CNC Quality

Conception to Realisation

Sandie Lenehan ND Division of Surgery Logan Bayside

Michelle Reardon CNC Quality Division of Surgery Logan Bayside

Logan Bayside Network –

Who are we?

350 beds

22 beds

113 beds

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

Creation of the Divisional Leadership

Birth of the universe as we know it.

CNC Quality

From idea to conception

IDEA FUNDING CONCEPT IS BORN

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.

First Job….Accreditation

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

Display the Data

Investigate Existing Audit Data

Auditors reluctant

to go into the units

Lots of PACU data

and not much else.

The first site of blood

Benchmarking across the network

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

TODAY LOGAN BAYSIDE AND TOMMOROW THE WORLD

Thanks for allowing us to present