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(1) RN, Renal Nursing Cert Occupational Health & Safety Nursing Cert
BN, GradDipPublic Health, Quality Coordinator, Sacred Heart Hospice
(2) RN, Cm, Cardothoracic Cert, BNAdmin, Quality Coordinator, St Vincent's
Private Hospital
(3) RN, CM, Oncology Cert, BN, Director of Nursing, Jean Colvin Hospital
[Abstract] [Jean Colvin Hospital] [St Vincent's Private Hospital] [The Sacred Heart Hospice] [References]
This paper will provide an overview of the successful transformation of organisational culture for three different facilities in metropolitan Sydney which have implemented EQuIP EQuIP was launched in mid 1996 by the Australian Council on Healthcare Standards. EQuIP provides health care organisations with the mane~ tools needed to focus on continuous quality improvement.
Two of the organisations were pilot sites for EQuIP and the other was the first organisation to be accredited with the Palliative Care guidelines in conjunction with EQuIP. The aim of the paper is to provide an opportunity to share the formal and informal experiences of each organisation. Discussion of the more conventional aspects of implementing EQuIP in an organisation will be outlined.
Consideration will also be given to the 'hidden' approaches which are not readily found in the guidelines or manuals. The elusive approaches that are central to the accreditation process, will be explored, in order to provide invaluable lessons for others embarking on the same journey. The problems and highlights encountered on the quality journey, will be outlined and the various strategies utilised to address problems arising will be discussed.
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The implementation of EQuIP at Jean Colvin Hospital (JCH), a 37 bed private charitable hospital for cancer patients, located in Darling Point Sydney, was the first hospital to be surveyed under this new program.
In 1994 the Charter for Change was announced by the Australian Council on Healthcare Standards (ACHS) and the previous management of JCH embraced the new concepts and ideas endorsed by the Charter. However, it was not until 1995 that the pilot network, a consultative group which included health care industry representatives was formed and the ACHS pilot network project was up and running. The program that was derived from the Charter for Change became known as EQuIP.
JCH was one of the pilot organisations and as such was involved in the trial and refinement of the standards. One of the exercises was a mock accreditation survey. This took place in February 1996 and was just two months after the Director of Nursing 1 Manager started at JCH. Prior to her commencement with the hospital, the Board had made the decision to employ a consultant to help the hospital prepare for accreditation and assist with the transition from the old standards to the new standards.
Whilst this was an extremely costly exercise it was very beneficial for the integration of the new standards into the hospital culture. The focus of the consultant and management at this time was on the education of the staff about the new standards and the fundamental role of the Improving Performance Standard. Whilst staff knew what quality improvement was, and were involved in it, our vision was for them to adopt it as a culture of continually improving and changing with a focus on customer satisfaction. The new standards guided our development of this philosophy.
Three functions of EQuIP were surveyed at the time of the mock survey. It was a great learning experience for our team and everyone took it very seriously. The trial run not only helped our team to prepare for the real survey but we also received the advice and guidance from the three expert surveyors which was invaluable to our preparation for the real survey which was to be held in June 1996.
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For both surveys our approach was to present. to the surveyors how we achieved each standard. These presentations were of a formal nature and facilitated by the staff involved with each standard. After the presentation the staff were available to answer questions and also for group discussion. The presentations were followed by a process of validation conducted by the surveyor.
As JCH is a small hospital most staff were able to be involved in the presentation process. Each department presented to the surveyors and the enthusiasm, dedication and involvement by all staff was obvious. This type of team involvement was not possible with the old ACHS survey system.
EQuIP has provided a framework to guide us with continually improving the services provided. The many benefits to the organisation include:
However, in our experience, the implementation of EQuIP is not without costs. For a small organisation the extra workload is considerable because it can not be easily distributed or devolved.
The recent completion of the self assessment tool required a collaborative effort and took approximately 40 hours of input by the staff over a five week period. To maintain organisational momentum with EQuIP requires a large commitment from management and also the Board.
Another considerable cost is the enrolment fee, which is payable on a yearly basis rather than every three years, as with the old system. This fee can create financial difficulties for organisations such as JCH which operates as a charity and receives no government assistance and has limited financial resources.
The implementation and maintenance of EQuIP has been worthwhile and it has been the - instrument by which JCH has been able to adopt a culture of continual improvement.
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With the implementation of EQuIP a more modem and sophisticated accreditation process has been developed that places the primary emphasis on actual performance and outcome measures. The road to the implementation of EQuIP was not always easy for either the ACHS or the hospitals who were members of the pilot network.
The first pilot presentation was conducted at St Vincent's Private Hospital in August 1995. In this pilot, the chapter to be presented was then entitled Leadership and Organisational Culture Two hours were scheduled for the presentation and there was much preparation by the staff involved as everyone was mindful that this was a 'first'.
Unfortunately, the presentation went way over time because there was a misunderstanding about the intent of the criteria and the links to the other chapters. Apart from going over time, the presentation was very well done. The surveyors left the organisation with a positive attitude toward the new process and the organisation was able to demonstrate that the draft standards were achievable.
Buoyed by the first experience, a second pilot was embarked upon. Ibis time the Continuum of Care was to be presented specifically the orthopaedic and cardiac services. This was a bit of a disaster. There were too many staff attempting to present their roles in patient care. The standards were not addressed by the presenters so the surveyors were left without any reference points. The presentation was too long the staff were nervous and the surveyors were confused. The verification was very difficult, the surveyors did not ask many questions and the debriefing was disappointing for the staff who had been involved.
EQuIP focuses on the hospital as a system with the functions configured around major patient functions and organisational structures. The standards are written in a generic fashion providing organisations with an opportunity to interpret the standards within the resources and capabilities of the facility. The standards are outcome focussed and are evaluated by reviewing actual results against expected results, the use of clinical indicators facility trends, and benchmarking.
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The primary goals when preparing for survey are to educate and support the staff. If the staff are well prepared anxiety is reduced. Following the education sessions each manager or person ~risible for a service was issued with what is now known as 'the workbook'. In conjunction with their staff the managers completed the self assessment workbook for their particular service identifying the outcomes pertinent to their department. The scope and the intent of the standards at times needed some explanation. The staff have to think about their practice or service and how they comply. It is very rewarding to see people eager to tell you how they deliver their service and how good they think it is.
The presentation teams were drawn from staff in all departments. The team members met to brainstorm ideas and create their presentations. The medical staff were involved by including some of them in the pilot presentations.
Like many other organisations St Vincent's Private Hospital began their quality journey a number of years ago. The model for Total Quality Management that was developed in 1993 at St Vincent's Private Hospital is not unlike the model adopted by the ACHS. So most organisations already have the structures and processes in place to facilitate the new accreditation process.
EQUIP is not the great ogre from the inner city, but if you approach it in a positive way the results can be rewarding. The process requires critical self-awareness, new knowledge, and a fresh approach to the way you prepare your organisation for survey. The challenge for the quality coordinator is to integrate the new concepts and successfully model and mentor EQUIP to fellow employees. Do not be misled. The first time around this process is difficult and the coordinator cannot do this job alone. Commitment from senior management is essential and staff at all levels must be involved. One of the hardest tasks is changing the mindset from descriptive details, on how departments or services function, to identifying the outcomes achieved and how to demonstrate them.
The transition for healthcare organisations to EQUIP does have significant consequences for all involved in the process in terms of cost and time preparing for the survey. At St Vincent's Private Hospital there was a different feel about the survey this time. The atmosphere was calm and there were no hasty phone calls announcing the surveyors imminent visit. The staff pulled together. Organisational barriers were broken down and became organisational strengths.
Accreditation is important, but it is even more important to remember that the primary purpose is to improve the structure, process and outcomes of care. If you take the process seriously then the organisation should be ready for the surveyors to visit at any time. The challenge is to ensure that the commitment and momentum are maintained.
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At Sacred Heart Hospice we are continually striving to improve our performance. Making the delivery of service and outcomes more effective through a process of problem identification, action and follow up provides a mechanism for incremental improvement. The framework and functions of EQUIP have greatly assisted in this process.
In August 1997 Sacred Heart Hospice was the first organisation in Australia to be surveyed with the Palliative Care Guidelines in conjunction with the EQUIP guidelines. The Australian Association for Hospice and Palliative Care developed the guidelines in close consultation with the ACHS.
The Quality Coordinator joined Sacred Heart Hospice in November 1996, which meant there was only ten months to implement EQUIP and prepare for the survey. Challenge number one was a tight time frame!
Many of the staff appeared cynical about the validity of the previous accreditation process. They were quick to discuss the frantic activity in the lead up to the last survey, which was conducted three years ago. It was extremely apparent that the planning and initial education phases were crucial for the effective implementation of EQUIP. Another challenge was how to implement the framework so it was more meaningful for the staff. The understanding and compliance with the standards and criteria needed to become part of the day to day functioning of the organisation.
Education was provided for the staff utilising the EQUIP Guide and the EQUIP video. The aim was to make the education as valuable, practical and meaningful as possible for each group. Regular and ongoing education sessions were provided in each department and clinical area where staff routinely worked. This approach provided the opportunity for the interpretation of the standards and criteria to be tailored specifically for staff, and how they impacted in their particular area or department. This approach was extremely time consuming but the outcome was that staff throughout the entire organisation had a very clear understanding of EQUIP.
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Some staff commented on the 'jargon' they were faced with when delving through documentation related to EQUIP. To overcome this language was used which was more easily understood. Asking staff questions, such as "what would you change in your area and why?" and ,,are we doing the things the right way to meet the patients' and our other customers' needs?", provided the opportunity for staff to work together to find the answers and resulted in a totally different approach to how quality improvement was perceived within the organisation. It was no longer a case of 'doing' quality activities but a pursuit of quality and continual improvement on a day to day basis. This has had an enormous impact and enhancement on organisational effectiveness, teambuilding and has heightened staffs' awareness of the meaning of continuous quality improvement.
A key principle required for implementation of EQUIP is commitment. Without commitment from the leaders and involvement of staff at all levels in the organisation, success cannot be ensured. There needs to be collaboration to enable staff to share in the shaping of the continuous quality improvement journey of the organisation. Many attitudes, beliefs and values influence the process of transforming organisational culture and change. An organisation which has a strong, coherent culture, based on values and beliefs which are shared by the staff, has the ability and potential to perform effectively.
In the early stages of implementing EQuIP one of the major components is to review the existing structures and processes to identify areas for improvement. A great deal of time was invested in identifying methods to improve the flow of communication within the organisation. Effective communication channels are vital for the successful implementation of EQuIP.
Minutes of the Quality Improvement Committee meetings were circulated to all department managers and many other staff within the organisation to facilitate dissemination of information.
A Quality Improvement Activity proforma was designed to address the standards and supporting functions of EQuIP. A Quality Quiz was commenced in January 1997 and conducted on a fortnightly basis. The questionnaires were attached to each staff member's payslip. A set of about ten questions were asked on a specific topic, for example fire and safety, occupational health issues, infection control, principles and functions of EQuIP. The answer sheets were sent to managers who placed the questions and answers in a folder. This folder was used as a resource folder to be utilised by staff. Many staff commented it was an effective method for disseminating important information and increasing the staff s awareness of key issues related to EQuIP.
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Implementing the Palliative Care Guidelines provided staff at the Hospice with not just another challenge, but an innovative opportunity. The ACHS had not developed clinical indicators for palliative care. Our medical staff took the initiative and developed specific palliative care clinical indicators that address common clinical and non clinical issues in palliative care and that are relevant to practice.
EQuIP has facilitated the concept that the responsibility for the quality of care, customer focus and service delivery within the organisation exists at all levels. Quality is seen as an integral part of everyday functioning and a continuing demonstration of the Hospice's commitment to excellence in healthcare for the community we serve. Individual effort is complemented by collaborative effort in achieving organisational goals and objectives.
Many organisational achievements and improved outcomes have been possible through the implementation of EQuIP at Sacred Heart Hospice which include:These improved outcomes encourage and provide staff with the impetus to continually ask are we doing the right things well and where can we improve.
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The EQuIP Guide: Standards and Guidelines for the Australian Council on Healthcare Standards Evaluation and Quality Improvement Program (1996) The Australian Council on Healthcare Standards: Sydney.
Guidelines for Palliative Care Services (1997) The Australian Council on Healthcare Standards & The Australian Association for Hospice and Palliative Care Incorporated: Sydney.
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