Q U A L I T Y. Entries in the 15th Annual ACHS Quality Improvements Awards 2012 I N I T I A T I V E S

Transcription

1 Q U A L I T Y I N I T I A T I V E S Entries in the 15th Annual ACHS Quality Improvements Awards 2012 Including the Student Award 2012 I University of Newcastle Supported by:

2 CONTENTS Introduction 2012 QI Award Winners and Highly Commended Non-Clinical Service Delivery Category Winner - Hunter New England Local Health District 1 Submissions 9 Clinical Excellence & Patient Safety Category Winner -Northern Beaches Health Service 10 Highly Commended Hong Kong Baptist Hospital 19 Highly Commended War Memorial Hospital 22 Submissions 24 Healthcare Measurement Category Winner - St Vincent s Private Hospital 27 Highly Commended Junee Correctional Centre 36 Submissions 38 Student Award Winners Aminuddin Hasnoi Aidi, Ettiene Musumeci, Subhash Nayar, Umi Qamruddin 39 Highly Commended 39 Submissions 40

3 Quality Improvement Awards Introduction The annual ACHS Quality Improvement (QI) Awards were introduced in 1998 to acknowledge and encourage outstanding quality improvement activities, programs or strategies that have been implemented in healthcare organisations. The QI Awards are open to all current Australasian and international members of the ACHS Evaluation and Quality Improvement Program (EQuIP) and the EQuIP Corporate program. Judging is conducted externally by separate panels of three in each of the categories: Non-Clinical Service Delivery This category supports the delivery and provision of safe high quality care. EQuIP standards that are relevant to this category include Quality Improvement and Risk Management, Human Resources Management, Information Management, Population Health, Research, Leadership and Management and Safe Practice and Environment. Clinical Excellence & Patient Safety This category focuses on quality of care and patient outcomes and relates to EQuIP standards for Continuity of Care, Access, Appropriateness, Effectiveness, Safety and Consumer Focus. Healthcare Measurement This category supports EQuIP5 criterion 1.1.4, a mandatory criterion relating to care evaluation and the measurement of outcome data. Each judging panel includes an ACHS Councillor, an ACHS surveyor and a representative from an EQuIP member organisation. Submissions are required to meet specific criteria, each weighted equally: Evidence that the activity incorporates the EQuIP principles and an evaluation process, and is effective and sustainable; The activity has a demonstrated outcome; The activity demonstrates innovation; The activity is applicable to other settings. Each winning organisation receives a Certificate of Acknowledgement and QI trophy from the ACHS. A cash prize is donated by Baxter Healthcare. The ACHS publishes submissions from all participating organisations to enable sharing of exceptional quality improvement strategies. The full reports of the winning submissions as well as the summaries of all submissions are published on the ACHS website:

4 QI Award Winners 2012 NON-CLINICAL SERVICE DELIVERY Organisation: HUNTER NEW ENGLAND LOCAL HEALTH DISTRICT Department: Clinical Governance Project: ISBAR in our communication building capacity and skill for healthcare communication Judges citations: The strength of this project is sustained effectiveness the project was commenced four years ago Project shows statistical proof in reduction of adverse events Project shows continuing Improvement HEALTHCARE MEASUREMENT Organisation: St VINCENT S PRIVATE HOSPITAL Department: Food and Nutrition Services Project: Making food and nutrition care a priority on St Vincent s Campus Judges citations: This category included some really impressive initiatives This submission is beautifully presented and articulated Shows clear evidence of monitored outcomes A project that is easily transportable to other similar organisations Not a great cost to the organisation CLINICAL EXCELLENCE & PATIENT SAFETY Organisation: NORTHERN BEACHES HEALTH SERVICE Department: Antibiotic Stewardship Team Project: Antibiotic Stewardship it s as EASY as easy Judges citations: This is a long term project that shows evidence of clear outcomes The strength of this project is that the outcomes have been sustained since 2006 There is evidence of continuing improvement The project clearly applicable to other settings Highly Commended Clinical Excellence & Patient Safety Organisation: Hong Kong Baptist Hospital Highly Commended Clinical Excellence & Patient Safety Organisation: War Memorial Hospital Highly Commended Healthcare Measurement Organisation: Junee Correctional Centre

5 Category: Non-Clinical Service Delivery QI Award Winner ISBAR in our communication building capacity and skill for healthcare communication CLINICAL GOVERNANCE HUNTER NEW ENGLAND LOCAL HEALTH DISTRICT NSW Rosemary Aldrich Kim Hill Juliana Ford Anne Duggan Aim By developing and implementing an innovative program implementation model for skill development we aimed to train 100% Hunter New England Health staff by 2012 to use the ISBAR tool to optimise healthcare communication and prevent communication-related incidents and severe adverse events Abstract Hunter New England Health (HNE Health) is a NSW public health organisation where more than 15,000 staff provide primary, secondary and tertiary services to approximately 850,000 people resident in metropolitan, regional, rural and remote centres across an area the size of England. With 45 inpatient facilities, 40 emergency departments (with 1,000-65,000 presentations annually), networked care for almost 3,000 inpatients effected through interhospital transfers where necessary, and millions of s, clinical and non-clinical conversations and items of correspondence annually, opportunities for healthcare communication-related incidents are limitless. In 2006 the HNE Health Director of Clinical Governance initiated a long-term strategy to enhance professional communication across all staff. Consistent with the literature, an evaluation of our incident data showed that 76% of the 127 HNE Health root cause analyses (RCAs) undertaken in 2006 cited communication failure as a causative factor, with devastating impacts on patients and their carers, and on staff, risking loss of productivity and ultimately, loss of staff. Funded by the Australian Commission on Safety and Quality in Health Care in , we identified, adapted (in consultation with local clinicians), trained staff to use, and piloted the use of the ISBAR (introduction, situation, background, assessment, recommendation) tool, aiming to improve the quality of clinical handover in inter-hospital transfer. Training staff in ISBAR enhanced their confidence to communicate, enhanced patient and carer perceptions of the quality of healthcare communication, and showed potential to reduce adverse incidents. Based on this evidence in 2010 and 2011 the ISBAR in our Communication program team (comprising the Director of Clinical Governance, the Program Leader, and Program Implementation Manager) used a seven-element approach to promote use of ISBAR across our organisation, to optimise healthcare communication (including for highrisk processes such as clinical handover, the need to escalate deteriorating patients, communication of results and communication with patients and carers), and prevent communication-related adverse events. The program team did not act alone: implementation was effected through strong Executive Team leadership, support from champions who formed our Communication Coalition, and many managers and clinician leaders who shaped the uptake of ISBAR across the organisation. 15 th Annual ACHS Quality Improvement Awards 2012 Page 1 of 41

6 Category: Non-Clinical Service Delivery QI Award Winner Simultaneous attention to Leadership and governance, Engaging with people and processes, Training and education, Tools and resources, Evaluation and audit, Reporting and communication, and Sustainability (our LETTERS model) resulted in more than 9,200 staff documented as having trained to use ISBAR in the year to end November 2011, at which time the Clinical Governance ISBAR Implementation Manager concluded their role. The number of staff documented as trained in the previous year had increased to nearly 10,000 by April Our challenge was to educate an entire workforce to address a critical skill gap, and promote a workplace culture valuing quality communication. A deliberate and broad strategy for sustaining staff training and embedding use of ISBAR (including making annual training mandatory, having an e- learning module, training 400 managers and supervisors as trainers, and having an ISBAR icon on every desktop) has turned ISBAR into a noun and a verb in our organisation. The format is used widely in many settings and forms of communication, and for recording information, which in turn has informed other quality activities. And there have been outcomes for patient safety: using our original methods for incident evaluation, and compared with 2006 data, in 2011 we observed a 75% reduction in the number of reported healthcare incidents concerning communication failure, a 50% reduction in the proportion of severe adverse events which implicated communication-failure as a root cause (from 76% to 38%), and a 75% reduction in the absolute number (from 96 to 23). Reductions in the number and severity of adverse events have resulted from a range of initiatives in our organisation, of which the ISBAR in our Communication program is one. Application of EQuIP Principles EQuIP principle 1. A Consumer / Patient Focus Communication failure can have catastrophic consequences for patients and their carers (and staff), and it was to address adverse events as a result of communication failure that the communication strategy was initiated in 2006 by the Director of Clinical Governance. Informed by a pilot evaluation of causes and types of communication-related adverse events and complaints, in we identified, adapted and trained staff to use the standard ISBAR format, and evaluated the communication experiences of patients and their carers before and after staff were trained (after which patients and carers rated the quality of their communication more highly, and documentation for care showed improvement). By building on this evidence - derived from interviewing patients and carers about their experience of healthcare communication - the ISBAR in our Communication strategy was able to deliver improved safety outcomes for consumers and patients. Using our original methods for incident evaluation, and compared with 2006 data, in 2011 there was a 50% reduction in the proportion of severe adverse events for which communication failure was a root cause (from 76% to 38%). Given the reduction in the number of severe adverse events over that time this meant a reduction by 75% in the absolute number of severe adverse events related to communication-failure. That there was no reduction in number of complaints between 2006 (308) and 2011 (389) about aspects of communication, however, demonstrates we still have work to do to improve the quality of healthcare communication with our patients and carers. We recognise that the potential exists to empower our consumers to be heard and demand the information they seek by developing consumer knowledge of the ISBAR format. EQuIP principle 2. Effective Leadership In response to evidence of effectiveness of training staff in ISBAR, in late 2009 the then Area Executive Team supported the organisation-wide roll-out of the program by dedicating resources for a 1FTE implementation manager position. Clinical Governance had devoted the time and expertise of the Director of Clinical Governance, as Executive Sponsor, and of the Program Leader (an Associate Director of Clinical Governance) to the program and its predecessor program (approximately 8 hours per week) since Page 2 of th Annual ACHS Quality Improvement Awards 2012

7 Category: Non-Clinical Service Delivery QI Award Winner Strong effective leadership has seen a tangible return on those investments. Through planning and enacting a capacity building model the program team was able to deliver notable achievements. By the end of 2011 more than 9000 staff members had been trained in, and approximately 400 managers and supervisors had been trained to train their own staff through in-person training. The training itself was highly acceptable to staff, with one person only in every 300 trained (29 in 8501) making a comment which could be considered mildly or strongly negative. The Executive Leadership Team agreed that ISBAR training should be mandatory annually, and ISBAR training has been incorporated into other training programs. Reference to ISBAR can be found in HNE Health s operational plan and has been picked up by other quality and practice programs such as the Excellence and Transfer of Care projects to enrich communication. Effective leaders within and beyond the program team, including the many general and service managers and supervisors in HNE Health who were trained to undertake their own training compliance analyses and to train their own staff using 6 to 30 minute formats, have promoted the use of ISBAR and have collectively delivered reductions in communication-related severe adverse events. EQuIP principle 3. Continuous Improvement The ISBAR in our Communication strategy was the third initiative led by Clinical Governance which aimed to improve healthcare communication. In 2007 HNE Health adverse event data were evaluated, with results informing a pilot study to identify, adapt and train staff to use a standardised tool for communication. The pilot study showed that staff training improved the healthcare communication experience of patients and carers, and in turn this evidence informed the organisation-wide ISBAR in our Communication strategy launched in December 2009, which contributed to the reduction in number and proportion of severe adverse events to October Importantly, with staff and managers encouraged to develop creative ways to use ISBAR and tools associated with it, there have been numerous local quality improvement initiatives developed in response to information recorded using the ISBAR format. outcomes. For example, led by communication champions throughout HNE Health, evaluation of expanded work to improve clinical handover using the ISBAR format in a range of clinical settings is under way. Further options for the next iteration / focus for work by Clinical Governance to improve healthcare communication are presently under consideration. EQuIP principle 4. Evidence of Outcomes The 24-month ISBAR in our Communication strategy was implemented using our purposedeveloped LETTERS model for change management, and associated processes for improvement, impacts and outcomes evaluated. Processes for improvement: Leadership and governance: Reporting, accountability and review structures were established and made routine; the Director of Clinical Governance worked tirelessly to ensure Executive peers and senior clinical leaders were fully engaged with the program. Engaging with people and processes: Change agents and ISBAR champions were engaged early and supported, and ISBAR was introduced into routine communication processes Training and education: Four strategies promoted staff training in ISBAR: ISBAR in all training - opportunities for using an ISBAR format and incorporating ISBAR training into other training (such as Orientation) were identified and exploited Managers and supervisors at all facilities and sites were trained to deliver ISBAR training Train the trainer - site and service educators added ISBAR training to training they gave, and ISBAR e-learning - an interactive 15- minute e-learning package was locally developed and made available to all staff through our intranet. Each stage of our strategy has prompted intense reflection about the work done and any 15 th Annual ACHS Quality Improvement Awards 2012 Page 3 of 41

8 Category: Non-Clinical Service Delivery QI Award Winner Tools and resources: ISBAR tools and resources developed included short films, tools for trainers, and templates for posters, reports, policies, presentations, and an template and icon placed on every HNE Health computer. Staff used, adapted and created new ISBARformatted tools for their own purposes and needs. Evaluation and audit: We developed a comprehensive evaluation plan regarding uptake of training across HNE Health, the impact of in-person and e-training on self-reported staff skills to communicate, and acceptability of the training (ISBAR training was well-regarded with <1 in 300 staff giving neutral or negative comments about their training). Systems for tracking adverse incident data were implemented. Reporting and communication: Executives, managers and educators received tailored reports of uptake of training by staff across HNE Health, and also by operational network, facility, professional grouping, routinely and on request. We promoted ISBAR Week to support and boost training, and provided regular updates for staff through Quality Matters and Chief Executive News. Sustainability: Strategies for sustainability included training 400 trainers to train others, making on-line training and ISBAR templates and resources accessible to staff, and having annual ISBAR training made mandatory, and part of the HNE Health operational plan. Impact of training and approach: More than 9,600 (60.4%) staff were trained in the year to April 2012, up >10% from December HNE Health facilities located in our rural and regional Primary and Community Network Clusters achieved high levels of compliance by November 2011 (Figure 1). Training rates of staff at the larger hospitals which collectively comprise our Acute Network were lower (Figure 2), given higher numbers of staff at the larger centres. Approximately 2,200 people had been trained at the John Hunter Hospital (a Level 6 tertiary centre) by end November Using a likerttype scale demonstrated skill improvement with equivalent efficacy for in-person and online training (Figures 3 and 4). The ISBAR format has shaped diverse communication processes including clinical handovers, disaster situation reports, incident reports, patient transfers, patient information and s. Outcomes of training and improvement activities: Compared with January-December 2006 data, and analysed using 2006 methods, data showed that 1) Communication-related incidents reduced (from 728 to 153; Table 1) 2) The number of RCAs where root causes were found reduced from 127 to 61; the proportion of RCAs citing communication as a root cause halved again, from 76% (n=96) to 38% (n=23); (Figures 5 and 6) 3) As 2011 progressed, fewer RCAs citied communication as a root cause (Figure 7). Without claiming reductions were due to the ISBAR strategy alone, we assessed it enhanced organisation-wide long-term efforts to improve healthcare safety and quality. EQuIP principle 5. Striving for Best Practice Informed by the experience of high-risk industries internationally, HNE Health identified in 2008 that use of the ISBAR format represented best practice for focused simple communication in health care. Accordingly, as described above, in consultation with the clinicians who would be using it we adapted, trained staff to use and evaluated whether and how using the ISBAR tool could improve the healthcare communication experience for patients, carers and staff. Informed by the evidence our pilot study generated, HNE Health committed to training all staff to use the ISBAR format, contributing to improvements in quality and safety outcomes. To achieve this goal we developed an innovative program implementation model which engaged staff at all levels of the organisation, developed and provided a range of simple and rapid training options for staff (based on the formats for which we had demonstrated statistically significant improvements in self-efficacy in relation to capacity to communicate), encouraged staff to creatively apply the tool, and promoted local ownership of and capacity to use the tool. We believe our engagement and implementation strategies have been effective, incorporating best-practice principles to a high standard. Page 4 of th Annual ACHS Quality Improvement Awards 2012

9 Category: Non-Clinical Service Delivery QI Award Winner Given our experience, the ISBAR in our Communication program has attracted interest outside HNE Health, and indeed internationally. NSW Health published and disseminated our ISBAR resource as its key tool in teaching communication skills to junior medical officers from Inquiries have been received from across Australia, and from the UK, USA and from New Zealand, where an ISBAR implementation program has commenced informed by our experience. While it is apparent in many ways that ISBAR has penetrated deeply into the processes of care in HNE Health, there remain many opportunities to improve communication between staff, patients and carers, and for this reason, a strong sustainability approach was always part of the program planning and outputs. Our efforts have focused on four elements of sustainability: training trainers to train, giving staff members direct access to ISBAR training resources, making training mandatory annually and so embedding ISBAR so that its use reaches a critical mass, and the idea pervades our organisation with a life of its own. We believe it can be said that the ISBAR program has, in many ways, settings, and processes, become embedded in HNE Health: ISBAR has turned into a noun and a verb in our organisation (as made evident by requests such as Can you send me an ISBAR on that? ). However, Clinical Governance will continue efforts to improve communication between staff, patients and carers, with, in 2012, a continuing plan for improving and building capacity in high-risk categories of health communication, such as clinical handover - that most fundamental of communication processes in health care. Maintaining ISBAR resources available to support staff in communication, as well as monitoring trends in communication incidents in health care, are part of Clinical Governance s on-going commitment to excellence in communication across the health services spectrum. Recommendations arising from lessons learnt during the development, implementation and evaluation of the ISBAR in our Communication program reflect this on-going commitment to excellent care. Innovation In Practice And Process The approach we developed for program implementation is innovative and useful. We were able to deliver on targets and aims by paying simultaneous attention to seven elements requiring action to effect change management: Leadership and governance, Engaging with people and processes, Training and education, Tools and resources, Evaluation and audit, Reporting and communication, and Sustainability (our LETTERS model). Other innovations in our program included developing at least four different strategies for ISBAR training (including an e-learning package for direct tuition). Where the literature would suggest that healthcare communication training required a workshop or session of some hours or even days, our training options were designed to take between 6 and 30 minutes to complete, so that any staff member, student or volunteer could undertake the training at times, places and pace most appropriate to them. For example, we demonstrated that a staff member could be effectively trained to use ISBAR in a few minutes at nursing shift handover using only a prompt card the size of an identification badge. Our innovative model for program sustainability was developed de novo by the program team to ensure growth, development and sustainability of workforce capacity to use and communication using the ISBAR format. Applicability To Other Settings HNE Health ISBAR tools, resources and training methods are already being used across NSW Health (in clinical handover and deteriorating patient programs), elsewhere in Australia, and in the United Kingdom and New Zealand. The LETTERS change management / program implementation model has informed program strategy outside HNE Health, including by the NSW Clinical Excellence Commission. The Australian Commission on Safety and Quality in Health Care website carries resources developed by HNE Health. Training in ISBAR has extended locally beyond HNE Health staff to undergraduate students at the Universities of Newcastle and New England, to staff within partner nongovernment organisations, and to general practitioner training. 15 th Annual ACHS Quality Improvement Awards 2012 Page 5 of 41

10 Category: Non-Clinical Service Delivery QI Award Winner We believe that due to skilful innovative planning, strong Executive support, sound capacity building principles and a sustainable transferrable training model the ISBAR in Our Communication program is an outstanding example of building the health workforce to improve the quality, safety and efficiency of health care. As we have found, as a tool ISBAR has universal application for all forms of communication.. References Agarwal R, Sands DZ, Schneider JD, et al, Quantifying the Economic Impact of Communication Inefficiencies in U.S Hospitals. Journal of Healthcare Management; Jul/Aug; 55, 4 ( ). Aldrich R, Duggan A, Lane K, Nair K and K Hill, ISBAR revisited: identifying and solving barriers to effective clinical handover in interhospital transfer. Final Report for the Australian Commission on Safety and Quality in Health Care. Newcastle: Clinical Governance. Finnigan MA, Marshall SD, Flanagan BT, ISBAR for clear communication: One hospital s experience spreading the message. Australian Health Review 34 (4): ill K, Aldrich R, Lawson D, Easton T, Enhancing clinical communication: characterising the role of communication in clinical incidents and complaints. International Society for Quality in Health Care Annual Conference, Boston, 30 September 3 October. Joint Commission. Improving America s hospitals: the Joint Commission s annual report on quality and safety, Available at: Annual_Report.pdf Scott SD, Hirschinger LE, Cox KR, et al, The natural history of recovery for the health care provider second victim after adverse patient events. Qual Saf Health Care;18:325e30. Victorian Quality Council, Promoting effective communication among healthcare professionals to improve patient safety and quality of care. Melbourne: Victorian Government Department of Health. Page 6 of th Annual ACHS Quality Improvement Awards 2012

11 Category: Non-Clinical Service Delivery QI Award Winner Figure 1. All HNE health cluster ISBAR training compliance report percentage of staff trained 2011 with ISBARimplementation target and cluster actual trend lines Proportion staff trained in ISBAR, Primary and Community Network Clusters, as of 30 November 2011 Figure 2. All HNE health acute services ISBAR training compliance report percentage of staff trained to 1 December 2011, with ISBAR implementation target and acute actual trend lines Proportion staff trained in ISBAR, Acute Networks, as of 30 November 2011 Figure 3. Pre and post training evaluation for in-person ISBAR training, January 2011 to November 2011: shifts in self-assessed confidence, skill, likelihood, ease of use and confidence to teach ISBAR n= th Annual ACHS Quality Improvement Awards 2012 Page 7 of 41

12 Category: Non-Clinical Service Delivery QI Award Winner Table Total incidents Communicationrelated incidents Total incidents Communication-related incidents Clinical incidents (IIMS) (5.4%) (0.75%) Number of communication-related incidents as a proportion of all reported incidents, Figures 5 and 6. Proportion of root cause analyses finding root causes in Jan-Dec 2006 (n=127) and Jan- Nov 2011 (n= 61) where communication was cited as a causal factor Figure 7. Page 8 of th Annual ACHS Quality Improvement Awards 2012

13 Category: Non-Clinical Service Delivery QI Award Submissions Submissions Hong Kong Baptist Hospital, Kowloon, Hong Kong Procurement and Supplies Department Advancement of medical equipment Hong Kong Baptist Hospital, Kowloon, Hong Kong Procurement and Supplies Department Streamline management and supply of nonmedical stock items Hunter New England Local Health District, New Lambton, NSW Hunter New England Pharmacy Services Enhancing clinical capacity of Hunter New England Pharmacy Services Junee Correctional Centre Junee, NSW Health Services Department Healthy Inside Program Karitane, Villawood, NSW Karitane Education and Research Department Karitane in China Lourdes Hospital and Community Health Service Dubbo, NSW Executive Lourdes Relocation Mater Misericordiae Health Services Brisbane Ltd South Brisbane, Qld Environmental Sustainability Turn it off: Encouraging environmentallyfriendly behaviours in the workplace Royal Brisbane and Women s Hospital Herston, Qld Critical Care and Clinical Support Services Procurement of nitrogen generator Royal Brisbane and Women s Hospital Herston, Qld Critical Care and Clinical Support Services A problem? Solve it! With a problem-solve-it St John of God Hospital Murdoch, WA Planning and Strategy Environmental Sustainability Program St John of God Hospital Murdoch, WA Workforce Take the pain out of workforce shortages St Vincent s Private Hospital, Darlinghurst, NSW Food and Nutrition Services Implementation of a Spoken Beside Menu Service across St Vincent s and Mater health, Sydney, using wireless technology Western District Health Service Hamilton, Vic Palliative Care Service Improving palliative care outcomes using peer review following the implementation of the National Standards Assessment Program Women s and Children s Health Network North Adelaide, SA BloodSafe elearning Australia, Centre for Education and Training BloodSafe elearning Australia Princess Alexandra Hospital Woolloongabba, Qld Centre Nursing Excellence, Clinical Practice, Nursing Standards and Innovation Building organisational culture through a nursing excellence framework Royal Brisbane and Women s Hospital Herston, Qld Department of Medical Imaging Reform Services GR8, Thanks 4 Da Reminder 15 th Annual ACHS Quality Improvement Awards 2012 Page 9 of 41

14 Category: Clinical Excellence & Patient Safety QI Award Winner Antibiotic Stewardship... It s as EASY as easy Antibiotic Stewardship Team Northern Beaches Health Service Mona Vale, NSW Andrew Montague Bernard Hudson Norman Masood Gianluca Parisi Deborah Tong Aim To optimise clinical outcomes while minimising unintended consequences of antibiotic use such as toxicity and resistance, and reduce healthcare costs associated with the management of multi-resistance organisms. Abstract Antibiotic stewardship is of critical importance to combat the growing problem of multiresistant bacteria. A multi-pronged intervention strategy was devised at Northern Beaches Health Service, which includes two district hospitals (Manly and Mona Vale). Interventions included implementation of a locally developed electronic antibiotic stewardship system easy, encouraging earlier de-escalation of therapy and planning for antibiotics in surgical prophylaxis. Application of EQuIP Principles EQuIP principle 1. A Consumer / Patient Focus The consumers were identified by the team as both staff and patients. Infectious disease is one of the major indications for admission to Manly and Mona Vale Hospitals. In hospitalised patients there is evidence to suggest that up to 50% of prescribing of antibiotics is inappropriate and that can potentially increase the risk of development of resistance. Patients presenting to hospital were noted to be elderly with multiple comorbidities. The choice and timely administration of antibiotics is a major determinant of positive outcomes in this group of patients. Antibiotic stewardship has been demonstrated to improve quality of prescribing. The four major problems faced by our consumers were found to be: 1. Patient safety: Inappropriate indication and dosing of antibiotics Delay in accessing vital antibiotics Delay in pharmacy review 2. Lack of communication: Process relied on prescribers and infectious diseases staff No designated infectious diseases physician or pharmacist as a point of reference for prescribing 3. Antibiotic access: Medical staff unaware of restriction status of different antibiotics Restricted antibiotics access could not be controlled effectively especially after-hours Page 10 of th Annual ACHS Quality Improvement Awards 2012

15 Category: Clinical Excellence & Patient Safety QI Award Winner 4. Lack of effective governance structure: Absence of local guidelines on antibiotics use No formal governance structure to oversee utilisation EQuIP principle 2. Effective Leadership A multidisciplinary Antibiotic Stewardship group was formed after the issue of Antibiotic Stewardship and the emergence of microbial resistance in the local catchment area was raised at the Infection Control Committee. Antibiotic Stewardship is one of the 5 main components of the Australian Commission on Safety and Quality in Health Care (ACSQHC). The latest publication from the same office recommends that Hospitals have an antimicrobial stewardship program that includes an antimicrobial prescribing and management policy, plan and implementation strategy that are regularly reviewed The easy project was developed as a joint initiative involving infectious diseases, Pharmacy, Information Technology and Northern Beaches Health Service Infection Control Services. It was endorsed by Northern Beaches Health Service Executive and Northern Sydney Local Health District Executive and Clinical Governance Unit. EQuIP principle 3. Continuous Improvement The group reviewed current practice at NBHS to identify current issues, and the extent of the problem related to antimicrobial management. The following issues were identified: Up to 30% of patients dispensed restricted antibiotics were not known to microbiology due to a lack of governance and monitoring structure Infectious disease physicians were not always accessible to approve therapy resulting in delays in initiation of life-saving therapy Significant issues were identified with dosing of antibiotics, with up to 50% of prescribed doses of some antibiotics being suboptimal The cost associated with restricted antibiotic use was increasing at a rate of 10% annually since 2005 Increased incidence of infections caused by resistant bacteria such as Vancomycin Resistant Enterococci and Methicillin Resistant Staphylococcus Aureus Northern Beaches Health Service was recording significantly high utilisation of broad spectrum intravenous antibiotics compared to other sector use No coordinated awareness of incorrect antibiotic use at an organisational level In order to achieve the objectives a stepwise approach to implementation was undertaken: 15 th Annual ACHS Quality Improvement Awards 2012 Page 11 of 41

16 Category: Clinical Excellence & Patient Safety QI Award Winner Step Date 1. Establishment of antibiotic stewardship group: pharmacy, infectious October 2010 diseases, divisional representatives and executive sponsor 2. Identification and contact with key stakeholders November Development and executive sign off of Project Plan February Recruitment of antibiotic stewardship pharmacists (0.4FTE) February Launch of awareness campaign to promote initiative and streamline its implementation including wall posters, presentations at clinical meetings, pharmacy newsletter and one-on-one discussion with senior clinicians November March Development of intervention strategies including: a. Implementation of restrictive process using easy March 2011 b. Registration with National Antimicrobial Utilisation Surveillance program January 2011 c. Implementation of Step-down (Intravenous to Oral switch) of therapy process Initial audit Feedback, clinical guideline development and implementation, distribution of lanyards Re-audit and feedback d. Implementation of Surgical Prophylaxis process Initial audit of appropriateness of choice of therapy Feedback (academic detailing), clinical guideline development and implementation, distribution of wall posters of recommendations Re-audit and feedback to clinicians e. Development and implementation of local antibiograms i.e resistance patterns of common antimicrobial agents in the local catchment area. Distributed to all clinical directors as well as made available through easy intranet site April 2011 May-June 2011 October 2011 May 2011 June-July 2011 November 2011 October 2011 Each of the clinical intervention strategies was implemented after a baseline audit, with feedback provided to the clinicians through the pharmacy newsletter and academic detailing by antibiotic stewardship pharmacists to clinicians. Screenshot of homepage: Page 12 of th Annual ACHS Quality Improvement Awards 2012

17 Category: Clinical Excellence & Patient Safety QI Award Winner EQuIP principle 4. Evidence of Outcomes A review of current practices with respect to antibiotic utilisation highlighted the following issues: 1. Suboptimal compliance with approval process with up to 30% of prescriptions for restricted antibiotics were without microbiology consult 2. Utilisation of key antibiotics such as third generation cephalosporin antibiotics and Fluoroquinolone antibiotics were significantly higher compared to similar facilities across Australia 3. In the setting of surgical prophylaxis, 32% of patients were prescribed antibiotics appropriately 4. Length of intravenous antibiotic therapy for management of common indications such as skin and soft tissue infections, community acquired pneumonia and urinary tract infections was inappropriate in up to 80% of patients Post Implementation of easy the following outcomes were recorded: 100% compliance with registration and feedback process with respect to restricted antibiotics prescribing Significant changes observed in utilisation of key antibiotics (see charts below) o 50% reduction in daily defined doses for Quinolone antibiotics o 30% reduction in daily defined doses for 3 rd generation Cephalosporins o Overall 25% reduction in Carbapenem use across both sites. After normalising for price changes, these interventions resulted in $60K savings over 12 months despite a 50% increase in individual patient use requests. 15 th Annual ACHS Quality Improvement Awards 2012 Page 13 of 41

18 Category: Clinical Excellence & Patient Safety QI Award Winner Surgical prophylaxis initiative Overall, a 19% change (p=0.053) in proportion of patients prescribed appropriate prophylactic antibiotic regimen. IV to Oral Switch initiative Patients prescribed inappropriate duration of IV antibiotics reduced by 57% (P<0.0002) Average extra days of IV antibiotics reduced from 3.4 to 0.6 days A 92% reduction in the cost of extra days of therapy equating to $10.5K saving in 50 patients Average length of stay reduced by ONE in-patient day Sustaining change National Antimicrobial Utilisation Surveillance program reports are published in the pharmacy newsletter and tabled at relevant organisational and departmental meetings The easy project information is part of the medical staff orientation package Ongoing audits (yearly) of prescribing with respect to step-down and surgical prophylaxis as part of the Pharmacy Department quality plan All restricted antibiotics must have a registration number from easy before being dispensed. EQuIP principle 5. Striving for Best Practice Quality Standard (ACSQHC) Hospitals have an antimicrobial stewardship program that includes an antimicrobial prescribing and management policy, plan and implementation strategy that are regularly reviewed Hospitals have an antimicrobial formulary and guidelines for antimicrobial treatment and prophylaxis that align with Therapeutic Guidelines: Antibiotic and are regularly reviewed Hospitals establish a multidisciplinary antimicrobial stewardship team that is responsible for implementing the antimicrobial stewardship program. At a minimum, the team should include either an infectious diseases physician, clinical microbiologist or nominated clinician (lead doctor), and a pharmacist The antimicrobial stewardship program resides within the hospital s quality improvement and patient safety governance structure and is included within the hospital s quality and safety strategic plan Antimicrobial stewardship teams have clearly defined links with the drug and therapeutics committee, infection prevention and control committee, and clinical governance or patient safety and quality units Team members have clearly defined roles and responsibilities. Team members should be sufficiently supported and trained to enable them to effectively and measurably optimise antimicrobial use by using interventions appropriate to local needs, resources and infrastructure Antimicrobial stewardship process and outcome indicators are measured and reported to the hospital executive. NBHS Achievement Fully functional antibiotic stewardship program complemented with endorsed guideline for prescribing and management. Established antimicrobial formulary that is part of guidelines and available on the easy intranet website. Decision support provided by easy is consistent with therapeutic gudielines. Antibiotic Stewardship implementation group established that includes: Executive sponsor, infectious diseases physician, antibiotic stewardship pharmacist, surgical and medical representatives as well as Director of Pharmacy. Part of NBHS medication safety committee regular agenda item. NBHS ASIG regularly meets and provides feedback to Drug committee, Infection control committee, Medication safety committee, NBHS Executive committee and NS LHD Infection and prevention control committee. A comprehensive project plan developed and made available to all team members. GANTT Chart reviewed at each meeting to monitor progress of the project. National Antimicrobial Utilisation Surveillance Program reports tabled at relevant committees. easy reports provided to relevant teams as well as Executive Sponsor for review. Page 14 of th Annual ACHS Quality Improvement Awards 2012

19 Category: Clinical Excellence & Patient Safety QI Award Winner Innovation In Practice And Process The fundamentals of an Antibiotic Stewardship program must include a restrictive process for accessing antibiotics, clinical decision support and prospective prescribing feedback. easy has been designed to incorporate all three aspects in a simple and streamlined process (See Appendix 1 and 2 for pre and post implementation flowcharts) for all stakeholders. Prescribers requesting a restricted antibiotic are directed to select the location and type of infection, e.g Genito-urinary Tract and Pyelonephritis. easy highlights guidelinebased therapy for the selected indication while at the same time allowing a request for therapy deviating from guidelines. Prescribers get immediate feedback about their prescribing as easy notifies the relevant stakeholders of the request and feeds back all comments and decisions back to prescribers. The status of all requests can be viewed by the medical (team specific requests), pharmacy (hospital specific requests) and infectious diseases teams (all requests). (See Appendix 3 on workflow with respect to accessing restricted antibiotics.) Of particular note are the rapid access to antibiotics, improvements in communication between stakeholders, rapid prospective feedback and decision support. easy is an innovative tool because it provides a basic framework for management of high risk medications in an institutional setting by combining the elements of safety and efficacy. Applicability To Other Settings The project has attracted significant interest across New South Wales Health. NBHS is currently in negotiation with other hospitals within Northern Sydney Local Health District and across other LHDs for transfer of the registration program and related guidelines free of charge. A similar decision support system is commercially available for purchase at a substantial cost. easy has multiple advantages that can make it useful to other hospitals and local health districts: 1. Cost effective 2. Allows organisations to tailor therapy recommendations based on local guidelines / preferences 3. Periodic reports can be used to monitor therapies and modulate prescribing behaviour 4. Is integrated with Citrix Powerchart References Cruickshank M, Ferguson J, Reducing Harm to patients from Healthcare associated Infection: The role of Surveillance. Sydney: Australian Commission on Safety and Quality in Health Care, Duguid M, Cruickshank M. Antimicrobial stewardship in Australian Hospitals 2011 Radford J Cardiff L, Pillans P, Fielding D, Looke D. Drug usage evaluation of antimicrobial therapy for community acquired pneumonia. Australian Journal of Hospital Pharmacy 1999;29: Robertson M, Korman T, Dartnell J, Ioannides- Demos L, Kirsa S, Lord J, Munafo L, Byrnes G. Ceftriaxone and Cefotaxime use in Victorian hospitals. Medical Journal of Australia 2002;176: To N, Khan Z, Chiu F, Jordan M, Koller L, Daly G, Amour C. Low levels of adherence to antibiotic prescribing guidelines within emergency departments. Australian Journal of Hospital Pharmacy 1999;29(3): th Annual ACHS Quality Improvement Awards 2012 Page 15 of 41

20 APPENDIX 1: APPROVAL PROCESS SINCE LAUNCH OF easy NBHS RESTRICTED ANTIBIOTIC APPROVAL PROCESS Note: This Approval process does not apply to patients in Intensive Care units but Approval will be required once patients are transferred to the general wards RESTRICTED ANTIBIOTIC REQUIRED Authorisation Number: Login to easy and obtained a temporary Approval Number prior to prescribing a restricted antibiotic Please note for certain products PRIOR approval will now be required before dispensation. Documentation: Prescriber obtaining authorisation number must document it in the pharmacy box of patient s medication chart. easy will notify on call ID Physician / Antibiotic Stewardship Pharmacist and provide a temporary approval number FAX MEDICATION CHART TO PHARMACY FOR SUPPLY DECLINED APPROVED Permanent Approval Number Request reviewed by the Antibiotic Stewardship Pharmacist After Hours Nurse Manager can dispense hours supply MEDICAL TEAM NOTIFIED APPROVAL NUMBER DOCUMENTED ON THE MEDICATION CHART Pharmacy to dispense hours supplies until ID Physician decision. Further supply dependant on decision Page 16 of 38 MEDICATION ORDER CEASED electronic Antibiotic Stewardship System (easy) If easy inaccessible contact: Microbiologist On call 24/7 RNSH:

21 APPENDIX 2: APPROVAL PROCESS BEFORE IMPLEMENTATION OF easy RESTRICTED ANTIBIOTIC APPROVAL PROCESS FOR THE NORTHERN BEACHES Note: This Approval process does not apply to patients in Intensive Care units but Approval will be required once patients are transferred to the general wards RESTRICTED ANTIBIOTIC REQUIRED Microbiologist On call 24/7 RNSH: Page through switch Authorisation Number Must be obtained prior to prescribing a restricted antibiotic OR Where this is not possible within 24 hours of therapy commencement. Please note for certain products PRIOR approval will now be required before dispensation. Documentation Prescriber obtaining authorisation number must document it in the pharmacy box of patient s medication chart. It is the MICROBIOLOGIST S responsibility to relay to PHARMACY any unusual doses or Non-Formulary products. Periodic audits will be carried out to monitor adherence. CONTACT WARD PHARMACIST OR AFTER HOURS NURSE MANAGER (AHNM) FOR AVAILABILITY PRODUCT AVAILABLE PRODUCT NOT AVAILABLE Pharmacy will dispense up to 5 days supply at a time for all approved products unless approval is for less than 5 days. For unapproved orders, 24 hours supply once AHNM will dispense 24 hours supply at a time for all approved and unapproved orders. Individual patient use form must be filled out and approved by Director of medical Services or Director of Pharmacy. Up to 24 hours delay can be only pending approval. No stock will be expected during weekdays and th dispensed Annual ACHS for Quality items requiring Improvement prior Awards approval 2012 Page hours 17 of 41 on the weekend until approved. AHNM can authorise access from another hospital after discussion with Executive on call or Director of Pharmacy

22 APPENDIX 3: easy workflow MICROBIOLOGIST LOGS-IN PHYSICIAN LOGS IN Views current requests Starts new request Enters Patient s MRN Selects location of infection and Indication System automatically generates recommended therapy as per etg and/or Local facility guidelines PHARMACIST LOGS IN Views Temporary approvals Physician selects recommended therapy or can choose to prescribe against local guideline Antibiotic(s) Selected VIEWS ALL RECENTLY ENTERED ORDERS PLUS CURRENT ORDERS RESTRICTED UNRESTRICTED Temporary Approval Number Thanks for notifications Notification to Microbiologist Physician Pharmacist Pharmacist s comment Decision APPROVE DECLINE Physician to document in medical records /NIMC Permanent approval number Microbiologist s history Physician s Team history Pharmacist s history Auto Refresh after 4 weeks unless approval still current Pharmacist s CLOSES non-current orders Pharmacist s history

23 Category: Clinical Excellence & Patient Safety QI Award Highly Commended Medication Safety Round together with other strategies to reduce medication incidents Hong Kong Baptist Hospital Kowloon, Hong Kong Cinder Chan Suky Lo Shuk Han Chan Samantha Chong Aim To reduce medication incidents by promoting a medication safety culture through frontline engagement. Summary of methodology and outcomes: To reduce the number of medication incidents proactively. Formation of working group that reviewed available literature and best-practice standards. Create a comprehensive medication management program including Medication Safety Round (MSR), incident review (root cause analysis), competence test, nursing audits, slogan creation competition, education talks and medication quiz. Starting from August 2010, Medication Safety Round (MSR) was implemented as a new initiative in order to examine any system and process deficits regarding medication safety. Starting from 2011, in addition to the regular Administration of Oral Medication (AOM) audits, all nurses were required to undergo an AOM Competence Test conducted by Advanced Practice Nurses or NOs (Clinical Management). The result was 100% compliance. An incident Root Cause Analysis (RCA) was conducted jointly by a DCNO/SNO/NO from the Nursing Administration Office (NAO) and the involved EQuIP principle 1. A Consumer / Patient Focus Abstract Application of EQuIP Principles department head for every Medication Incident (MI) in RCA skills have been transferred to department heads. Starting from Jan 2012, incident RCA was carried out by the respective department heads. Slogan competition was held in The winning slogans have been used in educational posters displayed in clinical areas. Education training and medication quiz were held to enhance the drug knowledge of nursing staff. Audit on administration of oral medication, administration of intramuscular medication, administration of intravenous solution with additives and administration of vaccination were conducted. Other strategies including use of medication vests during medication administration rounds.the outcome was a significant reduction of medication incidents from 0.20% (2011) to 0.03% (2Q 2012). A safe medication culture was built as frontline staff were actively engaged. A working group with frontline nurses led by a DCNO was formed in The focus was on medication management for safety of consumers. Stakeholders were extensively 15 th Annual ACHS Quality Improvement Awards 2012 Page 19 of 41

24 Category: Clinical Excellence & Patient Safety QI Award Highly Commended consulted on related policies and practices, and storage of high risk drugs. Staff engagement was ensured by MSR on the field, with participation of the frontline throughout the process from initial review, improvement planning and debriefings. Slogan competition attracted 29 submissions from frontline. A Medication Safety Vest was designed with frontline input for put-on by nurses during medication administration round, to reduce avoidable distraction and interruption. EQuIP principle 2. Effective Leadership The senior management of HKBH is committed to ensuring patient safety by promoting a culture of safety. Medication Safety Committee, chaired by the Director of Medical Services, has the mission to prevent and reduce MIs by putting in place an effective medication management system. It reviews medication related policies and practices, drug distribution and administration, as well as education for staff and the public. Hospital Quality Risk and Safety Steering Committee, chaired by the Chief Executive Officer, monitors and receives reports from the Medication Safety Committee. The CNO has started and led the safe medication management program since Aug EQuIP principle 3. Continuous Improvement Introduction of Medication Safety Round from Aug Introduction of incident Root Cause Analysis from Jan A Working Group on Safe Medication Management with frontline nurses led by a DCNO was formed in The strategy was to engage frontline staff and to build a safety culture. Regular AOM Audit was conducted. Education talks provided by pharmacists and other professionals to all nurses. Results of the incident RCAs presented to all nursing staff via NOs at the monthly ward meetings. Bi-annual Medication Quiz for all nursing staff including NOs for knowledge enhancement. Review of high-risk medication storage. Review of medication policies regularly. EQuIP principle 4. Evidence of Outcomes Medication incidents were significantly reduced from 0.20% (2011) to 0.03% (2Q 2012). 88 medication safety rounds conducted in all clinical areas, observations were debriefed with department heads and open discussions were encouraged. 100% of nursing staff went through the AOM competence test in Good compliance audit results on administration of oral medication, administration of intramuscular medication, administration of IV infusion with additives and administration of vaccination (oral and injection). EQuIP principle 5. Striving for Best Practice The nursing leadership team (CNO, DCNOs, SNOs and NOs) demonstrated their commitment to strive for best practice by continuous learning through attending national and international seminars. Updated knowledge was applied to develop the new medication management system in HKBH. Regular review of literature on current best practice based on scientific evidence by senior nurses of NAO. Monthly data analysis of Key Performance Indicators (KPI) by SNO / NO of NAO to monitor the performance, and to make performance based plan for continuous improvement. Monthly KPI data are reviewed by CNO. The strive to reduce MI will continue by promoting a medication safety culture through frontline engagement. Innovation in Practice and Process The innovative MSRs proved to be an effective staff engagement process in MI risk identification and improvement Page 20 of th Annual ACHS Quality Improvement Awards 2012

25 Category: Clinical Excellence & Patient Safety QI Award Highly Commended planning. Numerous improvement measures have been instituted. Incident review (Root Cause Analysis) of all medication incidents to identify the root causes and skills have been transferred to the department heads so they would own the issue. Design of the Medication Safety Vest and Slogan Competition have added artistic flavour and intellectual challenges to a basically technical operational issue. A Risk Register was compiled to record and review medication-associated risks. Applicability to Other Settings The works and results of the medication safety program were shared with staff of different departments within the hospital through meetings and newsletters. A poster on MSR - Walk the Talk - Medication Safety Round in HKBH was presented at the International Medication Safety Conference in Hong Kong in Nov Safe medication management is a challenge of universal interest in all hospitals. The innovative programs (MSR, AOM Competence Test, Incident RCAs, Medication Safety Vest, Slogan Competition, Risk Register) presented in this report are simple to adapt in any hospital. These programs, together with the results showing initial success, could be shared with any hospital with the same vision to reduce MIs. The MSR in particular is highly recommended to other hospitals as it proves to be an effective staff engagement process in MI risk identification and improvement planning. 15 th Annual ACHS Quality Improvement Awards 2012 Page 21 of 41

26 Category: Clinical Excellence & Patient Safety QI Award Highly Commended The Geriatric Flying Squad an initiative in aged care community management War Memorial Hospital Waverley, NSW Amanda Klahr Aim To reduce acute hospitalisation and Emergency Department (ED) attendances through the provision of timely multi-disciplinary community-based care for frail elderly patients with a sub acute decline in health and to improve levels of satisfaction with service provision from both GPs and clients. Background The Geriatric Flying Squad (GFS), based at War Memorial Hospital (WMH), is a rapid response, multi-disciplinary team (MDT) model of care providing comprehensive geriatric assessment and management for communitydwelling elders failing at home. Methodology MDT, Geriatric specialist nurses, Geriatrician, Social Work, Psychology, Physiotherapy, and Occupational Therapy. Referrals can be made by anyone in contact with the client. Clients are triaged, assessed and managed in the community. Direct admission bypassing ED if hospitalisation needed. EQuIP principle 1. A Consumer / Patient Focus The Flying Squad provides a service that is fast, accessible and is tailored to the individual patient s needs Demonstrates fast response times Covers a large geographical area Takes care to the client providing most of its service in the client s home Broad admission criteria No barrier to referral Abstract Application of EQuIP Principles Flexible model of care. Assessment and management entirely by Geriatric Flying Squad (GFS) team. Paperless service using Virtual Private Network (VPN) and wireless technology. Outcomes Prevention of acute care and Emergency Department (ED) admissions. Improved functioning and quality of life. Patient and GP satisfaction. Flexible program of care. EQuIP principle 2: Effective Leadership Networking and canvassing a multitude of existing community and health related services that service the GFS clientele. The Flying Squad has presented its model and outcomes all over NSW and Australia in an effort to encourage other organisations to adapt the model. Page 22 of th Annual ACHS Quality Improvement Awards 2012

27 Category: Clinical Excellence & Patient Safety QI Award Highly Commended GFS clinicians provide education to nurses and doctors, medical and nursing students at the WMH. The GFS: Is coordinated and led by a geriatric CNC Has a weekly multi-disciplinary case conference Has a monthly debriefing lunch. EQuIP principle 3. Continuous Improvement The Flying Squad has surveyed client, care givers and referrers twice to use feedback to improve the service. Data are collected on GFS referrers, clientele, intervention and outcomes. It manages its own database as well as using data collected through CHIME and SPARC. Regrade of allied health team members from level 2 to level 3. Increase in specialist geriatric nursing hours to accommodate for large demand on the service. Addition of dietician to team in January EQuIP principle 4. Evidence of Outcomes Hundreds of clients have been assessed. Rapid response times achieved. High client, carer and referrer satisfaction and many ED and acute hospital admissions avoided EQuIP principle 5. Evidence of Best Practice Use of standardised assessment tools across all disciplines to provide objective and transferable measures. Taking clinical notes to the bedside allows for real time clinical handover whenever transfer of care is required or there are multiple teams or clinicians involved. Follows principles of NSW Health Redesign. Innovation in Practice and Process The Flying Squad uses specialist geriatric nurses with direct routes of admission into geriatric medical assessment units and sub acute geriatric rehabilitation units as well as the backing of a specialised geriatric multidisciplinary team to allow for rapid, efficient, patient-centered care. The Flying Squad is paperless, using the Community Health Information Management Enterprise (CHIME) database. It also uses laptops, VPN and wireless internet technology to take clinical notes to the bed side. Applicability to Other Settings The Flying Squad model has been adapted to other sites, with Geriatric Flying Squads now operating out of St. George and Sutherland hospitals. 15 th Annual ACHS Quality Improvement Awards 2012 Page 23 of 41

28 Category: Clinical Excellence & Patient Safety QI Award Submissions Alfred Health Pharmacy Department and Infectious Disease Unit Improving antimicrobial use in hospitals:the impact of formal antimicrobial stewardship implementation Ballarat Health Services Sub-acute Services The Dementia Care in Hospitals Program Bentley Health Service Nutrition & Dietetics, Patient Support Services and Catering Assessment of Nourishing Snack consumption on aged care rehabilitation ward Cabrini Health Emergency Department Phone follow-up of patients discharged from the Emergency Department Central Adelaide Local Health Network FAST-NOF Team, The Queen Elizabeth Hospital Improving the care of people admitted with a neck of femur fracture Central Coast Local Health District Psycho Social Team, Cancer Services An innovative approach to the management of cancer related fatigue Central Coast Local Health District Children s Ward, Gosford Hospital Safe paediatric administration if medications (SPAM) Eastern Health Intensive Care Services Introduction of an integrated clinical deterioration framework across a health network Goulburn Health Service Goulburn Base Hospital Stroke Referral Project Hong Kong Baptist Hospital Central Sterile Processing Department / Operating Theatre Patient safety through quality management systems in decontamination and sterilisation Submissions Hunter New England Local Health District Cessnock District Hospital Nurse initiated thrombolysis in rural facilities (NIT) Hunter New England Local Health District Cessnock Drug and Alcohol Service and Community Engagement and Action Program Perfect Pegs Hunter New England Local Health District Hunter New England Oral Health Resi-DENTAL Care Program Hunter New England Local Health District Acute Stroke Service, Department of Neurology, John Hunter Hospital The rural pre-hospital acute stroke triage (rural PAST) project Hunter New England Local Health District Hunter Institute of Mental Health (HIMH) Partners in depression supporting those who care Hunter New England Local Health District Division of Emergency Medicine Chronic pain in the Emergency Department Hunter New England Local Health District Emergency Department, John Hunter Hospital OPTA-mising the ED care for older people at risk of delirium Hunter New England Local Health District Emergency Department, John Hunter Hospital ACE-ing emergency care of people in residential aged care Karitane Liverpool Family Care Centre In sync at Karitane Kyabram and District Health Service Clinical Services End of Life Care (EOLC) Pathway Project Lourdes Hospital and Community Health Service Nursing Transfer of care Lourdes Hospital and Community Health Allied Health Therapy Activity Group Page 24 of th Annual ACHS Quality Improvement Awards 2012

29 Category: Clinical Excellence & Patient Safety QI Award Submissions Mater Hospital Sydney Quality Department Hardwiring Excellence Mercy Hospital for Women Emergency Department Improving triage of pregnant women in the emergency department NephroCare Clinics-Fresenius Medical Care NephroCare Clinics Nurse initiated hypotension prevention in dialysis North Shore and Ryde Health Service Renal Department Vascular access surveillance using Transonic Flow Measurement Northern Health Organ and Tissue Donation Service Interpreter education on end-of-life and organ donation conversations Peninsula Health Pharmacy Department PRO-STEO Project (improving osteoporosis management in the acute hospital setting) Peninsula Health Medication Safety Team A continuous improvement approach to engaging staff in the uptake of Smart Pumps with medication safety software Royal Brisbane and Women s Hospital CT Radiography Team, Department of Medical Imaging, 24/7 CT Service in DEM Royal Brisbane and Women s Hospital Safety and Quality Unit and Department of Internal Medicine and Aged Care Eat Walk Engage Royal Brisbane and Women s Hospital Thoracic Medicine Reducing chest tub complications Royal Brisbane and Women s Hospital Nursing Staff, Department of Emergency Medicine, Critical Care and Clinical Support Services AIN rounding in DEM Royal Brisbane and Women s Hospital Department of Emergency Medicine and Patient Flow Unit Ready Set Go Meeting NEAT Royal Brisbane and Women s Hospital Nursing Staff, Department of Emergency Medicine No pain is a gain: Time to analgesia improvement in DEM Royal Victorian Eye and Ear Hospital Ophthalmology Services Optometry-Ophthalmology Workforce Collaboration Southern NSW Local Health District Eurobadalla Community Health Falls prevention minimisation with music and dance South Western Sydney Local Health District Renal Services, Liverpool Hospital RENEW Improving the healthcare experience for renal patients planning for dialysis South Western Sydney Local Health District Physiotherapy Department, Liverpool Hospital Effectiveness of a home based Pulmonary Rehabilitation Program (PRP) in patients with COPD who are unable to attend a hospitalbased pulmonary rehabilitation program: a retrospective review Southern NSW Local Health District Goulburn Mental Health Inpatient Service Mental Health between the flags DETECT workshops Southern NSW Local Health District Emergency Department, Queanbeyan Hospital Implementation of Critical Emergency Response System (CERS) Queanbeyan Southern NSW Local Health District Oral Health Services, Queanbeyan Hospital Radiographs as diagnostic tools for Queanbeyan Oral Health Services St Vincent s Private Hospital Nursing Harnessing quality and governance frameworks for clinical excellence and patient safety The Children s Hospital at Westmead Department of Emergency Medicine and Operating Suite Improving patient care through enhancing staff skills and competencies an interdisciplinary in-situ simulation program 15 th Annual ACHS Quality Improvement Awards 2012 Page 25 of 41

30 Category: Clinical Excellence & Patient Safety QI Award Submissions The Haymarket Foundation The Bourke Street Project Increasing the effectiveness and appropriateness of care by reducing incidence of relapse within a dual diagnosis recovery program Western Health Nursing Executive I thought I would die from it Wollongong Hospitals and Community Health Service Primary Health Nursing Team and Ambulatory Care Team Operation cooperation: a shared care model for peri-operative anticoagulation management Wollongong Hospitals and Community Health Service Day Rehabilitation Program Developing a day rehabilitation program to improve outpatient services and save inpatient bed days Page 26 of th Annual ACHS Quality Improvement Awards 2012

31 Category: Healthcare Measurement QI Award Winner Making food and nutrition care a priority on St Vincent s Campus FOOD AND NUTRITION SERVICES ST VINCENT S PRIVATE HOSPITAL NSW Carmel Lazarus Guy Nelligan Aim To provide optimal nutritional care and professional hospitality, as a critical component of the patient s total clinical care package; engendering a collaborative and coordinated approach to patient care Abstract The evidence indicates that 30-50% of patients in hospitals in Australia and overseas suffer from malnutrition, and good nutrition and a positive patient experience directly impacts patients health outcomes. Recognising that Food and Nutrition care is a complex process, a review, including a gap analysis, was done of the current Food and Nutrition services on St Vincent s Campus to identify shortfalls in the nutrition care. St Vincent s Campus, Darlinghurst, encompasses St Vincent s Hospital, Sacred Heart and St Vincent s Private Hospital and is part of St Vincent s Health Australia. By monitoring available data sources such as patient feedback, patient satisfaction surveys and quality assurance data, the following observations were made confusion with staff roles, some meal issues remained unresolved, patients felt disconnected and meal access was an issue. St Vincent s Campus Food and Nutrition Services was a key contributor to the Agency for Clinical Innovation (ACI) Nutrition in Hospitals Network in the development of a model which encourages a collaborative and coordinated approach to nutrition care in NSW hospitals. This endorsed framework maps the patient s nutrition care journey and identifies best-practice systems to ensure patients receive an optimal Food and Nutrition service. This framework was adapted for St Vincent s Campus to improve the patient s healthcare experience. Our patient-centered Food and Nutrition care model involved the following: Governance committee structure established including Nutrition and Quality Committees, ensuring coordinated care. An overarching nutrition policy developed which included a charter of staff responsibilities and ownership. Nutrition screening on admission (Malnutrition Screening Tool as part of the patient s risk assessment on admission) and identification of nutritionally at-risk patients throughout admission. A Spoken Bedside Menu Service with qualified Nutrition Assistants, providing advice to meet nutrition targets prescribed by the Dietitians. Meals and Beverage Service DVD training program developed with Hunter TAFE, achieving excellence in service standards and patient interaction from meals service staff. New menu and recipe program developed incorporating the NSW Nutrition Standards, with an engaged patient representative on the Menu committee and Sensory Analysis panel. Patient Advocacy established with consistent high volumes of patientgenerated feedback and patient representation in committee structure. 15 th Annual ACHS Quality Improvement Awards 2012 Page 27 of 41

32 Category: Healthcare Measurement QI Award Winner Meal Access procedure whereby Meals Service Staff ensure the patient s tray table is within reach and any food packaging is opened as required. These outcomes of the above programs include the following achievements: 1. Increase in Press Ganey patient satisfaction results following the implementation of the Food and Nutrition care model, with benchmarks well exceeded. 2. Threefold increase in the quantity of patient feedback after implementation of the Food and Nutrition care model. 3. Recipient of SVHA 2012 Quality Awards Exceptional Care for Patients - St Vincent s Campus Food and Nutrition Care Model. 4. Awarded Outstanding Achievement for ACHS EQuIP5 Nutrition Criterion. 5. Finalist for Bedside Menu Service in SVHA Quality Awards Nomination as a finalist for the CBORD Visionary award. Application of EQuIP Principles EQuIP principle 1. A Consumer / Patient Focus Application of this patient-centered framework has engendered a collaborative approach to nutrition care, ensuring that the finite resources are well targeted for effective patient recovery. Working relationships between Food Services Staff, Dietitians, Nutrition Assistants, and other Clinical Staff were strengthened due to the patient being the central focus. A high volume of patient feedback is received monthly, with significant increases in February and March 2012 compared to the same period in Press Ganey patient satisfaction data for staff courtesy and menu service significantly increased in February and March 2012 compared to the same period in The model allows staff to be connected with the patient experience and respond to meal service issues in a timely manner. Figure 1: Patient Feedback Sample Page 28 of th Annual ACHS Quality Improvement Awards 2012

33 Category: Healthcare Measurement QI Award Winner Figure 2: Patient Feedback Sample Figure 3: Patient Feedback Sample Through the Patient Advocacy program there is effective patient engagement in menu development and service provision. Our Patient Advocate visits inpatients across the Campus and is in contact post discharge. This patient feedback is tabled at monthly Menu Review committee meetings. Recipe development and taste testing involves patient representation and, coupled with the documented patient feedback, provides a robust system to drive change and improvement in services. Committee minutes record patient feedback and resultant actions to improve processes generated from this feedback. Qualified Nutrition Assistants are now ward-based rather than office-based and take menu selections at the bedside, providing nutrition advice and supporting Clinicians in nutrition care delivery, with wireless real time access to Clinicians instructions about meal prescriptions. 15 th Annual ACHS Quality Improvement Awards 2012 Page 29 of 41

34 Category: Healthcare Measurement QI Award Winner Following Meals Service training, staff engage in a professional manner at the point of meal delivery, assisting patients with access to their meals, reinforcing to patients that they are valued and respected, ensuring tray tables are in reach and packaging is opened. Customer Service DVD Training Figure 4: Nutrition Assistant at the Bedside with a Patient Figure 5: Training DVD EQuIP principle 2. Effective Leadership An overarching governance structure and policy was established, which generated implementation of best practice strategies. A Nutrition policy was developed collectively with members of the healthcare team. Effective governance is now in place through the Nutrition and Quality committees to ensure sustainability in the long term, monitoring compliance and evaluating the program effectiveness. Patient advocacy is a key driver to ensure effective and enduring change. This is embedded into the Food and Nutrition care model through committee membership and the documented patient feedback program. EQuIP principle 3. Continuous Improvement Press Ganey data, patient feedback and other in-house quality data identified shortfalls with confusion around staff roles and responsibilities, patient disconnect with menu and recipe review, service standards lacking awareness of patient value and existing procedures and systems outmoded. The Governance structures are now in place monthly menu review committee, Campus Nutrition Committee and Quality and Safety meetings with staff from a variety of departments. A Nutrition Policy has been developed with identified roles and responsibilities for key staff and a Nutrition Governance working party has been formed to implement nutrition strategies such as regular weights during admission for patients with LOS > 7 days. Technology is used to generate reports and used by Clinicians to screen for patients who are NBM / Clear fluids for > 3 days. The Spoken Bedside Menu Service used by Nutrition Assistants to take menu selections and provide basic nutrition instructions has now been implemented across St Vincent s and Mater Health facilities - St Vincent s Hospital, Sacred Heart, St Vincent s Private and the Mater Page 30 of th Annual ACHS Quality Improvement Awards 2012

35 Category: Healthcare Measurement QI Award Winner Hospital. The patient feedback continues to be positive as reported in Press Ganey, Acute Care Hospital Food Service Satisfaction survey results and written patient feedback. The training and education grant awarded to St Vincent s Campus allowed us to engage with Hunter TAFE to assist in the production of a customer service training DVD. All Food Service staff attended meals service training, with an emphasis on staff roles and ownership, professional presentation and service skills. A documented patient feedback program including written feedback collection and collation is tabled at monthly Menu Review Committee and Quality meetings, with patient concerns actioned. Improved meal access whereby meal service staff assist patients to access their meals and open packaging as required. Patient Advocate attendance at menu review committee and sensory analysis program. Development of a menu and recipe planning program - involving qualified Dietitians and Chefs to incorporate the NSW Nutrition standards for hospital inpatients. EQuIP principle 4. Evidence of Outcomes Press Ganey results, in-house patient satisfaction surveys, the written patient feedback system and the Patient Advocate feedback reports tabled at a range of committees across the Campus indicate that St Vincent s Campus Food and Nutrition Service has: 1. A robust system in place to capture patient responses. These responses drive change to meet our patients needs. 2. A consistently high level of patient satisfaction and confidence in the Food and Nutrition care provided. ACHS has awarded our organisation with an Outstanding Achievement rating. Graph 1: Patient Feedback Before and After Model Implementation 15 th Annual ACHS Quality Improvement Awards 2012 Page 31 of 41

36 Category: Healthcare Measurement QI Award Winner Graph 2: Press Ganey Results - Before and After Model Implementation EQuIP principle 5. Striving for Best Practice The use of this model applies best practice as it recognises all parts of the Food and Nutrition care journey from admission through to discharge and beyond and acknowledges the importance of developing effective working relationships with other members of the healthcare team in order to be of value in the long term. Implementation of various components of the Food and Nutrition care model involved collaboration with all departments, including Nursing, IT, Food Services, Quality, Dietetics, HR and Allied Health. Innovation In Practice And Process The patient-centered model provides the governance structure to ensure staff remain connected to the patient experience. This partnership extends into planning of services for the future, which may involve improved use of technology at the bedside to provide additional clinical information or a new food service system model. Applicability To Other Settings The framework underpinning the Food and Nutrition model was adapted for use across St Vincent s Campus and provides a systems approach to care that is enduring as it is not individual dependent. It was based on the ACI Nutrition Network Patient Care Nutrition Journey and ACHS EQuIP5 Program guidelines. The initiatives were developed using in-house Food and Nutrition expertise but have wider applicability in a private and public setting. Screening tools for at-risk patients and governance structures such as menu review and campus nutrition committees and the inclusion of patient representatives within the committee structures can all be applied to other departments and facilities. The meals service training program reflected our expectations for meal service and can be applied to promote customer service training in any healthcare facilities. References Capra S, Wright O, Sardie M, et al. The acute hospital foodservice satisfaction questionnaire: the development of a valid and reliable tool to measure patient satisfaction with acute care hospital food services. Foodservice Research Int 2005;16:1-14 Dube L, Trudeau E and Belanger M. Determining the complexity of patient satisfaction with Foodservices. J Am Diet Assoc 1994; 94 (2):394-8 Middleton M, Nazarenko G, Nivison-Smith I, et al. Prevalence of malnutrition and 12 month incidence of mortality in two Sydney teaching hospitals. Int Med J 2001;31: Lazarus C and Hamlyn J. Prevalence and Documentation of Malnutrition in hospitals: a case study in a large private hospital setting. Nutr & Diet 2005; 62(1):41-7 Page 32 of th Annual ACHS Quality Improvement Awards 2012

37 Category: Healthcare Measurement QI Award Winner Council of Europe, Food and Nutritional Care in hospitals: How to prevent under nutrition Council of Europe: Strasbourg. Agency for Clinical Innovation Nutrition Network, 2012, Patient Nutrition Care Journey - A guide to support implementation of the NSW Health Nutrition Care Policy St Vincent s and Mater Health, 2011, Recipe Development Program, Food and Nutrition Services Agency for Clinical Innovation Nutrition Network, 2011, Nutrition Standards for Adult Inpatients in NSW Hospitals St Vincent s Private Hospital, 2011, Nutrition Care of Patients Policy and Procedure, Document No. D/2012/8462 TAFE NSW Hunter Institute, 2011, Customer Service Training Food and Beverage Service DVD Terms of Reference Menu Review Committee Appendices Sensory Analysis Panel (Taste Testing) for Menu Development 15 th Annual ACHS Quality Improvement Awards 2012 Page 33 of 41

38 Category: Healthcare Measurement QI Award Winner Nutrition Policy Staff Roles and Responsibilities - Section 6 Meal Planning and Delivery Written Patient Feedback Program Nutrition Risk Screening During Admission Page 34 of th Annual ACHS Quality Improvement Awards 2012

39 Category: Healthcare Measurement QI Award Winner Food and Nutrition Care Model - Adapted from ACI Nutrition Network Patient Nutrition Care Journey - A guide to support implementation of the NSW Health Nutrition Care Policy 15 th Annual ACHS Quality Improvement Awards 2012 Page 35 of 41