Implementing the National
Standards in the Operating
Theatre Suite –
A guide to Preparing for
Accreditation
Ben Lockwood
C...
Flinders Medical Centre (FMC)
> Tertiary Trauma Centre
> Part of Southern Adelaide Local Health
Network (SALHN)
2013 Accredited as a Network
> Southern Adelaide Local Health
Network (SALHN)
• FMC, RGH, NHS, GP Plus Clinic
 Flinders M...
Network-wide quality framework
> Formation of SALHN accreditation steering
committees
> One committee for each standard
• ...
Operating Theatre Suite approach
> Mirror network-wide methodology
> Clinical leads for each standard
• 2-3 ACSCs & CNs (L...
Operating Theatre Suite approach
> Education and awareness campaign
• Regular National Standard in-services
• Driven by ea...
Revision of Governance Structure
> Divisional reporting lines were strengthened
• Nursing, anaesthesia, surgery, CSSD, oth...
Next step… Gap Analysis
> Reviewed information packs (available online)
> Assessed each item/action
• Organisational wide?...
Gap Analysis
> NSQHSS Standards Monitoring Tool
• Excel Spreadsheet
> Available online
• http://www.safetyandquality.gov.au
OTS Quality Improvement Plan
> Documented presentation of the improvement
activities being undertaken within the suite
> O...
Quality Improvement Activities
> Policy, procedure & protocol/guideline review
and endorsement
> Auditing & Reporting
• KP...
Policy, procedure & protocol
> Process of review
• Frequency, risk rating, compliance monitoring
• Policy = SA Health
• Pr...
Auditing & Reporting
> Who is auditing what, when & where?
• Past audit schedules
• New requirements
> Developed comprehen...
Auditing & Reporting
Auditing & Reporting
> Reporting aligned with meeting structure
• Reporting template created
• Actions plans formalised & ...
Risk Identification & Escalation
> Risk register
• Human & material resources
• Financial
• Political or Legal
• Service d...
Accreditation process
> Robust governance structure
> Systems in place
• Quality Improvement Plan
• Policy & Procedure rev...
Accreditation process
> Clinical leads for each standard
• Reported updates at Clinical Leadership Meeting
> NSQHSS Standa...
The week of the survey
> Network survey activities
• Organisational meetings for each standard
> Local (OTS) survey activi...
Summary
> Organisational approach
> Everyone must be engaged
• Educational package
• Accreditation awareness
> Review gove...
Persevere… success takes effort!
Questions?
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Ben Lockwood - Flinders Medical Centre - Implementing the National Standards in the Operating Theatre Suite - A Guide to Preparing for Accreditation

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Ben Lockwood delivered the presentation at the 2014 Operating Theatre Management Conference.

Focusing on strategies for implementing the National Safety and Quality Health Service Standards and the importance of communication to improve patient safety and clinical practice, the 2014 Operating Theatre Management Conference brought together operating room management and perioperative professionals to review current initiatives across the country.

For more information about the event, please visit: http://bit.ly/optheatremgmt14

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Ben Lockwood - Flinders Medical Centre - Implementing the National Standards in the Operating Theatre Suite - A Guide to Preparing for Accreditation

  1. 1. Implementing the National Standards in the Operating Theatre Suite – A guide to Preparing for Accreditation Ben Lockwood Clinical Practice Consultant Flinders Medical Centre South Australia
  2. 2. Flinders Medical Centre (FMC) > Tertiary Trauma Centre > Part of Southern Adelaide Local Health Network (SALHN)
  3. 3. 2013 Accredited as a Network > Southern Adelaide Local Health Network (SALHN) • FMC, RGH, NHS, GP Plus Clinic  Flinders Medical Centre > Division of Surgery o Sub-division Surgical & Perioperative Medicine (SAPOM) • Operating Theatre Suite
  4. 4. Network-wide quality framework > Formation of SALHN accreditation steering committees > One committee for each standard • Executive leads • Medical leads • Nursing leads > Organisational focus is imperative!
  5. 5. Operating Theatre Suite approach > Mirror network-wide methodology > Clinical leads for each standard • 2-3 ACSCs & CNs (Level 2) • Level 1 RN/EN engagement • Driven by Clinical Practice Consultant > Standard 1 led by OTS Governance group
  6. 6. Operating Theatre Suite approach > Education and awareness campaign • Regular National Standard in-services • Driven by each lead group • Explained what does ‘National Standards’ and ‘accreditation’ mean for ALL staff
  7. 7. Revision of Governance Structure > Divisional reporting lines were strengthened • Nursing, anaesthesia, surgery, CSSD, other depts. > Meeting groups with clear TOR > NSQHSS focussed Clinical Leadership meeting
  8. 8. Next step… Gap Analysis > Reviewed information packs (available online) > Assessed each item/action • Organisational wide? • Operating Theatre Suite focus?  If OTS, what do we need to do?
  9. 9. Gap Analysis > NSQHSS Standards Monitoring Tool • Excel Spreadsheet > Available online • http://www.safetyandquality.gov.au
  10. 10. OTS Quality Improvement Plan > Documented presentation of the improvement activities being undertaken within the suite > Ongoing use post-accreditation
  11. 11. Quality Improvement Activities > Policy, procedure & protocol/guideline review and endorsement > Auditing & Reporting • KPI monitoring > Risk identification & escalation
  12. 12. Policy, procedure & protocol > Process of review • Frequency, risk rating, compliance monitoring • Policy = SA Health • Procedure/Protocol = SALHN, FMC or OTS • ACORN Standards • Right input, right focus, right people > Process of endorsement • Right input, right focus, right people • Locally endorsed • FMC or SALHN endorsed > Upload to the intranet > Ongoing process…!
  13. 13. Auditing & Reporting > Who is auditing what, when & where? • Past audit schedules • New requirements > Developed comprehensive audit schedule • NSQHSS requirements • SA Health audits • ACORN Standards • SALHN or FMC audits • OTS requirements
  14. 14. Auditing & Reporting
  15. 15. Auditing & Reporting > Reporting aligned with meeting structure • Reporting template created • Actions plans formalised & communicated  What is working well?  What needs changing/improving?  Responsibilities & timeframes • KPI monitoring  Access & capacity  Clinical performance > Results focussed • Accountability • Clarity
  16. 16. Risk Identification & Escalation > Risk register • Human & material resources • Financial • Political or Legal • Service delivery & clinical risks > OTS (local) risk register • Managed internally • Items identified via reporting mechanisms • Items escalated as required > Network (SALHN) risk register • Managed network wide
  17. 17. Accreditation process > Robust governance structure > Systems in place • Quality Improvement Plan • Policy & Procedure review • Auditing & Reporting • Risk Management > Collect our evidence for National Standards • Items & Actions for each standard
  18. 18. Accreditation process > Clinical leads for each standard • Reported updates at Clinical Leadership Meeting > NSQHSS Standards Monitoring Tool • Data input & evidence collation          
  19. 19. The week of the survey > Network survey activities • Organisational meetings for each standard > Local (OTS) survey activities • Produced overview presentations for each standard • Summarised our evidence • Participated in walkthroughs • Question & answers • Showed off our achievements!
  20. 20. Summary > Organisational approach > Everyone must be engaged • Educational package • Accreditation awareness > Review governance systems > Quality improvement plan • Policy, procedure, protocols  Review & endorsement processes • Auditing, reporting and KPI monitoring > Risk management > Presented our work during survey/audit
  21. 21. Persevere… success takes effort!
  22. 22. Questions?
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