Date post: | 20-Jun-2015 |
Category: |
Health & Medicine |
Upload: | informa-australia |
View: | 447 times |
Download: | 1 times |
Implementing the National
Standards in the Operating
Theatre Suite – A guide to Preparing for
Accreditation
Ben Lockwood Clinical Practice Consultant
Flinders Medical Centre
South Australia
Flinders Medical Centre (FMC)
> Tertiary Trauma Centre
> Part of Southern Adelaide Local Health
Network (SALHN)
2013 Accredited as a Network
> Southern Adelaide Local Health
Network (SALHN)
• FMC, RGH, NHS, GP Plus Clinic
Flinders Medical Centre
> Division of Surgery
o Sub-division Surgical &
Perioperative Medicine (SAPOM)
• Operating Theatre Suite
Network-wide quality framework
> Formation of SALHN accreditation steering
committees
> One committee for each standard
• Executive leads
• Medical leads
• Nursing leads
> Organisational focus is imperative!
Operating Theatre Suite approach
> Mirror network-wide methodology
> Clinical leads for each standard
• 2-3 ACSCs & CNs (Level 2)
• Level 1 RN/EN engagement
• Driven by Clinical Practice Consultant
> Standard 1 led by OTS Governance group
Operating Theatre Suite approach
> Education and awareness campaign
• Regular National Standard in-services
• Driven by each lead group
• Explained what does ‘National Standards’ and
‘accreditation’ mean for ALL staff
Revision of Governance Structure
> Divisional reporting lines were strengthened
• Nursing, anaesthesia, surgery, CSSD, other depts.
> Meeting groups with clear TOR
> NSQHSS focussed Clinical Leadership
meeting
Next step… Gap Analysis
> Reviewed information packs (available online)
> Assessed each item/action
• Organisational wide?
• Operating Theatre Suite focus?
If OTS, what do we need to do?
Gap Analysis
> NSQHSS Standards Monitoring Tool
• Excel Spreadsheet
> Available online
• http://www.safetyandquality.gov.au
OTS Quality Improvement Plan
> Documented presentation of the improvement
activities being undertaken within the suite
> Ongoing use post-accreditation
Quality Improvement Activities
> Policy, procedure & protocol/guideline review
and endorsement
> Auditing & Reporting
• KPI monitoring
> Risk identification & escalation
Policy, procedure & protocol
> Process of review
• Frequency, risk rating, compliance monitoring
• Policy = SA Health
• Procedure/Protocol = SALHN, FMC or OTS
• ACORN Standards
• Right input, right focus, right people
> Process of endorsement
• Right input, right focus, right people
• Locally endorsed
• FMC or SALHN endorsed
> Upload to the intranet
> Ongoing process…!
Auditing & Reporting
> Who is auditing what, when & where?
• Past audit schedules
• New requirements
> Developed comprehensive audit schedule
• NSQHSS requirements
• SA Health audits
• ACORN Standards
• SALHN or FMC audits
• OTS requirements
Auditing & Reporting
Auditing & Reporting
> Reporting aligned with meeting structure
• Reporting template created
• Actions plans formalised & communicated
What is working well?
What needs changing/improving?
Responsibilities & timeframes
• KPI monitoring
Access & capacity
Clinical performance
> Results focussed
• Accountability
• Clarity
Risk Identification & Escalation
> Risk register
• Human & material resources
• Financial
• Political or Legal
• Service delivery & clinical risks
> OTS (local) risk register
• Managed internally
• Items identified via reporting
mechanisms
• Items escalated as required
> Network (SALHN) risk register
• Managed network wide
Accreditation process
> Robust governance structure
> Systems in place
• Quality Improvement Plan
• Policy & Procedure review
• Auditing & Reporting
• Risk Management
> Collect our evidence for National Standards
• Items & Actions
for each standard
Accreditation process
> Clinical leads for each standard
• Reported updates at Clinical Leadership Meeting
> NSQHSS Standards Monitoring Tool
• Data input & evidence collation
The week of the survey
> Network survey activities
• Organisational meetings for each standard
> Local (OTS) survey activities
• Produced overview presentations for each standard
• Summarised our evidence
• Participated in walkthroughs
• Question & answers
• Showed off our
achievements!
Summary
> Organisational approach
> Everyone must be engaged
• Educational package
• Accreditation awareness
> Review governance systems
> Quality improvement plan
• Policy, procedure, protocols
Review & endorsement processes
• Auditing, reporting and KPI monitoring
> Risk management
> Presented our work during survey/audit
Persevere… success takes effort!
Questions?