The 20th Annual ACHS Quality Improvement Awards

48 Pages·2017·2.12 MB·English

by  Mark Burgess

Quality Initiatives
Entries in the 20th Annual ACHS Quality Improvement Awards 2017.
Published by:

The Australian Council on Healthcare Standards (ACHS)
September 2017

© The Australian Council on Healthcare Standards 2017

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Recommended citation:
Quality Initiatives - Entries in the 20th Annual ACHS Quality Improvement Awards 2017. The
Australian Council on Healthcare Standards. ISBN 978-1-921806-90-2 (Paperback) 978-1-
921806-91-9 (Web).

Previous volumes in this series:
1st Edition 1998 8th Edition 2005 15th Edition 2012
2nd Edition 1999 9th Edition 2006 16th Edition 2013
3rd Edition 2000 10th Edition 2007 17th Edition 2014
4th Edition 2001 11th Edition 2008 18th Edition 2015
5th Edition 2002 12th Edition 2009 19th Edition 2016
6th Edition 2003 13th Edition 2010
7th Edition 2004 14thEdition 2011
The 20th Annual ACHS QI Awards 2017

Table of Contents
Introduction ............................................................................................................................... 2
Winner Submissions ................................................................................................................... 3
Highly Commended Submissions ............................................................................................... 4
Category: Clinical Excellence and Patient Safety ....................................................................... 5
Winner ................................................................................................................................... 5
Highly Commended .............................................................................................................. 13
Table of Submissions............................................................................................................ 16
Category: Non-Clinical Service Delivery ................................................................................... 20
Winner ................................................................................................................................. 20
Highly Commended .............................................................................................................. 28
Table of Submissions............................................................................................................ 32
Category: Healthcare Measurement ....................................................................................... 34
Winner ................................................................................................................................. 34
Table of Submissions............................................................................................................ 44

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20th Annual ACHS Quality Improvement Awards 2017
Introduction The 20th Annual ACHS QI Awards 2017

Introduction
The ACHS Quality Improvement Awards
The annual ACHS Quality Improvement (QI) Awards were introduced in 1997 to acknowledge
and encourage outstanding quality improvement activities, programs or strategies that have
been implemented in healthcare organisations.
In 2017, the 20th Annual ACHS QI Awards were open to submissions from all domestic ACHS
and international ACHSI member organisations following the ACHS NSQHS (National Safety
and Quality Health Service) Standards Program, EQuIP5 (Evaluation and Quality Improvement
Program), EQuIPNational, EQuIPNational Corporate Health Services, EQuIPNational Day
Procedure Centres, EQuIP6, EQuIP6 Day Procedure Centres, EQuIP6 Oral Health Services,
EQuIP6 Haemodialysis, EQuIP6 Healthcare Support Services, and the ACHS Clinical Indicator
Program.
This year 61% were submitted in the Clinical Excellence and Patient Safety category, 24% in
the Non-Clinical Service Delivery category and 15% in the Healthcare Measurement category.
Judging was conducted externally with separate panels of three judges for each of the QI
Awards categories:
• Clinical Excellence and Patient Safety: This category recognises innovation and
demonstrated quality improvement in the delivery of safe, effective patient care.
• Non-Clinical Service Delivery: This category acknowledges a demonstrated outcome of
improvement and innovation in patient and/or consumer services and organisation-wide
practice including services provided by community and allied health organisations.
• Healthcare Measurement: This category recognises organisations that have measured an
aspect of clinical management and/or outcome of care, taken appropriate action in
response to that measurement, and demonstrated improved patient care and
organisational performance upon further measurement. Healthcare measurement can
include data collected from the ACHS Clinical Indicator program or other methods of
monitoring patient care processes or outcomes. Both quantitative and qualitative data
can be used, however this category must describe the initial measurement, the analysis
of that measurement, the action(s) implemented, and the improved measurement(s).
Each judging panel consisted of an ACHS Councillor, an ACHS surveyor and a representative
from an ACHS member organisation.
Submissions were required to meet specific criteria that were weighted equally:
• Judges assessed all eligible submissions on the five (5) ACHS principles of: consumer focus,
effective leadership, continuous improvement, evidence of outcomes and best practice;
• Judges assessed additional criteria: improvement in patient safety and care, measured
outcomes, applicability in other settings, innovation in patient care and/or processes and
relevance to the QI Awards category;
• The submission MUST relate to a period of up to no more than two (2) years prior to the
year of entry.

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20th Annual ACHS Quality Improvement Awards 2017
Winning Submissions The 20th Annual ACHS QI Awards 2017

The 20th Annual ACHS QI Awards 2017
Winner Submissions
Clinical Excellence and Patient Safety
Royal Brisbane Women’s Hospital
Metro North Hospital and Health Service, QLD
Kidney Health Service
Kidney Supportive Care – our patients, our care
Helen Healy, IIse Berquier, Louise Purtell, Ann Bonner,
Carol Douglas, Danielle Heffernan, Luke Worth, Bernadette Taylor

Full Submission page 5

Non-Clinical Service Delivery

North Eastern Community Hospital, SA
First demonstration in an Australian healthcare setting of an
in-line electrochemical water treatment system for
optimising potable water quality
Scott Williams, Antony Amorico, Associate Professor Erica Donner

Full Submission page 20

Healthcare Measurement
Nepean Blue Mountains Local Health District, NSW
Blue Mountains District Anzac Memorial Hospital
Breathe Better at Blue Mountains – a multidisciplinary approach to
reducing length of stay for Chronic Obstructive Pulmonary Disease patients
at Blue Mountains Hospital
Penny Lees, Andrea Williams, Therese Underwood, Alicia Gordon,
Luke Bellman, Rachell Greentree, Jamieleigh Petersen, Dorothy Clampett

Full Submission page 34

Each winning submission in the ACHS QI Awards receives a Certificate of Acknowledgement,
a QI Awards trophy, and a cash prize provided by ACHS.
ACHS publishes submissions from all participating organisations to share and encourage
exceptional quality improvement strategies amongst the ACHS member organisations.
The full version of this document will be published on the ACHS website (www.achs.org.au).

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20th Annual ACHS Quality Improvement Awards 2017
Highly Commended Submissions The 20th Annual ACHS QI Awards 2017

The 20th Annual ACHS QI Awards 2017
Highly Commended Submissions
Clinical Excellence and Patient Safety

Melbourne Health, VIC
Transformation and Quality
Improving the management of sepsis with a hospital-wide sepsis pathway
Kelly Sykes, Karin Thursky, Cate Kelly, Tristan Vasquez, Lizzie Summers, Dominic Gasparini, Robert McCubbin

Summary Abstract page 13

North Metropolitan Health Service, Mental Health, WA
Clinical Research Centre
Sleep Well, Feel Well With a Mental Illness: Implementation of a
specialised Sleep service in North Metro Health Service Mental Health
Flavie Waters, Melissa Ree, Vivian Chiu, Danny Rock, Aleksandar Janca

Summary Abstract page 14
Non-Clinical Service Delivery

Western Sydney Local Health District, Energesse, MES, NSW
Clinical Governance and Quality & Accreditation
Patient Experience: Real Time, Real Engagement, Real Improvement
Kay de Ridder, Kay Babalis, Jessica Evans, Vesna Janjic, Avnesh Ratnanesan, Kiran Nair

Summary Abstract page 28

The Mater Hospital North Sydney, NSW
Food Services
Room Service - Enhancing the patient meal-time experience
Carmel Lazarus, Tamsyn Gardner

Summary Abstract page 29

Our Lady of Maryknoll Hospital, Hong Kong
Community Services
Connecting with Community – Achieving Better Health and Wellbeing to
Community
Dr T C Wong, Jenny Tsoi, Kathy Chow, Chui Han Yiu, Eric Wong, Dr Winnie Chan

Summary Abstract page 30

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20th Annual ACHS Quality Improvement Awards 2017
Category: Clinical Excellence and Patient Safety Winner

Category: Clinical Excellence and Patient Safety
Winner
Royal Brisbane Women’s Hospital Metro North Hospital and Health Service
Kidney Health Service
Kidney Supportive Care – our patients, our care
Helen Healy, IIse Berquier, Louise Purtell, Ann Bonner,
Carol Douglas, Danielle Heffernan, Luke Worth, Bernadette Taylor

A. AIM shared decision making with our patients and their
communities of families and carers and patient
Patients with advanced kidney disease experience
distress through a focus on remediating symptom
high symptom burden requiring complex health care
burden.
decision making eg benefits of dialysis, declining
quality of life, etc. At its core the Kidney Supportive
The program is modeled off similar work at St
Care program aims to educate and coach our
George Hospital, Sydney. We adapted the model,
patients, their families and carers in discovery of
focusing on the process work patients do in the
patients’ preferences, expectations and decisions
discovery and articulation of what they expect their
about their health care and how it will be delivered,
healthcare to deliver. We retained the outstanding
contoured to their specific values framework. The
work the St George team does in remediating
fully integrated specialist kidney and palliative care
symptom burden and acknowledge and thank them
teams then work to remediate symptom burden on
for their generous sharing of processes and tools.
the one hand and activate specific care pathways on
Patients report on the performance of the program,
the other eg progress dialysis, community centred
using the patient reported outcome measures
supportive care, palliative care, etc. Of note, these
(PROMS) and patient reported experience measures
care pathways are not mutually exclusive.
(PREMS) suite of tools. System level PROMS and
PREMS reporting is new business in our Kidney
B. SUMMARY ABSTRACT
Health Service. We introduced the change in
Severe chronic kidney disease (CKD) is experienced
practice using a research framework.
as emotionally and physically distressing in an
increasing number of Australians. This cohort does
The Kidney Health Service, MNHHS includes clinician
not experience the advantages that the standard scientists who are Chief Investigators in several
practice of dialysis delivered when it was
research collaborations. Relevant to this submission
introduced. What has changed in the intervening
are NHMRC funded Centres of Research Excellence
decades is the patient cohort, with a shift in the
in CKD (CKD.CRE) and End of Life CRE (EoL CRE). A
demography to older, frailer Australians with high
collaboration of these investigators and Senior
co-morbid loads of diseases, all markers of poor
Executives of the Royal Brisbane and Women’s
survival. Clinicians grapple with the boundaries of
Hospital (RBWH) were awarded a competitive
benefit of dialysis, a care pathway that has not been
Australian Centre for Health Services Innovation
tested in randomized control trials comparing other
(AusHSI) grant to research the implementation of
care pathways nor in patient demographics that are
the KSCp. The Investigators selected the
materially different from the early patient groups.
methodology of the Consolidated Framework for
Observational and small cohort studies find that
Implementation Research (CFIR) from the emerging
care pathways that do not include dialysis do not
field of Implementation Science. The method was
disadvantage survival in some cohorts with end
selected because it sampled both qualitative and
stage kidney disease and offer superior quality of
quantitative variables and captured PROMS and
life. PREMS. We are analyzing the first 12 months of data
and present some of these results.
The Kidney Supportive Care program (KSCp) was
developed to resolve this clinical equipoise. It is a
There was good acceptance of the program with
product of the innovation space in the Metro North
nephrologists referring 129 patients (mean age 71.6
Hospital and Health Service, funded initially through
years [range 27–91], 52% men, 53% on dialysis)
its SEED Innovation program. The KSCp addresses
compared with 27 referrals to palliative care in the
the dual challenges of clinical equipoise through
preceding 12 months. Patients who had attended at

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20th Annual ACHS Quality Improvement Awards 2017
Category: Clinical Excellence and Patient Safety Winner

least one KSCp appointment (n=101) were in the of cardiovascular events, including cardiac death
program for a median of 203 days (range 1-350). At (Australian Institute of Health and Welfare, 2009).
12 months 82 patients were attending the KSCp with
a median time of 189 days (range 42-350) and 25% Treatment pathways of severe kidney disease,
have left the program. dating from the 1980s, focus on life sustaining
dialysis. However the patient population entering
Changes in overall symptom burden were assessed End Stage Kidney Disease (ESKD) has shifted in the
in all patients. Of those who attended more than intervening years to an older demographic, with
one KSCp appointment, 59% experienced multiple co-morbidities and symptom burdens that
improvement. 41% did not report improvement in we are now understanding are greater than cancer
overall symptom burden although individual sufferers (Murtagh et al., 2010). People with CKD say
symptoms may have improved. their experience of healthcare in the last weeks and
months of life is of poor quality, notwithstanding a
Of the 39 patients exploring the dialysis pathway of
high utilization of the acute sector (Murtagh et al.,
care, 10 elected to proceed with dialysis, 10 chose
2010, Wang et al., 2016). Patients, carers, families
to withdraw from dialysis and 19 elected not to
and clinicians struggle with defining the boundaries
accept a dialysis pathway of care.
of care where technologies, like dialysis, may have
no survival benefit and negatively affect quality of
19 patients died during these 12 months. Of these,
life (Murtagh et al., 2007, Verberne et al., 2016,
14 died at their place of choice (75%). Of those who
Hussain et al., 2013). The ethical impossibility of
died in their place of choice 3 died at home, 7 in
conducting randomized controlled trials of these
community facilities and 4 in the acute care sector.
technologies adds to uncertainty and equipoise.
Those who chose to die in an acute hospital did so
because it was where they routinely attended for
The Kidney Supportive Care program (KSCp)
dialysis. Of the 5 who did not die in their place of
addresses this uncertainty through shared decision
choice, all died in the acute care sector. Significance
making with our patients and their community,
testing is not done because of the small sample size
anchored in open disclosure of all care pathways
in some of these cohorts.
and exploration of the expectations of the patient.
Key activities include information sharing, coaching
The PREMS found high levels of satisfaction with the
in self-discovery of patient expectations and
program with 95% of patients and 100% of carers
supporting patients, families and carers making
highly satisfied. We are still evaluating the
complex health decisions, including advanced care
qualitative data from deductive thematic analyses of
planning, suitability of dialysis, withdrawal from
interviews and conducting more mature health
dialysis and what to do when a new diagnosis of a
economic evaluations.
second life limiting disease is made. Concurrently
Collectively the outcomes of the program and its the KSCp team focuses on remediating and
evaluation are a compelling case, from patients’, alleviating patients’ emotional and symptom
clinicians’ and health systems perspectives. Our distress.
Executive Champion Dr Amanda Dines, Executive
Director RBWH, recognises the importance of the
work the program does with vulnerable patients,
ranking it amongst the top candidate programs for
new funding in 2017 and championing it in the
competitive pitching for HHS funding.
C. REPORT
Importantly our patients and their communities of
APPLICATION OF ACHS PRINCIPLES families and carers evaluate the performance of the
program through the patient reported outcome
1. Consumer Focus measures (PROMS) and patient reported experience
Chronic Kidney Disease (CKD) is common, affecting measures (PREMS) suite of tools. These are part of
more than 10% of the world’s adult population, the Consolidated Framework for Implementation
increasing in prevalence with age (Hill et al., 2016). Research (CFIR) methodology that we are using to
CKD is harmful, accounting for 10% of all deaths in evaluate the implementation of the program.
the National Mortality Database, an excess of Program reports are submitted to the KSCp Steering
premature mortality and conflation of the likelihood

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Committee, with a consumer representative collaboration of these investigators and Senior
amongst its membership. Executives of the RBWH were awarded a
competitive Australian Centre for Health Services
Innovation (AusHSI) grant that mobilized the
resources needed to systematically study the
implementation of the KSCp. The methodology used
in this work is the novel CFIR from the emerging field
of Implementation Science. The method was
selected because it samples both qualitative and
quantitative variables and captures PROMS and
PREMS. Our HHS recognized the quality of the
research in the KSCp at the 2017 MNHHS Research
The KSCp is delivering a care pathway that matches Excellence Awards, winning in the category Health
the right resources to meet individual patient needs. Services and Implementation Research Award.
129 patients were referred to the KSCp in its first 12
KSCp has been the vision of a group of clinicians for
months of operation, compared with 27 referrals to
a number of years, led by a senior kidney nurse, Ms
a palliative care service in the preceding 12 months.
Ilse Berquier. In 2015 our leader successfully pitched
Patients/carers were highly satisfied (95% and 100%
for proof of concept funding through the MNHHS
respectively) with the care they received. Thematic
SEED Innovation funding program, an initiative of
analysis revealed the key reasons for both groups’
the Senior Executive of our organization. The KSCp
satisfaction were feeling supported, receiving
commenced in February 2016 in a community
personalized care and the clinic’s focus on wellbeing
health facility. Ms Berquier recruited the Metro
rather than biochemical markers. Symptom burden
North Kidney Health Service (MN KHS) Executive in
decreased in 69% of patients. Further outcome
successfully pitching to MNHHS for two further
measures are reported in section 4, evidence of
cycles of funding to extend the proof of concept out
outcomes. Patients continue to evaluate the
to 12 months. Ms Berquier influenced into
program through structured feedback that is now
Queensland Health through the Clinical Senate,
embedded in business as usual.
presenting our work at a day long workshop on
2. Effective Leadership health needs at the end of life attended by key
The KSCp is providing direction in Queensland by thinkers across the health jurisdictions in
offering our patients with end stage chronic disease Queensland. Members of the team have now
choices that focus on wellbeing in addition to the presented at a number of health planning and key
biological construct models in clinical practice. In the clinician meetings in Queensland and nationally–
applicability to other settings section we describe see applicability to other settings section for a
how the KSCp is influencing the development of like comprehensive list of briefings, workshops, think
programs in our HHS, other Hospital and Health tanks, conferences and other meeting formats. In
Services in Queensland, nationally and addition our methodical approach to developing the
internationally. Please note this influencing and KSCp and systematic reporting of its outcomes is
translation into other healthcare settings is a work building workforce capacity in evaluating
in progress. Dr Amanda Dines, Executive Director of implementations of health services, including two
the Royal Brisbane and Women’s Hospital (RBWH), early career postdoctoral Fellows - one in models of
recognises the importance of the work the program care research and one in health economics – funded
does with vulnerable patients, ranking it amongst through the research collaborations.
the top candidate programs for new funding in
The KSCp is a product of the innovation space in the
financial year 2017-2018 and championing it in the
Metro North Hospital and Health Service, funded
competitive pitching for HHS funding.
initially through its SEED Innovation program. We
The KSCp continues to develop. In addition to the turned to the emerging field of Implementation
directional work we describe in the previous Science to inform us on how to evaluate the
paragraph and building collaborations outlined in implementation of this new service and in particular
the next section on continuous improvement, we the novel methodology of CFIR. We adapted the
are using the principles of research to further processes in the methodology to expand the
develop the program. The KSCp brings together sampling of patient expectations, experiences and
clinicians who are Chief Investigators in NHMRC outcomes. Importantly we extend sampling into the
funded Centres of Research Excellence in CKD patient community ie their families and their carers.
(CKD.CRE) and End of Life CRE (EoL CRE). A This approach was endorsed by AusHSI who

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20th Annual ACHS Quality Improvement Awards 2017
Category: Clinical Excellence and Patient Safety Winner

awarded the program a competitive grant to moving between community health centres. In the
conduct the evaluation. The research approach has next year the reach of this highly specialized, small
left a legacy of processes and tools that are team will be extended into additional fixed clinics in
sustainably embedded into the business as usual of the northern part of MNHHS with the aim of
the clinical program. We are publishing the bringing the service into the local communities of
outcomes of the evaluations widely. more of our patients. We continue to process the
themes from our qualitative analyses of patients,
3. Continuous Improvement carers and stakeholders’ surveys and the outputs
The KSCp systematically measures, analyses, reports will inform further service redesign.
and acts on patient outcomes and the performance
of the program. Into the future we are extending our collaborations
with early adoptors/adaptors of this model in
Our innovative approach to measuring patient Australia and linking them with leading researchers
expectations, and the expectations of their in Australia (CKD.CRE and End of Life CRE) and
communities, is described in the previous section. internationally for the purposes of evaluating the
These are analysed individually by the KSCp team impacts of differences in the models practiced at
using a case conference methodology and the different sites – see section striving for best practice.
outcomes communicated to the patients’ kidney This work will bring our patients and/or consumers
clinician and GP. Formal documentation of these into the collaborations where they will be present at
care expectations are recorded in tools such as earlier points in the service planning cycle. Their
Statement of Choice. PROMS and PREMS are also presence is particularly important given there are no
analysed at group level. Important measures like universally agreed targets of care and the
stakeholder engagement, health economics, etc not collaborations will be valuable opportunities to set
covered by the patient centricity evaluations are benchmarks for quality of care. The intellectual
similarly being sampled as part of the scrutiny and thinking of these collaborations will be
implementation research of the performance of the injected into future planning of the program.
program.
An early observation is an interesting change in how
The performance of the program is monitored the multidisciplinary KSCp team works, to a model of
regularly and reported in a number of forums that interaction that looks more like transdisciplinary.
include the KSCp Steering Committee, KSCp We are planning on studying the impact of team
Research and Operational meetings, KHS functioning – see section innovation in practice and
Management Advisory Group and monthly KHS process. One small example of this observation is
scorecard to the funders. Activity and budget continuing to staff the KSCp with advanced trainees
measures were reported to the initial SEED funders in renal medicine with the aim to build the capacity
at MNHHS for the life of the funding and have now of future generations of nephrologists to deliver
transitioned to business as usual reporting to these services. Our plans will extend the workforce
management of the RBWH. These reports are in the evaluation to other professions and be conducted
organizational template formats. Collectively the within a rigorous methodology.
results of the monitoring activities over the first 12
months are the subject of reports to AusHSI, 4. Evidence of Outcomes
presentations nationally and internationally and of The evaluation of the KSCp provides robust evidence
manuscripts in preparation for publication. Extracts of individual, service and community level benefits.
of these reports and summaries in the format of The infographic at appendix 1 lists headline
infographics are used to brief stakeholders. qualitative and quantitative outcomes of the KSCp.
The first tranche of analyses have already led the In brief, our nephrologists referred 129 patients
KSCp clinical team to rethinking the model, with the (mean age 71.6 years [range 27–91], 52% men, 53%
commencement of nursing outreach into the four on dialysis) into the program compared with 27
dialysis units across the MNHHS. In mid-2016 KSCp referrals to palliative care in the preceding 12
alerts were added to the Patient Admission System months. Patients who had attended at least one
(PAS Hospital Based Corporate Information System) KSCp appointment (n=101) were in the program for
so that the Palliative Care team is informed of a median of 203 days (range 1-350). At 12 months
admissions of patients of the program to the RBWH, 82 patients were attending the KSCp with a median
resulting in improved communication between time of 189 days (range 42-350) and 25% had left.
specialties particularly of patients’ expectations. Patients remain under the care of their nephrologist
Further, the clinical team is planning mobile clinics, throughout the KSCp pathway of care.

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20th Annual ACHS Quality Improvement Awards 2017