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Triple CCC Project - Care, Communication, Coordinate

Project Added:
7 August 2015
Last updated:
4 November 2015

Triple CCC Project – Care, Communication, Coordinate


The project team redesigned and implemented a new care coordination model which has transformed care delivery on the medical respiratory ward, improving safety, patient, carer and staff satisfaction. 

This project was a finalist in the 2015 NSW Health Awards, Collaborative Team category. Watch a video on this project.

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



To improve patient, carer and staff experiences with care coordination, communication and increase compliance with the NSW Ministry of Health (MoH) Care Coordination Policy (PD 2011_015).


  • Significant improvements in patient/carer satisfaction with:
    • care coordination
    • information/education
    • transition/continuity
    • emotional support.
  • Increased productivity by reducing delays in team referral processes.
  • Improved patient safety with the use of safety checklists on ward rounds.
  • Improved teamwork and communication between clinicians
  • Improved documentation of Multidisciplinary Team (MDT) meetings and compliance with the MoH Care Coordination Policy (PD 2011_15).

Project status

Project started: 16 July 2014

Status: Implementation - the project is currently being implemented.


The project team undertook ten patient stories which identified only 20% of patients had a positive experience with care coordination. Patient and carer surveys also revealed patients were being discharged unexpectedly and family/carers were unaware of their loved ones expected date of discharge (EDD), prior to the day of discharge.  A medical record audit revealed a 6 hour median delay for referrals - from request in the medical record to entry into the electronic medical record (eMR) referral system. 

Staff tag-a-longs identified multiple delays in referral processes and lack of communication between clinical teams with 68% of staff reporting MDT communication as requiring improvement.

Process mapping identified that nursing staff placed no value on completion of the Admission Discharge Risk Assessment, a form used to identify team referrals. 

In addition, Shellharbour Hospital identified the need to improve compliance with the MoH Policy Care Coordination: Planning from Admission to Transfer of Care in NSW Public Hospitals (PD 2011_15).

There were no MDT meetings, EDDs were not being developed or documented in the medical record. The Transfer of Care Risk Assessment was not being completed in the required timeframe resulting in delayed or inappropriate referrals.

Structured Interdisciplinary bedside rounds (SIBR) evolved from the Clinical Excellence Commission ‘In safe hands’ program and from the model implemented by Professor Harris - Liverpool Hospital.


A new care coordination model was developed and implemented which included the following.

  • Daily MDT meetings at the electronic patient journey board to discuss care planning, document and revise EDDs.
  • Resource tool to assist teams to develop EDD.
  • Computer on wheels for referrals to be entered in ‘real time’ at the point of care.
  • Structured post intake ward rounds with, agreed ways of working, nurse participation and inclusion of a safety checklist.
  • Transfer of Care Risk Assessment used during post intake ward round to identify new referrals.
  • Team education on completion and use of Admission Discharge Risk Assessment.
  • SIBR enabling patient and carers to participate in care planning, with the inclusion of a safety checklist.

Medical Respiratory Unit Care Coordiantion Model

Resources developed

  • Electronic patient journey board MDT form for documentation, business rule, leadership scripts for Nurse Unit Manager in charge, EDD resource tool.
  • Post Intake Medical Ward Round form for documentation including safety checklist, nursing training competencies, business rule.
  • SIBR form for documentation, nursing training competencies, structured scripts.
  • Orientation/Education package for new staff.


  • Coaching staff with each new solution.
  • Education and simulation training with staff for SIBR.

The daily MDT meetings at the electronic patient journey board have been implemented since December 2014, and well embedded on the ward.  The meeting process is incorporated in the hospitals business rule and a form available to document this meeting.  Education programs are provided to new staff at orientation and on commencement of work.

The Medical Post Intake Ward Rounds have been implemented since February 2015 with 8/11 physicians participating. The ‘agreed ways of working’ between medical and nursing teams is incorporated into a business rule for future reference, teaching and sustainability.

SIBR currently takes place twice per week and is in the process of spread. Currently we have three physicians trained with another two physicians agreeable to participate weekly.  A ‘team communication script’ and nursing clinical competencies are available however, further spread within a medical model ward is challenging and a review of the medical working model is underway.

Implementation sites

The Medical Respiratory Ward, Shellharbour Hospital, Illawarra Shoalhaven Local Health District (ISLHD).


This project was developed and implemented in partnership with the Agency for Clinical Innovation’s Centre for Healthcare Redesign program. 


The following methods were used for evaluation.

  • Patient stories collected and evaluated.
  • Patient Experience Trackers (PETS) used to survey staff, patients and carers.
  • Medical record audit.
  • Semi-structured interviews with medical, nursing and allied health staff.


The implementation of the new model of care resulted in:

  • 69% improvement in patient/carer satisfaction
  • 96% improvement in documentation of multidisciplinary team meetings
  • reduction in referral delays from request in the medical record to entry in the eMR system from 6 hrs to 14 mins (median)
  • 100% improvement in documentation of EDDs
  • increase in the number of multidisciplinary meetings held at the patient’s bedside
  • 43% improvement in completion of the Admission Discharge Risk Assessment.

The implementation of the patient safety checklist resulted in:

  • 100% removal of an intra venous cannula if not in use
  • 25% improvement in the prescription of venous thromboembolism prophylaxis
  • 64% improvement in the documentation of an end of life care plan
  • 54% likelihood that referrals would be entered in real time.

The new care coordination model has transformed care delivery on the medical respiratory ward improving safety, patient, carer and staff satisfaction.

"The coordination of my care was excellent. There is only one word for it … Excellent."

Charlie, Patient

"I think it has been a very good initiative in improving communication between, medical nursing and allied health staff. I think it has had a positive experience, both at a ward level for staff who are working there, with interaction and team work, and also with improving patient care. Streamlining care, having a plan, working out patients’ needs while they are in hospital, determining when they are most appropriate to be discharged."

Dr Ford, Physician.


  • Winner of the 2015 ISHLHD Quality Awards Category 6 – Team Collaboration.
  • Winner ISLHD Special Award – Zero Movement Patient Safety Award.
  • Finalist in the 2015 NSW Health Awards, Collaborative Team category

Lessons learnt

Using the AIM principles at all times is paramount to success.



Tracey Hinke
Patient Journey Facilitator
Shellharbour Hospital
Illawarra Shoalhaven Local Health District
Phone: 0409 569 343

Kerrie O’Leary
A/ISLHDClinical Redesign Coordinator
Shellharbour Hospital
Illawarra Shoalhaven Local Health District
Phone: 0477 329 606

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