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
Elizabeth Harnett - Effective Governance of Quality Improvement Activities
EffectiveGovernance of QualityImproveme nt Activities Kay BabalisThe Children’s Hospital at Westmead (CHW)
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 activitiesTo support teams undertaking improvement activitiesTo be able to report on activities undertaken e.g. for Accreditation Documentation
Why do we need governance of improvement activities? Cont’dFor Information Sharing − Avoid duplication − Learn from others − Maintain history of activities undertakenTo ensure improvement activities align with organisational goalsTo increase the number and quality of activities available to enter in Quality Awards
What do you need to achieve effective governance? • Appropriate policies & templates in place • Clear process for staff to follow • Education for staff
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
What does CHW have in place to ensure effective governance of improvement activities?Procedure for Ethical Review of Improvement ActivitiesCGU staff work with the Team Leader to ensure best methodology is usedCGU & Human Research Ethics Committee (HREC) work closely together
Improvement Project Review MeetingTwice weekly 30 minute meeting of CGU staffImprovement activities assigned to CGU staff member based on their area of expertise
Improvement Project Review MeetingCGU Reviewers help staff inexperienced in Continuous ImprovementActivity methodology is adjusted if required
Improvement Project Review Meeting Approval decision is made: Modifications required Not approved Approved with QI Ethics No. Approved without QI Ethics No. Review Only
What is the CHARLI database?Children’sHospitalAchievementsResearchLinks and CHARLI is a web based in house builtImprovements database available to Database all staff.
Each hyperlink opens a new tab for collecting activity information details Multiple documents can be attached including EXCEL & PowerPointDifferentrecord typescan beentered Approval history is recorded A series of questions in the Ethical Review Tab determine whether the activity needs an ethical review to be conducted
What sort of questions do CGU ask when reviewing improvement activities?
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
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
What about Education/Training?CGU offers various standard courses such as Evaluating Improvement Activities & Involving consumers in Improvement.
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
How is our governance system working out? No. of Improvement No. of ImprovementYear Activities ethically Activities CGU aware of reviewed by CGU2006 87 Data not available2007 139 127 CHARLI2008 185 164 introduced2009 385 293 December 20082010 499 3542011 322 319up to June 155 1232012
KPIs Key Performance Indicator Target 2011 Results (Business Days) (Business Days)Days to first contact Team Leader once 3 3.58activity is submitted in CHARLIDays to complete an improvement activity 10 10.49review - QI Ethics No. allocatedDays to complete an improvement activity 5 7.28review – approved without a QI EthicsNo.Days to complete an improvement activity 5 6.18review – review onlySince 2005 number of Activities granted a QIEthics Number which were not endorsed by theHREC = 0
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.
Lessons LearntChanging organisational culture does not happen overnightStructures need to be put in place to help staff know what they need to doStaff want to have their activities ethically reviewed so long as it does not take too long and the process is not too hard
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
What can you do to improvegovernance 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
What can you do to improvegovernance 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
What can you do to improvegovernance of improvement activities?Put mechanisms in place for sharing informationReward & recognise staff by implementing Quality AwardsFeed back regularly to staff & Department Heads