Therese Oates - Lady Cilento Children's Hospital - Building a Culture of Redesign into Children’s Health Queensland

Embedding a culture of Redesign into Children's Health Queensland Therese Oates Nurse Manager Clinical Redesign LCCH

The Lady Cilento Children's Hospital Children's Health Queensland HHS

2 Clinical Redesign

What is LCCH

• Commissioned at the end of 2014

• Part of Children's Health Queensland HHS

• Combined RCH and MCH – 3400 staff

• Acute statewide level 6 tertiary service

• Predictive 75 000 annual emergency occasions of care

• Some current patient flow issues include:

• Access block steadily rising sitting at 29% in May 2015

• Discharge by 1100 hours 28%

• Long stay issues – 37% patients with LOS <7 days; 12% with LOS >29 days

3 Clinical Redesign

Optimising Nursing Strategy

4 Clinical Redesign

• Enable nurses to work to their full scope of practice

• Acute Expand the delivery of nursing services – to increase service capacity and consumer choice

• Launched in Queensland 2013

Clinical Pathways

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• Historical variation in clinical practice

• LOS variance between RCH and

MCH in standard DRGs

• Safety events/ PRIME data

leading the case for change

Clinical Redesign

‘How to’ Procedure developed

Mature pathway template incorporates ‘outcomes’ as the focus, encouraging clinically sound critical

thinking

Robust project methodology guides & facilitates clinician ownership during development

NSQHS prompts included in template Falls risk Skin integrity Clinical handover Clinical rounding logs

Education materials provided to support a pathway launch

Link to local CHQ Leadership Program

Ryan's Rule/ Australian Charter of Healthcare Rights prompts

Audit and evaluation triggers in development focusing on compliance; LOS; variance analysis and

pathway outcome

Family Advisory Council contribution to pathway development

Clinical Pathways

6 Clinical Redesign

Clinical Redesign Outcomes

56 published Clinical

Pathways

12 currently in development

14 further pathways planned

7 Clinical Redesign

Planned audit and evaluation tool for local clinician use

Appendicectomy / asthma / neutropenia sepsis pathways/ T’s A’s / Compromised nutritional status evaluated for compliance/ documentary completion/ variation analysis / satisfaction

540 cases T’s /A’s; close to 500 Asthma/ RAD separation codes evaluated / all neutropenia sepsis since November 2014

LOS analysis – post operative complication and readmission rate; overall LOS broken down into phases

Engagement with LCCH PSQS to create suite of clinician reports in MARS, enabling clinical staff to enter and collect data as to audit and evaluation

Audit and Evaluation of Clinical Pathways

• Patient safety/ coronial recommendations/ best practice

• CHQ Clinical Pathway procedure

articulates compliance and identification of systemic quality improvement issues in regard to care of the patient and pathway improvement

• Clinical Pathway MOC rolled out during widespread organisational change, placing impact on ongoing compliance

8 Clinical Redesign

Audit and Evaluation of Clinical Pathways

Recommendations as result of deep dive evaluation Appendicectomy pathway suited to post operative phase – not

emergency phase as is emergent pathway Coronial implications considered in asthma audit Highlighted risk for organisation – around non completion

mandatory care requirements with poor discharge planning / critical thinking components targeted

Duplication of effort noted Cohorting of specific patient groups State-wide roll out of Neutropenia Sepsis


Criteria Led Discharge

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• LOS at LCCH is longer than at both the MCH and RCH LOS for same DRGs.

• Current Access block at LCCH is 29% with delayed entry into PICU and cancelled surgery related to the acute bed shortage

• Current admission spikes for LCCH is 0700 & 1100 with peak discharge time being the late afternoon

• Improved family and staff

satisfaction, parents more involved; staff feel empowered and demonstrate collaborative with families

CLD incorporated into CHQ Clinical Pathways

Evaluation of the impact on LOS in nominated groups, as well as compliance in target DRGs measured against balanced safety metrics of PRIME; unplanned readmission and consumer complaints

Teach-back methodology incorporated into the CLD forms and education materials

Go-live in Babies ward May 2015 CLD to be rolled out in day surgery in July 2015

Review of current EDD data informing care at LCCH to increase reliability and rigor with EDD as predictive discharge and bed Mx tool

Generic and condition specific CLD forms developed along with suite of information; procedures and education tools for LCCH

Clinical Redesign

Review of key works Queensland DoH CARU / NSW ACI works

Criteria Led Discharge

10 Clinical Redesign


CLD procedure articulating rigor around CLD clinician eligibility

Competency assessment/ learning tool developed for eligible JMOs and RNs

Customised CLD forms accommodating for risk, while enacting discharge at the right time for the patient and family

Family Fact sheet/ flow charts and Clinician FAQs for CLD

NEAT attainment

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Streamlined bed request processes provide accurate data capture at LCCH and improved experience

Streaming model of care from triage to direct patients to appropriate multidisciplinary staff

Detailed role descriptions developed for all nursing roles in Emergency and SSU, with ongoing review

Implementation of PS tools into ESSU (18 beds) to provide for improved access (currently 39% acute admissions are directed to ESSU)

Mapping of current inter-hospital transfer processes, along with key stakeholders with identification of bottle necks; and agreed safe processes for LCCH that has been outlined in the LCCH SOP

Parent/Carer discharge summary developed to facilitate ongoing discharge planning and bed availability. PFM links and robust EDD data entry to assist accurate bed planning

• NEAT nationally set at 90% attainment for 2015

• LCCH integration of process to sustained NEAT

• Patient centric journey underpins case for change

High Acuity Nurse : Patient Ratios


• There was high utilisation of pool and agency staff for nursing ‘specials’ with little or no governance describing same

• Most clinical areas were above their BPF staffing budget for such activity

• There was a lack of defined process and procedure to underpin LCCH Standard Operating procedure description of high acuity ‘specials’

Review of key works from GCUH and RCH Melbourne

Clarification of the ordering of higher acuity N: P ratios, including Nursing Director review; and ongoing surveillance by senior nursing roles within LCCH

Link to Nursing Hours per Patient Day and the inpatient unit BPF in order to provide Divisional fiscal accountability

Articulation of minimal review timeframes for patients on High Acuity Nurse: Patient Ratios

Formulation of a ‘Nursing Order for a Increased Nurse: Patient Ratio’ form

Distinction between level of staffing or supervision required for that timeframe of high acuity ratio

Alternative Cohorting placement indicated within the procedure

Strategies to optimise medical care for that patient included as prompt within the work

High Acuity Nurse : Patient Ratios



Published High Acuity Nurse: Patient (N: P) Ratio excluding Mental Health Procedure Nursing Order forms utilised to enact a Higher Acuity N: P ratio Rigor existing with identifying and providing care for nominated patient groups Geography of LCCH considered in solution


Productive Series

PS Mapped into overarching CHQ nursing

clinical excellence program to increase

awareness and authenticity of program to CHQ

nursing staff; links to alternate CQI initiatives –

Magnet/ Advisory Board

Foundation modules undertaken in clinical area

of LCCH and the wider CHQ, with identification

and ongoing monitoring of key performance

data

Safety cross measurement utilised throughout

LCCH

Plans for all of CHQ rollout of the series

To provide improved with effectiveness; safety and reliability across all clinical areas in CHQ, within existing resources. Themes for clinical excellence requiring framework structure

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• Inadequate communication pathway to provide nursing care plans to specific specialty CNCs/ NEs and NPs

• Adhoc ward round information and no correlation to current PFM information, high risk in practice

• Missed and delayed AH referrals

Review PFM Journey Board to ascertain potential referral paths within program

Consider implementation of a reverse referral system whereby specialty CNC / NP or NE refer patients of concern or clinical issues to CNC Clinical Safety

Consider template email that is prioritised that can be sent from CNC Safety to specialty CNC/ NE or NP / Allied Health

Review of current Daily Operating Brief ‘inpatient unit report’ specifically patients of concern, and whether escalation and care planning is consistently highlighted. Consider trigger in script to include referral to specialty group if required

Communication pathways – Patient Flow Manager

Clinical Redesign

Ward round sheet audit across all medical and surgical subspecialties

Questions


Acknowledgements:

Shelley Nowlan EDNS CHQ

Andrew Hallahan Medical Lead Patient Safety CHQ

Brenda Edwards Clinical Redesign LCCH