Leading Practice Support Program
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Top level
Reports & Plans
Quality
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Author: John Olds
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Publishing date: 01 November 2005 3:20am
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Service Excellence Framework
Leading Practice Support Program
Kangaroo Island Health Service Inc.
in partnership with the Mallee Health Service Inc.
Final Report May 2005
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Project TitleA pilot study for the implementation of Service Excellence Framework (SEF) as a suitable method for improving quality, risk and safety in Multi Purpose Services.
Executive Summary
The Kangaroo Island Health Service Inc. and the Mallee Health Service Inc. have over the past twelve months have undertaken a collaborative approach to determine assess and if the Service Excellence Framework is an appropriate tool to help improve quality, risk and safety within the Multi Purpose Service setting.
Early on it became apparent that there was much work to be done in helping differing levels of staff to overcome their allegiance towards the previous Australian Council of Healthcare Standards (EQuIP) accreditation tool. A number of staff education sessions were held across both sites, self-assessments completed and initial external validations were made. Over this period the earlier resistance to change was generally overcome.
Issues / positives experienced during the 12 month program-
Ø The Service Excellence Framework (SEF)is less prescriptive, thereby making it more open to interpretation and flexible. This is seen as a positive outcome as it is thought it can accommodate all our service programs into the SEF.
Ø To confirm the thinking, a Focus Forum was conducted on KangarooIsland to critically assess the framework. Twenty persons attended and at the end of the day, nineteen people were convinced that the framework was more than suitable for MPS’s.
Ø As the SEF is new, the reviewing agency (QMS) had no preconceived ideas on what they expected. This resulted in the reviewer asking a lot of questions in relation to our services and a greater understanding of what MPS’s are about.
Ø The Essential Minimum level of the Service Excellence Framework concentrates on the basic requirements either legally binding or necessary in the development of a sound management system. This was found to be an extremely useful process in developing systems that previous accreditation processes had over looked.
The Kangaroo Island Health Service and the Mallee Health Service believe and support that the Service Excellence Framework is an appropriate tool in which Quality, Risk and Safety can be progressed within an MPS setting.
Project Objectives
1.Benchmarking of two MPS services with the view to being able to replicate the quality processes and tools across other MPS sites
2.The development of a new culture of quality and learning across campuses within the two MPS and other MPS sites through the sharing of information resources and strategies
Performance Indicators1.Engage a quality reviewer
2.Identification of common quality tools and processes
3.Develop a communication plan between the Multi Purpose Services utilising the Websites and paper based formats
Progress regarding Project’s objectives
Objective 1Benchmarking of two MPS services with the view to being able to replicate the quality processes and tools in other MPS sites
* Engage a quality reviewer
Quality Management Services (QMS) was contracted to provide independent and internal assessments of both Mallee Health Service Inc. (5th and 6th October 2004) and Kangaroo Island Health Service (11th and 12th October 2004). (See Reports attached)
Quality Management Services (QMS) was contracted to provide independent follow up re–validation assessments of both the Mallee Health Service Inc. (7th March 2005) and the Kangaroo Island Health Service (24th of March 2005) (See Reports attached)
* Identification of common quality tools and processes
Following the independent assessment and based on the validation findings, each service developed appropriate action plans. (See attached Action Plans.)
Following the independent re-validation, each service completed action plan templates as sent out by the Service Excellence Office. (See attached Action Plans)
* Develop a communication plan between the Multi Purpose Services utilising the Websites and paper based formats
A Website that is linked to Mallee Health Service Website has been developed during the project. This will allow online discussion and storage of useful information and documents relating to MPSs. The final report relating to this project will be posted on that site. All MPS sites and other services involved in supporting this project will be provided with the final report and any supporting documents that are generated from this project. A number of sites who were a part of the consultation process to set up MPS’s have also been made aware of the web site.
Objective 2
The development of a new culture of quality and learning across campuses within the MPS and other MPS sites with the sharing of information resources and strategies
To commence the project, a one day Focus Forum was conducted on KangarooIsland. This allowed a group of professionals knowledgeable in the fields of the MPS model, the DHS Service Excellence Framework, individuals who are leaders in their field at the Mallee Health Service and the Kangaroo Island Health Service, and others who are directly involved in implementing the SEF, to come together to share information, raise concerns and analyse the SEF in relation to QRS in an MPS. Representatives from the Commonwealth Department of Health and Ageing and the South Australian Department of Health Service Excellence Office also participated. (See Report Attached)
A later follow up session was held in Mannum (South Australia) to address two issues arising from the first session. This latter session was facilitated by two consultants and additional attendance invitations were issued to relevant staff of the MannumDistrictHospital, TailemBendHospital, MeningieHospital, Gawler Health Service and the Barossa Area Health Service.
(See Report Attached)
i)What major project activities have occurred so far?
√ Project Officer has been employed.
√ Project Plan has been developed.
√ An article regarding the Leading Practice Support Program and the grant was published in the local paper.
√ Staff information, training and education sessions have been held for staff and Board members at both Kangaroo Island Health Service and the Mallee Health Service.
√ Mallee Health Service and Kangaroo Island Health Service have completed the Essential Minimum Criteria Workbooks in relation to the Service Excellence Framework
√ Site visits of the Tasmanian Multi Purpose Services have been undertaken.
√ Staff information, training and education sessions have been held for staff at three (3) Tasmanian Multi Purpose Services. (West Tamar Health and CommunityServicesCampbellTown MPS and Nubeena MPS)
√ Site visit to Corryong MPS (Victoria)
√ Regular meetings have been held with the Department of Human Services and the South Australian representative for Multi Purpose Services to share information about the implementation of the Service Excellence Framework and to identify issues relating to the Multi Purpose Services.
√ Liaison with other consortium sites that are part of the consortium has occurred to determine their level of involvement and to learn from their knowledge and experience regarding Multi Purpose sites.
√ CEO Advisory Counsel has been formed. Membership will include other community groups and consumer representatives. One of the roles of this group will be to advise on changes recommended as outcomes of the project.
√ Draft proposal for restructuring of the committees in the Mallee Health Service has been developed.
√ Initial scoping exercise to determine the level of compliance against the minimum Service Excellence Framework criteria has been completed
√ Action plans to progress the services to the next level of organisational development have been completed
√ External quality reviewer has undertaken assessment of both services against the Essential Minimum Service Excellence Framework.
√ Website developed which is linked to Mallee Health Service Website, this will allow online discussion and storage of useful information and documents relating to MPSs.
√ Health Services have developed Action Plans and are preparing for next external validation
√ Focus Forums have been held
√ QMS have been contracted to undertake next external validation
√ Restructuring of Working Groups has been implemented.
√ Re-validation survey has been undertaken by both sites.
√ Follow up Focus Forum has been held.
√ Action Plans completed by both sites.
ii) What processes is your organisation using to plan, do, check and act on the quality improvement initiative?
The Service Excellence Framework is being used to measure the organisations’ performance against the essential minimum criteria.
A gap analysis will inform the organisations of deficit areas and the activities that need to be undertaken to advance the organisations to their next levels. Workbooks have been developed in response to areas that are not fully in place and will form the ‘Action Plan.’
The external review of the organisations’ compliance against the essential minimum criteria of the Service Excellence Framework has been undertaken and feedback provided on areas that require further action.
Following the external review, the organisations have revised their Action Plans in response to feedback from the external review and have developed strategies for further improvement. All activities have been time lined, the responsible person nominated, the quality improvement activities for which they are responsible and the actions that need to be taken.
The external re-validation review of the organisations gaps identified from the initial/external review has been conducted and the few remaining gaps action-planned.
iii) In what way has the project helped your organisation’s understanding and implementation of quality improvement?
This project is allowing the organisations to review their performance against other documented standards i.e. the Service Excellence Framework as a means of improving the quality of the organisation. It is also allowing the services to utilise each other’s knowledge and expertise and that of other MPS services, in relation to the role and philosophy on which Multi Purpose Services have been established, to determine if those principles are applied and improved on. The project is also aiming to embed a culture of continuous quality improvement throughout the organisation. This component has been achieved as shown by the vast improvement in both organizations re-validation results. The introduction of the working groups was highlighted as a major achievement. (See Working Group Terms of Reference Attachment)
iv) What collaborations and partnerships between organisations have been supported through the Program?
The following Multi Purpose Services are involved in this project.
As partners;
KangarooIsland Health Service South Australia
Mallee Health Service South Australia
Support and collaboration;
CampbellTown Health and Community Service Tasmania
Eyre Regional Health Service Mid-West Health South Australia
Upper Murray Health and Community Services Corryong Victoria
West Tamar Health and Community Services. Tasmania
Nubeena MPS Tasmania
Department of Human Services. South Australia
Department of Health and Ageing
MannumDistrictHospital (Non MPS)
Barossa Area Health Service (Non MPS)
Gawler Health Service. (Non MPS)
v) What has been done so far to make the outcomes of the projects sustainable?
The Mallee Health Service Inc
* Has reviewed its committee structure and terms of Reference. The new format has Working Parties each of which is responsible for components of the Service Excellence Framework. (See attached)* The Quality, Risk and Safety Committee has carriage for all activities relating to the Service Excellence Framework and all Working Groups report through and have access to the expertise of that committee, which reports directly to management.
* The QRS Manager now attends and reports at each Executive meeting in relation to QRS
* The lines of reporting of the QRS Manager have been changed and are now direct to the Deputy Area Manager for the Mallee Coorong Region.
* Drafted a document titled “The QRS Framework in Mallee Health Service Inc” (Attached)
Kangaroo Island Health Service Inc* Has formed the MOD Squad, an acronym for Motivating Organisational Development. (See attached)
* A separate meeting has been established for the Management Team, which is dedicated to the progress of the Service Excellence Framework and Continuous Quality Improvement and which is attended by the Quality Manager.
vi)What factors have helped/ hindered your organisation’s ability to achieve quality improvement through your project?
The number of people to undertake any type of activity in small organisations such as the KangarooIsland and Mallee Health Services is always limited and therefore the workloads are heavily borne among a few people. Both the MPSs involved in this project have undertaken both ACHS EQuIP reviews and HACC reviews during the first six months that the project was running. This made it very difficult for the organisations to focus on the LPSP Project in the early stages.
The support for the project has increased as the project has progressed. The introduction of the Working Groups has had the most positive significant impact on the project.
vii) What are the learnings from the project
As the MPS’s were attempting to move away from the old forms of accreditation that we all grew up with and implement the new form of accreditation, both agencies needed to work extremely hard to involve and inform all levels of staff at the start of the project as to what achievements we were expected to achieve and how to go about it. The Service Excellence Framework looks to be an appropriate accreditation tool for Multi Purpose Services and for small rural and remote health units requiring only minor adjustments to the content modules.
viii) To what extent have learnings from projects so far been disseminated to other MPS?
This is being addressed at present with a small group of Mallee Health service staff travelling to the mid north of the state to do a presentation on Quality, Risk & Safety and Management Structures to a cluster of four health units interested in forming a Multi Purpose Service.
The full report will be posted on the KangarooIsland and Mallee Health Services websites and the dedicated MPS website within the Mallee Health Service website.
ix) What could be done within the Program to better help your organisation achieve quality improvement in your project?
It would be of benefit for representatives of the MPSs and the Project Managers to meet regularly to further exchange ideas and learnings, provide updates on the completed projects, and to provide general ongoing support.
John Olds
Acting Project Manager
Leading Practice Support Program
Kangaroo Island Health Service/Mallee Health Service Inc.
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