Section 3 Templates and examples Contents 4 TEMPLATES AND EXAMPLES... 55 Quality improvement planning template... 55 Domain and key performance area checklist.... 56 Standards, guidelines and policy checklist.... 57 Action plan template... 58 PDSA cycle template... 59 Example 1. Cultural competence activity.... 62 Example 2. Care pathway activity.... 64 Example 3. Workforce activity... 66 Example 4. Governance activity.... 68 5 REFERENCES... 70 6 APPENDICES... 73 Appendix 1 About The Heart Foundation and the Australian Healthcare and Hospitals Association.. 73 Appendix 2 Acronyms and Abbreviations.... 74 Appendix 3 Definitions.... 75 1
4 Templates and examples Quality improvement planning template 1. What are we trying to achieve? (Purpose of the project, scope, objectives) Note: Review domains and key priority areas 2. How will we know this is an improvement? 3. What changes can we make that will result in an improvement? Note: Use the Domain and key performance area checklist to choose key domains and key performance areas to address the issue. Review activities in your chosen key performance area and brainstorm ideas to enable this change within your local setting. 4. Who should be involved? Executive lead: Cultural lead: Clinical lead: Project team: (Include executive managers/board members, managers/senior clinical staff, frontline staff) 55
Domain and key performance area checklist Use this checklist to select the areas where you will seek to make improvements. Domain 1 Governance Key performance area 1.1.1: Effective and accountable leadership by all staff Key performance area 1.2.1: Integrate opportunities for community-led health initiatives Domain 2 Cultural competence Key performance area 2.1.1: Build capacity for culturally appropriate, patient centred-care Key performance area 2.1.2: Provide patient resources that are relevant and appropriate for Aboriginal and Torres Strait Islander peoples Key performance area 2.1.3: Create an environment that is acceptable and meaningful to Aboriginal and Torres Strait Islander peoples Domain 3 Workforce Key performance area 3.1.1: Provision of best-practice training for staff to increase knowledge and understanding of Aboriginal and Torres Strait Islander culture Key performance area 3.2.1: Obvious presence and integration of Aboriginal and Torres Strait Islander staff across the care system Domain 4 Care pathways Key performance area 4.1.1: Improve identification of Aboriginal and Torres Strait Islander peoples Key performance area 4.1.2: Ensure Aboriginal and Torres Strait Islander peoples receive evidence-based ACS care Key performance area 4.1.3: Improve discharge processes and post-discharge care for Aboriginal and Torres Strait Islander peoples 56
Standards, guidelines and policy checklist Use this checklist to indicate the standards, guidelines and policies that your CQI action plan correlates to. ACSQHC Hospital Standards Standard 1 Governance for safety and quality in health service organisations Standard 2 Partnering with consumers Standard 4 Medication safety Standard 5 Patient identification and procedure matching Standard 6 Clinical handover Standard 9 Recognising and responding to clinical deterioration in acute health care Better Cardiac Care [Insert specific detail about Better Cardiac Care] Essential Standards for Equitable National Cardiovascular Care (ESSENCE) [Insert specific detail about ESSENCE] Clinical Standards for Acute Coronary Syndromes [Insert specific detail about standards] Aboriginal and Torres Strait Islander Health Performance Framework [Insert specific detail] State Health Plans [e.g. State Aboriginal and Torres Strait Islander peoples Health plan, state Aboriginal and Torres Strait Islander peoples cardiac care plan] [Insert specific detail] [Insert specific detail] [Insert specific detail] Hospital guidelines, policies and procedures [e.g. Hospital Reconciliation Action Plan] [Insert specific detail] [Insert specific detail] [Insert specific detail] [Insert specific detail] 57
PDSA cycle template Domain: Key performance area: Activity: Start date: Steps Plan Do Check/Study Act End date: Actions Clarify activity(ies) to be addressed Collect and review existing data and relevant information including information on the Aboriginal and Torres Strait Islander patient experience Distinguish any barriers or enablers to the proposed activity(ies) Clarify outcomes for the activity(ies) Identify ways to measure and data to collect for the desired outcome Develop strategies to implement improvements, identifying key tasks and ensuring they are culturally appropriate and responsive Gain input and approval from relevant stakeholders/organisations, including Aboriginal and Torres Strait Islander staff Assign key tasks and implement activity(ies) Monitor implementation to ensure key tasks are completed Collect and review data on activity(ies) Did the activity(ies) result in improvement? If not, why not? Were there any unintended consequences? Collect ongoing data on the operations of your organisation (e.g. client feedback, staff feedback, accident/incident reports, hazard reports, audits) What do the data tell you about the activity(ies) and/or improvements? Consider the activity(ies) and improvements. Do they suggest the need for other activity(ies) for further improvements (e.g. staff training, review of procedures, changes to organisation operations) If the activity(ies) did not result in improvements, why? What next? If there were unintended consequences to the activity(ies), what needs to be done about them? Consider new data; Do they suggest improvements or new activity(ies) to be undertaken? Identify a new activity(ies) in the toolkit and consider solutions 58
PDSA cycle template Domain: Key performance area: Activity: Start date: End date: Steps Actions Plan Do Study Act Next steps 59
Action plan template Note: This action plan should contain the multiple activities that the hospital plans to undertake. Once you have chosen the activities, you must complete a PDSA cycle(s) for each activity. The PDSA cycle is a method of turning planning into activities that can be actioned and connecting action to learning. Domain Key performance area Activity 60
Responsibility Time frame 61
Example 1. Cultural competence activity Quality improvement planning 1. What are we trying to achieve? Domain 2 Cultural competence: Create an environment that is acceptable and meaningful to Aboriginal and Torres Strait Islander peoples. 2. How will we know this is an improvement? We will seek community and patient feedback on how comfortable Aboriginal and Torres Strait Islander peoples feel coming to the hospital. 3. What changes can we make that will lead to an improvement? Ideas for change Display Aboriginal and Torres Strait Islander artwork within the hospital. Create a meeting place within the hospital grounds. Display Aboriginal and Torres Strait Islander flags. 4. Who should be involved? Executive lead, cultural lead, clinical lead and project team (outlined in the PDSA cycle template). 62
PDSA cycle template Domain: Cultural competence Key performance area: Create an environment that is acceptable and meaningful to Aboriginal and Torres Strait Islander peoples. Activity: Purchase and display Aboriginal and Torres Strait Islander flags at the entrance of the hospital. Start date: October End date: November Steps Plan Actions Staff The Lighthouse project officer, maintenance or building staff. Actions Source information on where to purchase flags. Seek advice from Reconciliation Australia and/or local community members on how to best display them, i.e. framed or free standing. Position flags at the entrance of the hospital. Time frame To be completed within 2 months. Objective To display a welcoming environment to Aboriginal and Torres Strait Islander patients and their families and carers. Do Study Act Next steps The flags were easily accessible and purchased online. The local Aboriginal community recommended that the flags be placed at the front of the hospital on flag poles alongside the Australian flag. Further information was sought from Reconciliation Australia as to the sequencing of the flags. Due to the additional flag poles being erected, the time frame was extended to 3 months. Voluntary feedback was sought from identified Aboriginal and Torres Strait Islander patients as to whether they felt welcomed or comfortable when coming to the hospital. The patient feedback indicated they now identified the hospital as one that would treat Aboriginal and Torres Strait Islander patients, but felt the hospital could display artwork on the walls to make the patients feel more comfortable. Source Aboriginal artwork. 63
Example 2. Care pathway activity Quality improvement planning 1. What are we trying to achieve? Domain 4 Care pathways: Ensure Aboriginal and Torres Strait Islanders receive evidence-based ACS care. 2. How will we know this is an improvement? Pre/post feedback from clinical staff related to their level of knowledge related to best practice guidelines. 3. What changes can we make that will lead to an improvement? Ideas for change Educate clinical staff who provide care to Aboriginal and Torres Strait Islander peoples. Identify and circulate best practice guidelines to all clinical staff. 4. Who should be involved? Executive lead, cultural lead, clinical lead and project team (outlined in the PDSA cycle template). 64
PDSA cycle template Domain: Care pathways Key performance area: Ensure Aboriginal and Torres Strait Islanders receive evidence-based ACS care. Activity: Identify and distribute current best practice guidelines to all clinical staff working in acute clinical areas. Start date: August End date: October Steps Plan Actions Staff The Lighthouse project officer, clinical managers in the acute care units, clinical educators working in acute care units. Actions Source current best practice guidelines for ACS care, and distribute to clinical managers. Time frame To be completed within 3 months. Objective To ensure staff are providing the most up-to-date clinical care. Do Study Act Next steps Access best-practice guidelines, develop pre/post surveys for clinical staff and inform clinical staff of the process. Clinical staff completed a survey assessing their current level of knowledge and care relating to clinical care standards. Guidelines were then distributed and staff were given 4 weeks to review them. They then completed a post survey to ascertain changes in knowledge, which would inform changes in care and behaviours as a result of reading the latest guidelines. Staff feedback on the post survey indicated that they would require further educational updates to ensure best practice was offered to all patients receiving care for ACS presentations. Provide skills-based training to coincide with ACS guideline updates. 65
Example 3. Workforce activity Quality improvement planning 1. What are we trying to achieve? Domain 3 Workforce: Provision of best-practice training for staff to increase knowledge and understanding of Aboriginal and Torres Strait Islander culture. 2. How will we know this is an improvement? Staff feedback survey to be conducted pre/post training to assess knowledge and confidence in delivering culturally appropriate care to Aboriginal and Torres Strait Islander patients. 3. What changes can we make that will lead to an improvement? Ideas for change Organise for staff to attend cultural awareness and safety training. Attend meetings and training on best practice guidelines of care for Aboriginal and Torrs Strait Islander peoples. Implement comprehensive orientation and ongoing training programs.* *Due to the complexity of this activity, it would take a staged, integrated process with multiple PDSA cycles. 4. Who should be involved? Executive lead, cultural lead, clinical lead and project team (outlined in the PDSA cycle template). 66
PDSA cycle template Domain: Workforce Key performance area: Provision of best-practice training for staff to increase knowledge and understanding of Aboriginal and Torres Strait Islander culture. Activity: Update current orientation video for new staff to include cultural awareness training section. Start date: July Steps Plan End date: July Actions Staff The Lighthouse project officer, internal stakeholders, local Aboriginal and Torres Strait Islander community members and Project sponsor. Actions From this plan activities would then be broken down into PDSA cycles. Discuss with internal stakeholders and local community members and to identify educational bodies that may assist with the education content framework, i.e. Reconciliation Australia to include in the video. A series of meetings will be conducted to gather information which will then be collated and presented to project sponsor and management. Time frame To be completed within 3 weeks. Do Study Act Next steps Meetings were conducted over a 2-week period with a key set of questions to determine what would influence behaviour, understanding and confidence of staff to provide care for Aboriginal and Torres Strait Islander patients. Collated responses were then provided to project sponsor and executive group for further consideration. The collated responses identified four key areas that would provide an over-arching educational framework to deliver within the orientation video. The current video did not meet these requirements, so to be able to produce such a video, further work would have to be done in developing content. Based upon this feedback, a decision was made to work with local communities, Reconciliation Australia and internal stakeholder to produce subject matter to be included in the video. Develop content for video. 67
Example 4. Governance activity Quality improvement planning 1. What are we trying to achieve? Domain 1 Governance: Integrate opportunities for community-led health initiatives. 2. How will we know this is an improvement? We will conduct a patient feedback survey prior to discharge to assess the awareness level of local services that are available via Aboriginal and Torres Strait Islander organisations and where they received the information. 3. What changes can we make that will lead to an improvement? Ideas for change Include links to local Aboriginal and Torres Strait Islanders services on hospital intranet and/or staff newsletter. Develop clinical discharge checklist to include information related to local Aboriginal and Torres Strait Islander agencies. Develop a conversation starter take home resource to include in discharge pack. Include ALO in discharge discussion to highlight/link available services. 4. Who should be involved? Executive lead, cultural lead, clinical lead and project team (outlined in the PDSA cycle template). 68
PDSA cycle overview Domain: Governance Key performance area: Integrate opportunities for community-led health initiatives. Activity: Develop a conversation starter discharge patient resource that will act as a reminder to patients of the pre-discharge discussion related to external services that are available to Aboriginal and Torres Strait Islander peoples. Start date: September End date: November Steps Plan Actions Staff The Lighthouse project officer, internal stakeholders, local Aboriginal and Torres Strait Islander services and Project sponsor. Actions Discuss with internal stakeholders the most effective medium for take home resources, i.e. fridge magnet/video/usb. Discuss with local services their inclusion/ commitment to this resource. Conduct a series of meetings to gather information that will then be collated and presented to project sponsor and management. Conduct a cost analysis of potential resource medium. Time frame To be completed in 3 months. Do Study Meetings were conducted over a 4-week period with a key set of questions to determine the best medium and information to be given to patients. A comparative cost analysis was also performed within this time frame based upon stakeholder feedback. Internal stakeholders had previously received positive feedback in relation to the use of fridge magnets. To be able to hold all the necessary information the magnets would have to be 10 cm x 15 cm. There would perhaps be an issue with currency of information. The allocated funding for this component of the project would only enable 100 magnets to be printed, which didn t appear to be a viable option. After further consultation, a suggestion was made to print the magnets with a web link to the hospital website, specifically the website related to external services, so the magnet could be smaller. As the hospital website links are reviewed on a 3-month basis, this would ensure currency of the information and, due to the decrease in size, there was budget to print 500 fridge magnets. Once included in the discharge packs, patients will be asked to complete a survey to indicate if staff had gone through and explained in detail the components of the pack specifically focussing on the local Aboriginal and Torres Strait Islander community services. Analysis of these surveys will be relayed to management with follow-up. Based on feedback of the survey, they agreed to continue with the current process. Act Next steps The patients stated that while the discharge process can be overwhelming, the magnets would act as a reminder of the conversation they had with the nurse or ALO prior to discharge. None. 69
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72 Improving health outcomes for Aboriginal and Torres Strait Islander peoples with acute coronary syndrome A practical toolkit for quality improvement
6 Appendices Appendix 1: About the Heart Foundation and the Australian Healthcare and Hospitals Association The Heart Foundation is the leading organisation in the fight against cardiovascular disease (heart disease, stroke and blood vessel disease). Our mission is to improve the cardiovascular health of all Australians. Since our establishment in 1959, we have championed the heart health of Australians by promoting health in the community, supporting health professionals and funding world-class research. As a charity, we rely on donations and gifts in wills to continue our work. The Australian Healthcare and Hospital Association (AHHA) is the only national organisation representing the public healthcare sector and the professionals working in it. The AHHA is uniquely positioned to facilitate collaboration between clinicians, academics, policy makers, administrators and politicians. The Heart Foundation and the AHHA formed an alliance to address the disparities in hospital care experienced by Aboriginal and Torres Strait Islander peoples who experience a heart attack. Together we are working with Aboriginal and Torres Strait Islander peoples and organisations, clinicians, researchers, statisticians, representatives of professional and non-government organisations, and representatives of government from across Australia, to help to close the gap in Aboriginal and Torres Strait Islander heart health. The Heart Foundation and the AHHA received funding from the Department of Health and Ageing to scope a national, innovative Lighthouse Hospital project 24 aimed at improving the care of Aboriginal and Torres Strait Islander peoples experiencing ACS. This was achieved by documenting the key elements of past and current initiatives that improved the patient journey, by sharing the knowledge, skills and experience from exemplary lighthouse hospitals. A conceptual framework (Figure 1) consisting of four domains across the journey trajectory, including cultural competence, clinical quality improvement, workforce and governance, was developed to guide data collection. This toolkit is a key resource of the Lighthouse project. It is designed to guide health professionals to make changes to ensure Aboriginal and Torres Strait Islander peoples receive clinically competent, culturally safe, accessible and responsive care in hospitals. The toolkit is a framework organised into four domains, which reflect key areas in which improvements to achieve change need to be focused. It suggests practical activities to be implemented using a continuous quality improvement methodology within the hospital s operational control and funding parameters. This toolkit was developed based on evaluation of a two-year pilot with eight hospital sites. 73
Appendix 2: Acronyms and abbreviations ACCHO ACS ACSQHC AHHA AHMAC AIDA AIHW AHW ALO AMS APPO CATSINaM CHD CQI CVD ECG ESSENCE GP HSNet KPA KPI NACCHO NAIDOC NATSIHEC NATSIHWA NGOs NHMRC NSQHS NSTEACS NSW OATSIH PCI PDCA/PDSA PHNs RACGP SAHMRI STEMI WHO Aboriginal Community Controlled Health Organisation Acute coronary syndrome (includes heart attack [STEMI: ST segment elevation myocardial infarction and NSTEMI: non-st segment elevation] and unstable angina) Australian Commission on Safety and Quality in Health Care Australian Healthcare and Hospitals Association Australian Health Ministers Advisory Council Australian Indigenous Doctors Association Australian Institute of Health and Welfare Aboriginal Health Worker Aboriginal Liaison Officer Aboriginal Medical Service Aboriginal Patient Pathway Officers Congress of Aboriginal and Torres Strait Islander Nurses and Midwives Coronary heart disease Continuous quality improvement Cardiovascular disease Electrocardiogram/electrocardiography Essential Service Standards for Equitable National Cardiovascular CarE Standards General practitioner Human Services Network Key performance area Key performance indicator National Aboriginal Community Controlled Health Organisation National Aborigines and Islander Day Observance Committee National Aboriginal and Torres Strait Islander Health Equality Council National Aboriginal and Torres Strait Islander Health Worker Association Non-government organisations National Health and Medical Research Council National Safety and Quality Health Service Standards Non-ST-segment-elevation acute coronary syndrome New South Wales Office for Aboriginal and Torres Strait Islander Health Percutaneous coronary intervention Plan-Do-Check-Act/Plan-Do-Study-Act Primary Health Networks Royal Australian College of General Practitioners South Australian Health and Medical Research Institute ST-segment-elevation myocardial infarction World Health Organisation 74
Appendix 3: Definitions Aboriginal Health Impact Statement Acute care sector Allied health professionals Angiography Clinical audit Continuous quality improvement (CQI) Continuum of care Coronary artery bypass graft surgery Coronary angioplasty Coronary revascularisation Cultural competence Patient-centred care The Aboriginal Health Impact Statement ensures the needs and interests of Aboriginal people are embedded into the development, implementation and evaluation of all initiatives. The Statement includes a declaration on whether an initiative will impact on the health of Aboriginal people and a checklist detailing how the needs and interests of Aboriginal people have been elicited and incorporated where appropriate. Healthcare oriented towards the care of critically ill patients, including emergency care and surgery. These include pharmacists, dietitians, nutritionists, physiotherapists, exercise physiologists and other non-medical and non-nursing health professionals. A procedure where dye is injected and an x-ray is taken of the vessels of the heart. It enables cardiologists to assess the integrity of vessels and establish whether there are narrowed or blocked vessels in the heart, requiring further management. The systematic review of elements of clinical care against predetermined criteria, with the aim of identifying areas for improvement and then developing, implementing and evaluating strategies intended to achieve that improvement. A system of regular reflection and refinement to improve processes and outcomes that will provide quality healthcare. Also referred to as the care continuum, this describes both the horizontal and vertical movement of patients through the health system, including identification of disease through to palliation, as well as coordination between primary care to hospital and back to primary care again. A surgical procedure in which one or more blocked coronary arteries are bypassed by a blood vessel graft to restore normal blood flow to the heart. A procedure used to open narrow or blocked coronary (heart) arteries. The procedure restores blood flow to the heart muscle. A thin, flexible catheter (tube) with a balloon at its tip is threaded through a blood vessel to the affected artery. Once in place, the balloon is inflated to restore blood flow through the artery. A general term to describe any procedure that restores blood flow to the vessel. The ability to interact effectively with people of different cultures and socioeconomic backgrounds; this may be among colleagues or community groups and stakeholders. A system where patients can move freely along a care pathway without regard to which physician, other healthcare provider, institution or community resources they need at that moment in time. A patient-centered care system is one that considers the individual needs of patients and treats them with respect and dignity. 75
For heart health information, please contact us 1300 36 27 87 heartfoundation.org.au 2016 National Heart Foundation of Australia, ABN 98 008 419 761 Disclaimer: This document has been produced by the National Heart Foundation of Australia for the information of health professionals. The statements and recommendations it contains are, unless labelled as expert opinion, based on independent review of the available evidence. Interpretation of this document by those without appropriate medical and/or clinical training is not recommended, other than at the request of, or in consultation with, a relevant health professional. While care has been taken in preparing the content of this material, the Heart Foundation and its employees cannot accept any liability, including for any loss or damage, resulting from the reliance on the content, or for its accuracy, currency and completeness. The information is obtained and developed from a variety of sources including, but not limited to, collaborations with third parties and information provided by third parties under licence. It is not an endorsement of any organisation, product or service. This material may be found in third parties programs or materials (including, but not limited to, show bags or advertising kits). This does not imply an endorsement or recommendation by the National Heart Foundation of Australia for such third parties organisations, products or services, including their materials or information. Any use of National Heart Foundation of Australia materials or information by another person or organisation is at the user s own risk. The entire contents of this material are subject to copyright protection. Enquiries concerning permissions should be directed to copyright@ heartfoundation.org.au PRO-171