swslhd fairfield hospital · in february 2018, the south western sydney local health district (lhd)...

Fairfield Hospital Operational Plan 2018 – 2020

South Western Sydney Local Health District 1

SWSLHD Fairfield Hospital

A Facility of South Western Sydney Local Health District Operational Plan

2018 – 2020

Leading care, healthier communities



Table of Contents Introduction ................................................................................................................................. 3

Map of South Western Sydney Local Health District ................................................................... 4

Values Framework ...................................................................................................................... 5

Community Profile ....................................................................................................................... 6

Facility Profile .............................................................................................................................. 7

Strategic Directions ..................................................................................................................... 8

Operational Plan Reporting and Monitoring Framework .............................................................. 9

SWSLHD Strategic Plan 2018 – 2021 – Applicable Strategies for Fairfield Hospital ................ 9

Fairfield Hospital Specific Initiatives July 2018 – June 2020 .................................................. 27

Appendix – SWSLHD Role Delineation Levels .......................................................................... 32



Introduction In February 2018, the South Western Sydney Local Health District (LHD) Strategic Plan 2018-21 was released, providing the healthcare services a development plan for the District for the next four years. This Strategic Plan forms the basis of aligning all SWSLHD services to achieving the vision of ‘Leading Care, Healthier Communities’. SWSLHD has identified six Strategic Directions to guide the development of the LHD and its services over the next four years:

• Safe Quality Care • A Health Community • Collaborative Partnerships • A Healthcare System for the Future • Our People make a Difference • A Leader in Research and Teaching

The strategic plan is underpinned by the NSW Health CORE values of Collaboration, Openness, Respect and Empowerment, which are the foundation stones for building trust with our local communities. The Fairfield Hospital Operational Plan 2018 - 2020 provides a framework through which the key priorities and strategies articulated in the SWSLHD Strategic Plan 2018 - 2021 will be addressed. The Plan outlines the actions that Fairfield Hospital will take over the next two years to realise the organisational goals and contribute to the achievement of the SWSLHD Vision. Fairfield Hospital is in regular consultation with the District Executive, working on strategies to develop processes to resolve current and future challenges in order to assist service delivery. Fairfield Hospital has identified a number of facility services to be enhanced or developed over the next two years through organisational planning for future growth and sustainability. Fairfield Hospital faces some fundamental challenges in achieving its vision and mission for the local community. The most significant future challenges are:

• the forecasted population growth • sufficient funding for service delivery requirements • recruitment and retainment of the workforce, particularly in an environment of an ageing

workforce, and • infrastructure to support all future demands



Map of South Western Sydney Local Health District



Values Framework



Community Profile



Facility Profile

Fairfield City comprises of 27 suburbs, broadly divided into four areas by Fairfield City Council. The Local Government Area (LGA) is one of seven LGAs covered by the South Western Sydney Local Health District (SWSLHD). (Map 1) Fairfield City is one of the most multicultural LGAs in Australia, with more than half of all residents born overseas (ABS 2016). Fairfield’s population grew by approximately 5.5% between 2011 and 2016. Fairfield Hospital is a 220 bed Major Metropolitan Group B1 hospital located within the SWSLHD. The hospital provides a range of hospital and community based health services commensurate with a level four facility. The majority of services provided at Fairfield Hospital are at role delineation levels 3 and 4 (see Appendix). These include:

• Acute care services in Medicine, Cardiology, surgery, Orthopaedics, Obstetrics, Paediatrics, and Emergency Medicine.

• Sub-acute care in Geriatrics / Rehabilitation, and services through the Ambulatory Care Unit in association with Fairfield Community Health Services as well as an outpatient Renal Dialysis Unit.

The services Fairfield Hospital currently provides include:

• Emergency Medicine • Cardiology • Surgical sub-specialties including General Surgery, Orthopaedics (provided in the

Whitlam Joint Replacement Centre), Gynaecology and Breast Surgery • Medical sub-specialties including General Medicine, Neurology and Renal with other sub-

specialties on consultation • Combined Intensive Care / Coronary Care Unit (ICU/CCU) • Maternity, Special Care Nursery and Paediatrics • Ambulatory Care Unit • Aged Care and Rehabilitation • Imaging – CT, Ultrasound and General Radiography.



Strategic Directions



Operational Plan Reporting and Monitoring Framework

SWSLHD Strategic Plan 2018 – 2021 – Applicable Strategies for Fairfield Hospital

ID

STRA

TEGI

C DI

RECT

ION

KEY

PRIO

RITY

AR

EA

STRATEGY LOCAL ACTIONS TO SUPPORT IMPLEMENTATION OF STRATEGY

LHD

EXEC

UTIV

E SP

ONSO

R (E

LT)

LHD

TIME

FRA

ME

LOCAL LEAD FRF TIME FRAME

Please Note: Rows shaded grey have a LHD Timeframe beyond the life of this plan (i.e. after Jun 2020)

1.1a

Safe,

Qua

lity

Care

Cons

isten

tly

safe

Implement the Safety Essentials program across all facilities and services

Implement Executive Rounding

Dire

ctor C

linica

l Gov

erna

nce

Dec-2

1

General Manager Dec-18

1.1b Facilitate the implementation of Nursing Leader Rounding Director of Nursing & Midwifery Jun-19

1.1c Facilitate the implementation of Medical Services Leader Rounding in Clinical Information, Pharmacy & Radiology

Director of Medical Services Jun-19

1.1d Implement Allied Health Leader Rounding Allied Health Executive Representative Jun-19

1.1e Implement Corporate Services Leader Rounding Director of Corporate Services Jun-19

1.1f Implement Administrative Services Leader Rounding Director of Financial Services Jun-19

1.2a

Safe,

Qua

lity

Care

Cons

isten

tly

safe

Implement the Feeling Safe in the Emergency Department project to enable better care of patients with a mental health condition in Emergency Departments

Learn and implement applicable strategies for Fairfield from the LHD 'Feeling Safe in the Emergency Department' project and other facilities

Dire

ctor N

ursin

g &

Midw

ifery

Dec-1

9

Director of Nursing & Midwifery Dec-19

1.2b Review care plans / escalation pathways for Mental Health patients in the Fairfield Emergency Department to ensure they are effective

Emergency Department Management Team Dec-19



ID

STRA

TEGI

C DI

RECT

ION

KEY

PRIO

RITY

AR

EA


LHD

EXEC

UTIV

E SP

ONSO

R (E

LT)

LHD

TIME

FRA

ME



1.3a

Safe,

Qua

lity

Care

Cons

isten

tly

safe

Develop and implement a Surgical and Procedural Care Plan which identifies the future location of services, expertise and equipment to improve patient safety

Participate in the development of the LHD 'Surgical and Procedural Care Plan'

Dire

ctor O

pera

tions

Jun-

19

General Manager Jun-19

1.3b

Review the LHD 'Surgical and Procedural Care Plan' & identify strategies relevant for FRF to implement Develop and implement an action plan to address any relevant strategies found.


1.3c Facilitate the relocation and review of the Hand Clinic Service Director of Medical Services Jun-20

1.4a

Safe,

Qua

lity

Care

Cons

isten

tly

safe

Expand the use of electronic data management systems such as eMR2 and eMeds prescribing across the District to improve point of care clinical documentation

Implementation of eMR2 and eMeds deferred due to inadequacy of power supply. General Manager to work with LHD Executive to secure adequacy of power

Chief

Infor

matio

n Offic

er

Dec-2

0


1.4b Relevant Clinicians participate in the eMR2 Subject Matter Expertise (SME) meetings for Allied Health when scheduled

Allied Health Managers Jun-20

1.4c Relevant Clinicians participate in the eMR2 /eMeds Subject Matter Expertise (SME) meetings for Medical Officers when scheduled


1.4d Relevant Clinicians participate in the eMR2 /eMeds Subject Matter Expertise meetings for Nursing Services when scheduled

Director of Nursing & Midwifery Jun-20

1.4e Relevant Clinicians participate in the eMR2 /eMeds Subject Matter Expertise meetings for Emergency Department when scheduled

Emergency Department Management Team Jun-20



ID

STRA

TEGI

C DI

RECT

ION

KEY

PRIO

RITY

AR

EA


LHD

EXEC

UTIV

E SP

ONSO

R (E

LT)

LHD

TIME

FRA

ME



1.6a

Safe,

Qua

lity

Care

Outst

andin

g

Quali

ty

Implement the R.E.A.C.H. program across all relevant units to strengthen responsiveness to patient, carer and family concerns about deteriorating patients

Conduct a formal evaluation of the REACH project

Dire

ctor C

linica

l Gov

erna

nce

Dec-2

0

Medical Emergency Team (MET) Coordinator

Jun-19

1.6b Develop and implement an action plan to address the ACHS EQuIPNational recommendation (9.9.3) to "Ensure that action is taken to improve the system for family escalation of care"


Jun-20

1.6c Develop and implement an action plan to address the ACHS EQuIPNational recommendation (9.9.4) to "Periodically review the effectiveness and performance of the system for family escalation of care"


Jun-20

1.6d Implement translated REACH Brochures


Consumer Participation Manager

Jun-19

1.8a

Safe,

Qua

lity

Care

Outst

andin

g

Quali

ty

Expand SWSLHD Centres of Excellence to strengthen clinical care through delivering services linked to research, teaching and education

Strengthen Clinical Care through the introduction of Advance Physician training

Chief

Exe

cutiv

e

Dec-2

1


1.8b Promote the ability for research to be undertaken at Fairfield Hospital


1.8c Strengthen Research Committee including links to Ingham Institute




ID

STRA

TEGI

C DI

RECT

ION

KEY

PRIO

RITY

AR

EA


LHD

EXEC

UTIV

E SP

ONSO

R (E

LT)

LHD

TIME

FRA

ME



1.9

Safe,

Qua

lity

Care

Appr

opria

te

and t

imely

care

Review models of care in Emergency Departments to improve responsiveness to weekend demand and improve consistency of service systems across the District

Review existing models of care for ED and implement a community friendly model of care that reflect the requirements of each redevelopment stage as well as the particular needs of the Fairfield community Di

recto

r Op

erati

ons

Jun-

20

Emergency Department Management Team Jun-20

1.10a

Safe,

Qua

lity

Care

Appr

opria

te an

d tim

ely

care

Invest in new technologies and models of care to reduce waiting time for elective surgery and improve the delivery of high quality, safe clinical care

Review the Surgical Models of Care with a view of implementing new technologies to reduce waiting time. - Hand Clinic

Dire

ctor O

pera

tions

Dec-2

1


1.10b Review the Surgical Models of Care with a view of implementing new technologies to reduce waiting time and improve patient flow for Paediatric patients

Paediatric Management Team Jun-19

1.12a

Safe,

Qua

lity

Care

Appr

opria

te an

d tim

ely ca

re Increase the accessibility of

support provided to people and their families at end of life, including inpatient, community based and bereavement support services

Facilitate the implementation of the CEC End of Life (EOL) Toolkit

Dire

ctor O

pera

tions

Dec-2

1

End of Life Coordinator Jun-19

1.12b Facilitate the refurbishment of the Quiet Room and Viewing Room

Director of Corporate Services Jun-19

1.14

Safe,

Qua

lity C

are

Evide

nce b

ased

an

d pati

ent-c

entre

d ca

re

Implement systems to capture patient reported outcomes in relation to physical and psycho-social needs to inform clinical decision making

Participate in the LHD implementation of a system to capture patient reported outcomes as required.

Dire

ctor C

linica

l Go

vern

ance

Dec-2

1 Patient Liaison Manager Jun-20



ID

STRA

TEGI

C DI

RECT

ION

KEY

PRIO

RITY

AR

EA


LHD

EXEC

UTIV

E SP

ONSO

R (E

LT)

LHD

TIME

FRA

ME



1.15a

Safe,

Qua

lity

Care

Evide

nce b

ased

and p

atien

t-cen

tred c

are

Expand the use of real time consumer experience monitoring systems to improve the way feedback is captured

Implement an interim solutions for real time patient feedback

Dire

ctor C

linica

l Gov

erna

nce

Jun-

18

Patient Liaison Manager Dec-18

1.15b Participate in the LHD expansion of the use of real time consumer experience monitoring systems as required

Patient Liaison Manager Jun-20

1.15c

Review the results of the NSW Health Patient Satisfaction Surveys as they are released Develop and implement an action plan to address any issues found.


1.15d Facilitate Patient Journey Interviews annually Consumer Participation Manager Jul-20

1.15e Relevant Service Manager to develop and implement an action plan to address any issues found in the annual patient journey interview project.

Relevant Service Manager


Jun-20

1.16

Safe,

Qua

lity C

are

Evide

nce b

ased

an

d pati

ent-c

entre

d ca

re Implement the You Say, We Did

program to provide evidence of changes implemented as a result of consumer feedback

Participate in the LHD implementation of "You Say, We Did" program as required

Dire

ctor C

linica

l Go

vern

ance

Jun-

20




ID

STRA

TEGI

C DI

RECT

ION

KEY

PRIO

RITY

AR

EA


LHD

EXEC

UTIV

E SP

ONSO

R (E

LT)

LHD

TIME

FRA

ME



1.17a

Safe,

Qua

lity

Care

Evide

nce b

ased

and

patie

nt-ce

ntred

care

Develop and implement a procedure for open visiting hours in appropriate clinical settings in order to better meet the support needs of patients, families and carers

Participate in the LHD development and implementation of a procedure for open visiting hours as required

Dire

ctor N

ursin

g &

Midw

ifery

Jun-

19

Operational Nurse Manager Jun-19

1.17b Develop initiatives to support ‘Carer friendly hospital’ and 24 hour hospital visiting


1.17c Review of the current 24 hour visiting policy at Fairfield Hospital


1.18

Safe,

Qua

lity

Care

Evide

nce b

ased

and

patie

nt-ce

ntred

care

Invest in the delivery of a broad range of support services which recognise the psycho-social needs of people to achieve and maintain health or recover from injury, with a focus on implementing the Arts and Health Strategic Plan

Activities associated with the SWSLHD Arts and Health Strategic Plan not appropriate for Fairfield Hospital during the life of this operating plan

Dire

ctor A

llied

Healt

h

Dec-2

1 Allied Health Executive Representative N/A

1.19a

Safe,

Qua

lity

Care

Cultu

ral s

afety Improve cultural safety for

people from diverse cultures through offering opportunities for staff to complete Respecting the Difference and other cultural competency training

Maintain a >90% completion rate for 'Respecting the Difference' online module

Dire

ctor W

orkfo

rce

Dec-2

1

Service Managers Jun-20

1.19b Increasing the completion rate for 'Respecting the Difference' face to face session by 20% annually Service Managers Jun-20

1.19c Promote attendance to cultural competency training sessions Human Resources Manager Jun-20

1.19d Service Manager to schedule staff to attend cultural based training sessions. Service Managers Jun-20



ID

STRA

TEGI

C DI

RECT

ION

KEY

PRIO

RITY

AR

EA


LHD

EXEC

UTIV

E SP

ONSO

R (E

LT)

LHD

TIME

FRA

ME



1.20

Safe,

Qua

lity C

are

Cultu

ral s

afety Enhance the Aboriginal Liaison

Officer program across the District to improve the way hospitals meet the needs of Aboriginal people and communities

Identify local strategies; develop and implement an action plan to enhance the Aboriginal Liaison Program at Fairfield Hospital.

Chief

Exe

cutiv

e

Dec-2

1 Social Work Manager Jun-20

1.21a

Safe,

Qua

lity

Care

Acco

untab

ility a

nd

gove

rnan

ce Implement the Enterprise Risk

Management Policy Framework 2017 to further develop risk maturity and reduce exposure to risk

Review self-assessment tool to align the tool to the SWSLHD Enterprise Risk Management Policy Framework 2017

Chief

Exe

cutiv

e

Jun-

21

Quality & Accreditation Manager Dec-18

1.21b

Complete the ERM Self-Assessment tool to identify any areas to action Develop and implement an action plan to address any issues found.

Quality & Accreditation Manager Jun-20

1.22

Safe,

Qua

lity

Care

Acco

untab

ility

and g

over

nanc

e Review the capabilities of the Risk Management Information System to determine suitability to meet future risk management, clinical governance and internal audit requirements

Participate in the LHD 'Risk Management Information System' Working party as required

Chief

Exe

cutiv

e

Jun-

19




ID

STRA

TEGI

C DI

RECT

ION

KEY

PRIO

RITY

AR

EA


LHD

EXEC

UTIV

E SP

ONSO

R (E

LT)

LHD

TIME

FRA

ME



1.23

Safe,

Qua

lity

Care

Acco

untab

ility

and g

over

nanc

e Implement the Legislative Compliance Policy Framework 2017 to ensure processes are in place to support and enhance staff awareness of statutory and organisational reporting requirements

Review the 'Legislative Compliance Policy Framework' for Fairfield Hospital to ensure alignment with the LHD framework Develop and implement an action plan to address any issues found. Ch

ief E

xecu

tive

Dec-2

0 General Manager Jun-20

1.24

Safe,

Qua

lity

Care

Acco

untab

ility

and g

over

nanc

e Embed a District-wide Policy Framework to ensure the development and implementation of consistent policies, procedures and guidelines across all facilities and services

Review the 'Policy and Procedure Framework' for Fairfield Hospital to ensure alignment with the LHD framework Develop and implement an action plan to address any issues found. Ch

ief E

xecu

tive

Dec-2

0 Quality & Accreditation Manager Jun-19

2.30

A He

althy

Co

mmun

ity

Prev

entio

n and

early

int

erve

ntion

Implement the Child Protection in Your Hands Strategy to support staff to identify the caring responsibilities of adult patients and incorporate stressors and risk issues in care planning to improve child safety

Review current process to ensure they are aligned to the "Child Protection in Your Hands Strategy" Develop and implement an action plan to address any strategies found. Di

recto

r Clin

ical

Gove

rnan

ce

Dec-2

1 Social Work Manager Jun-19



ID

STRA

TEGI

C DI

RECT

ION

KEY

PRIO

RITY

AR

EA


LHD

EXEC

UTIV

E SP

ONSO

R (E

LT)

LHD

TIME

FRA

ME



2.31

A He

althy

C

ommu

nity

Prev

entio

n and

ea

rly in

terve

ntion

Collaboratively implement the SWS Childhood Overweight and Obesity Action Plan 'Growing Healthy Kids'

Review current process to ensure they are aligned to the "SWS Childhood Overweight and Obesity Action Plan 'Growing Healthy Kids'" Develop and implement an action plan to address any issues found.

Dire

ctor

Popu

lation

Hea

lth

Dec-2

1 Paediatric Management Team Jun-19

2.32a

A He

althy

Co

mmun

ity

Prev

entio

n and

early

inter

venti

on

Embed into clinical practice the identification of modifiable risk factors and referral to appropriate support services, with an initial focus on smoking and high body mass index

Organise and conduct education sessions regarding various modifiable risk factors to staff

Dire

ctor O

pera

tions

Dec-2

1

Work Health Safety Manager Jun-20

2.32b Partnering with various Health Promotion programs to facilitate embedding the programs into clinical practice.

Allied Health Executive Representative Jun-20

2.32c Partnering with various Health Promotion programs to facilitate embedding the programs into clinical practice.


2.32d Partnering with various Health Promotion programs to facilitate embedding the programs into clinical practice.


2.32e Review Grand Rounds to increase attendance of Medical Officers.


2.35

A He

althy

Co

mmun

ity

Prev

entio

n and

ea

rly in

terve

ntion

Develop an integrated network of drug and alcohol treatment intervention services to reduce the harm from substance use and increase access to treatment

Explore opportunities to develop further drug & alcohol network services with the Emergency Department and with Women's and Children's Services Di

recto

r Op

erati

ons

Dec-2

1

Director of Nursing & Midwifery

Director of Medical Services

Jun-20



ID

STRA

TEGI

C DI

RECT

ION

KEY

PRIO

RITY

AR

EA


LHD

EXEC

UTIV

E SP

ONSO

R (E

LT)

LHD

TIME

FRA

ME



3.44a

Colla

bora

tive

Partn

ersh

ips

Cons

umer

, pati

ent

and c

arer

inv

olvem

ent

Increase the number and diversity of people participating in formal Consumer and Community Participation processes to better represent the views of the local community

Identifying existing CALD community groups and reaching out to facilitate consumer consultation.

Chief

Exe

cutiv

e

Jun-

18

Consumer Participation Manager Jun-18

3.44b Promote the Fairfield Hospital Community Participation (CP) Network to increase membership

Consumer Participation Manager Jun-20

3.45a

Colla

bora

tive

Pa

rtner

ships

Cons

umer

, pati

ent a

nd ca

rer

involv

emen

t Increase the involvement of children and young people as partners in care, consistent with the Charter on the Rights of Children and Young People in Healthcare Services in Australia

Implement the Bedside Communication Patient Boards in Ward 1C Paediatrics

Dire

ctor C

linica

l Gov

erna

nce

Dec-2

1

Nurse Unit Manager: Paediatrics Dec-18

3.45b Implement the Paediatric 'Passport of Care' in Ward 1C Paediatrics

Nurse Unit Manager: Paediatrics Dec-18

3.45c Implement 'Family Integrated Care" in Special Care Nursery Paediatric Management Team Jun-20

3.45d Implement the HEADDS Assessment protocol Paediatric Management Team Jun-20

3.46

Colla

bora

tive

Partn

ersh

ips

Cons

umer

, pati

ent

and c

arer

inv

olvem

ent Build staff capacity to

understand and initiate consumer participation approaches to their clinical and non-clinical practice

Establish a staff training program to increase their understanding of consumer participation.

Chief

Exe

cutiv

e

Dec-2

1 Consumer Participation Manager Jun-19



ID

STRA

TEGI

C DI

RECT

ION

KEY

PRIO

RITY

AR

EA


LHD

EXEC

UTIV

E SP

ONSO

R (E

LT)

LHD

TIME

FRA

ME



3.48a

Colla

bora

tive

Pa

rtner

ships

Genu

ine en

gage

ment

and c

ommu

nicati

on

Implement a core District wide communication program to support effective communication with patients and staff

Implement CORE Chat

Dire

ctor W

orkfo

rce

Dec-2

0


3.48b Implement Nursing Patient Leader Rounding Director of Nursing & Midwifery Dec-19

3.48c Implement Medical Patient Leader Rounding Director of Medical Services Dec-19

3.48d Implement Allied Health Patient Leader Rounding Allied Health Executive Representative Dec-19

3.48e Implement Administrative Services Patient Leader Rounding Director of Financial Services Dec-19

3.52

Colla

bora

tive

Pa

rtner

ships

Stra

tegic

partn

ersh

ips

Build on partnerships with the NSW Ambulance Extended Care Paramedic Program

Implement a regular meeting with the Ambulance Liaison Manager and the ED Management Team. Di

recto

r Op

erati

ons

Dec-2

1 Emergency Department Management Team Dec-18

3.56

Colla

bora

tive

Pa

rtner

ships

Stra

tegic

partn

ersh

ips Establish innovative

partnerships models with the private sector to reduce the cost of providing and replacing high end technology

Participate in the SWSLHD Fundraising Steering Committee Facilitate fundraising activities as required.

Dire

ctor F

inanc

e

Dec-2

1

Director of Financial Services


Jun-20



ID

STRA

TEGI

C DI

RECT

ION

KEY

PRIO

RITY

AR

EA


LHD

EXEC

UTIV

E SP

ONSO

R (E

LT)

LHD

TIME

FRA

ME



3.57

Colla

bora

tive

Pa

rtner

ships

Fund

ing

oppo

rtunit

ies

Widely promote South West Giving to facilitate fundraising from the local community, consumers and staff

Introduce 'South West Giving' promotional activities to Fairfield event days.

Chief

Exe

cutiv

e

Dec-2

1 Director of Financial Services Jun-20

4.65a

A He

althc

are

Syste

m

for th

e Futu

re

Build

ing an

d ada

pting

for

the f

uture

Progress planning for the redevelopment of Bankstown-Lidcombe and Fairfield Hospitals and community health facilities across the District to ensure capacity to meet increasing demand

Participate in SWSLHD Redevelopment Planning meetings

Chief

Exe

cutiv

e

Dec-2

1


4.65b Facilitate the redevelopment of the Emergency Department and building of a new Medical Assessment Unit (MAU) / Emergency Short Stay Unit (ESSU)


4.68a

A He

althc

are

Syste

m

for th

e Futu

re

Build

ing an

d ada

pting

for t

he fu

ture

Implement existing plans addressing future healthcare development, including the SWSLHD Cancer Plan and SWSLHD Advance Care Planning, End of Life and Palliative Care Plan

Review the SWSLHD SWSLHD Advance Care Planning, End of Life and Palliative Care Plan to identify the gaps at Fairfield Hospital.Develop and implement an action plan to address any gaps found.

Dire

ctor O

pera

tions

Dec-2

1

End of Life Coordinator Jun-20

4.68b

Review the SWSLHD Disability and Carers Strategy 2017-2022 to identify the gaps at Fairfield Hospital. Develop and implement an action plan to address any gaps found.

Chairperson - Disability Committee Jun-20

4.68c

Review the Implementation of the 'ACI Framework: Building capability in NSW Health services for people with intellectual disability: the Essentials' to identify the gaps at Fairfield Hospital. Develop and implement an action plan to address any gaps found.

Social Work Manager Jun-20



ID

STRA

TEGI

C DI

RECT

ION

KEY

PRIO

RITY

AR

EA


LHD

EXEC

UTIV

E SP

ONSO

R (E

LT)

LHD

TIME

FRA

ME



4.69

A He

althc

are

Syste

m for

the

Futur

e Bu

ilding

and

adap

ting

for th

e futu

re

Expand existing Wi-Fi capability and incorporate digital readiness into new health care facilities

Facilitate the installation of WIFI infrastructure

Chief

Infor

matio

n Of

ficer

Dec-2

1 Director of Corporate Services Jun-20

4.72a

A He

althc

are

Syste

m

for th

e Futu

re

Netw

orke

d and

integ

rated

se

rvice

s

Develop Emergency Department avoidance strategies in collaboration with the residential aged care and primary health sector to improve community based management of chronic disease and end of life care

Introduce a Fairfield Hospital Geriatric Flying Squad program to support the local Residential Aged Care Facilities.

Dire

ctor O

pera

tions

Dec-2

1


4.72b Establish the Clinical Variation committee to identify potential preventable hospital admission

Director of Financial Services Dec-19

4.72c Investigate enhancing the model of care for Allied Health Services in the Ambulatory Care Unit and the Emergency Department.


4.73

A He

althc

are

Syste

m for

the

Futur

e

Netw

orke

d and

int

egra

ted se

rvice

s

Extend the hours of operation of designated ambulatory services to improve access and flexibility to meet consumer needs

Explore opportunities to extend hours of operation of the ambulatory care services Di

recto

r Op

erati

ons

Dec-2

1


Head of Department: Ambulatory Care

Jun-20

4.74

A He

althc

are

Syste

m

for th

e Futu

re

Netw

orke

d and

integ

rated

se

rvice

s

Increase access to acute or post-acute services delivered in community or ambulatory settings to provide more accessible services to the community and reduce the need for Emergency Department presentations and inpatient admissions

Explore opportunities to increase access to acute or post-acute services delivered in the ambulatory care settings

Dire

ctor O

pera

tions

Dec-2

1


Head of Department: Ambulatory Care

Jun-20



ID

STRA

TEGI

C DI

RECT

ION

KEY

PRIO

RITY

AR

EA


LHD

EXEC

UTIV

E SP

ONSO

R (E

LT)

LHD

TIME

FRA

ME



4.76a

A He

althc

are

Syste

m

for th

e Futu

re

Agile

and i

nnov

ative

care

Implement evidence based models of care in priority clinical areas identified through the Leading Better Value Care initiative to improve health outcomes, improve the experience of care and provide efficient and effective care

Participate in 'Leading Better Value Care' Collaborative for Falls

Dire

ctor F

inanc

e

Jun-

19

Clinical Nurse Consultant: ASET Jun-20

4.76b Participate in 'Leading Better Value Care' Collaborative for 3rd & 4th Degree tears in Maternity patients

Nurse Manager: Midwifery Services Jun-20

4.80

A He

althc

are

Syste

m

for th

e Futu

re

Resp

onsiv

e to

comm

unity

div

ersit

y

Grow the use of telehealth models of care to support people living in rural areas of the District and beyond to access specialist expertise

Ensure that Model of Care Reviews consider and incorporate the use of telehealth modalities. Ch

ief

Infor

matio

n Of

ficer

Dec-2

1 General Manager Jun-20

4.83a

A He

althc

are

Syste

m for

the

Futur

e

Resp

onsiv

e to c

ommu

nity

diver

sity

Develop services to provide improved access, care coordination and self-management of chronic and complex conditions, with a focus on clients from a CALD background

Participate in the LHD implementation of the 'Integrated Care for People with Chronic Conditions' (ICPCC) Model of Care.

Dire

ctor O

pera

tions

Dec-2

1


4.83b Review the LHD 'ICPCC Model of Care Implementation Plan' & identify strategies relevant for FRF to implement Develop and implement an action plan to address any relevant strategies found.


4.83c Incorporate Interpreters into joint replacement and post-op review outpatient clinics

Physiotherapy Managers Jun-20



ID

STRA

TEGI

C DI

RECT

ION

KEY

PRIO

RITY

AR

EA


LHD

EXEC

UTIV

E SP

ONSO

R (E

LT)

LHD

TIME

FRA

ME



5.87a

Our P

eople

Mak

e a D

iffere

nce

Wor

kforce

for t

he fu

ture

Strengthen the professional development review process and increase uptake of professional development plans to support staff to achieve their career goals and meet the needs of the community

Maintain a >90%compliance for PDRs

Dire

ctor W

orkfo

rce

Dec-1

8


5.87b Maintain a >90%compliance for PDRs Director of Nursing & Midwifery Jun-20

5.87c Maintain a >90%compliance for PDRs Director of Medical Services Jun-20

5.87d Maintain a >90%compliance for PDRs Allied Health Executive Representative Jun-20

5.87e Maintain a >90%compliance for PDRs Director of Corporate Services Jun-20

5.87f Maintain a >90%compliance for PDRs Director of Financial Services Jun-20

5.87g

Performance review processes are reviewed to ensure alignment to the LHD processes Develop and implement an action plan to address any issues found.

Human Resources Manager Jun-20

5.88

Our P

eople

Ma

ke a

Diffe

renc

e

Wor

kforce

for

the fu

ture

Build the Nurse Practitioner workforce across hospital and community settings to provide more timely and responsive expert clinical care

Explore the opportunities for building the Nurse Practitioner workforce at Fairfield Hospital as they arise. Di

recto

r Nu

rsing

&

Midw

ifery

Jun-

20




ID

STRA

TEGI

C DI

RECT

ION

KEY

PRIO

RITY

AR

EA


LHD

EXEC

UTIV

E SP

ONSO

R (E

LT)

LHD

TIME

FRA

ME



5.89a

Our P

eople

Mak

e a D

iffere

nce

Wor

kforce

for

the f

uture

Develop a SWSLHD Volunteer Program to coordinate the engagement and support of volunteers

Review the current processes of volunteer engagement and support

Dire

ctor W

orkfo

rce

Dec-2

0

Human Resources Manager Jun-19

5.89b Develop and Implement a palliative care volunteer program End of Life Coordinator Jun-19

5.91a

Our P

eople

Mak

e

a Diffe

renc

e

Cultu

re of

resp

ect a

nd co

mpas

sion

Review the SWSLHD On-Boarding Program to ensure alignment with Transforming Your Experience

Facilitate the local 'onboarding' program for new employees

Dire

ctor W

orkfo

rce

Dec-1

8

Human Resources Manager Dec-18

5.91b Monitor local compliance to the 'on boarding' program Human Resources Manager Dec-18

5.91c Develop an onboarding 'People Management' checklist for new Service Managers

Human Resources Manager Jan-19

5.91d Develop an onboarding 'Quality & Safety' checklist for new Service Managers

Quality & Accreditation Manager Dec-18

5.92a

Our P

eople

Mak

e a D

iffere

nce

Cultu

re of

resp

ect a

nd

comp

assio

n Develop and implement a District wide coaching and mentoring program to support staff development

Encourage nursing staff to access and complete TYE leadership modules

Dire

ctor W

orkfo

rce

Jun-

20


5.92b Review the pre-employment Orientation program (basic skills) for New RN Graduates employed at Fairfield Hospital

Operational Nurse Manager Jun-19

5.92c Ensure all Visiting Medical Officers & Staff Specialist have completed Clinical Supervision Training for Medical Officers


5.92e Ensure all AH Managers have completed the Clinical Supervision Training for Allied Health




ID

STRA

TEGI

C DI

RECT

ION

KEY

PRIO

RITY

AR

EA


LHD

EXEC

UTIV

E SP

ONSO

R (E

LT)

LHD

TIME

FRA

ME



5.94

Our P

eople

Mak

e a D

iffere

nce

Emplo

yer o

f ch

oice

Develop and implement a SWSLHD Workplace Safety and Wellbeing Program to support the physical, mental and emotional health and wellbeing of staff

Facilitate the Fairfield Hospital Staff Bounce Back program to promote a healthy work-life balance while integrating various health promotion activities.

Dire

ctor W

orkfo

rce

Jun-

20


6.11a

A Le

ader

in R

esea

rch an

d Tea

ching

Ackn

owled

geme

nt an

d rec

ognit

ion of

rese

arch

Expand the research profile of SWSLHD through the establishment of new research institutes in priority areas including Robotics and Automation in Health, Innovation in Medical Technology, Cancer and Cardiovascular Disease and strengthen the roles of existing Research Institutes

Participate in the LHD expansion of the SWSLHD research profile as required.

Chief

Exe

cutiv

e

Jun-

20


6.11b Participate in relevant research projects as required. Director of Medical Services Jun-20

6.11c Participate in relevant research projects as required. Director of Nursing & Midwifery Jun-20

6.11d Participate in relevant research projects as required. Allied Health Executive Representative Jun-20

6.11e Support staff to develop their research skills through education and research activities.


6.11f Support staff to develop their research skills through education and research activities.


6.11g Support staff to develop their research skills through education and research activities.




ID

STRA

TEGI

C DI

RECT

ION

KEY

PRIO

RITY

AR

EA


LHD

EXEC

UTIV

E SP

ONSO

R (E

LT)

LHD

TIME

FRA

ME



6.113a

A Le

ader

in R

esea

rch an

d Te

achin

g

Conti

nuou

s edu

catio

n, tea

ching

and t

raini

ng

Investigate opportunities to increase the number of undergraduate student placements and post graduate fellows across all disciplines

Explore opportunities to recruit undergraduate nursing and midwifery students as casual pool AINs

Dire

ctor W

orkfo

rce

Dec-1

9


6.113b Explore the potential to increase the number of Medical Students that are placed at Fairfield Hospital.


6.113c Implementation of Student Led Allied Health Models of Care Allied Health Executive Representative Jun-20



Fairfield Hospital Specific Initiatives July 2018 – June 2020

ID ST

RATE

GIC

DIRE

CTIO

N

KEY

PRIO

RITY

AR

EA

STRATEGY ACTIONS TO SUPPORT IMPLEMENTATION OF STRATEGY

FACILITY EXECUTIVE SPONSOR

LOCAL LEAD FRF TIME

FRAME

FRF 1.1

Safe,

Qua

lity

Care

Cons

isten

tly

Safe

Ensure the provision of safe quality Maternity Services

Finalise the implementation of the Maternity Risk action plan, developed in liaison with the Clinical Excellence Commission.



General Manager

Nurse Manager: Maternity Services Jun-20

FRF 1.2

Safe,

Qua

lity

Care

Cons

isten

tly

Safe

Medication Safety Standard Action item 4.8.1: "Current medicines are documented and reconciled at admission and transfer of care between healthcare settings"

Develop an action plan to address the ACHS EQuIPNational recommendation to "Provide evidence to demonstrate that current medications are documented and reconciled at admission and transfer of care between healthcare settings"


Director of Pharmacy Jun-20

FRF 1.3

Safe,

Qua

lity

Care

Cons

isten

tly

Safe

Clinical Handover Standard Action 6.3.2: "Local processes for clinical handover are reviewed in collaboration with clinicians, patients and carers"

Develop an action plan to address the ACHS EQuIPNational recommendation to "Ensure that local processes for clinical handover are reviewed in collaboration with clinicians, patients and carers"



Patient Safety Manager Jun-20

FRF 1.4

Safe,

Qua

lity

Care

Cons

isten

tly

Safe

Clinical Handover Standard Action 6.5.1: "Mechanisms to involve a patient and, where relevant, their carer in clinical handover are in use"

Develop an action plan to address the ACHS EQuIPNational recommendation to "Ensure that mechanisms are in use to involve the patient, and where relevant their carer, in clinical handover"






ID

STRA

TEGI

C DI

RECT

ION

KEY

PRIO

RITY

AR

EA



LOCAL LEAD FRF TIME

FRAME

FRF 1.5a

Safe,

Qua

lity

Care

Cons

isten

tly

Safe

Evaluate the use of the “Sepsis Pathway” to improve recognition and management of severe infection and sepsis

Evaluate the use of the ED, Maternity & inpatient pathways. Develop an action plan to address any issues found in the evaluation.

General Manager


FRF 1.5b Ensure the Sepsis database data is current and up to date General

Manager Patient Safety

Manager Jun-20

FRF 1.6

Safe,

Qua

lity

Care

Cons

isten

tly

Safe

Improve the Safety & Quality Culture within Fairfield Hospital

Develop and implement an Action Plan to the results of the Safety & Quality Culture Survey conducted in November 2017 and the subsequent focus groups held in the first half of 2018.

General Manager

Fairfield ‘Transforming Your Experience’ (TYE)

Coach Jun-20

FRF 1.7a

Safe,

Qua

lity

Care

Cons

isten

tly

Safe

Develop web-based information about resources available to staff to ensure the delivery of

Safe Quality Care

Develop Quality & Safety Websites General Manager


FRF 1.7b Develop a Nursing & Midwifery website Director of

Nursing & Midwifery Operational

Nurse Manager Jun-20

FRF 1.8

Safe,

Qua

lity

Care

Appr

opria

te

and t

imely

care

Review, develop and implement Models of Care - Diabetes

Review the Diabetes Models of Care with a view of implementing new technologies to facilitate appropriate and timely care

Operational Nurse Manager Project Lead Jun-20

FRF 1.9

Safe,

Qua

lity

Care

Appr

opria

te an

d tim

ely ca

re

Review, develop and implement Models of Care - Intensive Care Services:

In conjunction with NSW Agency for Clinical Innovation implement the Intensive Care Service Model of Care


Director of Intensive Care

Nurse Unit Manager: ICU/CCU

Jun-20

FRF 1.10

Safe,

Qua

lity

Care

Appr

opria

te

and t

imely

care

Review the local governance structure for the Antimicrobial Stewardship Program

Engage with local Medical Teams to ensure antibiotics are prescribed appropriately


Staff Specialist: Medicine Jun-20



ID

STRA

TEGI

C DI

RECT

ION

KEY

PRIO

RITY

AR

EA



LOCAL LEAD FRF TIME

FRAME

FRF 1.11

Safe,

Qua

lity C

are

Acco

untab

ility

& Go

vern

ance

Embed the Performance Framework processes into operational activity

Document the performance framework at Fairfield Hospital identifying the Managers and committees responsible for reviewing the KPIs within the framework

General Manager


FRF 1.12a

Safe,

Qua

lity C

are

Acco

untab

ility

& Go

vern

ance

Meet National Patient Safety and Quality Standards through participation in external accreditation schemes and quality processes

Develop and implemented an action plan to translate to version 2 of the NSQHS Standards

General Manager


FRF 1.13b

Participate in the ACHS EQuIP National Accreditation Program Develop and implement an Action Plan to address any recommendations received.

General Manager


FRF 1.14a

Safe,

Qua

lity C

are

Acco

untab

ility

& Go

vern

ance

Embed governance structures and arrangements into day to day operation

Review Organisational Committees Structure and Governance

General Manager

Director of Corporate Services

Quality & Accreditation Manager

Dec-18

FRF 1.14b

Review Organisational Committees’ terms of references (TOR) and agendas to ensure that - The committee’s “Risk Management” responsibilities are outlined on their TOR- “Risk Management” is a standing agenda item.- That all KPIs associated with the committee’s risk profile are outlined on the agenda.

General Manager


FRF 1.15

Safe,

Qua

lity C

are

Acco

untab

ility

& Go

vern

ance

Review functions of local Clinical Governance Unit

Participate in the SWSLHD Clinical Governance Review Project Develop and implement an action plan to address any relevant strategies relevant to Fairfield

General Manager




ID

STRA

TEGI

C DI

RECT

ION

KEY

PRIO

RITY

AR

EA



LOCAL LEAD FRF TIME

FRAME

FRF 1.16

Safe,

Qua

lity C

are

Acco

untab

ility

& Go

vern

ance

Ensure Fairfield Executive understand their responsibilities and accountabilities regarding the audit management process

Define the Executive responsibilities and accountabilities General Manager


FRF 1.17

Safe,

Qua

lity C

are

Acco

untab

ility

& Go

vern

ance

Implement a comprehensive rolling program of audit and implement the recommendations

Review the audit system (clinical / non clinical) to ensure the audits effectively monitor recognised facility risks and services Participate in the SWSLHD development of an electronic audit tool application. Implement the SWSLHD electronic audit tool when developed.

General Manager


FRF 1.18a

Safe,

Qua

lity C

are

Acco

untab

ility

& Go

vern

ance

Develop the management and decision making skills of the Executive

Ensure Fairfield Executive understand their responsibilities and accountabilities regarding the audit management process General

Manager


FRF 1.18b

Develop and monitor the Orientation / Mentoring Framework for Executive on Call


FRF 2.1

A He

althy

Co

mmun

ity

Safe,

healt

hy

envir

onme

nts

Strengthen preparedness to respond to major incidents, disasters and health emergencies

Review the facility Disaster PlanReview of any incidents that results in activation of the plan



FRF 2.2

A He

althy

Co

mmun

ity

Safe,

healt

hy

envir

onme

nts Meet Work Health Safety

Obligations as outlined in the relevant legislation participation in the LHD WHS Audit processes

Participate in the WHS Audit every 2 years Develop and implement an Action Plan to address any recommendations received.





ID

STRA

TEGI

C DI

RECT

ION

KEY

PRIO

RITY

AR

EA



LOCAL LEAD FRF TIME

FRAME

FRF 2.3

A He

althy

Co

mmun

ity

Safe,

healt

hy

envir

onme

nts

Develop and implement an Asset Maintenance, Replacement and Disposal Program

Review local amenities and infrastructure for replacement (such as chairs, commodes etc.) Develop and implement an action plan to instigate the replacement program at Fairfield Hospital

General Manager


FRF 3.1

Colla

bora

tive

Partn

ersh

ips

Stra

tegic

Partn

ersh

ips Work in partnerships with other

Health Services located on the Fairfield Hospital Campus to share infrastructure and corporate resources.

Explore the feasibility to share infrastructure and corporate resources with other Health Services located on the Fairfield Hospital Campus, i.e. Braeside Hospital, Drug & Alcohol Services and Dental Services.

General Manager


FRF 4.1

A He

althc

are

Syste

m

for th

e Futu

re

Resp

onsiv

e to

Comm

unity

Di

versi

ty Invest in new technologies to assist our community to find their way when visiting the facility

Explore the feasibility to implement electronic 'Way finding' modalities.

General Manager




Appendix – SWSLHD Role Delineation Levels

Service B’town Lidcombe Bowral Braeside Camden Campbell

town Fairfield Liverpool

Core Services

Anaesthetics and Recovery 5 3 NPS 1 5 3 6 Operating Suites 5 3 NPS 1 5 3 6 Close Observation Unit NPS 3 NPS NPS NPS NPS NPS Intensive Care 5 NPS NPS NPS 5 4 6 Nuclear Medicine 5 4 4 4 4 4 6 Radiology / Interventional 5 4 4 3 5 3 6 Pathology 5 3 4 2 5 4 6 Pharmacy 5 3 4 4 5 4 6

Clinical Services ED Emergency Medicine 5 3 NPS 2 5 3 6

Medi

cine

Cardiology / Interventional 4 3 NPS NPS 4 3 6 Clinical Genetics NPS NPS NPS NPS NPS NPS 6 Dermatology 3 3 NPS NPS 3 NPS 6 Endocrinology 5 3 NPS NPS 5 3 6 Gastroenterology 6 3 NPS NPS 5 3 6 General and Acute Medicine 6 3 NPS NPS 5 3 6 Geriatric Medicine 6 4 NPS NPS 5 3 5 Haematology 3 NPS NPS NPS 3 NPS 6 Immunology 4 2 NPS NPS 5 NPS 6 Infectious Diseases 5 2 NPS NPS 5 2 6 Neurology 5 3 NPS NPS 5 3 6 Medical Oncology 5 3 NPS NPS 5 1 6 Radiation Oncology 4 NPS NPS NPS 5 NPS 6 Palliative care 3 3 6 6 3 3 6 Rehabilitation 5 2 6 5 2 4 6 Renal Medicine 5 2 NPS NPS 4 3 6 Respiratory and Sleep Medicine 5 3 NPS NPS 5 3 6 Rheumatology 5 2 NPS NPS 5 2 6 Sexual Assault Services 3 1 NPS NPS 3 1 4 Sexual Health and HIV Medicine NPS 1 NPS NPS 2 NPS 4

Surg

ery

Burns 2 2 NPS NPS 2 2 4 Cardiothoracic Surgery NPS NPS NPS NPS NPS NPS 6 Ear, Nose and Throat 5 NPS NPS NPS 4 NPS 6 General Surgery 5 3 NPS NPS 4 3 6 Gynaecology 5 3 NPS NPS 5 3 6 Neurosurgery 4 NPS NPS NPS NPS NPS 6 Ophthalmology 5 3 NPS NPS 3 NPS 6 Oral health 3 3 NPS 3 3 3 5 Orthopaedic Surgery 5 3 NPS NPS 5 3 6 Plastic Surgery 5 NPS NPS NPS NPS NPS 6 Urology 5 NPS NPS NPS 5 NPS 6 Vascular Surgery 4 NPS NPS NPS NPS NPS 6



Service B’stown

Lidcombe Bowral Braeside Camden Campbell town Fairfield Liverpool

Child

and

fam

ily H

ealth

Se

rvice

s Child and Family Health 4 2 NPS 5 5 5 6 Child Protection Services 3 3 NPS 1 4 4 4 Maternity 4 3 NPS 1 4 3 6 Neonatal 3 2 NPS NPS 3 3 5 Paediatric Medicine 4 3 NPS NPS 5 3 4 Surgery for Children 3 2 NPS 2 3 3 4 Youth Health 4 2 NPS NPS 4 3 4

Ment

al He

alth

and

Drug

and

Alco

hol

Serv

ices

Child/Adolescent Mental Health (I/P) 3 NPS NPS NPS 5 NPS 3

Child/Adolescent Mental Health (Community) 3 3 NPS NPS 3 3 4

Adult Mental Health (Inpatient) 5 1 NPS NPS 5 NPS 5

Adult Mental Health (Community) 4 4 NPS NPS 4 4 4

Older Adult Mental Health (I/P) 2 NPS 2 NPS NPS NPS 1

Older Adult Mental Health (Community) 4 2 2 3 2 2 4

Drug and Alcohol Services 6 4 NPS 3 6 6 6

Com

mun

ity

Base

d

Aboriginal Health 4 2 2 4 4 4 6

Community Health 4 4 NPS 4 4 4 4

Notes:

• NPS - No Planned Service • Role delineation levels are guided by NSW Health Guide to the Role Delineation of

Clinical Services 2018 accessible via https://www.health.nsw.gov.au/services/Publications/role-delineation-of-clinical-services.PDF

• Role delineation levels may be updated in line with 2018 review.

https://www.health.nsw.gov.au/services/Publications/role-delineation-of-clinical-services.PDF

https://www.health.nsw.gov.au/services/Publications/role-delineation-of-clinical-services.PDF

swslhd fairfield hospital · in february 2018, the south western sydney local health district (lhd)...

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