The Nepean Hospital Redevelopment: A study in clinical innovation
Professor Mohamed Khadra AO, Director of Strategy and Innovation and Clinical Director of Surgery, Nepean Blue Mountains Local Health District (NBMLHD)
The mark of a great society is when an old person plants a tree under the shade of which he will not live long enough to be able to sit.
When one thinks of the major hospitals of New South Wales - Westmead, Concord, Royal North Shore - the list often leaves out Nepean Hospital.
Located on the furthest reaches of Sydney’s western perimeter, the hospital has transformed from its earliest iterations, 150 years ago, as a cottage hospital located in the High Street of Penrith, through to a district hospital in the early 1980’s and most recently as a large, developing and innovative tertiary referral hospital.
The NSW Government’s investment of $1 billion to redevelop the hospital has provided a burst of transformative energy. By the time Nepean Hospital is rebuilt, it will be one of the largest hospitals in Sydney. While planning is underway, there are some unknown factors that may affect the redevelopment. For example, it is unknown how the planned Badgerys Creek Airport will impact the number of patients and community needs for the hospital into the future.
Nepean Hospital prides itself on two major cultural achievements which have been the product of an investment by senior hospital staff over a number of years. The first is a collaborative culture between staff, staff and administration and between the hospital and the community. For example, senior clinicians and administration hold weekly partnership meetings, and managers and clinicians partner to draft the best possible outcomes for patients.
The second cultural hallmark of Nepean Hospital is innovation. It is the first public hospital in NSW to have a da Vinci Robot and the hospital recently celebrated 500 cases completed by the robot. The advanced use of cardiac ultrasound in monitoring critically ill patients developed by Nepean has international recognition, as does our care of women with high-risk pregnancy.
Innovation occurs at all levels of the hospital. A recently launched project sees patients leading their own nursing handover and conducting the conversation about their wellbeing and welfare. This has increased patient satisfaction and empowers patients to feel a part of their own care.
The redevelopment of Nepean Hospital provides a focus to capture the culture of innovation and create a hospital of the future. The challenge, of course, is that it is impossible to predict the development of technologies and their impact on everyday healthcare in a large tertiary hospital. When the last building was added to the hospital the iPhone didn’t exist. The building added before that predated the internet. Who knows what major technologies will exist after this hospital is commissioned.
The approach of senior hospital staff has been to try and capture the thoughts, ideas and opinions of the largest cross-section of the hospital possible. We have asked the ACI to assist us in conducting a number of forums where medical, nursing and (in forthcoming forums) community members present their view of what makes a modern hospital great. The forums have been attended by representatives from all departments of the hospital, senior ACI staff including the chief executive, community representatives, as well a senior hospital administration and members of the hospital’s design and build team.
This is an exciting and wonderful opportunity.
Consumers are the bridge
Julie Russell, Chairperson, Community Advisory Committee to Nepean Blue Mountains Local Health District (NBMLHD) and Nepean Blue Mountains Primary Health Network (NBMPHN)
I was recently invited to speak at two planning forums with staff and members of the redevelopment team at the NBMLHD. The theme was: Let’s Build a Great Hospital. My colleague, Joe Rzepecki, and I represented consumers in the discussion.
Why were we there? How could we possibly imagine what the needs of clinicians might be in 2031 (the date towards which they were asked to project services)?
We were invited as the consumer voice is vital to the success of such an important project. I am very pleased to say that consumers have been a valued voice throughout the consultation on the $1 billion redevelopment of Nepean Hospital.
The NBMLHD covers 9,063 square km on the fringes of Sydney’s north and west incorporating the Hawkesbury, Penrith, Lithgow and the Blue Mountains. It includes towns, as well as rural and semi-rural aspects. There are Consumer Working Groups in each district who meet regularly and advise both the NBMLHD and the NBMPHN via the Community Advisory Committee to both bodies.
In the consultation process, we are the bridge between primary and secondary care. We provide clinicians and hospital administration with insights into the patient journey - how it is and how it needs to be. With a move towards patient-centred care, staff can see that health consumer representatives can bring practical ideas, life experience and patient stories into planning.
The redevelopment team has consulted with consumers from all walks of life about the new multi-storey car park and stage one of the project. It was necessary to recruit outside our established consumer family to create a larger pool and encourage diversity. People of all ages, cultural backgrounds, levels of ability, staff and carers from across the NBMLHD have joined in Project User Groups for planning the car park, neonatal intensive care unit, emergency department, interior design and wayfinding, to name a few. They have helped bring the design of stage one to the schematic design stage.
As a participant in the redevelopment planning, I have had the opportunity to gain a thorough understanding of the process. This was a steep learning curve requiring a whole new raft of acronyms to add to the health related ones!
Speaking to staff as they grapple with how to make their dreams a reality was the next step across the bridge. It was exciting to hear plans to conquer distance with technology, as this is a huge problem for consumers in NBMLHD. To hear passionate pleas for breaking down silos and for redesign of care focusing on individual patient needs and pathways, more collaboration with primary care to care for patients at home, the push for more research to be done on site and for innovation was exhilarating and encouraging. This change will happen with this perfect opportunity.
No matter how much technology we employ and how much data we collect, nothing will replace clear communication, listening, transparency, compassion and empathy. It is still these qualities that will determine excellence and the best quality of care for patients. Our patient pathway at every stage of life is shared with the clinicians delivering our care and we can bridge any gaps together.
Chief Executive Comment
Dr Jean-Frédéric Levesque
Buildings as innovations
It is well known that the physical environment that we work in has an influence on what we do in a clinical setting. The location of a nursing station can influence how easy it is to monitor patients, to hold case discussions and ultimately to respond to deteriorating patients. This influence on our practice can be more subtle. For example, the evidence around hand washing or patient engagement and experience is increasing. It is timely to consider how the physical environment is designed to support clinical practice and change.
We often see the built environment as fixed or, at least, onerous to change. New infrastructure projects are key opportunities to act on crucial aspects of performance and system transformation. This is why the NBMLHD’s invitation to participate in and facilitate workshops around the redevelopment of Nepean Hospital was a unique opportunity for the ACI. If we could support the discussions of clinicians in planning the services to be delivered in the new buildings, we can help prepare for the innovations of the future.
The discussion started with examining the influences as to why care is currently delivered in the way it is. There were several aspects to consider. Firstly, clinicians who have provided care in a certain way tend to continue using the same clinical options on an ongoing basis. They also tend to refer the same patient groups to hospital on an ongoing basis. In addition to this, the existing physical infrastructure – including the number of wards, outpatient settings, surgical and interventional medical theatres, alongside established clinical models, routines and processes – contributes to the momentum that keeps the current delivery of services in our hospitals moving. Finally, organisational culture and funding arrangements influence how care is delivered. A system of this scale has great momentum, and all of these aspects can work against changing how clinical services are provided.
Working in healthcare, we live in a context of change. Patients are older and increasingly living with multiple chronic problems when they present to hospital for very acute illnesses – they expect a more personalised approach to their care. The era of clinical guidelines is being replaced by the era of tailored or personalised medicine. Clinicians now work in teams; very few hospital trajectories are now the focus of a single provider or type of clinician. Telemedicine and greater recourse to information technology is increasing our capacity to ambulatorize care that used to be delivered from a hospital admission model. Adding to this changing environment, healthcare managers are increasingly recognising that many services paid on a volume perspective are not changing the quality of life of patients despite being effective therapies. We need to look at the value for patients of the therapeutic options offered.
This all means that we need to think about new ways to deliver care and how they can be supported by buildings, but also to consider how change may actually be blocked by buildings which were built in line with previous ways of delivering services. New buildings are opportunities not to be missed if we are to continue to respond to the changing face of healthcare.
The discussions at Nepean Hospital were rich, despite the challenges related to the complexity of care and the diversity of views about how to respond to these challenges. The clinicians there have taken on the challenges of influencing the design of the redevelopment and of the clinical strategy that is required to ensure that the new infrastructure fits with the clinical model of the future that they envisage and want to promote. This is a healthy process that the ACI is happy to support.
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Can we make innovation the norm?
The ACI’s inaugural Innovation as Usual seminar was held in early July, with a focus on promoting and normalising continued innovation in healthcare.
Keynote presenter Dr Ian Scott, Director, Department of Internal Medicine and Clinical Epidemiology at Princess Alexandra Hospital, Brisbane, started the conversation around what drives innovation in a clinical environment. His keynote explored why innovation in healthcare is needed and what is stopping innovation from being the norm.
The following panel discussion featured Professor Nicholas Mays, Policy Innovation Research Unit, London School of Hygiene and Tropical Medicine, and Erica Kneipp, Assistant Secretary, Australian Government Department of Health, who shared their perspectives on innovation in healthcare. The panel was chaired by the ACI Chief Executive, Dr Jean-Frederic Levesque.
The speakers and audience members participated in a lively debate following the presentations. The keynote presentation and videos from the event are available on the Sax Institute website.
The Innovation as Usual seminar series will be a platform for leaders and innovators to debate topics that are changing the healthcare landscape.
Innovation as Usual speakers: Dr Ian Scott, Dr Jean-Frederic Levesque, Professor Nicholas Mays and Erica Kneipp. Photo: Sax Institute.
Centre for Healthcare Redesign Update
Associate Director, Clinical Innovation Redesign and Consumer Engagement
Keeping it SIMPLE with hospital stock and inventory
After finding that wards were holding excessive medical supplies on shelves and in storage rooms, a South East Sydney LHD project team redesigned the procurement and inventory management at Sutherland Hospital.
Team members Simone Kelly, Marianne Camper and Edmund Ng developed the SIMPLE project – a Sustainable Inventory Management Process for Lean Environments – as part of the graduate certificate program offered by the Centre for Healthcare Redesign.
The team found that storage rooms were overcrowded, which resulted in financial inefficiencies and frustration when locating stock.
An inventory cleanse, revamp of the storage rooms and dressing centralisation led to a reduction in the number of dressings in stock on some wards by as much as a third. Several items that were being held ‘just in case’ were eliminated, and excess stock reduced, including 3000 blue sheets!
The SIMPLE team developed clear business rules and new processes for the management of inventory and stock, and the responsibility of ordering and stocking of supplies shifted from clinical staff to a support officer. This gives nurses more clinical time with patients and also saves money.
The SIMPLE team members recently presented the project to the ACI and CEC Board. The board congratulated the team for the improved productivity and outstanding financial savings.
Institute of Trauma and Injury Management Update
ITIM Trauma evening reaches a global audience
The Institute of Trauma and Injury Management’s (ITIM) inaugural Pre Hospital and Retrieval Medicine (PHARM) Trauma evening reached a global audience, with more than 300 attendees livestreaming the event from around Australia, the USA, New Zealand, South Africa, Myanmar and Europe. More than 7,900 minutes of livestreamed video was viewed by participants. The video of the event is available on the ITIM webpage.
In addition to the strong livestreaming numbers, 109 people attended the event in person. It was held on 20 June at the Aeromedical Crewing Excellence (ACE) Training Centre at Bankstown Airport and hosted by the Greater Sydney Area Helicopter Emergency Medical Service (GSA-HEMS). GSA-HEMS is the largest retrieval service within the broader NSW aeromedical retrieval system.
The evening included presentations on Code Crimson, paediatric trauma, pre hospital care and a trauma team simulation demonstration.
Aeromedical retrieval services are now a major part of the trauma response system in NSW and this education evening served not only to help train retrieval clinicians and paramedics, but also raise awareness of the vital work being done by retrieval services.
ITIM Education Evening at the ACE Training Centre, Bankstown Airport
ITIM Trauma Evening at the ACE Training Centre, Bankstown Airport. Photo: Christine Lassen.
Intensive Care NSW Update
Stream Manager, Intensive and Urgent Care
ICU Exit Block Pilot leads the way
The ICU Exit Block Pilot Project, led by the Central Coast LHD in partnership with the ACI, was launched at Liverpool, Nepean, Gosford and Wyong hospitals in March 2018.
Since the launch, a huge volume of work has been undertaken, with sites conducting thorough diagnostics to understand the issues affecting exit block.
Staff, patient and carer interviews have shed light on various issues that not only impact on ICU exit block, but also patient flow as a whole across the hospital. Surveys, data analysis and process mapping have highlighted similar information.
This work has uncovered challenges currently being experienced, but it has also highlighted successes and positive aspects of the care provided in the units, including one carer who commented that 'if asked to rate the staff and experience out of 10, I would give it 11’.
Over the coming months, sites will commence theming and prioritising identified issues to develop local strategies, which meet the needs of the services, staff, patients and families. Project officers will participate in solution design and implementation capability days, delivered in partnership with the ACI Clinical Healthcare Redesign and Implementation teams.
The progress of the pilot has supported the establishment and planning of statewide rollout of the project. More information about the project, its scope and objectives will be available in the coming months.
Aligning with the Ministry of Health patient flow collaborative, it is anticipated that the solutions developed in the pilot and statewide rollout will ensure successful sharing between sites across NSW.
Patient Flow Portal ICU Bed Status
New information about adult ICU beds is now available in the Electronic Patient Journey Board (EPJB). The EPJB is a module of the Patient Flow Portal (PFP).
The new PFP fields include information on:
- ICU Bed status (available empty staffed beds)
- Intensive Care Consultant on call contact details
- Patient acuity (mechanical ventilation status and patient nursing dependency).
This update provides information on adult ICU bed status across NSW via a report which can be accessed through the PFP by all users who have access.
The Ministry of Health Patient Flow team and the ACI Intensive Care NSW team will work with local sponsors, champions and clinical leads throughout 2018 to provide tailored education and training on use of the new PFP fields.
Preliminary visits have been conducted at a number of sites, including Bega, Coffs Harbour, Concord, Gosford, Lismore, Prince of Wales, St Vincent’s, Tweed, Royal North Shore, Westmead and Wollongong hospitals.
Formal implementation visits have been completed at John Hunter, Calvary Mater, Tamworth, Manning, Maitland, Bathurst, Dubbo, Orange and Sutherland ICUs.
Following implementation, the teams will consider feedback about refinements that should be included in the next phase of the PFP rebuild. This is expected to occur over the next two years.
For more information about these updates, contact Danielle Kerrigan, Manager, Critical Care and Rural Critical Care Taskforces, on email@example.com or 02 9464 4705.
Musculoskeletal Network Update
Updated model of care for osteoporotic refracture prevention
The ACI Musculoskeletal Network is pleased to announce the release of the updated Model of Care for Osteoporotic Refracture Prevention.
Since the development of the original version in 2010, the model of care has been used to support the development and implementation of evidence-based and effective services for people living in NSW who sustain minimal trauma fractures and are at risk of refracture.
An evaluation of the model in 2011 provided evidence of its positive effect in preventing fractures and improving quality of life. From 2017 NSW Health has supported the systematic implementation of the Model of Care for Osteoporotic Refracture Prevention across all LHDs in NSW as part of Leading Better Value Care.
With osteoporotic refracture prevention services being rolled out across the state, it was timely to undertake a review of the evidence, guidelines and principles that underpin the model of care.
There was collaboration with Aboriginal people during the development of this document, and the model aims to ensure services across NSW provide Aboriginal people every opportunity to access culturally appropriate care.
Updates to the model include:
- updated evidence on refracture prevention
- a greater emphasis on holistic person-centred care
- inclusion of a medical officer as part of the core team, with medical therapy initiated as part of the service prior to handover to the individual’s general practitioner
- an emphasis on the importance of patient reported outcomes and experience measures (PROMs and PREMs) as part of clinical assessment and to support service development.
The model retains the main concepts of care coordination, medical therapy, self-management support, access to community-based peer support (such as falls prevention groups) and follow-up over time.
Paediatric Network Update
Establishment of Paediatric Innovation Collaborative
A new Paediatric Improvement Collaborative aims to improve the safety, reliability and effectiveness of care for children in any acute setting.
The ACI, Queensland Health Clinical Excellence Division, Safer Care Victoria and the Royal Children’s Hospital Melbourne (RCH) have jointly committed funds over three years to further enhance the quality of the statewide clinical practice guidelines (CPGs), actively promote their use and assess their impact on patient care.
The focus is on the development, endorsement, publication and promotion of evidence-based paediatric CPGs that outline best practice clinical management of high volume and high risk paediatric clinical conditions.
The RCH has been producing paediatric CPGs for more than 20 years. They are extensively used throughout Australia with about 1000 website hits in each state recorded every day. There are more than 400 topics covered and many have been adapted for use outside the RCH.
As part of the agreement, NSW and Queensland also have membership on the RCH Clinical Practice Guideline (RCH CPG) Group and the Safer Care Victoria Evidence Based Care Committee (EBCC). The Paediatric Network Executive is conducting an expression of interest to determine the NSW representative on the RCH CPG Group. The NSW representatives on the EBCC are Paediatric Network Co-Chair Matt O’Meara and network manager Mary Crum.
The ACI, Queensland Health Clinical Excellence Division, Safer Care Victoria and the RCH have formed a governance committee to oversee the collaborative and have committed to a review process.
If the model is successful, the longer term aim will be to broaden it to encompass other interested states and territories.
Pain Management Network Update
Building capacity to manage pain in primary care in Mid North Coast
The ACI Pain Management Network has recently entered into a two year partnership with the North Coast Primary Health Network to improve the management of chronic pain in the Mid North Coast.
The aim of the partnership is to reduce the prescribing of opioids in the community, while increasing access to self-management strategies for people who experience chronic pain. This will be achieved through webinar training and skill development in pain management for 100 primary care clinicians.
General practitioners (GPs) in the region will be able to refer patients directly to these providers and will also be able to access a pain management specialist via telehealth for up to eight hours per week. This arrangement will assist GPs in the management of complex patients, including those who are on high doses of opioids, and help reduce opioid prescribing rates in the region.
Showcasing pain programs in South East Sydney and Illawarra
The pain clinics at St George, Port Kembla and Prince of Wales Hospitals held a full day workshop on chronic pain at the St George Leagues Club on 4 July.
The event showcased achievements in the pain programs running across these services, and provided updates on cannabis, pelvic pain, opioid prescribing and work being done in multicultural and Aboriginal communities.
Attendees heard from a Chinese multicultural facilitator about her experience running two community pain programs in her local district. Aunty Lindy Lawler, an Aboriginal Elder of the Illawarra region, shared her story of ‘silent pain’ associated with being removed from her parents at the age of five months, when she and her twin sister were brought to hospital with an illness.
About 100 staff attended the event, encouraging ongoing connections between the pain clinics across the South Eastern Sydney and Illawarra Shoalhaven LHDs.
Rehabilitation Network Update
Rehabilitation Network education forum 2018
The annual Rehabilitation Network education forum was well attended, with more than 110 clinicians attending in person and a further 61 livestreaming the event.
There were 15 presentations from medical, nursing and allied health network members at the event held on 29 June at Liverpool Hospital. Presentations covered a range of topics, including rehabilitation in the home, the development of co-located shared trauma services and the use of prosthetic devices.
The Rehabilitation Network Co-Chairs, Dr Kathleen McCarthy and Sandra Lever, provided members with an update on recent achievements and future directions for the network.
Feedback from participants has been very positive and will be used to plan future events. All presentations are available on the Rehabilitation Network webpage.
2018 Rehabilitation Network Education Forum. Photo: Carmel Thorn.
New Rehabilitation network manager appointed
The Rehabilitation Network welcomes Louise Sellars who started as the new network manager on 18 June 2018. Louise joined the ACI in May 2017 as a clinical auditor in the Investigating Clinical Variation team for Leading Better Value Care, then was the A/Network Manager for the Cardiac Network.
Louise has a background in intensive care nursing and has also previously studied law and business.
Strategic Plan Update
Strategic Plan - Program Manager
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Building the ACI’s strategic plan for 2019-22
The ACI is currently building its strategic plan for 2019-22. This plan will be used to communicate the ACI’s goals and the actions needed to achieve those goals.
The strategic planning approach includes diverse activities to ensure broad consultation from clinicians, consumers, Pillar organisations, the NSW Ministry of Health and primary and Aboriginal health services.
Since beginning this process in May, the ACI has:
- surveyed people who have been previously involved in ACI projects (led by market research firm EY Sweeney)
- engaged with the ACI/CEC Consumer Council and network, institute and taskforce executives and members, asking about the key challenges in the health system and opportunities for the ACI
- held program logic building sessions with staff to explore the future of the ACI
- conducted a desktop review and interviews with similar international and domestic organisations to identify key themes and approaches in strategic direction
- consulted with the ACI Co-Chairs and network, institute and taskforce managers at the Co-Chairs Forum on 31 July.
Further interviews with clinical, Pillar and health executives are currently underway to provide additional information on what is needed from the ACI by the health sector.
The final plan is due to be presented to the board in December 2018.
Further information on the strategic planning process is available by contacting Sarah Jane Waller, Program Manager – Strategic Plan on firstname.lastname@example.org
ACI program logic building session with staff. Photo: Sarah-Jane Waller.
Surgical Services Taskforce Update
Surgical Services Taskforce Manager
Plans to grow the National Surgical Quality Improvement Program
The National Surgical Quality Improvement Program (NSQIP) is currently in place in eight hospitals across NSW and the ACI Surgical Services Taskforce (SST) is planning to expand the program to bring additional hospitals on board.
The program supports the delivery of high quality, patient-centred surgical services, using risk-adjusted, benchmarked clinical data to inform quality improvement initiatives.
Participating hospitals benefit through having a more comprehensive understanding of their local surgical performance, enabling targeted quality improvement initiatives to enhance patient outcomes.
Earlier this year members of the NSW NSQIP Collaborative met with Dr Clifford Ko, founder of NSQIP and Director of Research and Optimal Patient Care at the American College of Surgeons.
Dr Ko’s experience developing the program and implementing it on an international scale provided unique insight into the current and future direction of surgical quality improvement. Participants had the opportunity to discuss implementation, capability development strategies and quality improvement initiatives underway in their facilities and consider how NSQIP in NSW may be further expanded.
Surgical Services Taskforce Manager appointed
The SST recently welcomed Crystal Burgess to the role of Surgical Services Taskforce Manager. Crystal joined the ACI in 2017, working across the surgery, anaesthesia, intensive care, urology and burns networks. She has a background in nuclear medicine and has previously studied health management and medical radiation science.
Review of NSW telehealth guidelines
The ACI is currently reviewing the Guidelines for the Use of Telehealth for Clinical and Non-clinical Settings in NSW. The review will ensure the guidelines are up to date with current practice and clinical need.
The review process includes:
- revision of the guidelines through a consultation process with stakeholders
- revision of the ACI Telehealth Resource Package
- development of a toolkit for using telehealth services.
The aim of the review is to develop a comprehensive set of documents providing everything needed to support and implement telehealth into practice.
Initial feedback on the guidelines was sought through a broad consultation process. The next stage will be to hold workshops for stakeholders to provide further input and review draft content.
If you would like to be involved in the review or have any feedback on the current guidelines please get in touch with the Telehealth team on email@example.com
Telehealth Capability Interest Group
The Telehealth Capability Interest Group (TCIG) was relaunched in June. The attendance and feedback for this forum has been overwhelming and extremely positive.
The TCIG is a virtual video forum that gives participants an opportunity to share the experiences, benefits and outcomes of using telehealth in clinical practice. The forum is held on the third Thursday of every month and each one will feature two presentations from telehealth champions from across the state.
If you’re interested in joining, visit the ACI Events Calendar to register to attend the meetings.