CONTINUOUS IMPROVEMENT

Transcription

1 SECTION 5 CONTINUOUS IMPROVEMENT Private Aged Care actively pursues and demnstrates cntinuus imprvement in all aspects f service management and delivery. Cllect infrmatin frm key stakehlders Implement any required immediate respnses Service users, staff, management, referrers using surveys, feedback frms, meetings, audits, incident/accident reprts, risk management prcess, etc. Cllate and analyse infrmatin Administratin Team Review infrmatin t identify areas fr imprvement and develp actin plans Implement imprvements Crdinatrs with Manager and Service Management Meeting input Evaluate imprvements FORMS AND RECORDS Minutes f Meetings Cntinuus Imprvement Mnthly Summary Tell Us What Yu Think frm Service User Cmplaint Frm Staff Accident Incident Reprt Adverse Event Reprt Hazard Reprt Medicatin Errr Reprt Maintenance Request Survey Audit Reprt Shared Drive Shared Drive Crdinatrs PRIVATE AGED CARE GGJ 2013 Page 1

2 5.1 Cntinuus Imprvement Overview Private Aged Care is cmmitted t cntinuusly imprving all aspects f its peratins with the aim f delivering imprved services t service users. The cntinuus imprvement prcess fr ur rganisatin is based n nging feedback frm: Service users (and representatives) Staff Management and Other stakehlders including funders, ther service prviders and cmmunity rganisatins. The cntinuus imprvement prcess, the rles f the Bard and key staff and the range f infrmatin surces is shwn in Figure 5.1 Cntinuus Imprvement Infrmatin Management Prcess. Figure 5.1: Cntinuus Imprvement Infrmatin Management Prcess Bard f Management Overall respnsibility fr ensuring the service cntinuusly imprves Manager Mnitrs, n behalf f the Bard, the cntinuus imprvement prcess and ensures that infrmatin is being cllected, reviewed fr imprvement pprtunities and that imprvements are implemented and evaluated. Als reprts t the Bard n the cntinuus imprvement prcess, activities and utcmes and ensures that the Imprvement Plan is maintained up t date Imprvement Plan All majr imprvements are recrded n the Imprvement Plan. The Plan is frwarded t the Quality review team every 12 mnths r as required t demnstrate nging cntinuus imprvement prcesses Imprvement Cmmittee Respnsible fr the Cntinuus Imprvement prcesses including the review f data cllected thrugh the infrmatin surces belw t identify imprvements Crdinatrs/ Review frms fr immediate actin which may be required and review frms fr imprvements prir t Imprvement Cmmittee meetings. Crdinatrs als clse ff n frms nt requiring lnger term actin Infrmatin Surces Tell Us What Yu Think Frm fr Service Users, Staff and Other Stakehlders Service User Cmplaint Frm Infrmal Service User Feedback Staff Accident Incident Reprts Adverse Event Reprts Medicatin Errr Reprts Hazard Reprts Maintenance Requests Safety Audits Surveys Meetings Plicies and Prcedures Reviews Respnsive Audits Risk Management Prcesses Regulatry Cmpliance Prcesses Quality Reviews PRIVATE AGED CARE GGJ 2013 Page 2

3 5.1.1 THE IMPROVEMENT COMMITTEE We have established an Imprvement Cmmittee t versee the cntinuus imprvement prcess. The Cmmittee is respnsible fr: Implementing the cntinuus imprvement prcesses The review f data t identify imprvements The implementatin f imprvements Maintaining the Imprvement Plan up t date (see Imprvement Plan) The evaluatin f imprvements Infrming key stakehlders f imprvements Identifying imprvements t the cntinuus imprvement prcesses. Imprvement cmmittee membership The Cmmittee includes: The Manager The Crdinatrs The Up t three Supprt Wrkers One vlunteer. Imprvement cmmittee meetings See Sectin 1: Crprate Gvernance (Table 1.1: Management Meetings). Imprvement cmmittee agenda See Sectin 1: Crprate Gvernance (Table 1.1: Management Meetings) CONTINUOUS IMPROVEMENT AND RISK MANAGEMENT Our rganisatin has integrated risk management int the cntinuus imprvement prcess by: Delegating respnsibility fr risk management versight t the Imprvement Cmmittee Including the identificatin and discussin f risks n the agenda fr the Imprvement Cmmittee Delegating respnsibility t the Imprvement Cmmittee fr develping, maintaining and reviewing the Risk Management Plans Including imprvements t reduce r cntrl risks in the imprvement prcess and in the Imprvement Plan. Our risk management prcesses are described in detail in Sectin 6: Risk Management IMPROVEMENT PLAN See 1.14 Planning IMPROVEMENT PROCESS The imprvement prcess used by ur rganisatin reflects the Plan, D, Check, Act mdel shwn in Figure 5.2: Plan D Check Act Imprvement Cycle. Figure 5.2: Plan D Check Act Imprvement Cycle PRIVATE AGED CARE GGJ 2013 Page 3

4 PLAN! (Plan imprvements) ACT! (Make changes t the imprvements. Identify new imprvements) Imprvements in Services t Service Users DO! (Implement the imprvements) Service User Needs Legislative Requirements Funding Requirements CHECK! (Are the imprvements ding what we wanted? Can we build n them?) Hme Care Standards Service Prvider Needs Cmmunity Expectatins These steps are further described belw. Plan: Clarify issues r prblems Cllect and review data r ther infrmatin related t the issues r prblems Identify the causes f the issue r prblem Clearly identify imprvements that can be made Clarify the utcmes fr imprvements Develp strategies t implement imprvements cnsider stakehlders cnsider strategies t get management supprt Identify hw t measure the success f the imprvement and identify hw t cllect the data Identify key tasks. D: Gain apprval fr imprvements Implement the imprvements assign key tasks Mnitr the implementatin make sure key tasks are cmpleted Cllect data n imprvements. Check: Did the imprvement wrk? If nt, why nt? Were there any unintended cnsequences? PRIVATE AGED CARE GGJ 2013 Page 4

5 Cllect nging data n the peratins f yur rganisatin - e.g. service user feedback, staff feedback, staff accident/incident reprts, adverse event reprts, hazard reprts, audits, etc. what des this tell us abut the imprvements? Act: Cnsider imprvements d they suggest ther imprvements e.g. staff training, review f prcedures, changes t rganisatin peratins? Share evaluatin feedback with relevant stakehlders If imprvements did nt wrk what d we need t d? If there were unintended cnsequences t imprvements - d we need t d anything abut them? Cnsider new data e.g. service user feedback, staff feedback, staff accident/incident reprts, adverse event reprts, hazard reprts, audits, etc des it suggest imprvements? Lk fr things t imprve lk at prblems and cnsider slutins. We are cmmitted t nging imprvement and it is built int the rganisatin s culture and practices. This ensures the rganisatin cntinues t change and adapt t the needs f its service users, funders and the wider cmmunity. 5.2 Cntinuus Imprvement Frms The cntinuus imprvement frms are described belw. A file is kept fr each type f cntinuus imprvement frm. Within each file there are tw tabs: pen and clsed where pen and clsed ut frms are stred. These are archived every year t reduce the bulk f the files TELL US WHAT YOU THINK FORM Feedback, bth psitive and negative, is actively sught frm service users, staff, management and ther peple using a Tell Us What Yu Think frm. Staff and service users are encuraged t prvide feedback thrugh meetings, newsletters and day t day cntact. Frms are prvided t service users at the time f assessment and review, at the day centre and their use prmted in ur Newsletter. Frms are als included in the supprt plan hme flder and staff als have frms that they can prvide t service users (see als Infrmal Service User Feedback). Cmpleted frms are frwarded t the apprpriate Team Leader fr any immediate actin required. The Crdinatr s advice may be sught. Cmpleted frms are prcessed as per 5.4 Prcessing Cntinuus Imprvement Frms and Other Imprvement Infrmatin SERVICE USER COMPLAINT FORM The Service User Cmplaint Frm is used fr mre frmal cmplaints r when negative feedback invlves a significant issue that requires detailed dcumentatin and actin. Staff may cmplete the frm fr the service user r may prvide a frm t them r their representative. If service users write a letter r telephne their cmplaint, staff cmplete a Service User Cmplaint Frm n their behalf. Cmpleted Service User Cmplaint Frms are frwarded t the apprpriate Team Leader wh reviews and investigates the cmplaint in line with the prcedures specified in Sectin 16: Cmplaints and Service User Feedback. The Crdinatr and Manager are infrmed f all cmplaints. Frms are prcessed as per the prcedure in 5.4 Prcessing Cntinuus Imprvement Frms and Other Imprvement Infrmatin. PRIVATE AGED CARE GGJ 2013 Page 5

6 5.2.3 STAFF ACCIDENT INCIDENT REPORT The Staff Accident Incident Reprt is used t reprt accidents r incidents that affect staff r vlunteers. Frms are filled ut immediately after the accident r incident and are frwarded t the apprpriate Team Leader r Crdinatr as sn as pssible. The Team Leader r Crdinatr reviews the frm making sure it is crrectly cmpleted and that any required actin is taken, including medical attentin, cntrl f hazards and the cmpletin f a Wrkers Cmpensatin reprt. The Team Leader r Crdinatr investigates the accident/incident as per the frm. Reprts are prcessed as per the prcedure in 5.4 Prcessing Cntinuus Imprvement Frms and Other Imprvement Infrmatin ADVERSE EVENT REPORT The Adverse Event Reprt is used t reprt accidents r incidents that affect service users r visitrs. Frms are filled ut immediately after the adverse event and are frwarded t the apprpriate Team Leader r Crdinatr as sn as pssible. The Team Leader r Crdinatr reviews the frm making sure it is crrectly cmpleted and that any required actin is taken, including medical attentin r the cntrl f hazards, and investigates the adverse event as per the frm. Reprts are prcessed as per the prcedure in 5.4 Prcessing Cntinuus Imprvement Frms and Other Imprvement Infrmatin HAZARD REPORT Hazard Reprts are used t reprt areas f risk r ptential risk t service users, staff r ther peple in ur wrk places, service user s hmes and external venues. Cmpleted Hazard Reprts are frwarded t the apprpriate Team Leader r Crdinatr wh arranges fr immediate cntrl f the hazard and fr any further actin such as repairs and maintenance, new equipment etc. Reprts are prcessed as per the prcedure in 5.4 Prcessing Cntinuus Imprvement Frms and Other Imprvement Infrmatin MEDICATION ERROR REPORT The Medicatin Errr Reprt is used t reprt any mishap r incident related t service user medicatin. Reprts are frwarded t the apprpriate manager/crdinatr wh carries ut any immediate actin required and investigates the incident. Frms are prcessed as per the prcedure in 5.4 Prcessing Cntinuus Imprvement Frms and Other Imprvement Infrmatin MAINTENANCE REQUEST Maintenance Request frms are used t reprt items requiring maintenance that are nt an immediate hazard. Cmpleted Reprts are frwarded t the Team Leader Administratin wh arranges the maintenance. Cmpleted frms are prcessed as per the prcedure in 5.4 Prcessing Cntinuus Imprvement Frms and Other Imprvement Infrmatin. PRIVATE AGED CARE GGJ 2013 Page 6

7 5.2.8 SURVEY AUDIT REPORT A Survey Audit Reprt is cmpleted by the individual cnducting the survey/audit r delegate fr every survey r audit and recrds a summary f the results and any actin required r imprvements that can be made. See als 5.4 Prcessing Cntinuus Imprvement Frms and Other Imprvement Infrmatin. 5.3 Other Cntinuus Imprvement Infrmatin Surces INFORMAL SERVICE USER FEEDBACK In additin t Tell Us What Yu Think frms and service user surveys ur staff recrd service user infrmal feedback r cmments regarding service delivery. These are recrded n a Tell Us What Yu Think frm and prcessed as per the prcedures in Tell Us What Yu Think Frm. Service user names are nt reprted MEETINGS Minutes f all meetings are reviewed by a designated Crdinatr at the end f each mnth t identify any pprtunities fr imprvement. These are recrded n a Tell Us What Yu Think frm and prcessed as per the prcedures in Tell Us What Yu Think Frm SAFETY AUDITS Safety audits are regularly cnducted in service user hmes, service facilities and external venues used fr service user activities using the fllwing frms: Hme Safety Checklist Safety Audit External Venue Safety Audit Facilities. (See 8.4 Safety Audits). Cmpleted audits are frwarded t the apprpriate Team Leader fr review and any actin. Cmpleted frms are prcessed as per the prcedure in 5.4 Prcessing Cntinuus Imprvement Frms and Other Imprvement Infrmatin POLICIES AND PROCEDURES REVIEWS Each sectin f the Plicies and Prcedures Manual is audited ver a three year perid t: Check what is written is what ccurs in practice Identify imprvements t practice Imprve the dcumented prcedures Imprve any frms r ther dcuments that supprt the prcedures and practices. The Crdinatrs maintain a plan fr plicies and prcedures review in the Crprate Calendar. The Crprate Calendar details the reviews, surveys, respnsive audits and ther data cllectin and mnitring activities scheduled fr the next 12 mnths. This is updated as reviews/audits are planned and cmpleted. Reviews are cnducted by a range f staff including the Crdinatrs,, administratin staff and supprt wrkers. The Crdinatrs identify relevant staff fr each review ensuring that staff d nt review their wn prcedures. PRIVATE AGED CARE GGJ 2013 Page 7

8 The fllwing prcess applies: Staff print (r cpy) the relevant sectin f the Plicies and Prcedures Manual, read the cntents and familiarise themselves with relevant frms and dcuments The staff wh wrk in the area that the plicies and prcedures relate t are advised that the staff persn is ging t be cnducting a review and will want t review dcuments and talk t relevant staff The plicies and prcedures are used t guide the review; the staff persn cnducting the review: Talks t relevant staff t discuss hw the prcess/prcedure wrks Observes the prcesses in actin (if relevant) Reviews and samples 1 a selectin f cmpleted frms and recrds referred t in the plicies and prcedures fr cmpleteness and adherence t prcedures Ntes n the cpy f the plicies and prcedures the dcuments sampled and staff wh participated in the review (this is the evidence that the prcess/prcedure has been reviewed) Ntes n the cpy f the plicies and prcedures where practices are different frm plicies and prcedures r where imprvements t practices are identified Prvides feedback t the staff participating in the review t clarify any infrmatin gained and highlight any identified imprvements Cmpletes a Survey Audit Reprt and attaches the cpy f the plicies and prcedures (with ntes frm the review) Prvides feedback t the relevant Team Leader regarding the review The Survey Audit Reprt is prcessed as per the prcedure in 5.4 Prcessing Cntinuus Imprvement Frms and Other Imprvement Infrmatin RESPONSIVE AUDITS Respnsive audits are cnducted if it is identified thrugh service user, staff r ther stakehlder feedback, review f plicies and prcedures r ther activities that a prcess may nt be wrking r require imprvement. The review prcess described abve is used t cnduct respnsive audits; they are used t ascertain what is happening and t identify imprvements and slutins. They are usually a fairly narrw scpe. Fr example, if it is identified that sme service users have advised that Supprt Wrkers have been arriving late fr their supprt visit, a respnsive audit may include: Talking with Supprt Wrkers t identify any barriers t them delivering services at the allcated time Reviewing the rsters and schedules f the relevant Supprt Wrkers Reviewing the supprt plans f the service users wh have prvided feedback and, if necessary, service users wh receive services earlier Identifying slutins t the issues Implementing slutins Prviding feedback t the service users and supprt wrkers n the actins taken Evaluating whether the actins have been effective. 1 Samples are selected depending n the number f recrds, service users, and dcuments available. A small sample is usually chsen t test the prcess. Fr example, a review f 5 service user recrds fr cmpletin f care plans wuld be randmly chsen initially. If issues are identified, a further sample f 5 recrds may be chsen t review. If multiple prgrams are delivered, the staff persn may chse t select 5 recrds frm each prgram. It is imprtant t nte yur sample recrds (service user initials r number r staff initials f wh yu spke with) n the cpy f the plicies and prcedures t validate the review f recrds. PRIVATE AGED CARE GGJ 2013 Page 8

9 A Survey Audit Reprt is cmpleted and attached t the cpy f the plicies and prcedures used during the review. Cmpleted frms are prcessed as per the prcedure in 5.4 Prcessing Cntinuus Imprvement Frms and Other Imprvement Infrmatin. Quality reviews As part f the cmmunity care funding requirements ur rganisatin underges a quality review every 3 years. The review identifies imprvements required t meet any unmet expected utcmes and pprtunities fr imprvement. The imprvements identified thrugh the quality review prcess are summarised n a Survey Audit Reprt and included in the Imprvement Plan (see Imprvement Plan.) Cmpleted Survey/Audit Reprts are prcessed as per the prcedure in 5.4 Prcessing Cntinuus Imprvement Frms and Other Imprvement Infrmatin. 5.4 Prcessing Cntinuus Imprvement Frms and Other Imprvement Infrmatin The fllwing prcess applies t cmpleted cntinuus imprvement frms: 1. If all required actin is cmpleted the frm may be clsed ut by the Team Leader r Crdinatr. 2. Frms are frwarded t the Team Leader Administratin wh prepares them fr presentatin at the next Imprvement Cmmittee meeting. 3. The Imprvement Cmmittee reviews the frms fr ptential imprvements and clses ut frms (if nt already clsed ut). 4. Where a frm leads t imprvements any actin n the imprvement is recrded n the back f the frm. Significant imprvements are als recrded n the Imprvement Plan (see Imprvement Plan and Strategic Plan). The frm is maintained in the pen sectin f the file fr that frm until all actin is cmpleted. 5. Clsed ut frms are filed in the clsed sectin f the file. 6. At the end f each mnth the number f frms received during the mnth, the key issues and majr imprvements implemented are recrded n the Cntinuus Imprvement Mnthly Summary t feed int ur Management Reprts (see 1.8 Management Reprts) COMMUNICATION OF IMPROVEMENTS An verview f imprvements is presented at: Mnthly Team Meetings and Six mnthly Whle f Cmmunity Care Team Meeting. A summary f imprvements is included in ur rganisatin s Newsletter EVALUATING IMPROVEMENTS An imprvement is nt clsed ut until the imprvement is evaluated; that is we have checked that the imprvement achieved what we expected and that there were n unintended cnsequences. If an imprvement did nt wrk we take it back t the next Imprvement Cmmittee meeting fr cnsideratin f new strategies. The extent t which imprvements are evaluated depends n the level and cmplexity f the imprvement. PRIVATE AGED CARE GGJ 2013 Page 9

10 Fr example, a service user request fr bigger fnts in letters culd be immediately implemented withut an evaluatin. Hwever, a mre cmplex imprvement such as changing all staff cmmencement and finishing times t fit in with schl clsing hurs requires cnsultatins with staff and users, infrmatin sharing and significant changes t practices. This imprvement wuld need t be evaluated with input frm service users, staff and management t ensure it was a psitive change with n unintended cnsequences. Significant imprvements can nly be clsed ut by the Manager r Crdinatr after it has been evaluated. 5.5 Mnitring Cntinuus Imprvement Prcesses and Systems Cntinuus imprvement prcesses and systems are regularly audited as part f ur audit prgram and staff, service users and ther stakehlders are encuraged t prvide nging feedback n issues and areas where imprvements can be made. Audits are scheduled in the Crprate Calendar. PRIVATE AGED CARE GGJ 2013 Page 10