Implementing the National

Standards in the Operating

Theatre Suite – A guide to Preparing for

Accreditation

Ben Lockwood Clinical Practice Consultant

Flinders Medical Centre

South Australia

Flinders Medical Centre (FMC)

> Tertiary Trauma Centre

> Part of Southern Adelaide Local Health

Network (SALHN)

2013 Accredited as a Network

> Southern Adelaide Local Health

Network (SALHN)

• FMC, RGH, NHS, GP Plus Clinic

Flinders Medical Centre

> Division of Surgery

o Sub-division Surgical &

Perioperative Medicine (SAPOM)

• Operating Theatre Suite

Network-wide quality framework

> Formation of SALHN accreditation steering

committees

> One committee for each standard

• Executive leads

• Medical leads

• Nursing leads

> Organisational focus is imperative!

Operating Theatre Suite approach

> Mirror network-wide methodology

> Clinical leads for each standard

• 2-3 ACSCs & CNs (Level 2)

• Level 1 RN/EN engagement

• Driven by Clinical Practice Consultant

> Standard 1 led by OTS Governance group

Operating Theatre Suite approach

> Education and awareness campaign

• Regular National Standard in-services

• Driven by each lead group

• Explained what does ‘National Standards’ and

‘accreditation’ mean for ALL staff

Revision of Governance Structure

> Divisional reporting lines were strengthened

• Nursing, anaesthesia, surgery, CSSD, other depts.

> Meeting groups with clear TOR

> NSQHSS focussed Clinical Leadership

meeting

Next step… Gap Analysis

> Reviewed information packs (available online)

> Assessed each item/action

• Organisational wide?

• Operating Theatre Suite focus?

If OTS, what do we need to do?

Gap Analysis

> NSQHSS Standards Monitoring Tool

• Excel Spreadsheet

> Available online

• http://www.safetyandquality.gov.au

OTS Quality Improvement Plan

> Documented presentation of the improvement

activities being undertaken within the suite

> Ongoing use post-accreditation

Quality Improvement Activities

> Policy, procedure & protocol/guideline review

and endorsement

> Auditing & Reporting

• KPI monitoring

> Risk identification & escalation

Policy, procedure & protocol

> Process of review

• Frequency, risk rating, compliance monitoring

• Policy = SA Health

• Procedure/Protocol = SALHN, FMC or OTS

• ACORN Standards

• Right input, right focus, right people

> Process of endorsement

• Right input, right focus, right people

• Locally endorsed

• FMC or SALHN endorsed

> Upload to the intranet

> Ongoing process…!

Auditing & Reporting

> Who is auditing what, when & where?

• Past audit schedules

• New requirements

> Developed comprehensive audit schedule

• NSQHSS requirements

• SA Health audits

• ACORN Standards

• SALHN or FMC audits

• OTS requirements

Auditing & Reporting

Auditing & Reporting

> Reporting aligned with meeting structure

• Reporting template created

• Actions plans formalised & communicated

What is working well?

What needs changing/improving?

Responsibilities & timeframes

• KPI monitoring

Access & capacity

Clinical performance

> Results focussed

• Accountability

• Clarity

Risk Identification & Escalation

> Risk register

• Human & material resources

• Financial

• Political or Legal

• Service delivery & clinical risks

> OTS (local) risk register

• Managed internally

• Items identified via reporting

mechanisms

• Items escalated as required

> Network (SALHN) risk register

• Managed network wide

Accreditation process

> Robust governance structure

> Systems in place

• Quality Improvement Plan

• Policy & Procedure review

• Auditing & Reporting

• Risk Management

> Collect our evidence for National Standards

• Items & Actions

for each standard

Accreditation process

> Clinical leads for each standard

• Reported updates at Clinical Leadership Meeting

> NSQHSS Standards Monitoring Tool

• Data input & evidence collation

The week of the survey

> Network survey activities

• Organisational meetings for each standard

> Local (OTS) survey activities

• Produced overview presentations for each standard

• Summarised our evidence

• Participated in walkthroughs

• Question & answers

• Showed off our

achievements!

Summary

> Organisational approach

> Everyone must be engaged

• Educational package

• Accreditation awareness

> Review governance systems

> Quality improvement plan

• Policy, procedure, protocols

Review & endorsement processes

• Auditing, reporting and KPI monitoring

> Risk management

> Presented our work during survey/audit

Persevere… success takes effort!

Questions?