A presentation given by Elizabeth Harnett at the CHA Conference 2012, The Journey, in the 'Delivering Safety & Quality: Innovations in Clinical Governance' stream.
2. Why do we need governance of
improvement activities?
To ensure
− Appropriate approval is obtained
− Ethical considerations are minimised
− Improvement activities are well structured
− Accountability and transparency for staff and
consumers involved in improvement activities
To support teams undertaking improvement
activities
To be able to report on activities undertaken
e.g. for Accreditation Documentation
3. Why do we need governance of
improvement activities? Cont’d
For Information Sharing
− Avoid duplication
− Learn from others
− Maintain history of activities undertaken
To ensure improvement activities
align with organisational goals
To increase the number and quality
of activities available to enter in
Quality Awards
4. What do you need to achieve
effective governance?
• Appropriate policies &
templates in place
• Clear process for staff to
follow
• Education for staff
5. What does CHW have in place to
ensure effective governance of
improvement activities?
• Policy on Initiating & Documenting
Improvement Activities
• CHARLI database
• Improvement Project Review
Meetings
6. What does CHW have in place to
ensure effective governance of
improvement activities?
Procedure for Ethical Review of
Improvement Activities
CGU staff work with the Team Leader to
ensure best methodology is used
CGU & Human Research Ethics
Committee (HREC) work closely together
8. Improvement Project Review Meeting
Twice weekly 30
minute meeting of CGU
staff
Improvement activities
assigned to CGU staff
member based on their
area of expertise
9. Improvement Project Review Meeting
CGU Reviewers help staff
inexperienced in
Continuous Improvement
Activity methodology is
adjusted if required
10. Improvement Project Review Meeting
Approval decision is made:
Modifications required
Not approved
Approved with QI Ethics No.
Approved without QI Ethics No.
Review Only
11. What is the CHARLI database?
Children’s
Hospital
Achievements
Research
Links and CHARLI is a web
based in house built
Improvements
database available to
Database all staff.
12. Each hyperlink opens a
new tab for collecting
activity information
details
Multiple documents
can be attached
including EXCEL &
PowerPoint
Different
record types
can be
entered
Approval history
is recorded
A series of questions in the Ethical
Review Tab determine whether the
activity needs an ethical review to be
conducted
13. What sort of questions do CGU ask when
reviewing improvement activities?
15. What does CHARLI do?
• Assists accountability
• Assists ethical review of
improvement activities
• Links information
• Issues email notifications to staff
• Maintains record of improvement
activities undertaken
16. What else do CGU do to monitor/track
improvement activities?
• CGU link all improvement activities to
EQuIP5 criteria
• CGU create accreditation
documentation in CHARLI on an
ongoing basis
• Reports are regularly sent to
Department Heads
17. What about Education/Training?
CGU offers
various
standard
courses such
as Evaluating
Improvement
Activities &
Involving
consumers in
Improvement.
18. Fact Sheets
27 Fact sheets available
on the intranet on topics
such as:
– Ethical Review
– Process Mapping
– Charts & Graphs
– Surveys
– Focus Groups
Links to Fact Sheets are
also in CHARLI
19. How is our governance system
working out?
No. of Improvement
No. of Improvement
Year Activities ethically
Activities CGU aware of
reviewed by CGU
2006 87 Data not available
2007 139 127
CHARLI
2008 185 164
introduced
2009 385 293 December 2008
2010 499 354
2011 322 319
up to June 155 123
2012
20. KPIs
Key Performance Indicator Target 2011 Results
(Business Days) (Business Days)
Days to first contact Team Leader once 3 3.58
activity is submitted in CHARLI
Days to complete an improvement activity 10 10.49
review - QI Ethics No. allocated
Days to complete an improvement activity 5 7.28
review – approved without a QI Ethics
No.
Days to complete an improvement activity 5 6.18
review – review only
Since 2005 number of Activities granted a QI
Ethics Number which were not endorsed by the
HREC = 0
21. How long did this all take?
2004 Paper based form used to record improvement activities.
CGU proposed to the HREC that CGU be able to grant ethics approval for quality improvement
activities.
2005 CGU grants first QI Ethics numbers.
2006 Due to increasing no. of improvement activities being recorded, decided needed better way to
document and monitor activities.
Became evident that as part of the ethical review of improvement activities, CGU was also
providing considerable support to staff undertaking improvement.
2007 Implemented a hospital wide policy called “Improvement Activities – Documentation and
Approval”, which required all improvement activities to be initiated using the paper based
Improvement Activity Start Form.
Began work on the CHARLI Database, to replace the paper based form.
Increasing number of activities being documented so we expanded the number of CGU staff
(CGU Reviewers) who could ethically review improvement activities.
Developed “Ethical Review and Approval of Improvement Activities” procedure.
2008 Implemented the CHARLI Database in December.
2009 Scheduled regular training sessions for staff in the use of CHARLI, as well as one on one
training as required. Fact Sheets & FAQ developed on CHARLI and Ethical Review of QI.
Regular reports available to Department Heads and Health Care Quality Committee on
activities submitted/approved/completed.
22. Lessons Learnt
Changing organisational culture does
not happen overnight
Structures need to be put in place to
help staff know what they
need to do
Staff want to have their
activities ethically reviewed
so long as it does not take
too long and the process is
not too hard
23. Lessons Learnt cont’d
• Staff need help to
distinguish between QI
and Research
• Staff prefer just in time
training
• More work needs to be
done with Departments on
how to identify which
improvement activities to
undertake
24. What can you do to improve
governance of improvement activities?
Work with your Human Research Ethics
Committee to agree on what constitutes
Quality Improvement/Research
Seek delegated authority from the HREC to
approve quality improvement activities
Formalise the process for initiation and
documentation of improvement activities by
creating and implementing a policy
25. What can you do to improve
governance of improvement activities?
Create a register of improvement activities:
EXCEL spread sheet
Database
Train core group of staff in Continuous
Improvement so they can support and work
with teams undertaking improvement
activities
Have incentives for staff to complete
activities
26. What can you do to improve
governance of improvement activities?
Put mechanisms in
place for sharing
information
Reward & recognise
staff by implementing
Quality Awards
Feed back regularly
to staff & Department
Heads
so that it is clear to staff what they need to do and when they need to do it by.
CHARLI Database used by staff to initiate, approve & document improvement activities
Procedure for Ethical review - to ensure consistency of decisions made by Clinical Governance Unit (CGU) staff CGU staff work with the Team Leader - to ensure that their activity methodology is appropriate including consumer participation and stakeholder engagement CGU and the Human Research Ethics Committee (HREC) work closely together, CGU grant QI Ethics Approval which the HREC later endorses
Assists accountability as all improvement activities are reviewed and approved Allows ethical review to be undertaken on improvement activities with ethical considerations All information can be linked e.g. activities to plan initiatives, activities to Presentations/Publications Issues email notifications to staff to remind them of due dates Keeps a record of improvement activities undertaken by each department
CGU link all improvement activities to EQuIP5 criteria (we are accredited by the Australian Council on Healthcare Standards) as they are approved in CHARLI CGU create accreditation documentation in CHARLI on an ongoing basis, approval & completion emails from CHARLI trigger this Reports are regularly sent to Department Heads re activities overdue for approval & completion
CGU offers various standard courses such as Evaluating Improvement Activities and Involving consumers in Improvement . We also tailor courses to specific departments on request. The courses are modular and are between 2 and 3 hours long, this makes it easier for staff to attend. Just in Time training
27 Fact sheets containing concise and relevant information are also available on the intranet on topics such as: Ethical Review Process Mapping Charts & Graphs Surveys Focus Groups Links to Fact Sheets are also in CHARLI
Have incentives for staff to complete activities and provide the details to you e.g. movie tickets, chocolates Create a register of improvement activities (Excel/Build Database/Purchase off the shelf package) If unable to create/purchase a database then create forms (paper based/electronic) for activity initiation & completion Train core group of staff in Continuous Improvement so they can support and work with teams undertaking improvement activities
Put mechanisms in place for sharing information on improvement activities e.g. newsletter, intranet site, foyer displays – activity of the month Reward & recognise staff by implementing Quality Awards Feed back regularly on no. of activities submitted, approved, completed, overdue for completion. – Newsletter, Intranet page and Improvement & Safety Dashboard