Effective Governance of Quality

Improvement Activities

Kay BabalisThe Children’s Hospital at

Westmead (CHW)

Why do we need governance of improvement activities?

To ensure Appropriate approval is obtained Ethical considerations are minimised Improvement activities are well structured Accountability and transparency for staff and consumers

involved in improvement activitiesTo support teams undertaking improvement

activitiesTo be able to report on activities undertaken e.g. for

Accreditation Documentation

Why do we need governance of improvement activities? Cont’d

For Information Sharing Avoid duplication Learn from others Maintain history of activities undertaken

To ensure improvement activities align with organisational goals

To increase the number and quality of activities available to enter in Quality Awards

What do you need to achieve effective governance?

• Appropriate policies & templates in place

• Clear process for staff to follow

• Education for staff

What does CHW have in place to ensure effective governance of improvement

activities?

• Policy on Initiating & Documenting Improvement Activities

• CHARLI database

• Improvement Project Review Meetings

What does CHW have in place to ensure effective governance of improvement

activities?Procedure for Ethical Review of

Improvement ActivitiesCGU staff work with the Team Leader to

ensure best methodology is usedCGU & Human Research Ethics Committee

(HREC) work closely together

QI Ethics Approval Process

Activity has potential ethical issues based on

responses to Ethical Review questions in CHARLI?

CHARLI automatically refers activity to CGU for

ethical review

CHARLI automatically sends

activity to Team Leader’s Manager

for approval to proceed

CGU discusses activity with project

Leader and if required with the Chair of the

HREC

Activity approved?

Activity is set to “Modifications Required”

in CHARLI so that the activity can be edited by

the team

Team resubmits

activity

CGU approves activity in CHARLI, and if ethics approval is required a

QIE no. is granted

yes

no

yes

no

Team submits

activity in CHARLI

Team undertakes

activity yes

Manager approves activity

in CHARLI ?

no

Activity to be cancelled?

no

Activity cancelled in CHARLI

End of Process

yes

Improvement Project Review Meeting

Twice weekly 30 minute meeting of CGU staff

Improvement activities assigned to CGU staff member based on their area of expertise

Improvement Project Review Meeting

CGU Reviewers help staff inexperienced in Continuous Improvement

Activity methodology is adjusted if required

Improvement Project Review Meeting

Approval decision is made:Modifications requiredNot approvedApproved with QI Ethics No.Approved without QI Ethics No.Review Only

What is the CHARLI database?

Children’sHospitalAchievementsResearch Links and Improvements

Database

CHARLI is a web based in house built database available to all staff.

Each hyperlink opens a new tab for collecting activity informationdetails

Approval history is recorded

Multiple documents can be attached including EXCEL & PowerPoint

Different

record types can be entered

A series of questions in the Ethical Review Tab determine whether the activity needs an ethical review to be conducted

What sort of questions do CGU ask when reviewing improvement activities?

Ethical Review Questions

What does CHARLI do?

• Assists accountability• Assists ethical review of

improvement activities• Links information • Issues email notifications to staff • Maintains record of improvement

activities undertaken

What else do CGU do to monitor/track improvement activities?

• CGU link all improvement activities to EQuIP5 criteria

• CGU create accreditation documentation in CHARLI on an ongoing basis

• Reports are regularly sent to Department Heads

What about Education/Training?

CGU offers various standard courses such as Evaluating Improvement Activities & Involving consumers in Improvement.

Fact Sheets27 Fact sheets available

on the intranet on topics such as:– Ethical Review– Process Mapping– Charts & Graphs– Surveys– Focus Groups

Links to Fact Sheets are also in CHARLI

How is our governance system working out?

Year No. of Improvement Activities CGU aware of

No. of Improvement Activities ethically reviewed by CGU

2006 87 Data not available

2007 139 127

2008 185 164

2009 385 293

2010 499 354

2011 322 319

up to June 2012

155 123

CHARLI introduced December 2008

KPIsKey Performance Indicator Target

(Business Days)2011 Results

(Business Days)

Days to first contact Team Leader once activity is submitted in CHARLI

3 3.58

Days to complete an improvement activity review - QI Ethics No. allocated

10 10.49

Days to complete an improvement activity review – approved without a QI Ethics No.

5 7.28

Days to complete an improvement activity review – review only

5 6.18

Since 2005 number of Activities granted a QI Ethics Number which were not endorsed by the HREC = 0

How long did this all take?2004 Paper based form used to record improvement activities.

CGU proposed to the HREC that CGU be able to grant ethics approval for quality improvement activities.

2005 CGU grants first QI Ethics numbers.

2006 Due to increasing no. of improvement activities being recorded, decided needed better way to document and monitor activities.

Became evident that as part of the ethical review of improvement activities, CGU was also providing considerable support to staff undertaking improvement.

2007 Implemented a hospital wide policy called “Improvement Activities – Documentation and Approval”, which required all improvement activities to be initiated using the paper based Improvement Activity Start Form.

Began work on the CHARLI Database, to replace the paper based form.

Increasing number of activities being documented so we expanded the number of CGU staff (CGU Reviewers) who could ethically review improvement activities.

Developed “Ethical Review and Approval of Improvement Activities” procedure.

2008 Implemented the CHARLI Database in December.

2009 Scheduled regular training sessions for staff in the use of CHARLI, as well as one on one training as required. Fact Sheets & FAQ developed on CHARLI and Ethical Review of QI.

Regular reports available to Department Heads and Health Care Quality Committee on activities submitted/approved/completed.

Lessons LearntChanging organisational culture does not

happen overnightStructures need to be put in place to help staff

know what theyneed to do

Staff want to have their activities ethically reviewed so long as it does not taketoo long and the process is not too hard

• Staff need help to distinguish between QI and Research

• Staff prefer just in time training

• More work needs to be done with Departments on how to identify which improvement activities to undertake

Lessons Learnt cont’d

What can you do to improve governance of improvement activities?

Work with your Human Research Ethics Committee to agree on what constitutes Quality Improvement/Research

Seek delegated authority from the HREC to approve quality improvement activities

Formalise the process for initiation and documentation of improvement activities by creating and implementing a policy

Create a register of improvement activities:EXCEL spread sheetDatabase

Train core group of staff in Continuous Improvement so they can support and work with teams undertaking improvement activities

Have incentives for staff to complete activities

What can you do to improve governance of improvement activities?

What can you do to improve governance of improvement activities?

Put mechanisms in place for sharing information

Reward & recognise staff by implementing Quality Awards

Feed back regularly to staff & Department Heads

Thank you