transforming your experience: implementation plan€¦ · pdp, pdr professional development plan,...

Transforming Your Experience: Implementation plan

2017 – 2021

South Western Sydney Local Health District

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Version Control Version Date Detail Author / Reviewer

1.0 June 2017

Implementation Plan finalised and uploaded on SWSLHD Intranet

Natalie Wilson, Director, Transforming Your Experience

1.1 February 2018

Updated with feedback from SWSLHD TYE Steering Committee. Meeting held February 2018.

Item 1.4, 1.6, 2.2, 2.3, 3.1 and 4.2

Natalie Wilson, Director, Transforming Your Experience

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Contents

Acronyms & Terminology ………………………………………………………… 3

Introduction ………………………………………………………………………… 4

Implementation Plan ……………………………………………………………… 5

1. Consistent delivery, quality and safe care………………………….. 5

2. Personalised, individual care…………………………………………. 7

3. Respectful communication & genuine engagement……………….. 8

4. Effective leadership & empowered staff……………………………. 10

Appendix 1: Safety Essentials Definitions……………………………………… 12

Appendix 2: Transforming Your Experience Logic Model……………………. 13

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Acronyms and Terminology

CALD Culturally and linguistically diverse

CCC Consumer and Community Council

CCP Consumer and Community Participation

CEWD Centre for Education and Workforce Development

CGU Clinical Governance Unit

Clinical Handover Transfer of professional responsibility and accountability for some or all aspects of care for a patient or group of patient to another person or group

ComPurS Communication with Purpose Strategy

CORE values Collaboration, Openness, Respect, Empowerment

CP SWSLHD Corporate Plan 2013 – 2017

CQI Continuous quality improvement

EMR 2 Electronic Medical Record (Version 2)

Essentials of Care A framework developed by NSW Health which aims to enhance patient, family carer and staff experience through ongoing evaluation and development of safe, effective and compassionate clinical workplace cultures

Executive Leader Rounding Executive Teams rounding with staff in their Units/Departments

GM General Manager

HSM Health Service Manager

ICTS SWSLHD Information Communications and Technology Strategy 2016 – 2021

KPI Key Performance Indicator

Leader Staff Rounding Managers round regularly with staff to identify issues and recognise achievements

Leader Rounding – with patients and customers

Managers round daily with patients (or customers) to identify issues or address concerns

PDP, PDR Professional Development Plan, Professional Development Review

PDSA Plan Do Act Study – quality cycle

Proactive Patient Rounding Nurses regularly check on patients to proactively meet the needs of patients

QARS Quality Audit Reporting System

Qlikview Data management software which can extract data from multiple databases (including Staff link and IMS)

R.E.A.C.H Recognise, Engage, Act, Call, Help. A patient and family focused model that empowers patients and families to identify and escalated concerns

RiskManQ A software tool which acts as a service improvement register/knowledge hub to record quality improvement, redesign and service improvement projects and changes being implemented

Safety- Risk Huddles Brief routine team meetings about potential or existing safety issues or risks

SWSLHD South Western Sydney Local Health District

Transfer of Care Strategy A framework to improve communication in regard to safe transfer of care out of hospital

TYE Transforming Your Experience

WSP SWSLHD Workforce Strategic Plan 2014 – 2021

You Said, We Did Defined process for providing feedback to patients and staff on complaints or issues

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Introduction The Transforming Your Experience Strategy is our five-year road map to positively transform

how our patients, consumers, staff and communities experience our organisation and

services. The Strategy provides us with a clear direction for working together to deliver safe

and quality health services and build the health of our communities – now and into the

future.

Transforming Your Experience is underpinned by four key focus areas which are the current

priorities for South Western Sydney Local Health District (SWSLHD):

1. Consistent delivery, quality and safe care

2. Personalised, individual care

3. Respectful communication and genuine engagement

4. Effective leadership and empowered staff

Each of these areas affect how people experience our organisation and health services

every day. Our efforts to improve how we do business in SWSLHD will address these areas

collectively.

This implementation plan has been developed to guide implementation of prioritised core

actions against these four priority areas. We acknowledge that there are a range of other

activities which will continue to be implemented across the District that will also contribute to

the goals of Transforming Your Experience.

The actions in this plan have been developed based on a review of the evidence of high

performing health organisations and extensive consultation with SWSLHD staff, patients,

consumers and the local community. It will be important that General Managers, Clinical

Council and a range of staff be further engaged on the approach and considerations for

implementing these actions.

The Transforming Your Experience logic model, which shows how core actions will

contribute to desired outcomes, is presented in Appendix 1.

Implementation Phases

Transforming Your Experience is a five year strategy. Implementation has been structured

into three phases:

Phase 1 (24 months): January 2017 to December 2018

Phase 2 (18 months): January 2019 to June 2020

Phase 3 (18 months): July 2020 to December 2021

This phased implementation approach will allow us to review progress – and adapt our

approach if needed – in order to deliver the best outcomes.

Monitoring Progress

Key Performance Indicators (KPIs) have been developed to measure output-level progress

for core actions (and, where more specificity was required, for select supporting activities).

Additionally, KPIs measuring the short-term outcomes of a small number of core actions are

included to inform continual improvement processes and ensure that actions contributing to

the desired improvements. These include qualitative measures and quantitative measures.

High-level outcome-level indicators are presented in the Transforming Your Experience

Evaluation Plan. Interim evaluations will occur at the end of each phase, with a final

evaluation will be undertaken at the end of Phase 3.

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Implementation Plan

1. Consistent delivery, quality and safe care

Actions Lead Completed by Key Performance Indicator (KPI)

1.1 Develop a Unit Support Model, aligning current change management teams, to support units to embed quality, safety and patient experience improvements.

District Executive Early Phase 1 (June 2017)

Clinical Unit Support Model is developed

1.2 Support patient safety and quality by consistently implementing the following ‘Safety Essentials’ at a Unit level:

Executive Leadership Rounding

Leader Rounding with patients & customers

Proactive Patient Rounding

Structured interdisciplinary bedside rounding (including after hours and weekend rounding)

Safety - Risk huddles

Transfer of care Strategy

Clinical handover

You Said, We Did Program (incorporated into quality boards)

District Executive GMs, Service Directors; Clinical Council; Heads of Department

End of Phase 3 (December 2021)

Proportion (%) of clinical units which are consistently implementing ‘Safety Essentials’ Patient feedback, complaints and other data sources indicate improvement in communication with care team, patient involvement in care, care continuity and transfer of care, and self-reported outcomes

1.2.1 Develop and implement additional ‘Safety Essentials’ program for Mental Health and Women’s and Children’s Health services, to address specific risks

District Executive; MH Services; W& CH Health Services


1.3 Communicate key TYE patient safety and quality messages to all staff through a District-wide communication and engagement strategy

TYE Manager Media Unit.


Proportion of facilities/services implementing communication strategy

1.4 Standardise and strengthen data collection and reporting through developing and implementing a quality and safety data strategy, including the EY Strategy recommendations

District CGU; GMs; Service Directors.

Mid-Phase 1 (December 2017)

Quality and safety data strategy is developed and implemented Proportion of clinical units undertaking regular audits Proportion of clinical units/ services

1.5 Implement the Quality Audit Reporting System (QARS) for regular collection, review and reporting of LHD and Facility level audit results to support benchmarking

District CGU End of Phase 1 (December 2018)

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1.6 Undertake regular audits at the clinical unit level using a consistent improvement science to drive the delivery of training and improvements.

Department Heads End of Phase 2 (June 2020)

collecting real time patient experience and patient outcome data

1.7 Develop and implement standard question sets and collection and feedback process for:

real time patient-reported experience data

patient-reported outcome data

CCP Manager, CCP; District CGU

End of Phase 2 (June 2020)

1.8 Undertake phased implementation of Qlikview data management software across services and facilities and provide automated reporting of accurate, meaningful and timely data

District CGU; GMs; Service Directors


1.9 Undertake phased implementation of RiskManQ as a service improvement register/knowledge hub for organisational quality improvement activities

District CGU, GMs; Service Directors


Proportion of clinical units implementing RiskManQ

1.10 Provide dedicated innovation grants for start-up programs and initiatives demonstrating alignment to TYE

District Executive, Innovation Unit

Phase 1 (June 2018)

Number of start-up initiatives aligning to TYE which receive grant funding per year

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2. Personalised, individual care


2.1. Implement R.E.A.C.H (Recognise, Engage, Act, Call, Help Program) across facilities/services

CGU, GM’s, Service Directors, Patient Safety Managers


Proportion of facilities/services implementing R.E.A.C.H

2.2. Identify and address the top 5 TYE implementation priorities for culturally and linguistically diverse (CALD) communities for each facility/service

1. Access to interpreters 2. Access to translated information 3. Care/Treatment that is explained in a way that the patient/carer can understand 4. Patients are treated with compassion and empathy 5. Respectful communication

GMs; Service Directors.


Proportion of facilities/services addressing top 5 TYE priorities

2.3 Identify and address the top 5 TYE implementation priorities for Aboriginal communities for each facility/service

1. Access to services 2. Respectful communication 3. More access to ALO’s and on weekends 4. Care/Treatment that is explained in a way that the patient/carer can understand 5. A more co-ordinated discharge (including to other services, GP etc)

Director Aboriginal Health


Proportion of facilities/services addressing top 5 TYE priorities

2.4 Develop and implement a procedure for open visiting hours, in appropriate clinical settings

Director Operations Director Nursing, GMs


Proportion of clinical units in appropriate clinical settings that have implemented open visiting hours

2.5 Prioritise the rapid implementation of eMR2 across all SWSLHD

facilities/services

IM&TD End of Phase 1 (December 2018)

Proportion of facilities/services that are implementing EMR 2

2.6 Implement transfer of care strategy to support care coordination in all

facilities/services (see 1.1.2 Safety Essentials)

District CGU; GMs; Heads of Department


Proportion of facilities/services that are implementing transfer of care strategy

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3. Respectful communication and genuine engagement


3.1. Implementation of a core District-wide communication programs to support effective communication with patients and staff including:

CORE Chat

Patient Bedside Communication Boards

Workforce and Development, GMs, Service Directors, CGU


Proportion of clinical units implementing initiatives/ processes specified in the patient and staff communication program

3.2. Consistently implement and communicate the use of quality boards, including ‘free text’ for unit-specific indicators and standardised data

District CGU; GMs, Service Directors


Proportion of clinical units consistently implementing quality boards

3.3. Develop and implement an education program for all staff focused on cultural competency

Workforce & Development

Phase 2 (December 2019)

Proportion of staff that have attended a cross-cultural diversity training

3.4. Develop a model to support sustainable implementation and prioritise training for new staff through the on-boarding program

3.5 Develop a structured TYE community engagement program and communication strategy addressing:

Awareness of SWSLHD services and navigation

Understanding of key TYE messages

Consumer engagement opportunities

CCC; CCP Units; Media Unit, TYE Manager


Evidence that structured TYE community engagement program and communication strategy are being implemented

3.6 Implement systems to ensure consistent two-way communication and

feedback for all staff at all levels of the organisation through regular:

Leader rounding with staff,

Open forum meetings with executive teams

Regular interdisciplinary departmental and team meetings

Executive team member involvement in orientation

Executive Leader Rounding (included in Safety Essentials)

District Executive; GMs, Service Directors

End of Phase 1 (Dec 2018)

Proportion of facilities/services consistently implementing systems to improve consistent two-way staff communication Evidence of effective two-way staff communication

3.8 Develop a ‘You Said, We Did’ program at all facilities/services to provide

transparent and timely feedback on key decisions to all staff

District CGU; GMs; Service Directors


Proportion of facilities/services implementing ‘You Said, We Did’ program

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3.9 Develop and implement a targeted engagement plan based on mapping of key external SWSLHD partnerships aligning with TYE

District Executive; GMs, Service Directors


Evidence that targeted partnership engagement plan implemented

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4. Effective leadership and empowered staff


4.1. Review SWSLHD on-boarding program to ensure alignment with TYE priorities and address any gaps.

quality and safety

customer service

patient experience

cross cultural awareness

shared leadership

the CORE values

Workforce and Development

Phase 1 (June 2018)

Review of on-boarding program conducted

4.2 Implement programs to support and develop staff capabilities in:

leadership (aligning with SWSLHD Leadership Model)

quality and safety

effective decision-making

coaching and mentoring

grievance and discipline

bullying and harassment


Phase 2 (December 2019)

Proportion of staff in appropriate positions within each facility/service who have participated in the TYE leadership program

4.3 Review current management programs addressing performance management and recruitment to ensure they align with TYE vision and strategies


Phase 1 (June 2018)

Review of management programs conducted

4.4 Develop and implement a District-wide coaching and mentoring program to support staff development



Evidence that coaching and mentoring is occurring systematically across all services/ facilities 4.4.1 Include coaching and mentoring responsibilities in designated position

descriptions

4.6. Develop a central database to identify:

skilled and high performing leaders

staff completion of leadership and management training

PDP learning and education priorities of staff



Evidence of database

4.7 Develop and implement a District-wide succession planning program Workforce and End of Phase 2 Evidence that succession planning is

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Development (June 2020) occurring systematically across services/facilities

4.8. Strengthen the professional development review (PDR) process and increase uptake of professional development plans (PDPs)



Proportion of staff in each facility/service with regularly reviewed PDPs

4.8.1 Develop a simplified, electronic PDR tool tied to professional development goals and opportunities

4.8.2 Develop guidance for managers on importance and effective use of PDRs

4.8.3 Set facility and department-level PDR uptake targets and accountabilities

4.9 Develop a SWSLHD workplace health and wellbeing program to support the physical, mental and emotional health and wellbeing of staff



Workplace health and wellbeing program developed

4.10. Review, revise and standardise recruitment procedures to align with TYE Workforce and Development


Evidence that recruitment procedures are revised and standardised

4.10.1 Undertake an audit of practices with a view to streamlining recruitment

4.10.2 Develop standardised guidelines for internal recruitment

4.10.3 Include defined behaviours (aligning with SWSLHD Leadership Model) in all staff position descriptions

4.10.4 Include behavioural interview questions for recruitment to all positions and a consumer representative for Health Manager (Level 4) positions and above

4.11 Establish multidisciplinary review committee to revise Delegations of Authority Manual and identify areas to lower decision-making thresholds

District Executive; GMs; Clinical Council;


Areas to lower decision-making thresholds clearly identified in a revised Delegations of Authority Manual Evidence that decision-making thresholds have been lowered

4.11.1 Undertake a risk analysis of agreed delegations, with a focus on financial, clinical and workforce risks.

4.11.2 Develop training and tools to support managers to make effective decisions (See also 4.1.2 – Leadership program)

4.12. Establish a consistent staff reward and recognition program to acknowledge:

demonstrating CORE values

TYE excellence

Years of service



Proportion of facilities/services with regular recognition of staff demonstration of CORE values, TYE excellence and years of service

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Appendix 1: Safety Essentials Definitions

•Executive teams rounding with staff at Units and Departments. Executive Leader Rounding

•Managers rounding daily with patients (or customers) to identify issues and address concerns. Leader Rounding with patients

(and customers)

•Nursing regularly check on patients to proactively meet the needs of the patients.

Pro-active Patient Rounding

•Structured multi-discpilinary handover with the patient +/- carer present. This may be at the bedside or other suitable area.

SIBR- Structured Interdisciplinary

Bedside Rounding

•Defined process for the transfer of professional responsibilities and accountabilitu for some or all aspects of care, for a patient or group of patients to another person or group.

Clinical Handover

•Brief routine meetings about potential or existing safety problems in clinica and non clinical areas. Safety - Risk Huddles

•A SWSLHD framework to improve communciation in regards to a safe transfer of care out of the hospital ; includes passport of care, patient care boards and follow up phone calls.

Transfer of Care

•A defined process for feedback to patients and staff on key issues. You Said, We Did Program

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Appendix 2: Transforming Your Experience logic model

IMPLEMENTATION ACTIVITIES INTERMEDIATE OUTCOMES (1-3 YEARS) LONG TERM OUTCOMES (3-5 YEARS) IMPACT (> 5

YEARS)

AREA 1: CONSISTENT DELIVERY, QUALITY & SAFE CARE

Improved health of people living in SWSLHD

Consistently high quality and safe service delivery at SWSLHD

Highly motivated and well supported staff working at SWSLHD

Clinical Unit Support Model

Safety Essentials

Quality and safety communication and engagement

strategy

Data strategy

RiskManQ

Innovation grants

Clinical unit improvements to quality, safety and patient experience

Safety Essentials implemented all clinical units

All staff have a good understanding of patient safety/quality

Availability of comprehensive, high quality, automated real-time audit,

patient and clinical data for analysis and CQI

Quality improvement activities consistently reported

Increase in TYE-related innovation activities

Quality and safety is integrated in day to day

business

Staff have the skills/understanding to provide quality

and safe care

Patients and consumers experience care that is high

quality and consistently safe

Safety and quality practices consistent/highest

standard

Research and improvement embedded into care

AREA 2: PERSONALISED, INDIVIDUAL CARE

R.E.A.C.H

TYE Priorities for CALD communities

TYE priorities for Aboriginal communities

Open visiting hours

EMR 2

Transfer of care for whole patient pathway

Patients/families empowered to escalate concerns

Tailored service delivery to meet CALD community priorities

Tailored service delivery to meet Aboriginal community priorities

Increased access for patients to their carers/families in clinical settings

through open visiting hours

Increased efficiency, quality and continuity of care and reduced errors

through the consistent use of EMR 2

Increased and consistent coordination of care

All patients/consumers feel valued, treated as

individuals

The diverse needs of our patients/ consumers are

consistently met

Appropriate care through effective multidisciplinary

approaches

Patients/consumers can access the right care, at the

right time, at the right place

Coordinated patient journey

AREA 3: RESPECTFUL COMMUNICATION AND GENUINE ENGAGEMENT

District communication program

Quality boards

TYE community engagement program

Two-way communication and feedback for staff

“You Said, We Did” program

Partnership engagement plan

Community communication strategy

Effective two-way patient communication

Feedback on quality improvements disseminated to patients/staff

Staff communication with patients consistently respectful and sensitive to

specific cultural needs

All staff are able to provide input and feedback across disciplines and to

the Executive and management

SWSLHD strategic partnership approach to improve patient experience

Greater community awareness of, and involvement in decision-making

for, SWSLHD services

Shared decision-making

Patient/consumer interactions are respectful, open

and accessible

Empowered communities take control of their health

and shape our services

Open and transparent communication exists

between staff and senior and executive management

Strong and meaningful partnerships

AREA 4: EFFECTIVE LEADERSHIP AND EMPOWERED STAFF

Review on-boarding program

TYE leadership program

Performance management and recruitment alignment

with TYE

Coaching and mentoring program

Professional development program & PDPs

Workplace health and wellbeing program

Recruitment procedure alignment with TYE

Revision of Delegations of Authority Manual

Staff reward and recognition program

All new staff have strong awareness of TYE priorities

Strengthened District-wide leadership capability in TYE priorities

Performance management/recruitment practices TYE aligned

Systematic coaching and mentoring for identified staff

Electronic PDPs used by all staff across the District to ensure consistent

staff accountability

Health & wellbeing of all staff is consistently supported

Efficient recruitment occurs to approve and fill new/existing positions

Defined behaviours are consistently included in all PDs & interviews

Increased decision-making authority for identified levels of management

Staff performance is recognised and rewarded consistently

Opportunity for staff to develop skills and achieve

their full potential

SWSLHD attracts the best and brightest talent & is

an employer of choice

Recruitment is timely, transparent and effective

Staff empowered and supported to make decisions

and lead change

Staff are responsible for their performance and are

regularly acknowledged for achievements

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