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NADC ACCREDITATION APPLICATION FORM
Name of Service : Lyell McEwin Hospital Diabetes Education Centre, Northern Adelaide Local Health Network (NALHN)
Service Type: Centre of Excellence Is yours a multi-site service? YesTertiary Care Diabetes Service NoSecondary Care Diabetes ServicePrimary Care Diabetes Service
List other associated sites (if any): Modbury GP Plus Superclinic
Location of service being accredited: Lyell McEwin Hospital
Name of contact person for this application: Dr Anthony Zimmermann
Contact person’s [email protected]
Contact person’s Phone No.
0407704465
Mailing Address Division of Medicine, Lyell McEwin Hospital, Haydown Road, Elizabeth Vale SA 5112
DETAILS ABOUT YOUR SERVICE 1. Please tick all health professional disciplines available at your service from the list below and the full time
equivalent (FTE) employment in your diabetes service. List any other disciplines involved in your services in the blank boxes.
STAFFING FTE STAFFING FTEDiabetes educator 11.33 Pathology/pathologist Endocrinologist 3.4 Vascular Surgeon 0.5Physician Cardiologist Dietitian 1.0
Podiatrist 0.9 Psychologist / counsellor Exercise Physiologist Administration service 1.6 Ophthalmologist/optometrist Nephrologist Paediatrician
2. Please list the names of the key health professionals employed at your service, starting with service leaders. If there is not enough space, further columns can be added.
Name Position Email FTE1 Dr Anthony Zimmermann Head of Diabetes and
Endocrine Services [email protected]
2 Ms Emily Tilley Nurse Unit Manager [email protected] 1.03 Ms Jill Lyon-Green CNC Diabetes
4 Ms Neroli Price CNC Diabetes Education
[email protected] 0.65 Ms Sandra Palazzo Endocrine Dietician [email protected] 0.86 Ms Kathy Barrett Podiatry Unit Manager [email protected] 0.97 Mr Robert Fitridge Vasular Surgical
Clinical Lead [email protected].
8 Ms Sally Holmes Administration Assistant
[email protected] 0.99 10 11 12
3. Please list any specialist clinics or services that your service offers and estimate of consumer numbers per month for each service. List any other services in the blank boxes.
SERVICE Pt/mnth SERVICE Pt/mnthType 1 100 Type 2 300 Newly Diagnosis type 1 5 Newly Diagnosis type 2 Gestational diabetes Newly diagnosed GDM Diabetes Foot Clinic 100 Insulin pump initiation 5 Insulin pump support/titration 25 Paediatric type 1 service CGM initiation and support 10
4. What areas does your diabetes service excel in?
Interdisciplinary team model of outpatient clinic service delivery resulting in improved access to appointments; reduction in wait list times; hospital admission avoidance; and facilitated early hospital discharge. Patients see the doctor, nurse educator and dietician during a single appointment. This model of care resulted in our service winning a SA Health award in 2017.Our service is the first in SA to introduce use of a clinical database (Biogrid) which now has grown to more than 5700 patients. We are now regular contributors to the ADDN (Australasian Diabetes Data Network) database, one of 4 Australian Adult diabetes services.Our service supports the education and use of technology (CSII, CGM, Flash glucose monitoring) for our consumers.
5. Please list any programs, initiatives, tools or experiences that are examples of Best Practice that your service shares, or could share, with other services:
Team led model of outpatient clinic careParticipation in audit and benchmarking activities: ANDA; ADDNIntranet Diabetes Education centre page which contains direct links to our internal Procedures, Protocols and Guidelines as well as links to external Diabetes resources including Diabetes SA, ADS, NADC, NDSS, JDRF to improve access for clinicians working within our service."Knowing how you are doing board" located within our centre for staff and consumers.Group education for consumers - New Type 2 DM; GDM; Group insulin starts.Telephone stabilisation service for consumers.
Signature of the service’s manger, CEO, Director of Nursing or other Senior Leader that this application is a true and accurate reflection of the organisation’s systems.
Signature: Name: Position:
Date of application: Select date from dropdown.
FINAL CHECKLISTEnsure the following are attached to your application and that all attachments are saved in PDF format and saved as per the naming conventions outlined in the workbook.
Accreditation application Timetable of clinicsOrganisational Structure Quality Improvement Plan
Section 1: Healthcare ImprovementStandard 1.1 Diagnosis and Treatment
Criterion 1.1.1: Evidence based careIndicator Met Not met Partially Met Not Applicable Comment
A The Diabetes Centre (DEC)
B QI1151 - The development of a Diabetes Education Page on the Nothern Adelaide Local Health Network (NALHN) Intranet Page
C
The DEC follow various NALHN Policies and Procedures located on the NALHN Policy, Procedure and Guideline (PPG) PortalQI1298 Insulin Self Titration Tool in ProgressInformation re Access to foot care is provided on the DEC Intranet Page
Criterion 1.1.2: Multidisciplinary careIndicator Met Not met Partially Met Not Applicable Comment
A CHAMP (Chronic Disease Management Unit)
B
Information is available on the SA Health Website and NALHN IntranetQI1145 re CSII pump failure plan in type 1 diabetes patientsCHAMP referral re frequent presentations MR037(psych service as a result of diabetes)Biogrid Clinical Consultation Tool has a question prompt around depression and also contains Quality of Life Questionaires
C Information is available on the SA Health Website and NALHN IntranetD
Criterion 1.1.3: Medication managementIndicator Met Not met Partially Met Not Applicable Comment
A NALHN Drug and Therapeutic Committee (DTC) Intranet Page
B DTC Education Resources
C DTC NALHN Intranet
D NALHN procedures, NALHN Clinical Fridge Audit
Criterion 1.1.4: Consumer rights and privacyIndicator Met Not met Partially Met Not Applicable Comment
A Private consulation rooms
B SA Health Policy Directive, Carer's week
C SA Health and NALHN policies and procedures, Charter of rights
Standard 1.2 Promotion of Consumer Self-Management
Criterion 1.2.1: Contribution to health improvement through consumer empowermentIndicator Met Not met Partially Met Not Applicable Comment
A
CHAMPQI1153 Newly Diagnosed Type 2 Group EvaluationQI1236 Group Insulin StartsLetters to consumers
B
QI1153 Newly Diagnosed Type 2 Group EvaluationDr Zimmermann's Evaluation FormQI1236 Patient survey group insulin start
C Credentialling and PR&D evidence available
D Mental Health Care Plans
Criterion 1.2.2: Improved consumer health literacyIndicator Met Not met Partially Met Not Applicable Comment
A QI's to review Consumer information, DEC intranet page, SA Health website
B NALHN PPG's and QI's as above
C NALHN PPG's and QI's as above
D NALNH PPGs
E NALNH PPGs
F NALNH PPGs
G QI in progress
Criterion 1.2.3: Consumer remindersIndicator Met Not met Partially Met Not Applicable Comment
A Tesxt messages, letters and telephone
B Letters and telephone
C Biogrid
Criterion 1.2.4: Individualised Consumer CareIndicator Met Not met Partially Met Not Applicable Comment
A CHAMP use Flinders Self-Management Model
B CHAMP use Flinders Self-Management Model
Standard 1.3 Improved Consumer Health OutcomesCriterion 1.3.1: Demonstrated activities to achieve desired health targetsIndicator Met Not met Partially Met Not Applicable Comment
A Biogrid
B
Biogrid; referral guidelines QAC appointments- Nerve conduction studies available within NALHN through our Neurology service
C Internal Referral form for outpatients
D On call Endocrine cover, Quick Access Clinics, Sick Day Management
E Biogrid, ANDA and ADDN benchmarking
Standard 1.4 Integrated CareCriterion 1.4.1: Engagement with other servicesIndicator Met Not met Partially Met Not Applicable Comment
A
Biogrid; Participation in GP care plans, Evening speaking invitations, Hand held App for reference to medications, Inpatient pharmacist assigned to Diabetes and Endocrine Unit, National Diabetes Insurance Scheme, Promotion of Diabetes Day, National Diabetes week, Rolling screen in Diabetes Education Centre waiting area, Diabetes Resources
B NALHN Outpatient Service Information, triage and referral guidelines
C Biogrid
D Biogrid letters
Criterion 1.4.2: Continuity of comprehensive careIndicator Met Not met Partially Met Not Applicable Comment
A
Consultant staff rostered to the same Diabetes Team Led clinics each week, mulitidisciplinary model of service care delivery, Biogrid and other consult letters, use of clinical handover tools routine including team briefs,
B Care planning, CHAMP - case conference for complex patients, Biogrid
C Medical records
D Homer - documented in appointment notes
Standard 1.5 Decision SupportCriterion 1.5.1: Clinician RemindersIndicator Met Not met Partially Met Not Applicable Comment
A Biogrid, in house staff education
B Biogrid, Intranet site links to guidelines
C Biogrid, QI to build into intranet
D Biogrid, Quit Line link to intranet, DSSA Link, Refer to CDMU Unit
Section 2 Governance and ProcessesStandard 2.1 Service Structure and Management
Criterion 2.1.1: Organisational structureIndicator Met Not met Partially Met Not Applicable Comment
A
B
C
Criterion 2.1.2: Leadership and accountabilityIndicator Met Not met Partially Met Not Applicable Comment
A
B Job and person specifications, organisation char
C Dr Zimmermann QI's, SA Health Award, NADC Accreditation, SLS review
D Dr Zimmermann QI's, SA Health Award, NADC Accreditation, SLS review
Standard 2.2 Service CommunicationCriterion 2.2.1: Information about the serviceIndicator Met Not met Partially Met Not Applicable Comment
A
QI to develop websiteInformation in the waiting roomNALHN outpatient service information, triage and referral guidelinesconsumer information sheetsRolling information on TV screen in Diabetes Education Centre Waiting RoomKnowing how we're doing board
B QI to develop website
C
D Outpatient service information, triage and referral guidelines, Internet page
E NALHN procedures
F QI to develop website
G Telephone, email
Section 3 Management of Quality and SafetyStandard 3.1 Risk Mitigation
Criterion 3.1.1: Risk mitigation processesIndicator Met Not Partially Not Applicable Comment
A SA Health Policy, SLS
B SA Health Policy, WHS Management, SLS
C NALHN Intranet SLS, WHS Needlestick/BBFE Management, NALHN Policy,
D Actions taken from 2 SLS incidents
E Medication audit results 2018, NALHN procedure
Standard 3.2 Infection ControlCriterion 3.2.1: Mitigation of infection related incidentsIndicator Met Not Partially Not Applicable Comment
A SA Health Policy, NALHN PPGs
B SA Health Policy, NALHN PPGs
C
SA Health Policy, NALHN PPGs
D SA Health Policy, NALHN PPGs
Standard 3.3 Quality Improvement and InnovationCriterion 3.3.1: Quality improvement practicesIndicator Met Not Partially Not Applicable Comment
A QI in progress
B QI in progress
C ANDA Presentations
D Presentations
E New model of care
F
Staff meetings, action plans, QI plans, newsletter, SA Health Award, monthly education and staff resentations
Criterion 3.3.2: Innovation programsIndicator Met Not Partially Not Applicable Comment
A SA Health Award Winner
B Diabetes team education
C SA HEalth Award Winner
Criterion 3.3.3: TechnologyIndicator Met Not Partially Not Applicable Comment
ABiogrid, PPGs, SLS, Mandatory training, QI's
B Education attendance sheets, updates on resources, industry reps
C competencies, QI
D Biogrid, OASIS
E CSII Download e.g. Carelink; Diasend- Email stabilisation service Standard 3.4 Education and Training
Criterion 3.4.1: Qualification and professional development of staffIndicator Met Not Partially Not Applicable Comment
A NALHN PPG, SA Health Policy, certificates available
B PPGs - SA Health Policy
C mandatory training records
D PR&D, monthly education
Criterion 3.4.2: HR management of staff qualificationsIndicator Met Not Partially Not Applicable Comment
A NALHN credentialling officer, PPG's and SA Health Policy
B NALHN PPG's and SA Health Policy
C Job descriptions
D Online, mandatory training, orientation
Criterion 3.4.3: Participation in knowledge-sharingIndicator Met Not Partially Not Applicable Comment
A team meetings, Divisional meetings, grand round, NADC presentations
B evidence of invitations to speak, Norther GP network, Riverland
C NADC using ANDA and data in practice
Criterion 3.4.4: Consumer education programsIndicator Met Not Partially Not Applicable Comment
A brochures, case notes, 1:1, QI's
B group education sessions, review letters
C c onsumer information sheets
D care plans
Section 4 Service ManagementStandard 4.1 Safety and Welfare of Staff, Consumers and Visitors
Criterion 4.1.1: Occupational health and safety (OH&S)Indicator Met Not Partially Not Applicable Comment
A
B NALHN intranet
C mandatory training, WHS system resources
D
E SLS, NALHN intranet page
Criterion 4.1.2: Management of clinical appointmentsIndicator Met Not Partially Not Applicable Comment
A outpatient consumer templates, HOMER
B
C Consumer referrals, template changes
D team leader role, service triage criteria document
E referral triaged
F referrals triaged based on priority
G consumers can be provided with resources before future appointments
H System in place for rebooking, letters,
Standard 4.2 Records ManagementCriterion 4.2.1: Business recordsIndicator Met Not Partially Not Applicable Comment
A NALHN and SA Health PPGs
B SLA with SA Health on intranet, QI re know how we're doing
C NALHN PPG
Criterion 4.2.2: Clinical records and consumer informationIndicator Met Not Partially Not Applicable Comment
A PPGs
B PPGs
C Forms, OASIS, Case notes, Biogrid
D Forms, OASIS, Case notes, Biogrid
E Biogrid, OASIS pass word required, NALHN PPG's
F SLS, NALHN PPG's
G NALH PPG's, Auto letters, Biogrid generated reports
H Oacis pathology and radiology ordering- biogrid
Criterion 4.2.3: Results ManagementIndicator Met Not Partially Not Applicable Comment
A OASIS
B Biogrid
Standard 4.3 Service Maintenance
Criterion 4.3.1: Cleaning and MaintenanceIndicator Met Not Partially Not Applicable Comment
A NALHN PPG's
B NAKHN PPG's
C NALHN PPG's - audit results
D NALHN Contract Management
Criterion 4.3.2: Service and replacement of equipmentIndicator Met Not Partially Not Applicable Comment
A NALHN Contract Management
B Records are maintained for calibrated equipment
C As above
D Managed by the Divisional Business Manager
E NALHN PPG's
CONCLUDING FEEDBACK
1. Did you find the NADC accreditation process beneficial to you and your service – why/why not?
The accreditation process assisted our service with identifying key ares for improvement . We have since adddessed these areas and now have in place a some key achievements such as an Diabetes and Endocrine intranet page, TV screen in our waiting area displaying key messages to our consumers and we are currently working on our own internet page.The NADC accrediation process has also made our service much more diligent in creating quality improvement activities and involving all our staff in this process.
2. Was the accreditation process easy to understand and were you able to fill out the criteria easily?
Through this process we have been fortunate enough to have the support of our Safety and Quality Manager who has assisted and guided us through the accreditation.
3. What improvements would you like to see included in future versions of the NADC accreditation standards?
4. Other comments.
Thank you
