sandra lenehan & michelle reardon - logan bayside - evolution of the divisional cnc quality role...
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CNC Quality
Conception to Realisation
Sandie Lenehan ND Division of Surgery Logan Bayside
Michelle Reardon CNC Quality Division of Surgery Logan Bayside
Division of Surgery Logan Bayside
2 Perioperative Units
12 Operating Rooms – 13th currently being built
2 CSD units
2 Endoscopy units – 3 endoscopy rooms
Outpatients Department
8 Bed ICU
3 x Surgical Wards
1 x short stay and extended day stay
1 x long stay
1 x mixed length of stay
Division of Surgery Vision
Teamwork “Built it and they will come”
Vision for the Surgical Division
Logan Bayside Health Network
To make Logan Bayside the best
public hospitals for patients to
have surgical care and the best
hospitals for staff to work and train
in to provide this care.
Jan 2013 DOSA Rates: 75% - target 80%
Jan 2013 Day Case Rates: 30% - target
50%
Total throughput: Elective 247 & Emergency
346
Cancellations: 180 cases Feb 2013
Avoidable Delays Feb 2013: 952 mins
approx. $42 840
CNC Quality - Purpose
The Clinical Nurse Consultant, Divisional Safety and
Quality will provide advanced management and
leadership skills, supporting the clinical units throughout
the relevant division.
It will provide coordination and guidance, supporting
operational and strategic departmental goals; assisting
the clinical units in obtaining benchmarks, maintaining
standards and optimising patient/divisional outcomes.
Stages of Accreditation
Stage 1 – Accredi-denial
Stage 2 – Accredi-anger
Stage 3 – Accredi-bargaining
Stage 4 – Accredi-depression
Stage 5 – Accredi-acceptance
Stage 6 – Accredi-done
Stage 7 – Accredi-hangover
Stage 1 Accredi-denial
Clinicians love data
Clinicians love policy
Clinicians love governance…
This will be easy
Investigate Existing Audit Data
Auditors reluctant
to go into the units
Lots of PACU data
and not much else.
The first site of blood
Engagement
Facilitate Executive Rounding in all units
Preparation presentations from all Directors of Specialities to
CEO, DMS and Director of Nursing and Director of Quality
Medical Consultants, Registrars and Residents presentation
Nursing staff presentation
Mock accreditation with standards leads throughout Metro
South – support the staff and environmental checks
Meetings ++++++
Cause of Stage 4 – Accredi-depression
Eventually leading to
Stage 5 – Accredi-acceptance
1 Week Out
Some staff were still in Stage 1 Denial
Most had moved to Stage 5 Acceptance
And a few others had moved into Stage 4
½ PANIC / VOMIT
Results
23 upgrades to Met with Merit – Logan Hospital
All components met including the Developmental
18 upgrades to Met with Merit – Redland Hospital
All components met including the Developmental
What now….
Continuous survey readiness
Pathway to Excellence
Planetree
Cognitive Institute
Meetings +++++
Key contact for the Division
Funnel for all sources for data – CSET; HRT; ACHS
Key connection between the clinical floor and executive staff
AND PREP TO DO IT ALL OVER AGAIN
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