Sharing Lessons from
Accreditation Standard 2
Partnering with
Consumers
(Private Hospital Perspective)
Developed by Ms Mary Anne Noonan &
Mrs Julie Behrens
Presented by: Ms Mary Anne Noonan
© Copyright Australasian Conference Association Limited 2014. This is protected by copyright. You may not use or
otherwise reproduce any of it in any form without the written permission of Adventist HealthCare Limited
Achievement
Implementation of significant governance structures and processes over 18
months has resulted in Sydney Adventist Hospital (SAH) achieving a “met with
merit” rating for ALL criterion in NSQHS Standard 2 – Partnering with
Consumers at our recent Certification in September 2014
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Overview
Key Problem
• Sydney Adventist Hospital had a number of well established systems and
basic policies in place to involve consumers, however there was no formal
governance structures, and further supporting policies were needed
Aim of Innovation
• Implement a governance framework for partnering with consumers with
supporting policies
• Increase consumer involvement at all levels both strategic and operational
to improve care planning and delivery
What we did
• Implemented a consumer framework & supporting policies
• Established a Consumer Council
Outcome
• Achieved “met with merit” rating for all criterion in NSQHS Standard 2 at
certification
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Key Problems
• No formal governance framework for consumer participation at a
strategic /operational level
• No governing consumer body
• No formal framework for consumer participation in safety and quality
performance data
• No formalised training for consumers on committees
• No formalised process for obtaining consumer feedback on consumer
information produced by the hospital
• Minimal staff training on partnering with consumers
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Baseline Data
This graph shows the change in rating for criterion in NSQHS Standard 2
from a pre-NSQHS review in December 2011 to our most recent
certification review in September 2014
16
14
12
10
Dec-11
8
Mar-13
6
Nov-14
4
2
0
not met
satisfactory met
met with merit
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Key Changes Implemented
Established Formal Governance Structures
• Developed consumer framework & supporting policies
• Established a Consumer Council and Terms of Reference
• Included a Board member on the Consumer Council
Enhanced mechanisms for engaging consumers in strategic / operational
planning
• Commenced Consumer Council with quarterly meetings
• Developed guidelines for consumer involvement in SAH committees
• Utilised existing regular consumer forums, patient surveys, patient
feedback, complaints & compliments
Improved access to relevant orientation and training for consumers
• Hospital orientation provided to all consumers appointed to committees
• Developed training material for consumers on committees
• Mentor provided to consumers on committees
• Developed and provided consumers with information re expectations of
role
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Key Changes Implemented
Consumer consultation on patient information material
• Policy updated to reinforce requirement for Marketing approval
to be obtained for all patient information material
• Formal processes established to incorporate consumer feedback for
all SAH produced patient information material including:
•
•
•
•
Specific print approval form developed
Developed template and instructions for gaining feedback on patient information
material
Documentation of changes made as a result of feedback
Logging of last date of review with consumer input
Involvement of consumers in design of health service
• Consumer forums enabling input into new facilities planning
• Continued consumer input through regular consumer forums,
consumer council, patient feedback
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Key Changes Implemented
Training on partnering with consumers
• E-learning package for National Standards developed
• Developed training package for staff on Patient Centred Care and
obtained consumer input on content
• Resources made available via intranet on partnering with consumers
Consumer involvement in safety and quality performance
• Developed a framework on information to be shared
• Quality & Safety report including key hospital safety & quality KPIs
presented and discussed at each Consumer Council meeting
• Encouraged increased involvement of consumers in SAH Committees
incorporating analysis of safety and quality data
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Outcomes Achieved
• Increased the number of consumers on hospital committees
• Prevention Strategies (fall & pressure Injury), Ethics, Blood
Transfusion Committee (new), Clinical Handover Working Group
(new), Infection Prevention & Control (awaiting sign off)
• Consumer Council with 6 consumer members and 6 hospital
representatives has completed 1 year. This has resulted in a total of 18
consumer initiated quality recommendations which have been
implemented
• Active involvement of consumer members on Consumer Council &
SAH Committees in review and analysis of safety & quality
performance
• 16 patient information brochures / booklets developed by SAH since
late 2011 have had consumer input prior to printing with numerous
changes implemented as a result of feedback obtained
• 13 consumer forums held across several different clinical specialty
areas during 2012, 2013 & 2014 to date incorporating feedback
regarding general services and input into the redevelopment program
• Clear policies and processes in place to support partnering with
consumers in the organisation
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Contacts
• Ms Mary Anne Noonan – Quality Management Coordinator
Sydney Adventist Hospital
Phone: (02)9487 9744
email: [email protected]
• Mrs Julie Behrens – Group Director Marketing & Business Development
Adventist HealthCare
Phone: (02) 9487 9874
email: [email protected]
© Copyright Australasian Conference Association Limited 2014. This is protected by copyright. You may not use or
otherwise reproduce any of it in any form without the written permission of Adventist HealthCare Limited
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