care Coordinator,
Changes made
The senior administration officer role was
redesigned to undertake the position of
intake officer. This created one point of
contact for all referrals to ACAT.
Daily clinical supervision by the CNC and
clinical staff was available to the intake
officer to provide support on complex
referrals.
Allocation of clients/referrals was changed to
fortnightly instead of weekly.
The addition of opportunistic delegation as
needed, and a weekly case conference for
complex matters requiring multi-disciplinary
team input, resulted in an increase in the
delegation of assessments from once a week
to three times a week.
Prioritisation of the clients now occurs on
first point of contact with the service.
19/10/2009 1:45:00 PM
The data collected at the completion of the
six months from July to September 2008,
and reported by the NSW Evaluation Unit,
demonstrated an improvement of 23% in
time to assessment for Category 3 clients
in the community, however the increase in
referrals affected the full achievement of the
mission statement. The rate of assessment
of Category 3 community clients within the
targeted three month timeframe improved
from 66.3% of all referrals in the period
January to March, to 89.2% in the period
July to September 2008.
Further exploration of the data demonstrated
that the average number of assessments
conducted per full time equivalent (FTE) over
the duration of the project increased from 12
to 24. This represents 100% improvement
in the number of assessments conducted
for community clients within the Category 3
Guidelines.
within the Commonwealth Guidelines’
timeframe. This demonstrates a continued
improvement in the initial project outcome
and the achievement of the original project
aim.
The improvement on waiting times has been
sustained through the following:
• Monthly waiting list reports to
management to assist with informed
decisions regarding service needs
• NSW Evaluation Unit quarterly reports
• Weekly team meetings to review
workload allocation
• Education of GPs and residential
aged care facilities’ staff regarding the
requirements for referral to ACAT
• Continuation of the PDSA cycles to
improve other areas affecting waitlist
efficiency.
The redesigned intake system and intake
tool resulted in an improved data collection
method which will more accurately reflect
the correct prioritisation of clients. The
waiting times from referral to first clinical
intervention will result in greater satisfaction
to community clients.
Data from the most recent quarterly report
(March 2009) indicates 98.7% of Category
3 clients in the community setting are seen
19/10/2009 1:45:00 PM
Nutrition Assistant in a Rural
Health Service: optimising
nutrition
Ms Elizabeth Scott Dietetics Adviser,
Orange Base Hospital
Greater Western Area Health Services
(GWAHS)
Problem/Background
Patient malnutrition is a significant health
issue and results in poor health outcomes,
while impacting significantly on costs (by a
factor of approximately two).
According to the literature, patients with
malnutrition will stay in hospital significantly
longer. Also, all patients’ nutritional status
declines with Length of Stay (LOS).
Malnutrition screening was introduced at
Orange Base Hospital (OBH) in 2002 but
due to the limited resources, intervention
for all patients, including those who were
malnourished, was also limited. Also, no
systematic intervention existed for patients
with Fractured Neck of Femur (#NOF), a
group known to have significantly improved
medical outcomes with early nutrition
intervention.
Aim
The aim of this project was to evaluate
the effectiveness of enhanced nutrition
intervention for patients with #NOF and
I 31
patients identified at risk of malnutrition,
using a nutrition assistant.
Problem identified
A project conducted in GWAHS in 2002
showed that the prevalence of malnutrition in
health facilities was 29%, a level consistent
with other Australian hospitals.
After introducing malnutrition screening,
a significantly increased workload was
experienced within the dietetics department.
Inpatient occasions of service more than
doubled in 2004–2007 within existing
resources. Anecdotally it was observed
that three to five patients with #NOF were
admitted weekly to OBH with no systematic
nutritional intervention possible. It was
projected that increased LOS and increased
costs would result if this problem was not
addressed.
Changes made
A proposal regarding the identified issues
was written and it was agreed to trial
one full time equivalent (FTE) position of
nutrition assistant. This position was trained
and supervised by dietitians and focused
on nutrition intervention for target patient
groups.
The nutrition assistant supervised and
monitored patients’ intake according to
protocol developed by the dietitians. This
involved:
19/10/2009 1:45:00 PM
• Provision of a high protein/high energy
diet together with routine nutritional
supplements (charted on the patient’s
medication chart)
• Education of the patient regarding good
nutrition and its role in recovery; and timely
discharge
• Monitoring and coaching of intake,
together with dietary adjustments
• Continuous liaison between the nutrition
assistant and dietitian.
The nutrition assistant telephoned these
patients at one week, one month and two
months post discharge for ongoing support.
Information was gathered at the beginning of
the project and after implementation of the
enhanced nutrition intervention for the target
groups.
The following data was collected:
• Age & gender
• Occasions of service for nutrition
intervention
• 3 day protein and energy intakes
• Length of stay
• Re-admissions within two months
• Living situation two months after
discharge
• Patient satisfaction with food service
• Patient satisfaction with clinical nutrition
services
The age and gender demographics for the
initial group (n=28, 76.9±9.3 years, 50%
male) and the group who experienced the
intervention (n=24, 74.6±14.4 years, 29%
male) were not significantly different.
Nutrition interventions increased from 2.6
(range 0-11) in the baseline group to 5.3
(range 2-11) in the intervention group. As
a result of enhanced nutrition intervention,
nutritional intakes significantly increased,
that is protein levels went from 43% to 95%
of requirements and kilojoules went from
40% to 86% of requirements.
Improved nutritional intake provided real
life impacts with improvements in patient
outcomes.
Median LOS reduced from 26 (range 4-98)
days before the intervention to 17.5 (5-66)
days after implementation (Mann-Whitney
U test, p=0.125). Although this does not
demonstrate a reduction of statistical
significance, clinically significant outcomes
were achieved in terms of patient care
Re-admissions to OBH within two months
were reduced by 40%.
The project showed that at two months after
discharge, the number of those patients
returning home increased from 25%, in the
baseline group to 58.8% in the group with
improved nutrition.
19/10/2009 1:45:00 PM
I 33
Patient satisfaction increased in regard to
both clinical nutrition services and food
services.
These results help address concerns and
recommendations raised in the Garling
Report regarding malnourished patients.
Enhanced nutrition intervention for these
patients helped GWAHS achieve the
following identified NSW Health “dashboard
indicators”:
• Reduction in bed days for patients over
75 years
• Reduction in avoidable admissions for
selected Diagnostic Related Groups.
Due to the demonstrated outcomes of the
project, sustainable access funding was
gained. This enabled inclusion of one FTE
nutrition assistant position in the Orange
Dietetics Department. The improved nutrition
support will provide the opportunity for
improved patient outcomes and efficiencies
of service for the hospital.
What the 2008 participants said about the program
“The program has taught me to treat
leadership as a skill set that can be developed
and improved rather than innate ability.”
“The program has given me a set of tools I
can use. I am now planning a major service
change and am mapping out my strategy,
engaging stakeholders and setting timelines
far more effectively than I would have a
year ago.”
“I would encourage anyone interested in
doing the program to participate if they
are looking to improve their interpersonal
and leadership skills, inspire and motivate
themselves and their team.”
Some other words from participants:
Excellent, challenging, intriguing
Innovative, hard work, life changing
Professional, inclusive and inspiring
19/10/2009 1:45:00 PM
CLP Project List
2008
The Children’s Hospital at Westmead
_____________________________________ 35
Greater Southern Area Health Service
_____________________________________ 35
Greater Western Area Health Service
_____________________________________ 36
Hunter New England Area Health Service
_____________________________________ 37
Justice Health
_____________________________________ 38
North Coast Area Health Service
_____________________________________ 39
Northern Sydney Central Coast Area Health Service
_____________________________________ 40
South Eastern Sydney Illawarra Area Health Service
_____________________________________ 41
Sydney South West Area Health Service
_____________________________________ 42
Sydney West Area Health Service
_____________________________________ 43
19/10/2009 1:45:00 PM
Clinical Leadership Program - List of Projects
The Children’s Hospital
at Westmead
Greater Southern Area Health
Service
Statewide CLP
Out of hours management of burn patients
presenting to CHW
Statewide CLP
Transitional Aged Care Service multidisciplinary care
Sarah Clarke
Catherine Barkley
Improving client attendance rates at Brain
Injury Clinic*
Monitoring of physiotherapy service
provision in the Eurobodalla
Jan Hancock
Tracey Bates
Fighting fits with fats
Reduce length of stay for joint
replacements
Tracy Harris
I 35
Catherine Blacker
Following Up - to call or not to call?
Streamlining follow-up calls to parents &
carers of children with asthma*
Falling in and out of Hospital
Fay Fox
Tracey Marshall
Aseptic Non Touch Technique (ANTT) and
Central Venous Access Devices (CVADs)
Integrated Community Health progress
notes
Skye Gray
Erin Sheehan
Mandatory Risk Assessments
Investigating readmission rates to CHW
of children with recurrent respiratory
illness due to dysphagia, and the level of
engagement of Speech Pathology in the
management of these children
Julie Henderson
ACE- Acute Care of Elderly, Bateman’s Bay
Hospital
Elizabeth Huppatz & Gaynor Jamieson
Gloria Tzannes
Modular CLP
Sharing the turf: introducing a point of care
ultrasound in the newborn intensive care
unit
Kathryn Carmo
WWBH Paediatric Clinical Pathways
Working Group
Lesley Jeffries
* see project summary
19/10/2009 1:45:00 PM
Access to Pathology Service
Karen Keith
Orthopaedic Occupational Therapy
Services
Linda McCormack
Keeping our eye on the goal: managing
goals with families
Jane Murtagh
Outreach and how do we do it better
Robert Parker
Management and prioritisation of
Occupational Therapy community caseload
and waiting list
Greater Western Area Health
Service
Statewide CLP
Spirometry Testing within CAPACS and
ambulatory care for clients with COPD
Nicole Baines
The Patient Safety Culture Survey…
emerging approaches in safety analysis
Carolyn Coleman
Point of Care Troponin Testing
Vicki Conyers Paediatric Medications
Karyn Fahy
Lisa Reade
Management of inpatient hyperglycaemia
Documentation / Care Plans for Agency /
Casual Staff
Debbie Scadden
Liz Greaves
Improving referral feedback mechanisms
within Community Health
Transfer of Patients from Base Hospital
to District Hospitals and Multi-Purpose
Services (MPS)
Karen Solah
Christine Hayes
Modular CLP
Development of an oncology shared care
model
Adolescent Vaccine Program
Kerry Inder
Christine Packer
Falls @ Blayney
Mental Health Medical Assessment Guide
For Emergency Departments
Jackie Kelly
Patricia Saccasan Whelan
‘Stopping the Leak’
Louise Linke
19/10/2009 1:45:01 PM
Effectiveness of occupational therapy
group work on symptom reduction in acute
inpatient psychiatric setting
I 37
Leadership Our Responsibility?
Our Legacy?
Deb Wilden
Claire Lynch
Acute Hospital Inpatient Admissions for
clients of the remote Sector’s Lower
Western Mental Health and Drug and
alcohol service
Derek Moore
Modular CLP
Root Cause Analysis in Mental Health:
Is it useful?
Greg Hugh
Anaesthetics pre-consent information
Frank Moloney
Redesign the storage areas to include a
separate triage area at Gilgandra MPS
Rural Critical Care Advisory Service (CCAS)
Jo Peterson
Kevan Quan
The GLUCOSE Solution
Kerry Porter
Forbes Health Service Orientation Manual
Patricia Rousell
Nutrition Assistant in a Rural Health
Service: optimising nutrition*
Elizabeth Scott
Positive outcome therapy for the aged
Caroline Squires
Circle of Care Project
Max Stonestreet
Pain relief post Caesar
Hunter New England Area
Health Service
Statewide CLP
Improving team communication through
regular team meetings
Jane Bourke
Maternity unit escalation plan
Sally Cameron
Accreditation and implementation of the
HNEAHS Advanced Life support program
– a leadership project
Karen Chronister Renee Walker
Men’s Health
Andrew Whale
19/10/2009 1:45:01 PM
Supporting clinical mentors and trainee
Paramedics
Improve service communication to improve
consumer outcomes
Peter Elliott Gail Stevens
Correct position of drug additive labels
on opioid syringes for patient controlled
analgesia and continuous infusions
Mental Health rehabilitation project
Gabrielle Williams
Forensic Medicine Services
Modular CLP
Developing a response service for inpatient
paediatric patients: “PAED MET” call
Tim Lyons
Helen Goodwin
Bring equity to the Bush. The effective
collaborative use of multidisciplinary teams
Bloodwatch program with the CEC
Annette Keegan
Murray Hyde Page
Fiona Lysaught
Management of urgent orthopaedic surgery
Reducing waiting time for inpatient cardiac
ultrasound
Jennifer Muir Stuart Turner
Phone calls to the ED at Singleton District
Hospital
Justice Health
Ann Relf Statewide CLP
Triage: “I dare you to see me”
Identifying and communicating risk within
the context of an acute mental health
inpatient unit
Derek Roberts
Palliative care pathway for end of life care*
Caroline Short Garry Clarke; Maxine McCarthy; Kerri Davidson;
Julie Skinner; Kathrin King
Modular CLP
“Growing your own” – development of a
forensic psychiatry program
Anthony Samuels
“The prescription black hole” How to
share prescription information between
GPs & Mental Health Services
Kate Simpson
19/10/2009 1:45:01 PM
North Coast Area Health Service
The 3 C Project: Cleaner, Clearer,
Colonoscopies
Statewide CLP
Letting Go of the Rope: What happens
to the cancer patient when no further
treatment can be offered?
Kathy Hanson
Nicole Abercrombie
Clare Harber
FRAGILE: Handle with Care. Effective
Coordination of services for complex
situations
Preventing emotional decline
Eric Belling
Sooner rather than later
I 39
Improving Discharge Processes – CHHC
Mental Health Inpatient Unit
Carolyn Heise
Deborah Huxstep
A Fraction of the Time: Reducing total
clinic time at Port Macquarie Base Hospital
fracture clinics Anthony Best
‘That’s my Baby’ - Social Work Referrals
for women presenting at Tweed Heads
Hospital with early pregnancy concerns
Janelle Jacobson
One Step at a Time: To improve access to
podiatry services for clients with high risk
or active problems*
David Cooper
Establishing a key worker for clients in the
Acute Care Service, Richmond Community
Mental Health Liz Joblin
Hastings Macleay Mental Health
Operational Guidelines
Matthew Eldridge
Discharge planning from a Mental Health
Unit
Michael Martin
Improving Cognition Management in
long-term care
Lynn Forsyth
Tweed Valley Aged Care Assessment Team:
Waiting Times Project*
Siobhan Laffey
Blood Sugar Level readings in all patients
who have experienced altered level of
consciousness
After hours medication access
Helen Lourens
Steve Fraser
19/10/2009 1:45:01 PM
“Paediatric Pain Management, No Laughing
Matter” Nitrous Oxide administration to
Paediatric Patients*
Improving fluid balance recording practices
on a paediatric ward
Kathy Chapman Belinda Porter
Time to Triage
Assessment of patients with cognitive
deficits
Emma Smith
Lois Clarke
Improving the care of women with
gestational diabetes
Youth Mental Health: Getting it right*
Adrian Cobbold and Sue Leonard
Ann Tippett
Access to emergency surgery at RNS
Modular CLP
Improving mental health clinical
governance (building teams)
Doug Andrews
Rosemary Cullen
PRN Medication and over sedation
– 2008 review
Paul Dimond
Reducing the wait in emergency
Martin Chase
Domestic Violence Assist
Ronald Gibbs
Northern Sydney Central Coast
Area Health Service
Medication storage & handling in radiation
oncology
Statewide CLP
Improved access and care – clozapine
clinic trial (IMPAACCCT)
Famous Last Lines - Documentation
in the Emergency Department
Tracey Gray & Eunice Chan
David Archer
Susan Hair
Achieving unique client goals through
collaborative community care planning
To improve the elective patient journey
from admission to discharge
Sandra Brown
Karen Jones and Kylie Whitehorn
Improve the dispensing processes of the
Level 1 Pharmacy
Improving referral processes for Coral Tree
Family Service (statewide tertiary child and
adolescent mental health service)
Pauline Calder
Bob King
19/10/2009 1:45:01 PM
Improving the provision of medication to
patients on the wards
Sally Nicolson
Gosford Home Based Treatment Team
(GHBTT) discharge process
Leilani Ormsby
Getting discharged patients off the ward
faster
Mark Pratt
Intensive Care Infection Control Working
Party: Royal North Shore Hospital
Rebecca Riordan & Leila Kuzmiuk
Risk management planning for a workforce
shortage of experienced haemodialysis
nurses
Lucy Spencer
South Eastern Sydney Illawarra
Area Health Service
Statewide CLP
Improving the nutritional status of hospital
inpatients
Janet Bell and Dominique Grognard
Designing a Paediatric Nursing Care Plan
which meets the needs of the chronic/
long-term patient
Helen Bullot
Equitable access to bereavement
counselling
Sara Burrett
Implementation of antenatal services
review recommendations
Louise Everitt
Modular CLP
“Are we there yet?” A Paediatric Service
Clinical Challenge - The Pregnancy
Journey*
Introducing a ward culture of critical
inquiry to improve outcomes
Joanne Ging & Michael Peregrina
Oral intake safety in elderly clients – a
multidisciplinary approach
The management of delirium in the older
patients in Manly and Mona Vale Hospitals
Helen Gillespie & Frances Monypenny
Improving training services for
management of the acutely deteriorating
patient
I 41
Jocelyn Guard
Jai Gupta
Improving practice management for
patients with foot ulcers at the STG
podiatry clinic
Sally-anne Jakowlew
Leonie Watterson
19/10/2009 1:45:01 PM
Psychosocial care for patients with a
cancer diagnosis in the outpatient setting
Prevention of falls with implementation of
Assistant in Nursing in Nursing trial
Judy Jeffery
Julie Spencer
Protected Engagement Time (PET) in
Mental Health Units
Client safety and satisfaction – preparing a
patient for tendon rehabilitation
Mark Koh
James Stormon
Improved reporting in the prevention
and management of pressure sores for
Community Health clients
Modular CLP
Drying out with Dignity - medically
supervised alcohol withdrawal in the
Shoalhaven, an Aboriginal Health solution*
Jacqueline Little
Katherine Brown
Improving the recording of information into
the IIMS system
Jane Newman
Introduction of “Life-jet” a new recovery
based care planning tool and its use within
Team and Primary Nursing.
Mark Perree
Increasing workforce flexibility in
Psychology: Feasibility at Sydney
Children’s Hospital
James Donnelly
Triple Zero Project at The Sutherland
Hospital Emergency Department
Michael Golding
A home-visit service to Cultural and
linguistic diverse (CALD) clients in the St
George Child and Family Health Service.
Robinson Jacky
Getting on TRACS: Investigating issues
affecting occupancy levels of the Illawarra
Transitional Aged Care Service*
Southern network participants:
Maren Jones; Verica Marin; Sue-Ellen Hogg;
Helen Troy; Sarah Foulstone; Anthony Arnold;
Susan Dileva; Rebekah Reurich; Anne Lees
Sydney South West Area
Health Service
Modular CLP
MHOAT Outcome measures and clinical
significance
Mark Cross
Improvement of care for patients with
severe psoriasis
Wolfgang Weninger
19/10/2009 1:45:01 PM
Sydney West Area
Health Service
Continuity of care and support following
discharge from Mental Health inpatient
Unit
Statewide CLP
Improving Social Work documentation,
reducing risks
Katrina Knight & Kathi Boorman
Pauline Barber & Rachel Oates
I 43
Developing a sustainable process to
monitor and improve patient outcomes
Lisa Newling
Reduce waiting times for clients after initial
base mammogram completed on the same
day
Reducing waiting times without reducing
care
Harj Bariana
Linda Robinson
Pain management in the Emergency
Department
Acute post partum pain management of
perineal trauma following vaginal birth
Ann Dudley
Julie Ann Swain
Mentorship
SWOT; Springwood Hospital Occupational
Therapy Service Project
Liz Eglington
Kathy Sweeny
Caring for the deferred patient
Rebecca Galvin & Tina Van Weelderen
The optimal management of perineal tears
Talat Uppal
Post natal group based education program
for S4EP
Susan Gawthorne
Modular CLP
Complex pre-surgical epilepsy evaluations
in SWAHS
Cardiac monitoring study
Mark Dexter
Pauline Higgs
WAAT Referral Process (WAARP)
Dermatology at Westmead. Model of care
and strategic plan
Richard Hoskins
Pablo Fernandez Peñas
Hand Hygiene compliance in Intensive Care
Unit
Brenton Hughes
19/10/2009 1:45:01 PM
Acknowledgements
CLP Modular Area Health Service Program Sponsors - 2008
Frank Horn___________________________________________
Joe McGirr___________________________________________
Jenny Coutts_ ________________________________________
Nigel Lyons_ _________________________________________
Bronwen Ross_ _______________________________________
David Hutton / Jane Boot_________________________________
Phillipa Blakey_ _______________________________________
Sue Browbank_ _______________________________________
Paul Gavel___________________________________________
Charles Pain__________________________________________
Greater Southern
Greater Western
Hunter New England
Justice Health Service
North Coast
North Sydney Central Coast
Sydney South West
Sydney West
CLP Statewide Area Health Service Program Sponsors/Contacts - 2008
Graeme Malone_ ______________________________________
Val Johnson__________________________________________
Maggie Crowley_______________________________________
Jenny Coutts_ ________________________________________
Allan Parsons_________________________________________
Alison Stevens_ _______________________________________
Katie Willey_ _________________________________________
Lynda-Mary Wood_ ____________________________________
Kim Olesen_ _________________________________________
Charles Pain, Sue Whitby_________________________________
Ambulance Service of NSW
Greater Southern Greater Western
Hunter New England
North Coast
Sydney West
CLP Statewide Facilitators / Program Managers – 2008
Helen O’Grady, Sonya Bubnij_ _____________________________
Amanda Baker________________________________________
Rachelle Ellem, Julie Swain_ ______________________________
Nicole Byrne, Alison Fielder_ ______________________________
Michelle Eason________________________________________
Margot Tugwell, Christine Lee______________________________
Raichel Green, Claire Nabke-Hatton_________________________
Mary Lambell, Louise Van Baarle_ __________________________
Karen Patterson, Jacqui Cross_ ____________________________
Ketty Rivas, Coral Levett_ ________________________________
Richard Tewson, Loretta Martin_____________________________
Greater Southern Greater Western
Hunter New England
North Coast
Sydney West
CLP Program Leaders 2008
Compiled and edited by
Bernie Harrison, Teresa Pudo,
Colleen Leathley
Teresa Pudo, Bernie Harrison,
Kay Wright, Brid Morahan
19/10/2009 1:45:01 PM
The Clinical Excellence Commission_ _______ 1
Clinical Leadership Program______________ 2
Selected Project Summaries______________ 6
Past Participant Testimonials_ ___________ 33
List of 2008 CLP Projects_ _____________ 34
Acknowledgements___________________ 44
PO Box 1614
Sydney NSW 2001
Tel: (02) 9382 7600
Fax: (02) 9382 7615
This work is copyright. It may be reproduced in whole
or part for study or training purposes subject to the
inclusion of an acknowledgement of the source.
It may not be reproduced for commercial usage or sale.
If you would like more information about the Clinical
Leadership Program or would like further details about
any of the projects please contact:
Reproduction for purposes other then those indicated
above require permission from the Clinical Excellence
Commission.
GPO Box 1614
Sydney NSW 2001
The CEC Clinical Leadership Program has no association
with the Royal College of Nursing, United Kingdom (RCN,
UK) Clinical Leadership Programme, represented in
Australia by the Royal Adelaide Hospital.
Ph: 02 9382 7600
Fax: 02 9382 7615
Email:[email protected]
19/10/2009 10:53:09 AM
Excellence
Excellence
19/10/2009 10:53:14 AM

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