2016 fwlhd health innovation awards finalist...
TRANSCRIPT
A local response to implementing the Recognition and Management of the deteriorating patient programs/policies
Kelly Dart NM Policy, Practice and Initiatives
2016 FWLHD Health Innovation Awards Finalist Presentation
Briana Bartley
Patient Safety & Clinical Quality Manager
Kelly Dart NM Policy, Practice & Initiatives
Kimberley Flood Critical Care Clinical
Nurse Consultant
Nurse Educators and Clinical
Nurse Educators
Frontline Clinical Staff
Between the Flags was introduced in NSW in January 2010, in response to Recommendation 91 of the Special Commission of Inquiry: Acute Care Services in NSW Public Hospitals. The Inquiry strongly recommended that a State-wide system for improving recognition and response to deteriorating patients be implemented across NSW.
The challenge presented by Recommendation 91 was to implement such a system in over 200 facilities in the State.
We collected numbers of rapid response and
cardiac arrest
We started DETECT training
SAGO charts were introduced
Patient care was not the centre
MoH RR KPIs
We were trying to implement over 90 recommendations from the Garling report and tick boxes
MoH PD2011_077
Released
SAC 1 FY
12
DONM released memo
Breaches in MoH policy identified
5 recorded deaths during
a rapid response
Accountability was the key
• NUMs received workflows to investigate breaches
• Performance Management was commenced
Key policies
were developed
• Roles and responsibility of the TL
• Team Nursing
• ISBAR Communication
• Alterations to Calling Criteria
Studer and
Advisory Board
• We developed reward and recognition for units that are doing a good job
• Introduced Critical Thinking toolkit into all N&M learning
The patient became the centre of our world
• Recognition and reward
• Foster a culture of safety
Studer
• Instilling Accountability
•Use of the Critical Thinking Toolkit
Advisory Board •Develop
learning packages/competencies around pt safety
Education & training
CORE Values
C: We collaborate with CGU O: transparency with staff R: Moved from reactive/punitive to positive/supportive E: Empowered to build nursing practice standards
2015/16 FY have seen 1 SAC 1
Wards are given certificates for how many days without a nursing breach of policy This concept was taken from our mining industry In Dec 2015 4 Units had gone 365 days with no deteriorating patient breaches
QARS audits and action plans
Nursing Practice Forums
NSQHS Standard 9 team meetings to
evaluate
Continue to foster a culture of
patient centred
care
Patient Rounding
Patient Stories
PDSA Cycle: Plan Do Study Act
Continue to audit and
action
Present case
studies and
promote reflective practice through
peer support
Clinical Governance
Unit
Executive Sponsor: Dale
Sutton (DDONM)
Executive Support: Zandra
Corey (DCG)
Clinical Education
Team
Kimberley Flood Critical
Care CNC
Unit Managers