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Deborah Stiles presented this at the 2014 Managing the Deteriorating Patient Conference. The conference discussed the latest strategies to recognise and respond to the acute patient in clinical deterioration. You can find out more about next year's conference at http://bit.ly/1sjQubi
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CHARMERS
Real-time feedback system
for improving
clinician performance
Presented by
Deborah Stiles
Resuscitation Coordinator
Gold Coast Hospital and Health Service Acknowledgement: Richard Oakham, Nurse Manager - eRoster
CHARMERS
Project Aim
To improve compliance
with Q-ADDS utilisation
through ongoing audit
and instant, comparative
and meaningful
feedback reports.
CHARMERS
Background
• GCHHS has 3 inpatient facilities – Carrara Health Centre – 63 bed
– Robina Hospital - 364 beds
– GCUH - 750 beds
(opened Sept 2013)
• Staffing – Nurses- 2542 FTE
– Medical- 858 FTE
(up by 17% in the last year)
CHARMERS
Background
• In preparation for the move to the new
university hospital
– Identified need to use and ensure correct use of
an early warning tool
• In July 2011, replaced 13 observation charts
with the one vital sign chart, Q-ADDS
(Queensland Health’s Adult Deterioration
System)
CHARMERS
CHARMERS
Background
• At Q-ADDS
implementation,
local auditing
was commenced
to track and
maintain quality
of charting
CHARMERS
The problem with auditing …
• Resource intensive for collection and analysis
• Difficult to collate & analyse
• Delayed reporting & feedback distribution
• Identified areas for improvement became irrelevant
CHARMERS
The Annual Queensland Bedside Audit (QBA) 2012
identified GCHHS issues in Q-ADDS charting
QBA Audit results - Nov 2012
72%
48%
40%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Complete set of vital signs Scored Correctly scored
Percentages are of
total charts audited
CHARMERS
Local plan to improve quality
• Frequent ongoing audits instead of a
single bulk audit
• Real-time feedback on results to promote
local quality improvement
• Desire to use technology for the process
• Consistent, standardised audit approach
CHARMERS
Audit
Report
Review
Educate
Solution: CHARMERS Charts, Audits, Records and Medical Emergency Report/Review System
Online & fun
Blocks poor data entry
Consistent with procedure
Takes 1 minute per chart
Min 10 per week
Automatic reports generated
Different level reports
Immediate feedback
Local review identifies
low-risk issues weekly.
High risk issues are reported
daily.
Result-based
improvements
Shows rapid, visible
change.
CHARMERS
• The audit is designed to take no more than
1 minute per chart
• We aimed for 10 audits per IPU, per week
(10 minutes work!)
• Natural competitiveness between IPU’s
helps us with maintaining the number and
quality of audits!
Q-ADDS Audit
CHARMERS
CHARMERS Audit
• The questions are designed
to rapidly identify poor
practice in Q-ADDS use
– Missed deterioration and
missed escalation
– MET criteria reached but
not acted on
• These type of practices are
then specifically identified on
the reports
• The questions directly relate
to and reinforce the GCHHS
Vital Signs Procedure
CHARMERS
CHARMERS
CHARMERS
Report and Review
• Daily, weekly and monthly reports are
automatically sent by CHARMERS to relevant
parties
– Giving real-time feedback to NUMs and
educators, which helps to improve local practice
• Staff can give their time to acting on the
reports, instead of collating and analysing the
data
CHARMERS
Daily resuscitation coordinator report
Not shown above – time, location, UR, auditor
CHARMERS Weekly IPU tearoom report
CHARMERS Weekly – a closer look
CHARMERS Weekly – a closer look
CHARMERS Monthly IPU tea-room report
CHARMERS
Educating and improving
• Closing the quality/education loop by using
these reports effectively at IPU level
– instant feedback and capability of showcasing
local results.
• Timely reporting is critical to this process
– Events and outcomes can easily be linked
CHARMERS
August 2014
58% Perfect
(73.2% Acceptable)
HHS Results to date
CHARMERS
GCHHS QBA results Percentages are of
total charts audited
QBA Audit results - Nov 2012 & Nov 2013
(CHARMERS intervention occurred July 2013)
2012 - 72%
2012 - 48%
2012 - 40%
2013 - 82%
2013 - 73%2013 - 70%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Complete set of vital signs Scored Correctly scored
CHARMERS
Summary
• CHARMERS is demonstrating the
effectiveness of frequent audits and high
quality real time reporting
• Positively impacting clinician behaviour in
regards to quality in patient safety initiative
– Improving vital sign charting and escalating
clinical concerns with use of Q-ADDS and
associated EWTs
CHARMERS
Leading through governance…
• with strong nursing leadership driving innovation,
• with establishment of norms and directing
expectations in the correct use of the vital signs
charting and escalation of clinical concerns aligning
to local procedures,
• with engaged participation at local level in auditing,
reporting and quality improvement strategies, and
• with educational and procedural developments -
locally and health service wide, to enhance overall
clinical performance and patient care and safety.
CHARMERS
Future plans
This audit and report system is being used (or in planning
for)
– Blood products (NSQHS Standard 7)
– Medication charts (NSQHS Standard 4)
– Resuscitation carts (NSQHS Standard 9)
– Code Blue/MET response (NSQHS Standard 9)
– Etc….
CHARMERS
Reference:
• Australian Commission on Safety and
Quality in Healthcare:
http://www.safetyandquality.gov.au
– Standard 9 - Recognition and Response to
Clinical Deterioration