A local response to implementing the Recognition and Management of the deteriorating patient programs/policies

Kelly Dart NM Policy, Practice and Initiatives

2016 FWLHD Health Innovation Awards Finalist Presentation

Briana Bartley

Patient Safety & Clinical Quality Manager

Kelly Dart NM Policy, Practice & Initiatives

Kimberley Flood Critical Care Clinical

Nurse Consultant

Nurse Educators and Clinical

Nurse Educators

Frontline Clinical Staff

Between the Flags was introduced in NSW in January 2010, in response to Recommendation 91 of the Special Commission of Inquiry: Acute Care Services in NSW Public Hospitals. The Inquiry strongly recommended that a State-wide system for improving recognition and response to deteriorating patients be implemented across NSW.

The challenge presented by Recommendation 91 was to implement such a system in over 200 facilities in the State.

We collected numbers of rapid response and

cardiac arrest

We started DETECT training

SAGO charts were introduced

Patient care was not the centre

MoH RR KPIs

We were trying to implement over 90 recommendations from the Garling report and tick boxes

MoH PD2011_077

Released

SAC 1 FY

12

DONM released memo

Breaches in MoH policy identified

5 recorded deaths during

a rapid response

Accountability was the key

• NUMs received workflows to investigate breaches

• Performance Management was commenced

Key policies

were developed

• Roles and responsibility of the TL

• Team Nursing

• ISBAR Communication

• Alterations to Calling Criteria

Studer and

Advisory Board

• We developed reward and recognition for units that are doing a good job

• Introduced Critical Thinking toolkit into all N&M learning

The patient became the centre of our world

• Recognition and reward

• Foster a culture of safety

Studer

• Instilling Accountability

•Use of the Critical Thinking Toolkit

Advisory Board •Develop

learning packages/competencies around pt safety

Education & training

CORE Values

C: We collaborate with CGU O: transparency with staff R: Moved from reactive/punitive to positive/supportive E: Empowered to build nursing practice standards

2015/16 FY have seen 1 SAC 1

Wards are given certificates for how many days without a nursing breach of policy This concept was taken from our mining industry In Dec 2015 4 Units had gone 365 days with no deteriorating patient breaches

QARS audits and action plans

Nursing Practice Forums

NSQHS Standard 9 team meetings to

evaluate

Continue to foster a culture of

patient centred

care

Patient Rounding

Patient Stories

PDSA Cycle: Plan Do Study Act

Continue to audit and

action

Present case

studies and

promote reflective practice through

peer support

Clinical Governance

Unit

Executive Sponsor: Dale

Sutton (DDONM)

Executive Support: Zandra

Corey (DCG)

Clinical Education

Team

Kimberley Flood Critical

Care CNC

Unit Managers