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About Face Project: Clinical Redesign of Cleft and Craniofacial Services

Sydney Children's Hospital Network
Project Added:
18 August 2015
Last updated:
21 August 2015

The About Face Project: Clinical Redesign of Cleft and Craniofacial Services within the Sydney Children’s Hospitals Network


This project is about starting the journey towards the provision of better, more organised and coordinated care to ensure the best possible cleft and craniofacial services and experience for patients and their families within the Sydney Children’s Hospitals Network (SCHN).

Download a poster from the Centre for Healthcare Redesign graduation, August 2015.


Children and young adults attending the SCHN cleft and craniofacial team outpatient services, will receive coordinated, timely, consistent, multidisciplinary care based upon documented, shared and evidence driven protocols, and standards of team care.


  • Patients will receive detailed clinical care plans following their clinical attendance. These care plans will clearly detail:
    • the results of the clinical assessment
    • the name of the professionals seen
    • a list and description (including results) of any investigations or procedures completed as part of the clinic appointment
    • a list of the issues discussed
    • details of any surgery recommended
    • details of any referrals given
    • details of any medication and/or prescription given
    • a plan for next clinical review, including:
      • when to be seen
      • who the patient will be seen by
      • a brief description of the purpose/aim of that review
    • a distribution list for copies of the care plan
    • contact details for who to contact should concerns arise.
      View a sample care plan.
  • Patients will be more empowered (and able) to contact the clinics should they feel that their care deviates from what is expected, as they will now have a better understanding of what is regarded as minimum standard care for individuals with cleft and craniofacial conditions.
  • The SCHN Executive will have access to a detailed description of what is internationally regarded as the minimum standard for cleft and craniofacial care, as it relates to NSW. This standard will be shared across the Network to ensure standardised, consistent care is delivered.
  • The SCHN will have an understanding of the issues currently facing the cleft and craniofacial care in NSW and be able to view those issues within the context of minimum standards of care.
  • The SCHN will have access to a broad plan, with suggestions for solutions, for improving the provision of care for children in NSW with cleft and/or craniofacial conditions.
  • Resource allocation will be able to be mapped directly to components of care provision to ensure that resources are optimally allocated to support minimum standards of care.
  • All members of the team will know the current stage of care for each patient as a result of the shared clinical care plan implementation.
  • Staff will be able to better plan and coordinate subsequent follow up and clinical care.
  • Staff could use the information within the care plans to provide a mechanism (or safety net) for ensuring that patients do not ‘fall through the cracks’.
  • Staff will be (and already are) encouraged that the SCHN Executive has invested in this project which paints a very clear picture that the executive is listening to their concerns, and is attempting to address their issues in a systematic way.

Project status

Project start date: 24 July 2014

Project status: Implementation - the initiative is ready for implementation, is currently being implemented, piloted or tested.


In 2011-2012, the cleft and craniofacial clinics within the SCHN were identified in the SCHN clinical service planning as areas of priority for improvement.

In 2013, a self-initiated review of the cleft palate clinic at The Children’s Hospital at Westmead was given to the SCHN Executive requesting urgent assistance with the clinic’s failure to provide internationally accepted minimum standards of clinical care.

In 2014, the SCHN Executive initiated a Cleft and Craniofacial Clinical Redesign Project across the Network.

It is well established that the provision of cleft and craniofacial care is best provided by a team of professionals, with adequate support, coordination and resourcing. At present, cleft and craniofacial care in NSW is provided by four hospitals from three organisations.

The SCHN has the two largest of four cleft palate teams, including the largest in Australasia, and both craniofacial teams. This project has highlighted the fact that there were:

  • very few written protocols of care
  • no shared protocols of care
  • poor level of coordination of care:
    • patients waiting too long for appointments
    • no consistent level of data collection across SCHN teams
    • no consistent provision of patient care plans
    • patients not receiving basic speech pathology and orthodontics services
    • patients missing or receiving late surgery, particularly alveolar bone graft surgery, due to a lack of coordination or pre- surgery orthodontic preparation
    • patients presenting with a high degree of preventable compensatory speech disorders due to a lack of routine assessment, particularly as an infant.
    • poor access to Paediatric care for at-risk patients
    • impacts on surgical and other treatment planning
  • no ability to conduct clinical audit, benchmarking (including the upcoming ANZCleft Project) or research projects as a single organization
  • increasing patient complaints
  • poor staff morale with real prospects of significant staff losses.


The following solutions are part of the implementation phase of this project.

  • Define and document the ideal patient journey, based upon internationally accepted minimum standards of care, in order to accurately identify the:
    • clinical and administrative coordination requirements,
    • clinical resource requirements required for cleft and craniofacial care.
  • Investigate the use of a single, standardised Clinical Database for Cleft and Craniofacial Care for SCHN, including:
    • technical implementation requirements
    • training requirements
    • administrative support requirements
    • required modifications to an existing database (Crux) used by one team to support:
      • other implementation goals e.g. clinical care plans
      • data collection and tracking requirements for participation in ANZCleft Audit.
  • Develop a strategy and a plan for our participation and leadership of the ANZCleft multicenter clinical outcomes audit with participation from both sites within SCHN.
  • Develop joint standardised protocols of care for cleft and craniofacial conditions for NSW.
  • Develop joint minimum standards for cleft and craniofacial care plans
    • the top five Network-wide shared clinical protocols for cleft and craniofacial care, identified and documented formally according to the SCHN ePolicy requirements, with a plan in place to monitor compliance.
  • A deployment plan (with timeline) describing the required modifications, as well as technical, training and administrative requirements for deployment of the Crux database across all four cleft and craniofacial teams within the SCHN.
  • A participation plan (with timeline) describing the methods and feasibility for both The Children’s Hospital at Westmead and the Sydney Children's Hospital cleft teams to participate in the ANZCleft Audit.
  • A current issues log (with suggested solutions) for each team within SCHN, relating to the ideal/minimum level of cleft and/or craniofacial care.
  • A list of potential system-based and clinical key performance indicators (and measurement methods) for cleft and craniofacial care within SCHN.
  • A recommendation for to the SCHN Executive detailed prioritised resource enhancements across both cleft and craniofacial care, with possible governance structures included.

Implementation sites

The cleft palate clinic and the craniofacial clinic, The Children’s Hospital at Westmead and The Sydney Children’s Hospital.


The outcomes for this project are in part, still to be determined, but achievements to date include the following.

  • The required content of the multidisciplinary care plans has been identified and agreed upon by all four teams across the SCHN.
  • The technical requirements of the interface between the Crux Cleft Palate Database and the electronic medical record have been determined.
  • The required frontline clinical enhancements have been documented with costings, based upon minimum standards of cleft and craniofacial care.
  • The Patient Journey Software (PJS) (Fitzsimons, 2010-2015), has been modified to allow for full documentation of the ideal patient journey, allowing for detailed issues logs to be developed for all aspects of cleft and craniofacial care.

The team has made contact with colleagues from New Zealand, USA and UK who are also experiencing similar issues with their respective services.

David Fitzsimons gave an invited keynote presentation based on this project at the preconference symposium of the 72nd Annual Meeting of the American Cleft Palate-Craniofacial Association in Palm Springs, USA, 20 April 2015. Symposium Title: What is the 'Ideal' Treatment Outcome for the Child with a Cleft?.Presentation Title: The Process of Delivering High Quality Cleft and Craniofacial Team Care: A Forgotten Outcome?.

Lessons learnt

  • The power, relevance and accuracy of the patient voice.
  • The need to keep the “patient” as the centre of our improvement efforts.
  • The value of a strong “diagnostic” phase of the project.
  • The need to accurately describe the current, or baseline situation in the clinics.
  • The value of determining the actual root cause of a problem.
  • The value of prioritisation
  • Process maps were kept at a high level to ensure that a picture across all four clinics could be obtained. This essentially lost some of the granularity/issues of the individual clinics.
  • The message from the patients across the focus groups and interviews were united in their request for detailed treatment plans.

Further reading


David Fitzsimons
Speech Pathologist
The Children’s Hospital at Westmead
Sydney Children’s Hospitals Network
Phone: 02 9845 2074

Melissa Parkin
Speech Pathologist
The Sydney Children’s Hospital
Sydney Children’s Hospitals Network
Phone: 02 9382 1019

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