CLINICAL SERVICES PLAN 2016 - 2020 · 2016-12-02 · NWHHS Clinical Services Plan 2016‐2020 Page | 2 Figure 1: Map of the North West Hospital and Health Service region in Queensland

THE NORTH WEST HOSPITAL AND HEALTH SERVICE

CLINICAL SERVICES PLAN 2016 - 2020

NWHHS Clinical Services Plan 2016‐2020 Page | 1

CONTENTS

Page No

1. INTRODUCTION ................................................................................................................................... 1

2. GEOGRAPHY AND POPULATION ........................................................................................................... 1

3. HEALTH SERVICE INFRASTRUCTURE ...................................................................................................... 2

3.1. NORTH WEST HHS SERVICE HUB – MOUNT ISA ..................................................................................... 3 3.2. NORTH WEST HHS ‐ RURAL AND REMOTE SERVICES ............................................................................. 3 3.3. NORTH WEST HHS ‐ KEY SERVICE PARTNERS ......................................................................................... 3

4. NORTH WEST HHS ‐ HEALTH PROFILE ................................................................................................... 5

5. NORTH WEST HHS ‐ SERVICE PRIORITIES .............................................................................................. 6

6. NORTH WEST HHS ‐ FRAMEWORK FOR SERVICE DELIVERY .................................................................... 7

7. NORTH WEST HHS ‐ MODELS OF CARE ................................................................................................ 10

7.1. CORE COMPONENTS OF MODELS OF CARE .................................................................................................... 11

8. CLINICAL SERVICES PLAN .................................................................................................................... 12

8.1. STRATEGIC PRIORITY 1: SAFE QUALITY SERVICE DELIVERY THROUGH CONTINUOUS IMPROVEMENT ........................... 12 8.2. STRATEGIC PRIORITY 2: A HIGHLY SKILLED MOTIVATED AND ENGAGED WORKFORCE WHICH CONTINUALLY STRIVES TO

IMPROVE PATIENT CARE AND HHS PERFORMANCE: ...................................................................................................... 18 8.3. STRATEGIC PRIORITY 3: STRONG PARTNERSHIPS WHICH BUILD BETTER INTEGRATED AND STREAMLINED SERVICES ........ 20 8.4. STRATEGIC PRIORITY 4: AN ENVIRONMENT THAT SUPPORTS INNOVATION, TECHNOLOGY AND RESEARCH ................... 23


1. INTRODUCTION The North West Hospital and Health Service aspires to be Queensland’s leading Hospital and Health

service delivering excellence in rural and remote health. For a rural and remote health service

provider this means providing access to clinical and clinical support services in the right place at the

right time with the right staff and equipment to deliver the right response for the location.

The geography and population of the North West Queensland region presents specific challenges for

clinical service delivery. The towns and communities across the region have vastly different

populations, infrastructure and transport options to support health service delivery. Health issues and

service delivery require different approaches depending on the population group and location, but all

services need to be managed as part of the same integrated health system. Innovative approaches to

service delivery using technology, collaborative approaches and shared resources will be developed

to leverage current and future investments to improve access to quality health services.

The North West Hospital and Health Service clinical service plan details the actions required to

progress clinical service planning, implementation and evaluation over the next 5 years to meet the

priorities defined in the North West Hospital and Health Service strategic plan 2016 ‐ 2020. The clinical

services plan also includes actions that contribute to achieving the strategic priorities defined in the:

Queensland Department of Health Strategic Plan 2016 – 2020

My Health, Queensland Future: Advancing Health 2026

Queensland statewide clinical service plans.

The key outcomes the clinical services plan is seeking to achieve include:

Self‐sufficiency in level 4 clinical service delivery.

Robust partnerships with tertiary specialist services to maintain level 5 and 6 service delivery

to deliver selected specialist services closer to home.

Reorient the use of health infrastructure and enhance service delivery to address priority

health issues.

Increased use of technology and integrated models of care to improve access to services as

close to home as possible.

Coordinated service delivery across the health continuum and service locations in the region.

Implementation of innovative and culturally appropriate partnership models of care to deliver

comprehensive primary health care services to remote Indigenous communities.

Meet national quality and safety standards.

A brief overview of the population, health service infrastructure and health profile of the North West

HHS is provided to understand the actions included in the clinical services plan. The framework for

service delivery in the region is described along with the components that need to be developed to

design, implement and support new models of care.

2. GEOGRAPHY AND POPULATION The North West Hospital and Health Service (North West HHS) covers an area of over 300,000 square kilometres and services the rural and remote communities within North Western Queensland and the

Gulf of Carpentaria. The North West HHS region includes the City of Mount Isa and the towns and

small communities of Burketown, Camooweal, Cloncurry, Dajarra, Doomadgee, Gregory Downs,

Gunpowder, Julia Creek, Karumba, Normanton, McKinlay, Mornington Island and Urandangi. Figure 1

show where the North West HHS is in Queensland.


Figure 1: Map of the North West Hospital and Health Service region in Queensland

The estimated population of the region in 2014 was 32,630. Aboriginal and Torres Strait Islander

people account for close to one quarter of the population (8587). The population is not expected to

increase significantly overall over the next 4 years with the most growth expected in the Aboriginal

and Torres Strait Islander population. This is due to the young age profile and higher fertility rates.

Figures w shows the communities in the region, distance from Mount Isa and the proportion of

Aboriginal and Torres Strait Islander people in each town.

Figure 2: Communities in the NWHHS with population profile and distance from Mt Isa

Key issues:

Young population profile in the Aboriginal communities

Ageing population in all communities.

3. HEALTH SERVICE INFRASTRUCTURE Clinical services are delivered by the North West HHS from a number of health facilities across the

region. The North West HHS uses a hub and spoke model of service delivery in the region with

specialist services provided to rural and remote communities from Mount Isa, Townsville or Brisbane.

Urandangi Population: 360

Distance from Mt Isa: 185km

McKinlay Population: 20 Distance from Mt Isa: 230km


3.1. NORTH WEST HHS SERVICE HUB – MOUNT ISA

Mount Isa hospital is a level 4 facility. The majority of inpatient care, surgery and diagnostic support

services in the North West HHS are delivered from Mount Isa Hospital. Some specialist services at level

5 and 6 are delivered in Mount Isa with support from visiting service providers from Townsville and

telehealth. This collaborative approach enables specialist care to be delivered closer to home.

Specialist services based in Mount Isa, visiting services and telehealth services are shown in Table 1.

Table 1: Mount Isa Based and Visiting Specialist services

Local specialist services Visiting specialist services Telehealth services Anaesthetics Allied Health (nutrition,

podiatry, physiotherapy, occupational therapy, social work and speech pathology)

Day surgery Diagnostic services Emergency medicine Endoscopy General physician General surgery High dependency unit Obstetrics and Gynaecology Paediatrics Psychiatry Pharmacy services Rehabilitation

Audiology Breastscreen Cardiology Deadly Ears program Endocrinology Gastroenterology Infectious disease Nephrology Ophthalmology Orthopaedics Pacemaker clinic Paediatric endocrinology Respiratory physician Renal Home Therapies Renal Physician Respiratory physician Rheumatology Vascular surgery Sexual Health

Aged Care assessment Allied Health Antenatal/Gynaecology Cardiology Emergency medicine Haematology Medical oncology

A range of community health services are based in Mount Isa that deliver health promotion,

prevention, early intervention and treatment services for child health, hearing health, chronic disease,

mental health, aged care, oral health and sexual health across the North West HHS region.

3.2. NORTH WEST HHS ‐ RURAL AND REMOTE SERVICES

Normanton, Cloncurry, Julia Creek, Doomadgee and Mornington Island deliver low level inpatient and

general practice care. Bed occupancy in these facilities is low. This is due to improved medical

technology, better access to local primary health care services and efficient transport services to

evacuate patients to Mount Isa or Townsville when required. Multipurpose services have been

established in Cloncurry and Julia Creek to reorient the health facility to respond to aged care and

community health needs in those communities. Medical, nursing and Aboriginal Health Workers

employed by the North West HHS work in the inpatient and outpatient service areas of these facilities.

Primary health care clinics are located in Mornington Island, Doomadgee, Burketown, Dajarra,

Kurumba, McKinlay and Camooweal. All facilities except McKinlay have access to emergency retrieval

services and telehealth services for emergency and specialist consultations. A range of specialist and

community health services visit rural and remote communities based on health needs.

3.3. NORTH WEST HHS ‐ KEY SERVICE PARTNERS

Private General Practitioners are a key service provider in the larger population centres of Mount Isa

and Cloncurry. Medical Officers from the North West HHS, Royal Flying Doctor (RFDS) or the North

and West Remote Health (NWRH) provide general practice services to all other communities.


The RFDS is a key service provider in the remote areas for both primary health care services and

emergency evacuations. The RFDS provide regular general practice and child health clinics from North

West HHS facilities in Burketown, Dajarra, Camooweal and McKinlay. A fortnightly RFDS child health

clinic is delivered to Doomadgee and Mornington Island. The RFDS supply medical chests to remote

stations and offer a telephone consultation services to treat people over the phone.

NWRH provide a range of medical and allied health services to support chronic disease management,

aged care and restorative care. A fortnightly visiting general practice and registered nurse service is

delivered to Mornington Island and Doomadgee. Allied health services delivered throughout the

region include diabetes education, podiatry, physiotherapy, speech therapy, occupational therapy,

dietitian, mental health workers and dementia advisor.

The Mount Isa Centre for Rural and Remote Health (MICCRH) play an important role for the North

West HHS in the preparation of the work force to meet local service needs and the placement and

supervision of a student workforce in the region. MICCRH manage and staff the rehabilitation services

in Mount Isa under a service contract with the North West HHS.

Many service providers are funded by the Australian government to deliver community aged care and

disability services the region. Collaborative relationships are essential to ensure continuity of care for

the frail aged and disabled. Table 2 is a summary of the type of health facility by location and the

visiting service providers that support health service delivery in North West HHS region.

Table 2: Location and type of health services, North West HHS

Town Type of facility PHC partners

HospitalsMPHS

Primary Health Care

Level 4 Level 2 Level 1 CH service RFDS NWRH

Mount Isa x x

Doomadgee x x x x

Mornington Island x x x x

Normanton x x x x

Cloncurry x x x

Julia Creek x x

Burketown x x x

Karumba x x

Camooweal x x x

Dajarra x x x

McKinlay x

Urandangi x

Gregory Downs x

Gunpowder x

Key issues

General practice services are limited in rural and remote areas.

Services are fragmented, there is duplication of services and poor communication among

primary health care service providers across region.

No common health plan or governance arrangement to direct primary health care services.

Inpatient facilities are underutilised due to changing clinical needs.

Relationships with tertiary hospitals need to be strengthened to sustain quality and safe

specialist service delivery.


4. NORTH WEST HHS ‐ HEALTH PROFILE A snapshot of the health profile for the NWHHS provides insight into the current and emerging health

issues that the clinical services need to address.

People are dying younger

The life expectancy for people living in the NWHHS is 74 years for males and 79.2.years for

females. This is lower than the Queensland average by almost 6 years for men and 3.8 years for

females.

The NWHHS has the highest death rate in Queensland.

The leading cause of death and disability is chronic disease (86%) and rates are rising.

The leading causes of premature deaths are coronary heart disease, type II diabetes and lung cancer.

People are admitted to hospital at higher rates

The rate of hospitalisation is 17% higher than metropolitan Queensland areas

12% of all hospitalisations for period 2011‐2012 were Potentially Preventable Hospitalisations

comprised equally of acute and chronic conditions compared to 8% for the rest of Queensland.

NWHHS has the highest rates of preventable hospitalisation for cancer in Queensland.

The rate of admission for diabetes was twice the rate as that for the rest of Queensland.

Many people in the population have chronic disease which is contributing to preventable deaths 10% of North West HHS population have diabetes.

33% of the population have hypertension.

North West HHS residents over 55 are 2.5 times more likely than the rest of Queensland to have

hypertension.

The population has many risk factors for chronic disease and premature death There is a growing ageing population.

67% of the North West HHS population are overweight or obese.

54% of the population are physically inactive.

26% of the population are consuming harmful levels of alcohol.

20% of the North West HHS population smoke tobacco.

The health of Aboriginal and Torres Strait Islander people is worse than the rest of the NWHHS

The life expectancy of Aboriginal and Torres Strait Islander people is 69.1 years for males and 73.7

years for female ‐ 10 years less than the average for men and women in Queensland.

The North West HHS Aboriginal and Torres Strait Islander perinatal death rate is 3 times the non‐

Indigenous population.

The leading causes of premature deaths for Aboriginal and Torres Strait Islander people is coronary heart disease, diabetes and suicide and self‐inflicted injury.

Aboriginal and Torres Strait Islander people are 2.1 times more likely to be admitted to hospital

increasing to 3 times in the remote areas.

Aboriginal and Torres Strait Islander people are admitted at 5 times the rate of the rest of the

population for chronic conditions the majority of which are preventable.

Aboriginal and Torres Strait Islander people are admitted to hospital for mental health issues at

5 times the rate of the rest of Queensland.

The rate of admission for Aboriginal and Torres Strait Islander people with hypertension is 3.3

times than non – Indigenous Queenslanders.

The incidence rate for chronic kidney disease is 7 times higher thanks for non‐Indigenous people.

11% of Aboriginal and Torres Strait Islander people in remote areas have diabetes, with diabetes

occurring at a younger age than in the mainstream population.


Cervical cancer 3.4 times higher than the non‐Indigenous population and lung cancer is 1.7 times

higher in Aboriginal and Torres Strait Islander people.

Key issues: Consumer, community and government expectation for equitable access to services and

improved health and wellbeing outcomes will constantly be challenged by distance and

geographical population dispersion.

The demand for aged care services will grow due to the aging population and disability cause by

early onset of chronic disease. As the population ages the demand for community based

residential aged care and the incidence of dementia will grow which will be a challenge to service

provision.

The demand for preventable inpatient admissions, renal dialysis and specialist services will

continue to rise if more effective action is not implemented to prevent and manage mental

health, chronic disease and aged care demands.

There is service fragmentation and the lack of collaborative service planning for primary health

care service delivery is leading to service duplication, patient confusion poor communication

between service providers and underutilisation of resources to provide comprehensive primary

health.

The cultural appropriateness of current service delivery models need to be questioned given the

poor health outcomes for Aboriginal and Torres Strait Islander people in the region.

Developing innovative approaches to service delivery using telehealth, other mobile health

technology and a more flexible workforce is the key to improving access to clinical services.

The health service Infrastructure does not support current or future health needs in remote

communities. Inpatient facilities need to be reorientated to better meet community health needs

which will result in a change of roles and responsibilities that may have professional and industrial

implications.

There is increasing competition for medical specialist and registered health care professionals.

5. NORTH WEST HHS ‐ SERVICE PRIORITIES The priority health issues the clinical service plan will address are:

Prevention and management of chronic conditions (including renal dialysis)

Mental health

Communicable disease

Maternal and child health

Youth health

Sexual health

Oral health

Aged care

Palliative care

Increased early access to acute medical and surgical services: orthopaedic, ophthalmology,

urology, ENT, renal, respiratory, vascular, cardiovascular and endocrine/diabetes.

Service enablers to assist with addressing health priorities include

Implementation of integrated service models: hospital, community health, primary health care

Use of multidisciplinary approaches to service delivery

Increased use of telehealth


Diagnostic services

Partnerships with other service providers Strategic actions required to address priorities and enhance the scope and quality of clinical service in the North West HHS:

Strengthen primary health care and aged care service delivery to reduce premature death and

high rates of hospitalisation for preventable hospital admissions.

Establish partnership arrangements with other primary, secondary and tertiary service providers

and MICRRH to increase the capacity of service providers to deliver services closer to home.

Improve service coordination by implementing collaborative multidisciplinary models of care

across inpatient and primary health care services and improved discharge planning.

Develop a common plan for Indigenous primary health care service delivery with implementation

strategies that enable information sharing between service partners, the use of agreed clinical

protocols, effective communication mechanisms and clarity of roles and responsibilities of all

service providers for clinical governance and service delivery.

Clearly define roles and responsibilities for nurse navigators and nurse practitioners to support

the implementation of models of care developed for each service area.

Enhance the built assets, information communication and technology ICT capacity to improve

service delivery.

6. NORTH WEST HHS ‐ FRAMEWORK FOR SERVICE DELIVERY The North West HHS is responsible for planning, managing and evaluating the delivery of clinical services defined in the health care agreement with the Queensland Department of Health. The clinical service plan will strengthen the health service framework and capacity of the North West HHS to ensure that clinical services are delivered in the right place at the right time by the right staff and equipment to deliver the right response for the location. The North West HHS is part of a wider health system that includes private, non‐government, Aboriginal Community Controlled Health Organisations (ACCHO), Townsville HHS and statewide health service providers. The Western Queensland Primary Health Network (PHN) has a key role in commissioning primary health care, mental health and aged care services in the region. Collaborative planning will occur with primary, secondary and tertiary service providers and the Western Queensland PHN to develop strategies for primary health care service delivery, visiting specialist service delivery and models of care to improve access and coordination across community and hospital settings. Partnership arrangements will be formalised with key service partners to strengthen collaboration and accountability to improve access to comprehensive health services from the cradle to grave. Partnership agreements will define governance arrangements for service planning and evaluation, clinical governance structures and define service delivery roles and responsibilities. Models of care that reflects best practice and define the clinical pathways from prevention through to tertiary level services will be developed and documented for each service area to support service integration. Embracing innovative workforce and technological strategies is the key to improving access to services for people living in the North West HHS. The introduction of Nurse Navigators will increase the capacity to case manage people with complex care needs and reduce preventable hospitalisation. Support systems to establish similar roles for Aboriginal Health Worker to create culturally appropriate models of care in Indigenous communities will be developed as part of the model of care for priority service areas. The number of Nurse Practitioner positions will also increase targeting areas where


general practitioner numbers are limited. Nurse practitioners are highly trained nurses who can work autonomously and collaboratively within healthcare system. An expansion of the roles for allied health professionals will also be investigated. Telehealth and other digital technology will be used to access specialist advice beyond that available in the local community, support self‐care strategies, assist service coordination and to provide education to health staff, patients and their families. The broad framework for clinical service relationships for the North West HHS to enable the delivery of seamless services across primary, secondary and tertiary services is illustrated in Diagram 1. Mount Isa hospital is the clinical service hub and central coordination point for specialist services into and out of the region. The thick lines with two way arrows between Mount Isa Hospital, Townsville HHS, statewide services and the RFDS depict that clinical pathways and communication processes are required to manage patient flow and timely access to secondary and tertiary level services. The thin lines show the two way relationship between primary and secondary service providers that

is required to implement comprehensive primary health care services. The communities and service

providers in the smaller colored circle on right hand side are all the same color to depict they will work

to the agreed model of care defined in the Lower Gulf Indigenous Health plan.


Townsville

HHS

Cloncurry

Mount

Isa

Karumba

Camooweal

RFDS

State‐wide

Government and

non‐government

services

Dajarra

McKinlay

Shire MPHS

Indigenous health plan

to achieve integrated service

delivery in Lower Gulf

GP’s

MountIsa

Community Health

DIAGRAM 1: NORTH WEST HOSPITAL AND HEALTH SERVICE CLINICAL SERVICE KEY RELATIONSHIPS

Mornington

IslandGidgee

Healing

Gidgee Healing

MountIsa

Integrated models of care for mental health, maternal health, child health, chronic disease and palliative care across primary, secondary and tertiary care

NWRH

Normanton

Doomadgee

NWRH

MICRRH Rehab Burketown

RFDS

Urandangi

Aged

Care

Julia Creek

Aged

Care

McKinlay

Gregory Downs


7. NORTH WEST HHS ‐ MODELS OF CARE A number of clinical areas have been identified where new models of care need to be developed to better meet the needs of the people in the region. A “Model of Care” broadly defines the way health services are delivered. It outlines best practice care and services for a person, population group or patient cohort as they progress through the stages of a condition, injury or event. It aims to ensure people get the right care, at the right time, by the right team and in the right place1 When designing a new “Model of Care” the aim is to bring about improvements in service delivery, patient outcomes and health status through effecting change. Creating a new Model of Care is a change management process. In addition to defining what the Model of Care looks like, strategies for implementation and evaluation of the model, and the change management from the old to new approach need to be included in the model design. Therefore developing a “Model of Care” is a project and as such should follow a project management methodology including the appointment of a project manager and resources to support the change management process. The Clinical Services Plan defines the priority areas to develop new Models of Care over the next 5 years and includes strategies to assist with the implementation of innovative solutions. The process to be followed to develop a Model of Care is summarised in diagram 2.

Diagram 2: Process Flow for Developing Model Of Care

The guiding principles to follow when designing a Model of Care are that it:

is patient centric has localised flexibility and considers equity of access supports integrated care supports efficient utilisation of resources supports safe, quality care for patients has a robust and standardised set of outcome measures and evaluation processes is innovative and considers new ways of organising and delivering care sets the vision for services in the future.

1 NSW Agency for clinical innovation, Understanding the process to develop a Model of Care, An ACI Framework

Project initiation

Identify an area of need, build a case for change and obtain sponsorship to proceed with the program of work.

Diagnostics

Define the problem‐understand the root cause to treat the real problem and not just the symptoms.

Solution design

Develop and select solutions. Create and document Model of Care.

Implementation

Support the health system to execute the changes needed to implement the model of care

Sustainability

Optomise use of Model of care, monitor the results and evaluate impact.


7.1. Core Components of Models of Care

Core components that need to be developed to define the model of care and facilitate implementation for each service area includes:

A description of the program area Defined target group for the service area Scope of service delivery covered in the model of care Location where different elements of care are delivered across the care continuum Standard clinical guidelines that direct the assessment and management of client care needs Standard electronic assessment and referral templates Documented care pathway for patients with complex care needs outside the community,

including the role of telehealth for assessment, referral and management. Designated leadership for program coordination in the community and at the hospital Designated responsibility for care coordination across the care continuum Defined role statements for each team member involved in service delivery across the

continuum Regular communication to elective surgery waiting list management. A clinical governance framework to monitor the quality of care and compliance with clinical

guidelines and care pathways for the service area. Orientation to ensure new staff understand the model of care and clinical governance

frameworks.


8. CLINICAL SERVICES PLAN The actions included in the clinical service plan are service enablers to implement the strategies contained in the North West HHS Strategic Plan 2016‐2020

to address health priorities. The Clinical Services Plan is a reference document which informs the content of the annual North West HHS Operational Plan.

8.1. Strategic priority 1: Safe Quality service delivery through continuous improvement

Strategic Plan 2016‐2020 Strategy

Clinical Service Plan Reference Number

Clinical Service Plan Cross References

Operational Plan 2016‐2017 Alignment

Action Time frame

a) Develop and implement models of care that are tailored to the specific needs of our communities, that are evidence based, clinically appropriate and cost effective

CSP 1.a.1 CSP 3.a.1 CSP 3.b.1 CSP 3.e.1 CSP 4.a.4

1 a i 1 a ii 1 a iii 1 b ii 1 e i 3 a i 3 a ii

Partner with the Western Queensland Primary Health Care Network and Gidgee Healing to develop a collaborative model of care for service delivery in Normanton, Doomadgee and Mornington Island.

Year 1

CSP 1.a.2 CSP 1.a.7 CSP 1.a.8 CSP 1.b.4 CSP 3.a.2 CSP 3.b.2

1 a i 1 a ii 1 a iii 1 b ii 3 a i 3 a ii 3 e ii

Develop a model of care for child health services across the region integrating primary and specialist care to enhance early diagnosis, delivery of treatment plans and management of children with behavioural disorders, learning disorders and complex needs.

Year 2

CSP 1.a.3 1 a i 1 a ii 1 a iii 1 b ii 3 a i 3 a ii 3 e ii 4 a ii

Review the model of care for oral health services to incorporate telehealth and Indigenous health workers to support oral health prevention activities.

Year 1






Action Time frame

CSP 1.a.4 1 b ii 3 a i 4 a ii

Implement a hub and spoke approach to Emergency Care using telehealth as a key strategy to improve communication between in rural and remote areas and Mount Isa Emergency Department.

Year 1

CSP 1.a.5 1 b ii 3 e ii 3 f i 3 f ii

Review the model of care for managing wound care using clinical pathways to determine where and by whom care can be delivered at Mount Isa Hospital.

Year 1

CSP 1.a.6 1 a i 1 a ii 1 a iii 3 a i 3 a ii 3 e ii

Review the model of care for managing surgical rosters and waiting lists to improve the sustainability of surgical team and waiting times for elective surgery.

Year 1



Develop a sustainable model of care for midwifery that links outreach midwifery services to the maternal health services in Mount Isa.

Year 2


1 a i 1 a ii 1 a iii 3 a i 3 a ii 3 e ii

Review the model of care for Mount Isa Hospital special care nursery to a “Family model of care.”

Year 2

CSP 1.a.9 1 a i 1 a ii 1 a iii

Develop a model of care to support tele‐pharmacy to manage complex medicine regimes for patient in remote communities.

Year 1






Action Time frame

3 a i 3 a ii 3 e ii 4 a ii

CSP 1.a.10 1 a i 1 a ii 1 a iii 1 b ii 3 a i 3 a ii 3 e ii 4 a ii

Develop a model of care for Eye health linking with outreach services from Townsville.

Year 2

CSP 1.a.11 CSP 1.a.18 CSP 4.a.2


Develop and pilot a model of care to support dialysis in remote hospitals. Year 2

CSP 1.a.12 CSP 3.b.4 1 a i 1 a ii 1 a iii 1 b ii 3 a i 3 a ii 3 e ii

Develop the model of care to implement Queensland Rural e‐Chemotherapy services to Cloncurry and Normanton.

Year 2

CSP 1.a.13 1 a i 1 a ii 1 a iii

Develop a model of care for assessment, case management and service delivery for NDIS clients.

Year 2






Action Time frame

1 b ii 3 a i 3 a ii

CSP 1.a.14 1 a i 1 a ii 1 a iii 3 a i 3 a ii 4 a iii

Develop a model of care for the Mount Isa Emergency Department integrating the use of Nurse practitioners.

Year 2

CSP 1.a.15 CSP 1.b.1 CSP 1.d.1 CSP 2.b.1 CSP 3.a.2 CSP 3.e.2


Develop a model of care for chronic disease management to support implementation of the regional chronic disease strategy.

Year 1

CSP 1.a.16 1 a i 1 a ii 1 a iii 3 a i 3 a ii 3 e ii

Develop a model of care for Ear Nose and Throat services in the North West HHS linked to the statewide Deadly Ears program.

Year 3

CSP 1.a.17 CSP 1.a.12 CSP 3.b.4

1 a i 1 a ii 1 a iii 3 a i 3 a ii

Develop a model of care for palliation to operationalise the State‐wide End of Life Strategy.

Year 1






Action Time frame

CSP 1.a.18 CSP 1.a.11 CSP 4.1.2


Collaborate with Townsville Renal Unit to develop a model of care for Continuous Veno‐Venous Haemofiltration for acute and acute on chronic renal failure patient.

Year 2

b) Partner with other health care providers and communities to create an integrated system of care for our local communities.

CSP 1.b.1 CSP 1.a.15 CSP 1.d.1 CSP 2.b.1 CSP 3.a.2 CSP 3.e.2

1 a ii 1 b ii 1 e i 3 a i 3 e ii

Partner with the Western Queensland Primary Health Care Network and Gidgee Healing to develop a region wide chronic disease strategy.

Year 2

CSP 1.b.2 1 b ii 3 e ii

Partner with Princess Alexandra and Townsville hospitals to develop a strategy for sustainable delivery of orthopaedic surgery and ambulatory rehabilitation in Mount Isa.

Year 2

CSP 1.b.3 CSP 4.a.2 CSP 4.a.3

1 a i 1 a ii 1 a iii 1 b ii 3 a i 3 a ii 3 e ii 4 a ii 4 a iii

Partner with The Townsville Hospital to develop an integrated model of care for mental health services that facilitates access to 24 hour acute mental health advice and support for low level inpatient mental health care using telehealth and nurse navigators.

(duplicate of CSP 4.a.3)

Year 2

CSP 1.b.4 CSP 1.a.2 CSP 1.a.7 CSP 1.a.8 CSP 3.a.2 CSP 3.b.2

1 b ii 1 e i 3 a i 3 e ii 3 f i

Partner with the Western Queensland PHN and RFDS to develop a collaborative partnership plan for child health.

Year 2






Action Time frame

CSP 1.b.5 1 b i 1 b ii 3 e ii 3 f i

Explore a service agreement for Community Palliative care service procurement with Mount Isa Blue Care Nursing.

Year 2

c) Monitor report and continuously improve the quality and safety of clinical care

CSP 1.c.1 1 a i 5 b i

Develop service profiles and reporting templates to improve reporting for catchment demographics, disease burden and service utilisation for different service areas.

Year 1

CSP 1.c.2 1 c ii 5 a ia 5 b i 5 b ii 5 d iii

Develop KPIs for: emergency department activity and performance reporting Specialist outpatient review Surgical services.

Year 1

d) Continue to meet or exceed national health care and other required standards

CSP 1.d.1 CSP 1.a.15 CSP 1.b.1 CSP 2.a.1 CSP 3.a.2 CSP 3.e.2

3 f i Meet with clinical leaders from Gidgee Healing and the RFDS and endorse the Chronic Disease Manual 2015 as the standard clinical guidelines for use in managing chronic disease patients for all service providers operating from North West HHS facilities.

Year 1

CSP 1.d.2 1 c ii 1 c iii 1 c iv 1 d i 1 d ii

Actively engage with the following accreditation programs to maintain and improve the quality of care provided in the North West HHS:

National Safety and Quality Health standards (NSQHS/EQuIP) Diagnostic Imaging Accreditation Scheme (DIAS) Medical Training programs.

Year 1

e) Engage with our communities to promote participation in health

CSP 1.e.1 1 b ii 1 e i 3 f i

In partnership with Western Queensland Primary Health Care Network, Gidgee Healing and RFDS develop a stakeholder engagement and partnership strategy for application across the region.

Year 1


8.2. Strategic priority 2: A highly skilled motivated and engaged workforce which continually strives to improve patient care and HHS performance:



Clinical Service

Plan Cross References

Operational Plan 2016‐

2017 Alignment

Action Time frame

a) Adopt a strategic approach to workforce planning that focuses on high levels of engagement through collaboration and growing our own

CSP 2.a.1 CSP 3.e.2 CSP 4.a.2

2 b i 2 b ii 2 b iii 2 b iv 2 b v

Develop a Workforce capacity and capability plan to implement the proposed models of care and a resource strategy for the workforce plan.

Year 1

CSP 2.a.2 3 a ii 4 a iii

Develop a policy position on the use and role of nurse navigators to support service coordination within and outside of the region.

Year 1

CSP 2.a.3 1 b ii 4 a iii

Create Nurse Navigator positions to coordinate care located in Doomadgee, Normanton, Mount Isa Hospital. focusing on PPH, DAMA and PTTS.

Year 2

b) Use contemporary initiatives to attract and retain people with the attributes, skills and experience to help achieve our ambitions

CSP 2.b.1 CSP 1.a.15 CSP 1.a.1 CSP 1.d.1 CSP 3.a.2 CSP 3.e.2

4 a iii Establish a nurse practitioner to support chronic disease care in Normanton. Year 1

CSP 2.b.2 4 a iv Define the scope of practice for AHPRA and non‐registered Aboriginal Health worker roles.

Year 1

CSP 2.b.3 4 a iii Establish a Rural/Remote Specialist nurse practitioner position to support emergency and acute service delivery in Mount Isa.

Year 2

CSP 2.b.4 4 a iii 4 a iv

Investigate the expansion of role / scope of practice for Nursing and Allied Health staff to support innovation in service delivery.

Year 2




Clinical Service



2017 Alignment

Action Time frame

c) Apply, allow and embed high quality management and leadership practices and behaviors

CSP 2.c.1 1 d iii 2 e ia 2 e ib 2 e ii

Investigate potential involvement with MAGNET accreditation as a means to develop nursing leadership.

Year 1


8.3. Strategic priority 3: Strong partnerships which build better integrated and streamlined services



Clinical Service



2017 Alignment

Action Time frame

a) Support and partner Indigenous health services

CSP 3.a.1 CSP 1.a.1 CSP 3.e.1 CSP 4.a.4

3 a i 3 a ii

Develop a Lower Gulf health plan with the North West Primary Health Network and Gidgee Healing to plan and deliver of comprehensive Indigenous primary health care service delivery in the region.

Year 1

CSP 3.a.2 CSP 1.a.2 CSP 1.a.7 CSP 1.a.8 CSP 1.a.15 CSP 1.b.1 CSP 1.b.3 CSP 1.b.4 CSP 1.d.1 CSP 2.b.1 CSP 3.b.2 CSP 3.c.1 CSP 3.e.2 CSP 4.a.1

1 b ii 3 e ii 3 f i 3 f ii

Implement outreach diabetes education, chronic disease nurse practitioner, mental health, maternal and child health and sexual health services to Gidgee Healing services at Burke St Health Hub and Pioneer clinic.

Year 1

b) Connect health services and shared patient information

CSP 3.b.1 CSP 1.a.1 CSP 3.e.1 CSP 4.a.4

3 b ii 3 b iii

Work with Gidgee Healing and RFDS to develop and implement solutions to enable external access to NWHHS electronic records in the lower gulf.

Year 1

CSP 3.b.2 CSP 1.a.2 CSP 1.a.7 CSP 1.a.8 CSP 1.b.4 CSP 3.a.2 CSP 3.b.2

1 b ii Develop a North West HHS Maternal, infant, child and family service integration strategy.

Year 1

CSP 3.b.3 CSP 3.f.3 3 b i Implement coordinated discharge planning in Cloncurry. Year 1




Clinical Service



2017 Alignment

Action Time frame

CSP 3.b.4 CSP 1.a.12 CSP 1.a.17

1 a i 1 a ii 1 a iii 3 a i 3 a ii 3 f i 3 f ii

Formalise the Cancer oncology and non‐oncology pathways with Townsville hospital.

Year 2

c) Drive a regional strategy which has a patient centred approach

CSP 3.c.1 CSP 3.a.2 1.a.i 1.a.ii 1.a.iii 1 b ii

Develop a regional strategy for Sexual Health and Blood Born Disease Direction and individual community action plans.

Year 1

CSP 3.c.2 1 b ii 1.e.i

Work with other service providers to improve case management of clients who require transport to Mt Isa to attend specialist appointments and elective surgery.

Year 2

CSP 3.c.3 1 b ii Develop and implement a regional Acute Care ‐ Dementia and Delirium Strategy and align to State‐wide Older Persons Strategy.

Year 3

d) Engage patients and families in a meaningful way to improve their health experience

CSP 3.d.1 1 e i 3 d ii

Develop resources to explain clinical governance mechanisms for mental health care to clients and families.

Year 2

e) Work with other service providers, patients and

CSP 3.e.1 CSP 1.a.1 CSP 3.b.1 CSP 3.a.1 CSP 4.a.4

3 a i 3 a ii

Work with WQPHN and Gidgee Healing to develop and implement the Lower Gulf Strategy.

Years 1 to 3




Clinical Service



2017 Alignment

Action Time frame

their families to design services which are easy to understand, access and navigate

CSP 3.e.2 CSP 1.a.15 CSP 1.b.1 CSP 1.d.1 CSP 2.a.1 CSP 2.b.1 CSP 3.a.2 CSP 4.a.2

1 b ii 2 b iii 3 f i 3 f ii 4 a iv

Map Allied Health services to the chronic disease strategy and other care pathways to inform workforce planning and service integration.

Year 2

f) Improve each patient’s pathway by working with other service providers and communities.

CSP 3.f.1 1 a i 1 a ii 1 a iii 1 b ii 3 f i 3 f ii

Document and formalise referral pathways for each different specialty area, to include referral to medical officers, nurse practitioners and Allied Health Practitioners to support coordinated and comprehensive service delivery.

Years 1 to 3

CSP 3.f.2 1 b i 1 b ii 3 f i 3 f ii

Develop Service level agreements to support patient access to care pathways with:

Gidgee Healing Laura Johnson North and West Remote Health Mount Isa Centre for Rural and Remote Health (community

rehabilitation).

Year 1

CSP 3.f.3 CSP 3.b.3 1 b ii 3 b i

Develop a discharge planning strategy for application across the North West HHS.

Year 1


8.4. Strategic priority 4: An environment that supports innovation, technology and research





2017 Alignment

Action Time frame

a) Develop new service models through technology and innovation

CSP 4.a.1 CSP 1.a.15 CSP 1.b.15 CSP 1.d.1 CSP 2.b.1 CSP 3.a.2 CSP 3.e.2

1 b ii 4 a iii 4 a iv

Develop a multidisciplinary approach to diabetes care involving nurse practitioners and Indigenous health workers as key members of a multidisciplinary team to improve the management and follow up care of diabetic clients.

Year 1

CSP 4.a.2 CSP 1.a.11 CSP 1.a.18 CSP 2.a.1 CSP 3.e.2

2 b i 2 b ii 2 b iii 4 a ii

Develop a telehealth strategy, infrastructure plan and workforce development plan that defines the investments required in equipment, resources, positions, orientation and consumables to support the sustainable telehealth services and expand the use of telehealth throughout the North West HHS for:

Emergency Medicine (TEMSU) Pre surgical assessment Antenatal/postnatal care Oral health assessment and supervision. Chemotherapy management Clinical pharmacy Dialysis support Ear Nose and Throat assessment, referral and management Aged Care assessment Staff education.

Year 1

CSP 4.a.3 CSP 1.b.3 CSP 4.a.2

1 a i 1 a ii 1 a iii 3 a i 3 a ii 3 e ii 4 a ii 4 a iii

Partner with Townsville hospital to develop an integrated model of care for mental health services that facilitates access to 24 hour acute mental health advice and support for low level inpatient mental health care using telehealth and nurse navigators.

(duplicate of CSP 1.b.3)

Year 2






2017 Alignment

Action Time frame

CSP 4.a.4 CSP 1.a.1 CSP 3.b.1 CSP 3.a.1 CSP 3.e.1

1 e i 3 a i 3 a ii

Reorient the use of health facilities and workforce resources in Normanton, Mornington Island and Doomadgee to support the implementation of the lower gulf health plan.

Year 3

CSP 4.a.5 1 e i Review and plan transition for McKinlay MPHS to a PHCC / MPHS for sustaining future services to meet community need.

Year 3

CSP 4.a.6 1 b ii 3 e ii

Work with service partners to develop a strategy for ATODS services in the region.

Year 3

b) Be an active member of any research body that provides benefit to the NWHHS

CSP 4.b.1 4 b ii Participate in ongoing research related to promote screening for lead in children and pregnant women.

Year 1

Documents

CLINICAL SERVICES PLAN 2016 - 2020 · 2016-12-02 · NWHHS Clinical Services Plan 2016‐2020 Page | 2 Figure 1: Map of the North West Hospital and Health Service region in Queensland