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SESLHD PROCEDURE
COVER SHEET
COMPLIANCE WITH THIS DOCUMENT IS MANDATORY This Procedure is intellectual property of South Eastern Sydney Local Health District.
Procedure content cannot be duplicated.
Feedback about this document can be sent to [email protected]
NAME OF DOCUMENT
Escalation Process and Expectations of Patient Flow Coordinators, After Hours Nurse Managers and District Executive Officers On-Call for SESLHD
TYPE OF DOCUMENT
Procedure
DOCUMENT NUMBER
SESLHDPR/410
DATE OF PUBLICATION
August 2015
RISK RATING
Medium Risk
LEVEL OF EVIDENCE
Standard 1: Governance for Safety and Quality in Health Service Organisations. Standard 15: Corporate Systems and Safety
REVIEW DATE
August 2018
FORMER REFERENCE(S)
N/A
EXECUTIVE SPONSOR or
EXECUTIVE CLINICAL SPONSOR
Ms Kim Olesen, District Director of Nursing & Midwifery | Access, Redesign & Clinical Services.
AUTHOR
Leanne Horvat – Acting District Manager, Access, Redesign & Clinical Services.
POSITION RESPONSIBLE FOR THE DOCUMENT
Acting District Manager, Access, Redesign & Clinical Services.
KEY TERMS Escalation, Patient Flow Management, On-Call Procedures, Patient Flow Coordinator, After Hours Nurse Manager, Facility Executive, District Executive, Mental Health Executive.
SUMMARY
This procedure will provide an overview of the role and responsibility of the Patient Flow Coordinator, After Hours Nurse Managers (AHNM), Executive On-Call and the escalation expectations to the District Executive Officer On-Call within South Eastern Sydney Local Health District (SESLHD) to ensure equity of access to care and equity of health outcomes for SESLHD residents.
SESLHD PROCEDURE
Escalation Process & Expectations of the Executive District Officer On-Call
SESLHDPR/410
Revision 5 Trim No. T15/9256 Date: August 2015 Page 1 of 11 COMPLIANCE WITH THIS DOCUMENT IS MANDATORY
This Procedure is intellectual property of South Eastern Sydney Local Health District. Procedure content cannot be duplicated.
1. POLICY STATEMENT
This procedure will provide an overview of the role and responsibility of the Patient Flow Coordinator (PFC), After Hours Nurse Managers (AHNM) roles, Executive On-Call and the escalation expectations to the District Executive Officer On-Call within South Eastern Sydney Local Health District (SESLHD) to ensure equity of access to care and equity of health outcomes for SESLHD residents. Each facility has an Executive On-Call process that ensures this is able to address any matters and incidents that occur out of usual business hours. This can be through either direct management of the situation or by escalating the response up through to the District Executive On-Call (Tier 2).
2. BACKGROUND
The focus of this document is to provide a framework governing the Patient Flow Coordinators (PFC), After Hours Nurse Managers (AHNM), Facility and District Executive On-Call strategies which underpin facility operational functions for patient flow systems. For further information on patient flow management refer to Care Coordination: Planning from Admission to Transfer of Care in NSW Public Hospitals PD 2011_015
3. RESPONSIBILITIES
3.1 Patient Flow Coordinators (PFC):
The Patient Flow Co-ordinator (PFC) is responsible for the efficient and effective care coordination and patient flow, to improve the patient experience and improve patient flow within the hospital. The PFC generally works a rotating roster which includes weekends. The PFC is responsible for the equitable allocation of beds for elective, direct and emergency admissions. These admissions must be triaged in relation to clinical need, provision of timely appropriate care and ability to meet Ministry of Health benchmarks.
To assist communication in our larger facilities Patient Flow Coordinators are to undertake a daily regular reporting / status update at 11:00 hours and at the end of each shift, daily weekdays at 16:00hours (if required more frequently through peak periods).
3.2 After Hours Nurse Managers (AHNM):
After Hours Nurse Managers (AHNMs) are extensions of the Facility Executive after hours. Facility Executives are to ensure that they communicate frequently to enable AHNMs to work consistently and confidently in the decisions they make. To assist communication in our larger facilities AHNM are to undertake a regular reporting / status update at at the end of each shift (if required more frequently through peak periods).
The PFC and/or AHNM are responsible for communication of the following information to their Facility Executive On-Call:
Number of patients waiting to be seen in ED
Number of patients waiting for beds
Number of patients who have breached
Demand management status
Bed availability and surge beds, medical/ surgical capacity
Emergency theatres activity, notifying after hours call back and time completing call
Birth Unit activity, NICU capacity
SESLHD PROCEDURE
Escalation Process & Expectations of the Executive District Officer On-Call
SESLHDPR/410
Revision 5 Trim No. T15/9256 Date: August 2015 Page 2 of 11 COMPLIANCE WITH THIS DOCUMENT IS MANDATORY
This Procedure is intellectual property of South Eastern Sydney Local Health District. Procedure content cannot be duplicated.
ICU/ HDU capacity
Overtime requirements
Concerns regarding patient care
Clinical incidents of concern
Security issues as they arise
Major complaints from the public
Issues of media interest
Staffing issues
The PFC, AHNM and Mental Health Delegate must provide an emergency department and hospital bed status report on Saturday and Sunday (by 11:00 hours) to the District Executive On-Call (Appendix 1), and be able to provide as requested to the District Executive On-Call with up to date information on the status of their facility including:
1. The status of the emergency Department (ED)
2. Status of ambulances offloads and any delays or long wait (>45 mins)
3. Demand management status
4. Bed availability - including surge capacity
5. Critical Care capacity - ICU/HDU/CICU beds
6. Number of patients in ED and waiting to be seen
7. Number of patients in access block
8. Mental health update – capacity and demand
9. Identification of issues impacting on patient flow
10. Staffing issues
3.3 Facility Executive On-Call:
This person is the representative for the Facility General Managers and generally the first point of contact for queries or problems that occur out of hours at any facility for the PFCs and AHNM. The majority of on-call matters will be dealt with at this point and escalated to the Facility General Manager as appropriate. It is likely that this person will be the first to become aware of an actual or potential internal incident that requires a co-ordinated response. This person is expected to be available to respond to requests for action by the on call in relation to any patient flow or access matters. It is expected that the Facility Executive On-Call will be:
Contactable at all times and mobile phones are to be on at all times. Home phone numbers should be documented and up to date with facility switchboards. If an Executive On-Call is to be going out of mobile phone range, alternate numbers are to be provided to the facility switch board operators.
Familiar with facility patient flow escalation plans and with the facility’s winter / summer access platform plans.
Executive On-Call when the is Chief Executive is unavailable, prior to submission with written media responses or statements filtered through the Media and Communications staff member On-Call. Each roster will consist of the facility staff rostered on-call and may include (but not limited to):
St George / Sutherland Hospitals o General Manager
SESLHD PROCEDURE
Escalation Process & Expectations of the Executive District Officer On-Call
SESLHDPR/410
Revision 5 Trim No. T15/9256 Date: August 2015 Page 3 of 11 COMPLIANCE WITH THIS DOCUMENT IS MANDATORY
This Procedure is intellectual property of South Eastern Sydney Local Health District. Procedure content cannot be duplicated.
o Director of Clinical Services o Director Nursing & Midwifery Services o Deputy Director of Nursing & Midwifery o Nursing Co-Directors / Clinical Group Managers
Prince of Wales / Sydney & Sydney Eye Hospitals o General Manager o Director of Clinical Services o Director of Nursing & Midwifery o Deputy Director of Nursing & Midwifery o Nursing Co-Directors / Clinical Group Managers
Royal Hospital for Women o General Manager o Director of Clinical Services o Director of Nursing & Midwifery
SESLHD Mental Health Service Executive o SESLHD Access o Sutherland MHS Executive o St George MHS Executive o Prince of Wales MH Executive
3.4 Escalation to Facility Executive On-Call:
It is expected that the PFC and/or AHNM will escalate the following issues in the first instance to the Facility Executive On-Call who will assist with an extensive contingency plan to manage the facility:
ED escalation level is on 4, i.e. ambulance OST > 120mins and no possibility of offload within next 20 minutes
Major failure of service e.g. CT breakdown, power failure, fire, IT system etc.
Internal disasters including small fires, flooding etc.
Major issues that will attract media attention including serious complaints or major VIP involved
Inability to resolve transfer of critically ill patients to another facility
Inability to resolve NSW Ambulance Service matrix issues Capacity issues – i.e. no capacity exists in the facility in key areas of risk – critical care
beds, surge beds, emergency theatre time unavailable.
It is the responsibility of the Facility Executive On-Call (and/or PFC / AHNM under instruction) to escalate any of the above issues to the District Executive On-Call and provide an extensive contingency plan to manage the facility.
4. PROCEDURE
4.1 District Executive On-Call Access / Rosters
The District Executive Officer On-Call will be a member of the District Executive Team (DET) (must have a clinical background). The District Executive On-Call will operate from 08:00 on Monday until 08:00 the following Monday and all senior managers who are on call should be contactable via mobile at all times throughout this period. On a public holiday the on-call listed on
SESLHD PROCEDURE
Escalation Process & Expectations of the Executive District Officer On-Call
SESLHDPR/410
Revision 5 Trim No. T15/9256 Date: August 2015 Page 4 of 11 COMPLIANCE WITH THIS DOCUMENT IS MANDATORY
This Procedure is intellectual property of South Eastern Sydney Local Health District. Procedure content cannot be duplicated.
the roster will continue to cover the on-call period until the next working day, unless this has been overridden by alternative arrangements. General Managers of facilities who are also members of the DET will not be required to be rostered On-Call as the District Executive Officer as they will continue to have delegation of responsibility for their own facilities. Monthly rosters for the upcoming month are to be submitted to the District Manager Access, Redesign and Clinical Services by COB Friday of the third week of each month. Once collated the combined roster outlining the weekly Executive On-Call for the SESLHD will be distributed to the District Executives, roster participants, the switchboards in each facility and the District Health Service Functional Area Coordinator (HSFAC). The District Executive Officer On-Call will be rostered for 24 hours / day for a week at a time and are contactable on the SESLHD Access phone number (02) 9540 8866.
Each roster will consist of the District Executive Team On-Call and may include (but is not limited to):
o District Director Nursing and Midwifery Services o Director of Programs and Performance o Director of Capital Redesign
District Executive On-Call must escalate to the Chief Executive any major issues and/or concerns by exception outlining the facilities operational contingency plans.
4.2 Demand Management Teleconferences (Weekdays 11:00 hours)
Teleconferencing needs will vary slightly with regards to the activity within the SESLHD and the requirements of the Chief Executive in regards to communication of issues within the facilities. The scheduling of the teleconferencing year round will be weekdays (Mon-Fri) daily at 11:00 hours with the following staff:
SESLHD Access and Clinical Services Manager or Delegate (Host)
Prince of Wales Hospital Patient Flow Manager
Sydney / Sydney Eye Hospital Patient Flow Manager
St George Hospital Patient Flow Coordinator
The Sutherland Hospital Patient Flow Coordinator
Royal Hospital for Women Patient Flow Manager
Ambulance Service NSW Ambulance Relationships Manager for SESLHD
SESLHD Mental Health Access and Service Integration Manager
The daily teleconference function is to provide a snapshot of current and previous 24 hours activity at all SESLHD facilities including essential information relating to predicted demand and capacity management for the next 24 hours, inter hospital transfer updates and the four day bed predictions for each site. The PFC will also be expected to identify actions /strategies required to address facility /sector patient flow escalations. Consultation with the SESLHD Access and Clinical Services Manager or delegate at the time of teleconferencing can be held regarding sector patient flow strategies or addressed at the quarterly SESLHD Demand Management Committee meetings which should align with local facility decision making by the Sector Executive.
SESLHD PROCEDURE
Escalation Process & Expectations of the Executive District Officer On-Call
SESLHDPR/410
Revision 5 Trim No. T15/9256 Date: August 2015 Page 5 of 11 COMPLIANCE WITH THIS DOCUMENT IS MANDATORY
This Procedure is intellectual property of South Eastern Sydney Local Health District. Procedure content cannot be duplicated.
It is anticipated that teleconferences will occur at a minimum daily and during periods of high activity (e.g. winter, epidemic) may increase to twice daily to ensure that system issues impeding patient flow are addressed and that the LHD’s in collaboration with ASNSW are meeting patient flow requirements with robust demand and capacity plans. This report is compiled daily by the Clinical Stream Nurse Managers and should be emailed to the following Demand Management distribution lists: [email protected]
4.3 Demand Management Reporting @ 16:00 hours
Monday to Friday at 16:00hrs, it is the responsibility of the PFC, AHNM and/or Bed Manager at each facility to provide a bed status report. This report should be emailed to the Access distribution list [email protected]
This information will inform Facility and District Executive On-Call officers of current facility occupancy, bed availability, staffing concerns and/or general concerns regarding demand and capacity of the facility for the next 12-16 hour period.
4.4 Weekend / Public Holiday Reporting @ 11:00 hours
On weekends and public holidays year round the PFC, AHNM and Mental Health Delegates are responsible for providing an 11:00 hour bed status report to the Facility and District Executive On-Call. This report will be collated by the facility PFC and/or AHNM and should be emailed to the Demand Management distribution list for the District Executive On-Call to review: [email protected]
5. DOCUMENTATION
Demand Management Weekend Teleconference templates are available in Appendix 1.
6. AUDIT / MONITORING
To ensure effectiveness, efficiency and compliance, these guidelines will be reviewed on an annual basis.
SESLHD PROCEDURE
Escalation Process & Expectations of the Executive District Officer On-Call
SESLHDPR/410
Revision 5 Trim No. T15/9256 Date: August 2015 Page 6 of 11 COMPLIANCE WITH THIS DOCUMENT IS MANDATORY
This Procedure is intellectual property of South Eastern Sydney Local Health District. Procedure content cannot be duplicated.
7. FURTHER READING / REFERENCES
Care Coordination: Planning from Admission to Transfer of Care in NSW Public Hospitals PD2011_015 http://www.health.nsw.gov.au/pfs/Pages/care-coordination-ref.aspx
Inter-facility Transfer Process for Adults Requiring Specialist Care PD2011_031 http://www0.health.nsw.gov.au/policies/pd/2011/PD2011_031.html
HEALTHPLAN - Medical Services Supporting Plan GL2010_011 http://www0.health.nsw.gov.au/policies/gl/2010/GL2010_011.html
Emergency Management Policy SESLHDPD/265 http://www.seslhd.health.nsw.gov.au/Policies_Procedures_Guidelines/Corporate/Disaster_Management/documents/SESLHDPD265-EmergencyManagement.pdf
Critical Care Tertiary Referral Networks (Paediatrics) PD2010_030 http://www0.health.nsw.gov.au/policies/pd/2010/PD2010_030.html
Complaint Management Policy PD2006_073 http://www0.health.nsw.gov.au/policies/pd/2006/PD2006_073.html
SESLHD Disaster Management – Garrawarra Centre Bushfire Relocation Standard Operating Procedure SESLHDPR/359 http://www.seslhd.health.nsw.gov.au/Policies_Procedures_Guidelines/Corporate/Disaster_Management/documents/SESLHDDisasterManagementGarrawarraCentreSESLHDPR359.pdf
SESLHD MHS Extraordinary Event Management and Demand Plan for Acute Inpatient Beds 2012-2013 SESLHDGL/017 http://www.seslhd.health.nsw.gov.au/Policies_Procedures_Guidelines/Clinical/Mental_Health/Guidelines/SESLHDGL017-SESLHD-MHS-ExtraordinaryEventManagementDemandPlanforAcuteInpatientBeds.pdf
Acute Patient Flow and Sustainable Access Management for Mental Health SESLHDGL/022 http://www.seslhd.health.nsw.gov.au/Policies_Procedures_Guidelines/Clinical/Mental_Health/Guidelines/SESLHDGL022-MH-AcutePatientFlowSustainableAccessMgt.pdf
8. REVISION AND APPROVAL HISTORY
Date Revision No.
Author and Approval
November 2014
1 Drafted from: SESLHD Access Demand and Capacity Reporting February 2013 http://seslhnweb/Access_and_Redesign/docs/SESLHDDemandCapacityReporting2013.pdf
Leanne Horvat, Acting District Manager - Access, Redesign & Clinical Services.
January 2015
2 Revised following feedback from Facility DOOs, DONM, DDONM, Mental Health Service.
Leanne Horvat, Acting District Manager - Access, Redesign & Clinical Services.
February 2015
3 Revised following feedback from Cath Whitehurst and Kim Olesen.
Leanne Horvat, Acting District Manager - Access, Redesign & Clinical Services.
March 2015 4 Revised following feedback from District Executive Team, General Managers, DONMs, DDONMs, AHNM & PFCs.
Leanne Horvat, Acting District Manager - Access, Redesign & Clinical Services
SESLHD PROCEDURE
Escalation Process & Expectations of the Executive District Officer On-Call
SESLHDPR/410
Revision 5 Trim No. T15/9256 Date: August 2015 Page 7 of 11 COMPLIANCE WITH THIS DOCUMENT IS MANDATORY
This Procedure is intellectual property of South Eastern Sydney Local Health District. Procedure content cannot be duplicated.
June–July 2015
5 Revised following feedback from District Executive Team & General Managers
Leanne Horvat, Acting District Manager - Access, Redesign & Clinical Services
August 2015
5 Approved by DET
SESLHD PROCEDURE
Escalation Process & Expectations of the Executive District Officer On-Call
SESLHDPR/410
Revision 5 Trim No. T15/9256 Date: August 2015 Page 8 of 11 COMPLIANCE WITH THIS DOCUMENT IS MANDATORY
This Procedure is intellectual property of South Eastern Sydney Local Health District. Procedure content cannot be duplicated.
Appendix 1: Weekend Demand Management Templates 11:00hours
Prince of Wales Hospital Access Report
Date: / / 2014 Reported by:
Demand Level
Ward Beds available
ICU/HDU
Staffing Issues
Hotspots
Emergency Department Patients in ED
WTBS
Admissions
Unplaced
Ambulances Delays
Patients in Amb Bay chairs
Predicted Net Capacity 8am Comments / Actions:
Sydney / Sydney Eye Hospital Access Report
Date: / / 2014 Reported by:
Demand Level
Ward Beds available
HDU
Staffing Issues
Hotspots
Emergency Department
General
ED Eye ED
Patients in ED
WTBS
Admissions
Unplaced
Ambulances Delays
Predicted Net Capacity 8am
SESLHD PROCEDURE
Escalation Process & Expectations of the Executive District Officer On-Call
SESLHDPR/410
Revision 5 Trim No. T15/9256 Date: August 2015 Page 9 of 11 COMPLIANCE WITH THIS DOCUMENT IS MANDATORY
This Procedure is intellectual property of South Eastern Sydney Local Health District. Procedure content cannot be duplicated.
Comments / Actions:
St George Hospital Access Report
Date: / / 2014 Reported by:
Demand Level
Ward Beds available
ICU 1 & ICU 2
Staffing Issues
Hotspots
Emergency Department Patients in ED
WTBS
Admissions
Unplaced
Ambulances Delays
Predicted Net Capacity 8am Comments / Actions:
The Sutherland Hospital Access Report
Date: / / 2014 Reported by:
Demand Level
Ward Beds available
ICU /HDU
Staffing Issues
Hotspots
Emergency Department Patients in ED
WTBS
Admissions
Unplaced
Ambulances Delays
Predicted Net Capacity 8am Comments / Actions:
SESLHD PROCEDURE
Escalation Process & Expectations of the Executive District Officer On-Call
SESLHDPR/410
Revision 5 Trim No. T15/9256 Date: August 2015 Page 10 of 11 COMPLIANCE WITH THIS DOCUMENT IS MANDATORY
This Procedure is intellectual property of South Eastern Sydney Local Health District. Procedure content cannot be duplicated.
The Royal Hospital for Women Access Report
Date: / / 2014 Reported by:
Neonatally
Obstetrically
HDU Beds
Staffing Issues
Hotspots
Rest of the State (Neonatally) RED
AMBER
GREEN
Predicted Net Capacity 8am Comments / Actions:
Prince of Wales Mental Health Access Report
Date: / / 2014 Reported by:
Kiloh Beds
PECC Beds
MHICU Beds
Euroa Beds
MHRU
Staffing Issues
Hotspots
Emergency Department Patients in ED
Admissions
Unplaced
Expected from Community
Predicted Net Capacity 8am Comments / Actions:
SESLHD PROCEDURE
Escalation Process & Expectations of the Executive District Officer On-Call
SESLHDPR/410
Revision 5 Trim No. T15/9256 Date: August 2015 Page 11 of 11 COMPLIANCE WITH THIS DOCUMENT IS MANDATORY
This Procedure is intellectual property of South Eastern Sydney Local Health District. Procedure content cannot be duplicated.
Sutherland & St George Hospitals Mental Health Access Report
Date: / / 2014 Reported by:
Sutherland Hospital St George Hospital
Mental Health Unit Beds PECC Beds N/A
OPU Beds N/A
MHRU Beds N/A
Staffing Issues
Hotspots
Emergency Department
Sutherland Hospital St George Hospital
Patients in ED Admissions Unplaced Expected from Community
Predicted Net Capacity 8am Comments / Actions:
