1. INNOVATION & RISK
JOSH STUART – MANAGER
HOSPITAL IN THE HOME (ALFRED @ HOME)
THE ALFRED, MELBOURNE
9th
Annual Hospital in the Home Conference 2009
2. PRESENTATION OVERVIEW
• INTRODUCTION
o What is Innovation and Risk?
o Overview
• WORKPLACE CULTURE
o Understanding culture
o Identifying the ‘current’ culture
o Generational change
o Understanding and identification to move forward
o Creating a ‘can do’ culture
o External Cultural Influence
• INNOVATIVE PROGRAMS
o Is INNOVATION possible only through targeted programs?
3. • INNOVATION THAT CROSSES TREATMENT BOUNDARIES
o Patient Self Administration (S/A)
o Alfred @ Home Self-Administration Background
o Current and Future Patient S/A
• QUALITY IMPROVEMENT
• PRACTICAL ISSUES
o Staff Education
o Staff Development
o Patient and Staff Compliance
• WHEN DOES IT STOP? THE FUTURE CONCLUSION
4. WHAT YOU WON’T FIND
ALL THE ANSWERS
BUT………
ANY QUESTIONS PLEASE ASK
5. INNOVATION
the introduction of something new
a new idea, method, or device
RISK
exposure to possible loss or injury
‘in this safe and tidy world there are visionaries who will always push the
boundaries of what is possible so that others might follow more safely in
their footsteps’ (Greg Caire)
6. INTRODUCTION
• SERVICE & DEMAND
• ORGANISATIONAL INTENT
• RESOURCES
• THE PATIENT
• PROGRAM WALK-THROUGH
• ALFRED @ HOME MODEL
7. ALFRED @ HOME (HITH) STRUCTURE
EXEC DIRECTOR AMBULATORY CARE
MANAGER ALFERD @ HOME
CLINICAL COORDINATORS
NURSE CLINICIANS
‘OUTSOURCED’ PATIENTS‘LOCAL’ PATIENTS
A@H PHARMACIST
ID PHYSICIAN
8. ALFRED HOSPITAL ALFRED @ HOME (HITH) MODEL
ALFRED @ HOME
ALFRED HOSPITAL IN-PATIENT WARD & UNIT
ALFRED HOSPITAL IN-PATIENT UNIT
ED
OP
D/AMDU
PrAC
DIRECT COMMUNITY
REFERRAL
(GP, RACF)
MOBILE ASSESSMENT
TREATMENT SERVICE (MATS)
9. WORKPLACE CULTURE
‘the way things are done around here’ (Drennan 1992)
Constructive Positive
Cultures
Participation
Self actualization
Defensive Cultures
Protect status
Hamper change
10. WORKPLACE CULTURE
• IDENTIFYING CURRENT WORKPLACE CULTURE AND TRENDS
‘there is a need to understand the culture of the individual unit prior to
implementing innovations or educational programmes’
(Schien 1990, Coeling & Simms 1993, Ingersoll et al.2000)
‘workplace culture is multifaceted and asserts a major influence on individual
and group behaviour, patient care, the change process, job satisfaction
and ultimately organisational success’
(Wilson et al.2005)
11. WORKPLACE CULTURE
• The New Workforce
o Generational changes (BB X Y)
o Implementing change
o Understanding effective communication strategies and tools
12. WORKPLACE CULTURE
CREATING A ‘CAN DO’ CULTURE
• Identification of where the unit had come from
o Activity V’s resource
o Strategic intent
• Establishing a Practice Development Framework
o In-line with Alfred Health Framework
o Literature Review
o Stakeholder discussion
13. WORKPLACE CULTURE
• Myers Briggs Type Indicator
• Agreed Mission/Vision
• Agreed Values
‘understanding values and beliefs is an important part of understanding a
workplace culture’
‘working with staff values and beliefs is a crucial first step in developing
practice and affecting cultural change’
(Wilson et al.2005)
14. WORKPLACE CULTURE
• Staff Empowerment
o Tools to succeed (all the above)
• Transformational Leadership
o Clear Vision/Mission
o Clear Values
o Adaptable
o Flexible
o Communicator
o Resourceful
o Transparent
15. WORKPLACE CULTURE
• EXTERNAL CULTURAL INFLUENCE
o Executive Support & Direction
o Medical Unit attitudes (leadership)
o In-Patient Wards
oThe Staff
oReferral Process
o Relationships OR Process
16. WHAT IS INNOVATION?
• INNOVATION THROUGH TARGETED PROGRAMS
• INNOVATION ON AN ‘AD-HOC’ BASIS
• ‘RUN OF THE MILL’ INNOVATION
17. TARGETED PROGRAMS
INOTROPE THERAPY FOR CARDIAC HEART FAILURE
• AIM – Establish a home based Inotrope treatment program for patients
with Cardiac Heart Failure to optimise cardiac function, bridge patient to
cardiac transplant and to improve patient (and family) quality of life.
• The Process
o Stakeholders
o Guideline development
o Reportable parameters set
o Staff Education and Support
o Recognition and Understanding of Roles and Responsibilities
19. INOTROPE THERAPY FOR CARDIAC
HEART FAILURE
• Why the Increase in Patient Numbers
o Expansion of approved drugs (dopamine) December 2007
o Review of Roles and Responsibilities April 2008
o Investigation of service expansion (‘outsourcing’)
o Greater access to acute in-patient ward beds (3CTC)
o Good patient outcomes
o 2 x Heart Transplants
o 1 x Patient weened from Inotrope
20. ‘AD-HOC’ BASIS
ARSENIC TRIOXIDE
52 Year old Male diagnosed with Acute Promyelocytic Leukaemia (APML)
referred for daily administration of Arsenic Trioxide Infusion
Date of Referral: 20/2/2009
Date of Transfer: 21/2/2009
• The Process
o Current drug administration process (ward)
o Policy/Guideline (Hospital)
o Literature Review
o Stakeholders
o Benchmarking
21. ARSENIC TRIOXIDE
• The Process
o Specific Work instructions (Pharmacy and Unit)
o Cytotoxic Precautions
o Patient Demographics
o ‘Outsourced’ service
o Referral as per normal process
o Internal review at completion of treatment
22. ‘RUN OF THE MILL’
ORTHOPAEDIC TOTAL HIP AND KNEE EARLY DISCHARGE PROGRAM
• AIM - Establishment of Orthopaedic Early Discharge Program (EDP) aimed
at reducing THR and TKR patients in-patient ward bed stay from 9 days to
3 days.
• The Process
o Establishment of Guideline
o Costing
o Commencement
o Review and Evaluate
o Growth and Development
23. ORTHOPAEDIC TOTAL HIP AND KNEE
EARLY DISCHARGE PROGRAM
ORTHOPAEDIC EDP
0
10
20
30
40
50
2006/07 2007/08
YEAR
PATIENTNUMBER
24. ORTHOPAEDIC TOTAL HIP AND KNEE
EARLY DISCHARGE PROGRAM
• WHY THE HUGE INCREASE
o Program evaluation
o Better strategic direction
o Increased collaboration with Peri-Operative Coordinator
o Increased collaboration with Physiotherapist
o Identification of deficiencies
o Increased understanding of expectations
o Pre-Admission Clinic
o Staff
o Patients
25. INNOVATION THAT CROSSES
TREATMENT BOUNDARIES
• Patient Self-Administration of Medications
1994
‘self medication in the hospital setting means that patients self administer
their medications under staff supervision whilst in hospital’ (Society of
Hospital Pharmacists of Australia)
2002
‘a strategy to identify and address problems associated with discharge
process’
• Organisational Demand and Access
26. • The Philosophy on Self Administration
‘patients should be as independent as possible, participate in their own care,
make decisions about their treatment in partnership with nursing and
medical staff and therefore be able to make informed choices’ (Bird,
Hassall 1993).
• Alfred @ Home Philosophy
‘Consistent with the vision of Alfred Health, Alfred @ Home strives to provide
high quality, efficient, evidenced based care to patients in their home
environment. We endeavour to support and encourage our patients,
involve them in care planning and promote a sense of independence and
empowerment for both patient and significant others. Alfred @ Home
strives to improve access to acute inpatient ward beds and reduce
emergency presentations through the development of sustainable
substitution and diversion models’ (Alfred @ Home 2008)
27. • Alfred @ Home Self Administration Process Background
• Alfred @ Home Self Administration Process
o Self-Administration of Injectable medications Guideline
o Patient/Carer suitability and selection
o Evolution of suitability and selection
o Patient/Carer Education & Competence
o Competence checklists (tools)
o Patient/Carer Consent
o Ability and Willingness to participate
28. • Alfred @ Home Self Administration (Current)
o Administration of Intermittent Intravenous Antibiotic via Gemini
Pump
o Administration of Pushed Intravenous Antibiotic
o Administration of Intermittent Baxter Infusor
o Administration of continuous Baxter Infusor
o Administration of IV Treatment via Gemstar Pump
o Administration of Subcutaneous Injection
• Alfred @ Home Self Administration / Self Care (Future)
o Administration of NG Fluids and Self Care of NGT
o Management and Self Care of closed Circuit ICC
o Self Collection of Drug Levels
29. QUALITY IMPROVEMENT
• AUDITS
o Patient care planning
o Unplanned re-admission rate
o Self administration
• IDENTIFYING EVOLUTION
• EVIDENCE BASED PRACTICE
• RISK MAN REPORTING
• BENCH MARKING
30. PRACTICAL ISSUES
• STAFF ORIENTATION & TRAINING
o Clinical Coordinators
o Nurse Clinicians
o Education & Credentialing
o Performance Management
o Staff compliance
• PATIENT COMPLIANCE
• IN-PATIENT WARD & UNIT COMPLIANCE
31. WHEN DOES IT STOP? THE FUTURE
CONCLUSION
• CONTINUOUS OPPORTUNITY FOR EXPANSION
• FOUNDATION MUST BE LAID
• LEADERSHIP SUPPORT
32. ‘Innovation is not the product of logical thought,
although the result is tied to logical structure’
Albert Einstein
