Read Microsoft Word - 1.CQIclustersv2.doc text version

PART 1

Advance Care Planning Process CQI Action Planner ­ Getting Started

How to use this CQI Priority Action Planner: 1. Ask each question and answer yes or no. If there is debate around the response, discuss further until consensus is reached or evidence provided to support response. (eg from pre implementation audit) Action is required for any questions with a `no' response 2. For each `no' answer consider the provided recommended actions; record who would be the most appropriate person, group etc to action the recommendation. Are there further actions that need to be developed/ considered? Use the Quality Improvement Cycle Template if needed. 3. Identify 3 organisational priority responses to discuss at ACP implementation workshop. Document these on the Quality Improvement Cycle Template. Bring to implementation workshop for group discussion. 4. Prioritise the remaining actions and determine the response order decided by the local implementation team. 5. Commit to a date to follow up the actions. Begin local actions as able. Review this planner regularly to monitor ACP process implementation

Priority Number

Question Is there manager commitment and access to clinical champions to facilitate ACP implementation?

Yes/ No yes

Recommended Action Manager and champion/s to review Getting Started pack to become familiar with what is required to support ACP implementation Discuss with senior manager/s whether this is the right time for implementation Ensure champions have the support they require to implement ACP. Discuss role and implementation at staff meetings etc Identify what further support is needed to engage champions and alert staff of their role Check it has been reviewed recently an reflects current best practice Download Consent to Medical Treatment-Patient Information http://www.health.nsw.gov.au/po licies/PD/2005/pdf/PD2005_406. pdf Discuss at staff meetings

Who will be responsible?

When?

Action / Comments

no

Are the clinical champion/s known to staff? Are they willing to lead the implementation of ACP practice?

yes

no

Is there a local policy that includes Advance Care Planning (ACP)?

yes

no

Developed by Mandy Harden, Kate Gunn and Lisa Shaw. ACP Project Officers. Hunter New England Health March 2009

Page 1 of 7

Priority Number

Question Are staff able to access electronic or hard copies of NSW Health `Using Advance Care Directives' and `End of Life Discussion' guidelines?

Yes/ No yes

Recommended Action Locate these documents in an accessible place in the clinical environment/computer Download copies of these from http://intranet.hne.health.nsw.go v.au/advance_care_planning health professionals section Develop an agreed process for communication of ACP discussion and document development within the care team Request medical champion/ Exec Sponsor to discuss ACP at meeting with MO's. Provide written information about ACP implementation. Raise at regular clinical management meetings Develop a way for staff to provide feedback and constructive comment on the process. Invite involvement and engagement Distribute ACP implementation fact sheets. Provide in-service. Raise at staff meetings Advertise when and how staff are able to access on-line ACP education; in-service and other ACP resources Discuss with manager/s. Contact ACP support unit for access to resources

Who will be responsible?

When?

Action / Comments

no

Have medical staff in the clinical area been engaged and informed of ACP implementation?

yes

no

Has there been information about ACP implementation made available to all staff within the area?

yes

no

Are staff able to access ACP education easily and in work time?

yes

no

Developed by Mandy Harden, Kate Gunn and Lisa Shaw. ACP Project Officers. Hunter New England Health March 2009

Page 2 of 7

Priority Number

Question Is there a divider system in the medical/clinical records that clearly identifies where ACP documents are stored?

Yes/ No yes

Recommended Action Check that staff are aware of this system and that it is in each patients notes Develop a system that allows ACP documents and documentation to be clearly visible and accessible Review where and how this is being documented. Seek regular feedback on if/how this process can be improved Review routine service/ nursing admission assessment process. How can this question be incorporated?

Who will be responsible?

When?

Action / Comments

no

Are competent adults asked to identify who they would like to have included in substitute medical decision discussions as part of routine service/nursing admission assessment?

yes

no

For incapable adults, is a `person responsible' identified using the NSW Guardianship Act hierarchy, and clearly documented during the routine clinical admission process?

yes

no

Is information on ACP routinely provided to patients/carers during the admission assessment process?

yes

no

Review where and how this is being documented. Seek regular feedback on how/if this process can be improved Review clinical admission process. How can this question be incorporated? Which key stakeholders need to be consulted in this process development? Check that information is accessible to all patients/carers and in a way that is appropriate to their needs Identify what is preventing this from happening. Discuss with manager/s how to overcome the barriers identified

Developed by Mandy Harden, Kate Gunn and Lisa Shaw. ACP Project Officers. Hunter New England Health March 2009

Page 3 of 7

Priority Number

Question Are patients/carers offered further opportunities to discuss ACP during their service admission/stay?

Yes/ No yes no

Recommended Action Check staff are aware of this system and it is working Is there an effective referral process to alert clinical champions that patients/carers would like to discuss ACP issues? Check that this is being recorded in the medical record and that process for team information dissemination is being followed Educate staff on the agreed ACP documentation, team discussion and storage process. Check staff are aware of these resources and that they are being offered. Seek feedback from patients/carers whether these resources are helpful Educate staff where ACP resources can be accessed and when/how to offer Review with doctors and care staff if this system is working and whether there are ways of improving same Consult with managers and medical staff how this can be incorporated into routine practice Check staff are aware of this system and it is working Educate staff on the need to include this information with every transfer/discharge

Who will be responsible?

When?

Action / Comments

Are ACP discussions documented on the ACP discussion record and stored in the ACP section of the notes?

yes

no

Are patients/carers offered ACP resources to use away from the clinical area?

yes

no

Are ACP discussions/documents referred to if the patient's clinical condition deteriorates and they are unable to discuss their own healthcare choices?

yes

no

Are ACP discussions/documents copied and transferred with patients when they are discharged/ transferred from the service/clinical area?

yes no

Developed by Mandy Harden, Kate Gunn and Lisa Shaw. ACP Project Officers. Hunter New England Health March 2009

Page 4 of 7

PART 2

Sustainable Advance Care Planning CQI Action Planner

Priority Number Question Is ACP education offered on a regular ongoing basis to all staff within unit/service, including new/casual staff? Yes/No yes Recommended Action Review if existing unit/service process for introducing ACP education is meeting staff needs Design process to include ACP education into orientation of new/casual staff. Consider incorporating ACP introduction PPT on unit/service desktop as part of orientation process Review if existing unit/service process for supporting on-line education is meeting staff needs Review if there is a process for releasing staff for on-line education completion. Are there barriers to accessing training? Does this need review at management level? Review with staff if this process is working effectively. Make training calendar available Review if there is an existing process to identify staff to attend further ACP training. Does this need review/design at management level? Who will be responsible? When? Action / Comments

no

Are staff who are interested in ACP offered work time to complete online Advance Care Planning Awareness Program available on myLink?

yes

no

http://mylink.hnehealth.nsw.gov. au/

Are staff who are interested in facilitating ACP discussion process supported to attend ACP facilitation workshops when available?

yes

no

Developed by Mandy Harden, Kate Gunn and Lisa Shaw. ACP Project Officers. Hunter New England Health March 2009

Page 5 of 7

Priority Number

Question Is a training record kept and reviewed annually to verify percentage of staff with ACP education?

Yes/No yes

Recommended Action Maintain with annual review. Encourage and support documented evidence of attendance / completion of available ACP training Develop training record process. Is it an option to include evidence of ACP education in staff performance appraisal process? Review if process is working and whether staff feel it could be further refined. Alter process as necessary using PDSA cycle. Are patient wishes routinely incorporated? Involve key stakeholders in redesigning existing `No CPR' order process

Who will be responsible?

When?

Action / Comments

no

Is the existing process of discussing and documenting `No CPR' orders in line with NSW Health guidelines `Decisions relating to No CPR Orders?' * NB for community based services, there may need to be discussion and agreement within service as to what is an appropriate `No CPR' order response Has the ACP process audit been scheduled as part of routine unit/service quality improvement calendar?

yes

no

yes

Conduct audits as per agreed timeframe. Implement changes as per the PDSA cycle Include audits at agreed timeframes in the quality improvement calendar or assign responsibility for completing same to designated staff member/s Conduct End of Life audit on patients dying in unit/service. Identify issues relating to ACP process. Apply Quality Improvement PDSA cycle to address identified issues.

Page 6 of 7

no

Are patient deaths reviewed/ discussed on a regular basis at Morbidity and Mortality or Case Review meetings?

yes

Developed by Mandy Harden, Kate Gunn and Lisa Shaw. ACP Project Officers. Hunter New England Health March 2009

no

Are medical staff kept informed of ACP process and quality improvement initiatives?

yes

no

Are partnerships with other health service providers and community groups actively encouraged?

yes

no

Initiate staff meetings on a regular basis where end of life care is reviewed based on case studies of patient/s who have died in unit/service. Discuss with Medical Staff if current communication process is meeting their needs. Refine process as required Identify what barriers exist with ACP process and medical staff involvement. Review at senior management level for strategies to invite and engage medical staff. Review existing process and information provided. Does this meet the group/s needs? What evidence is collected to confirm this? As a unit/service identify key groups that could be partnered with to support ACP process. Are there staff who would be interested in doing ACP information sessions?

This planner can be used as evidence of ongoing ACP process implementation. It is recommended that when all `yes' responses have been recorded, that the plan is signed off by the appropriate manager/s. It may be appropriate to review key elements of the planner on a annual basis to ensure that process reflects clients service requirements.

Developed by Mandy Harden, Kate Gunn and Lisa Shaw. ACP Project Officers. Hunter New England Health March 2009

Page 7 of 7

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