A presentation given by Sue Peter at the 2012 CHA Conference, The Journey, in the 'Delivering Safety & Quality: Innovations in Clinical Governance' stream

1. Enhancing the quality and safety of
the nursing model of care: planning
for a new children’s hospital in
Western Australia
Sue Peter
Princess Margaret Hospital for
Children
Child and Adolescent Health Service
Delivering a Healthy WA

2. Background
• Impetus for change
– Nursing shortage and skill mix
– New Children's Hospital (NCH) Project
– Accreditation
– Clinical incidents

3. Nursing Model of Care Project
Aim: The delivery of safe, quality care by nurses
who critically think, analyse, openly question
and challenge.
• Practice Environment
• Leadership
• Frontline accountability and local ownership
• Culture and practice development
• Integration

4. Practice Environment Survey –
Nursing Workforce Index (PES-NWI)
Subscales
1. Nurse Participation in Hospital Affairs 2.43
2. Nursing Foundations for Quality of Care 2.78
3. CNM Ability, Leadership and Support of Nurses 2.79
4. Staffing and Resource Adequacy 2.44
5. Collegial Nurse-Doctor Relations 2.93
Result in 2011 MIXED

5. Actions from the PES-NWI results
• Nursing executive visibility
– EDON Communication meetings
– Members from Nursing Executive attending
ward/local area meetings
– NUM strategic planning forums
• Rewards and recognition
– Letter of acknowledgement to all nursing staff
– Nurses Round Table

6. Patient Experience Trackers

7. Staff Tracking – Direct care time

8. Daily Activity Breakdown
(8A & 5C)
Motion
Admin
Handovers
Medicines Management
Discussion
PPE
Patient Flow
Other
Direct Care

9. Direct Care Breakdown
(8A & 5C)
Ward Round
Medicine Round
Toileting
Meal Round
Nutritional Management
Mobilising
Observations
Assessments
Nursing Procedure
Hygiene
Bed Making
Social Care
Parent/Patient Communicatin
Relative Liasion
Documentation

11. 7:
0
5
10
15
20
25
00
:0
0
AM
8:
00
:0
0
AM
9:
00
:0
0
AM
10
:0
0 :0
0
AM
11
:0
0 :0
0
AM
12
:0
0 :0
0
PM
1:
00
:0
0
Interruption Tracking
PM
2:
00
:0
0
PM
3:
00
:0
0
PM
RN (8A)
GN (8A)
EN (5C)
RN (5C)
Coodintator (5C)

12. Topic of Interruption
Patient Status
Patient Flow
Clinical Advice/support
Location of Equipment
Location of Information
Clinical Education
Other

13. Practice Environment
• Partnership model
- Nurses working in skill matched pairs
- Mutual planning and organisation
- Critical conversation and communication
- “Its about sharing the care safely”
 Joint hourly worksheet
 Hourly rounding

14. Hourly Rounding
• Hourly the partnership
will meet to critically
discuss patient care
and at least one of
the nurses will visit all
the patients in the
allocated group
utilising PROACT.

15. Components of Hourly Rounding
• PROACT
– Patient medications
– Review clinical status
– Observations
– Anticipate next hour’s patient needs
– Communicate with the patient/family
– Teach

16. Staff Feedback
– More conversations about patients
– More aware of partners workload
– Nurse specialling a patient felt more supported
– Families feedback they feel reassured having two
nurses
– Junior staff know who to go to for support
… “I used to feel like I was bothering the
coordinator all the time, now I don’t”

17. Staff Feedback
– Experienced staff able to identify partners teaching
needs for that shift, including how to support
communication with patients family
– Staff feel that there is more forward planning
– Definitely less call bells when we do hourly rounding
… “I know now, that when I am with a really sick
patient, someone else is there and will look after
my other patients”

18. Practice Environment
• Geographical patient allocation
• Devolved nursing stations and consumables
• Medication management
• Electronic journey board

19. Patient Status at a Glance
Visual management is used to
communicate the status of a patient
within 3 seconds.

21. Leadership and Support
• CNM Leadership
– Review of the CNM role to enable expertise and
leadership to drive safety and quality
– Availability of CNM to facilitate organisational
change
– Introduction of administrative support 0.5 EFT
Activity % Pre % Post
Admin Admin
Clinical Leadership 28% 45%
Managerial/Administrative 72% 55%

22. CNM Ability, Leadership and Support
September May
Sig
2011 2012
A supervisory staff that is 2.91 3.27 .068
supportive of the nurses
Supervisors use mistakes as 2.62 3.11 .029
learning opportunities, not
criticism
A Clinical Nurse Manager is a 3.05 3.38 .206
good manager and leader.
I receive praise and recognition 2.24 2.97 .007
for a job well done
A Clinical Nurse Manager who 2.99 3.27 .182
backs up the nursing staff in
decision making, even if the
conflict is with a physician
OVERALL TOTAL 2.76 3.19 .049

23. Frontline Accountability
• Nursing Governance reformed
– Defined process for nurses
– Using Nursing Quality Indicator data to identify areas
for improvement and activate organisational support
for change required at local level
– Focus of the week/month, ”reminders on handover
sheet”

24. Culture and Practice Development
• Facilitates a “bottom up” approach to identify the
values and current practices at ward/unit level
• Culture change from “this is how things are done
around here” to zero tolerance to unsafe
practice where anyone can speak up and
question
• Provides a platform:
– Enable nurses to refine and reform nursing work
– Critically analyse
– Support organisational change
– High challenge, high support environment

25. What did we agree on at PD School?
• Common goal - high quality and safe care
• Nurses who are empowered and supported and
accountable at ward level through:
– Shared vision for nursing care locally and
organisation wide
– A safety culture
– Empowering nurses to drive change at ward level
– High challenge/high support environments
– Two-way communication throughout the organisation
– Nurturing critical thinking and innovation

26. Integration
• Multidisciplinary teams
• Safety, Performance and Quality Department
• Nursing Governance
• New Children's Hospital Project
• Nursing Education
• Clinical Planning and Reform Unit