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(NMAHS) Strategic Plan 2012-2015

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North Metropolitan
Health Service
Strategic Plan: 2012 - 2015
The NMAHS acknowledges the traditional owners of the land, the Noongar
people. We pay our respects to the elders past and present and recognise the
continuing cultural and spiritual practices of the Noongar people.
Contents
1
Introduction from the Chief Executive
2
Background Information about North Metropolitan Area Health Service
3
Purpose of the Plan
4
Our Vision, Mission and Values
5
Our Achievements
6
Our Challenges and Opportunities
7
Our Strategic Priorities 2012-2015
a.
Strategic Priority 1
b.
Strategic Priority 2
c.
Strategic Priority 3
d.
Strategic Priority 4
e.
Strategic Priority 5
8
Governance
9
Enabling Strategies
10
Implementation
Page 3 of 44
Introduction from the Chief Executive
The release of the Strategic Plan 2012 - 2015 marks a pivotal
moment in the history of the North Metropolitan Area Health
Service (NMAHS). As a relatively young service, the intention is
to unite the hospitals and community services that comprise
NMAHS with a common vision and approach to improve the
wellbeing of those we care for as we mature through this
strategic plan.
Rising demand for services and the other challenges we face
necessitate an innovative approach to health care delivery.
Building on our achievements so far, this Strategic Plan will
channel our focus and attention to make the necessary whole-ofsystem improvements to ensure our patients receive safe, high quality, culturally secure care
in an environment that delivers a positive patient experience. We are committed to continuous
improvement and strong relationships amongst our staff, services and other stakeholders
including WA Health, patients, carers and primary care providers.
Essential to our journey is the commitment of our staff in an evolving environment. We
recognise the valuable team we have and the Strategic Plan outlines our intent to complement
our team’s skills and diversity through attraction, retention and education strategies in the
coming years.
This Strategic Plan outlines how we will shape the future so our community can live longer,
healthier, more fulfilling lives. It is ambitious and, through implementation, will lay the
foundations for a strong, sustainable future.
Dr D J Russell-Weisz
Page 4 of 44
North Metropolitan Area Health Service
The NMAHS is a leader in delivering timely access to high quality health care to Western
Australians and is the major provider of health services for the people in the north and eastern
regions of Perth. The NMAHS is the largest health service in the metropolitan area with a
3,000 square kilometre catchment, including 17 local governments, and in which almost
1 million people – over 40 percent of the State’s population – reside.
Our Health Service provides a comprehensive range of health services within a number of
locations including hospital, home and community based settings.
The Health Service manages over 1,840 beds through three tertiary hospitals and three outer
metropolitan hospitals, oversees the provision of contracted public health care from the
privately operated Joondalup Health Campus and oversees the delivery of pathology and
dental services across the State. A range of state-wide, highly specialised multi-disciplinary
services are also offered from several hospital and clinic sites. In addition to providing clinical
care, NMAHS also has a key role in research and education to ensure world-class evidence
based health care and community capacity building interventions can continue to be delivered
into the future.
NMAHS comprises the NMAHS Mental Health Program (including Graylands Hospital),
NMAHS Public Health and Ambulatory Care, PathWest, Sir Charles Gairdner Group, Swan
Kalamunda Health Service and Women and Newborn Health Service. NMAHS manages the
contract for the delivery of public health care at Joondalup Health Campus under a Public
Private Partnership and manages the Queen Elizabeth II Medical Centre site (QEIIMC), a
delegated responsibility of the QEIIMC Trust.
NMAHS employs over 8,500 staff across our services, is aided by the support from our
volunteers and assists with the teaching and training of students from a range of disciplines.
On any average day, NMAHS (including contracted services):
•
•
•
•
•
•
•
•
•
•
•
Cares for 1,659 people in its hospitals
Performs 132 elective surgery procedures
Delivers 29 babies through its hospitals and community midwifery program
Provides radiotherapy for 224 people
Sees 5,066 people in its outpatient clinics
Sees 519 people in its Emergency Departments
Has 590 people enrolled in its community mental health and rehabilitation programmes
Has 87 people enrolled in hospital in the home services
Has 2,022 people attending Dental Health Services
Conducts 270 community physiotherapy classes per week across the metropolitan area
Spends $5.1 million per day in delivering its services
Page 5 of 44
This Strategic Plan
This Strategic Plan sets a clear direction and focus for NMAHS from 2012 to 2015. It sets the
high level strategic agenda and is enabled by the delivery of workforce, financial, Information
Communication Technology (ICT) and infrastructure programs across NMAHS and the wider
WA Health system.
As a health service, it is critical that efforts are focussed on strategies that will deliver the best
clinical outcomes for our patients and the best working environment for our staff. As demand
for health services is ever increasing, NMAHS must remain responsive through clinical
process redesign and continuous improvement. For this reason, the Strategic Plan is
underpinned by evidence based practice.
This Strategic Plan details our mission, vision and values that guide the day to day work of
NMAHS and provide a focus for longer term planning, as outlined later in the document.
Importantly, this Strategic Plan communicates to our key stakeholders where our efforts will be
invested over the coming three years.
This Strategic Plan sits within the wider planning context of WA Health, and in particular has
been guided by the following documents:
1.
WA Health Strategic Intent
The NMAHS Strategic Plan aligns directly to WA Health’s Strategic Intent 20102015, which focuses on care being provided across four pillars:
1. Caring for individuals and the community
2. Caring for those who need it most
3. Making best use of funds and resources
4. Supporting our team.
2.
WA Health Clinical Services Framework 2010-2020 (CSF)
The CSF is the principal clinical planning document for WA Health. The CSF
describes the high level service profile for hospital and non-hospital based services
planned across NMAHS until 2020, and is based on current demographic data and
projections of future service needs.
Page 6 of 44
Our Vision, Mission and Values
Our Vision:
Excellence in health care for our community.
Our Mission:
To improve, promote and protect the health of Western Australians within the NMAHS
catchment by:
•
•
•
•
Caring for individuals and the community
Caring for those who need it most
Making the best use of funds and resources
Supporting our team.
Our Values:
Care by demonstrating commitment and consideration to others as we work.
Respect for each other, our clients and their families, carers and the community by preserving
individual dignity and supporting the right of everyone to make choices.
Excellence by providing high quality, accessible, integrated and safe health care to the
community. We believe in working in partnership with clients to improve their health.
Integrity by providing quality services and advice for the common good and having honest
dealings and communication with other people.
Teamwork by valuing the contribution of the team, working safely and cooperatively and
communicating effectively with the team.
Leadership by communicating NMAHS’s vision, taking responsibility for our actions and
decisions and displaying trust in our colleagues.
Page 7 of 44
Our Achievements
Over the past three years NMAHS has achieved a number of significant improvements in the
way we deliver care to our community whilst ensuring a sustainable approach to the utilisation
of resources. These achievements provide a solid base for continuing our service
improvements over the next three years and include:
Elective Surgery
Capacity for elective surgery has been increased with an expanded Surgicentre, including a
Pre-Admission Clinic and a Central Sterilising Support Department at Osborne Park Hospital
(OPH). There has been an increase in the referral of medically suitable patients from tertiary
to secondary sites for elective procedures, more effective waitlist management and increased
recruitment of salaried surgeons. In addition, extended surgery sessions have been
commenced and an accelerated rehabilitation program implemented post elective orthopaedic
surgery at SCGH and OPH to improve patient flow. NMAHS is committed to further
improvement to meet the National Elective Surgery Targets (NEST) which requires 95 per cent
of Category 1 and 2 patients to be treated within clinically recommended times.
Emergency Care
The Four Hour Rule program which aims to admit, discharge or transfer 85% of patients who
attend an emergency department within four hours has been progressively introduced at
NMAHS sites since 2009. All sites have made significant gains in refining service provision to
achieve this target as evidenced below, in an environment of significant increased demand.
Reforms are now continuing at all sites in line with NMAHS commitment to achieving the
National Emergency Access Target (NEAT) of 90% of patients admitted or discharged within
four hours by 2015.
Percentage of patients admitted, discharged or transferred within four hours
Site
Baseline
Current Performance
(March Quarter 2012)
Current
Target
Sir Charles Gairdner Hospital
44%
70.9%
85%
Swan District Hospital
67%
79.9%
85%
Joondalup Health Campus
67%
67.5%
85%
King Edward Memorial Hospital
89%
89.0%
85%
Additionally, Joondalup Health Campus (JHC) Emergency Department capacity has doubled
as part of the site’s redevelopment and Swan District Hospital’s Emergency Department
upgrade is nearing completion.
Meeting Demand through New Infrastructure
The expansion of the Neonatal Critical Care Unit and Maternal Foetal Assessment Unit at King
Edward Memorial Hospital is complete. This follows the opening of the Mother and Baby Unit
in June 2007.
Joondalup Health Campus has opened a new 55-bed public ward block, a new emergency
department and an expanded Mental Health Unit as part of its continued redevelopment.
Page 8 of 44
Sir Charles Gairdner Hospital has expanded its Intensive Care Unit, opened a new Geriatric
Evaluation and Management Unit, new Nursing Observation Specials Area and an expanded
Interventional Neuroradiology suite. Establishment of the Gairdner Rehabilitation Unit and the
recruitment of a Rehabilitation Physician providing enhanced rehabilitation services for
patients requiring slow stream rehabilitation has also occurred.
New public health facilities include purpose fit clinics for the Humanitarian Entrant Health
Service and the WA Tuberculosis Control Program.
Reduced Dependency on Hospital Care
Access to flexible home care has improved across NMAHS with increased staffing for the
improved coordination of care for complex patients to reduce avoidable emergency
department and hospital admissions. There has also been continued expansion of NMAHS inhome services through the Rehabilitation in the Home (RITH), Hospital in the Home (HITH),
Rehabilitation and Aged Care Intervention Liaison Service (RAILS) at OPH and ongoing
access to Hospital at the Home (HATH).
Services in the community include the Early Supported Discharge Stroke Program, the
Community Physiotherapy Service, the Women and Newborn Drug and Alcohol Service’s
satellite clinic at Bandyup Prison and Breastscreen mobile screening and health promotion
initiatives.
Access to community mental health services has been further enhanced through the
development of extended hours (0830 to 2200) Assessment and Treatment teams.
Innovative Practices to Enable Care Closer to Home
NMAHS has embraced a number of practices to facilitate care being provided closer to home,
including:
• Wounds West education online
• Telehealth
• New emergency department and inpatient unit at JHC
• Stroke unit at SDH
• Expanded emergency department at SDH
Aboriginal Health is Everyone’s Business
Aboriginal Health is a key area of achievement that NMAHS is keen to build upon. This
requires collaborative partnerships between the Aboriginal and non Aboriginal NMAHS key
stakeholders to ensure that when Aboriginal people utilise services within the NMAHS, their
cultural needs are recognised and met.
The Aboriginal Health Unit (AHU) was established as a part of the NMAHS Public Health Unit
in 2008. The role of the AHU is to develop and implement programs specific to the 12,000
Aboriginal people living in the north metropolitan region of Perth. The AHU strives to be a best
practice unit which provides a supportive environment for its workforce to deliver effective and
secure services to and for the local Aboriginal community. It consists of local Aboriginal
people with strong community connections and knowledge.
Page 9 of 44
An Aboriginal Maternity Services Support Unit has been established at the Women and
Newborn Health Service with the key goals of building capacity and sustainability within the
Aboriginal Community Controlled Health Sector and building/fostering partnerships between
maternal and child health service providers, whilst improving the cultural competence/security
of main stream health services. The overall aim is to improve access to maternal and child
health services for all Aboriginal women and families to close the gap in these important health
outcomes.
Specialist Aboriginal Mental Health Services were implemented in 2011 to enhance access to
specialist mental health services through a co-consultancy model of care promoting cultural
competency and security of mainstream mental health services.
Page 10 of 44
Our Challenges and Opportunities
Health care providers throughout Australia and other developed countries are facing many
pressures and challenges as demand for services increase. NMAHS is no different, and as
implementation of this Strategic Plan progresses, many challenges will be encountered.
However, where there are challenges, there are also great opportunities to strengthen and
build on the work that is already underway, and in doing so ensure the services provided are
relevant for the future needs of our community.
Challenges
National Challenges
The National Health Reform Report identified a number of challenges applicable to all health
services:
•
•
•
•
Ageing population
Growing demand
Increasing health care costs
Increasing prevalence of chronic disease and co-morbidities
NMAHS Key Challenges
In addition to the above challenges, NMAHS faces a number of specific challenges in
delivering services to its community.
•
•
•
•
Population Distribution
There are considerable demands on health services in the growing northern and
eastern corridors of Perth. Infrastructure and workforce are key factors in meeting the
growing needs of our community.
Workforce Capacity and Skill Development
Workforce pressures are already being felt across our health service and will increase
with the impact of infrastructure and clinical reform and increased demand for services.
There is an urgent need at a macro and micro level to become more effective at
retaining the skills of our existing workforce and also continuing to attract new staff with
the right skill set.
Aboriginal Health
NMAHS aims to achieve equity in access to health services for Aboriginal people in
order to improve their health outcomes and life expectancy.
Financial Sustainability
Cost pressures continue to rise in health with 24% of the State budget spent on health,
or almost $2,500 for every person each year in WA. Strong strategies are necessary to
improve financial sustainability, including providing care closer to home and increasing
primary health interventions and community care to reduce demand for expensive
hospital services.
Page 11 of 44
•
•
Clinical Service Reform
There is a requirement for the development of new services and the changing
requirements of existing services to match the CSF and to ensure models of care are
based on evidence based services targetted to priority population needs.
Staff Engagement
NMAHS recognises there is still opportunity to engage with our staff to ensure that our
service mix and delivery models are viable. Engagement, leadership and accountability
with our staff at all levels can bring sustainable improvements in both productivity and
quality of service.
Opportunities
•
•
•
•
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National Health Reform Agenda
In response to the ongoing growth in demand, the National Health Reform Agenda will
see the Commonwealth Government increase its contribution to the funding of our
public hospitals in the years ahead. The focus of this reform agenda is to ensure
sustainability of our health and hospital services. This offers an exciting opportunity to
improve performance for the best patient outcomes.
Establishment of Governing Councils
Under the national health reforms, the NMAHS will become a Local Health Network,
with a Governing Council of community members and clinicians representing a broad
range of interests, skills and experience. A key role of Governing Council members will
be engaging with community members to ensure their needs and concerns are reflected
in service planning and performance evaluation.
Infrastructure Programme
The infrastructure programme has a broad inpatient and non-inpatient focus including
hospital and non-inpatient infrastructure to ensure that wherever possible seamless,
patient focussed care is provided closer to home.
Activity Based Funding/Activity Based Management (ABF/ABM)
The ABF/ABM programme will integrate the key components of health service planning,
funding and delivery to improve accountability and transparency to the community and
our key stakeholders.
Community Engagement
To ensure all services are patient focussed, community engagement offers an
opportunity for community involvement in decision making about the delivery of health
services.
Redevelopment Programme QEIIMC and the New Children’s Hospital
The collaboration of children’s services with existing adult services on the QEIIMC
provides a unique opportunity to enhance care pathways for adolescents and young
people as they transition to adult care.
Mental Health Commission
Joint planning with the Mental Health Commission provides opportunities for enhanced
collaboration with the community managed sector and primary care.
Page 12 of 44
Our Strategic Priorities 2012 – 2015
NMAHS has identified five strategic priority areas that provide the focus to enable us to deliver
on our commitments towards achieving our vision over the next three years. The strategic
priorities build on the organisation’s achievements to date and reflect our response to the
challenges and opportunities that have been previously described.
Strategic goals have been developed for each Strategic Priority, and for each Goal actions
detail how and when these Goals will be achieved within the life of this Plan.
The Strategic Priorities and Goals build on WA Health’s four Strategic Intent Pillars and the
pillars of our NMAHS Mission:
•
•
•
•
Caring for individuals and the community
Caring for those who need it most
Making best use of funds and resources
Supporting our team.
The alignment of our Strategic Priorities with these Pillars is represented in the table on the
following page:
Our Strategic Priorities for 2012-2015 are:
•
•
•
•
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Clinical reform and reconfiguration
Quality and safety
Community and partnerships
People and workplace culture
Resourcing for sustainability.
Page 13 of 44
1. Clinical
Reform and
Reconfiguration
2. Quality and
Safety
●●
●●
1.1 Incorporate
clinical
innovation and
best practice
into delivery of
care
2.1 Deliver high
quality, reliable
and safe health
care to every
patient, every
time,
everywhere
1.2 Deliver
services closer
to home where
appropriate
2.2 Achieve or
exceed all
required
standards of
service and
care
Strategic Goals
Strategic Goals
Strategic
Strategic
Priorities
Priorities
Our Strategic Priorities 2012 – 2015
1.3 Enhance
access to
services
1.4 Provide
seamless
service delivery
within NMAHS
and integration
with other
AHSs
Page 14 of 44
3. Community
and
Partnerships
4. People and
Workplace
Culture
5. Resourcing
for
Sustainability
●●
●●●
●●
3.1 Engage
with our
community
4.1 Build and
maintain a
flexible,
motivated and
skilled
workforce to
meet current
and future
needs
5.1 Ensure
optimal use of
all resources
across the
NMAHS
4.2 Ensure a
healthy and
safe workplace
environment
and culture
where staff are
motivated and
treated fairly
and with
respect
5.2 Manage
financial
resources to
achieve a
sustainable
financial
position
2.3 Deliver
care in
accordance
with quality,
standardised
evidence
based practice
3.2 Deliver well
coordinated,
need-specific
and culturally
sensitive health
services to
indigenous
Australians
4.3 Develop
the leadership
and
management
capacity and
performance of
our staff
5.3 Deliver our
infrastructure
programme
2.4 Ensure
patient safety
through the
management of
clinical risks
3.3 Work
innovatively
with the
community and
partners to
reduce
dependency on
hospital care
4.4 Enhance
and maintain
culture and
processes to
support ethical
and
professional
conduct by all
staff
5.4 ICT
requirements to
support service
delivery across
NMAHS sites
are identified
and prioritised.
3.4 Work
innovatively
with all
partners to
ensure
seamless care,
close to home
4.5 Strengthen
teaching,
training and
research with a
focus on
improved
health
outcomes
5.5 Plan for
future physical
infrastructure
requirements
● caring for individuals
and the community
● caring for those who
need it most
● making best use of
funds and resources
● supporting our team
Strategic Priority 1 – Clinical Reform and Reconfiguration
Strategic Goal 1.1: Incorporate clinical innovation and best practice
into delivery of care
Outcomes
Deliverables
Responsibility
Services are provided in accordance
with agreed models of care.
• Area wide specialty framework
developed.
ED CP&R
• Specialty specific service delivery
models are developed and role
delineations in place.
ED CP&R
• Review workforce implications of
models of care.
ED WF
• Innovation and Improvement Unit
established at SCGH.
ED SCGG
• Review requirement for Area-wide
Innovation and Improvement Unit.
ED SCGG
• Continual improvement philosophy
and approach established across
the AHS, as evidenced through
the implementation of continuous
improvement strategies.
ED SQ&P
• Process in place to identify
ongoing priority areas for
innovation and improvement
projects.
DSD
Clinical innovation and improvement is
evident across the organisation.
Page 15 of 44
Strategic Goal 1.2: Deliver services closer to home where
appropriate
Outcomes
Deliverables
Responsibility
Infrastructure and resources are in
place to support the reconfiguration of
services.
• Funded business plan to support
transition / reconfiguration.
DSD
Reconfiguration achieved in
accordance with the CSF.
• Physical infrastructure capacity
available in accordance with CSF.
ED CP&R
• Activity shifted from tertiary
hospitals to JHC and SDH.
ED CM / ED SKHS
• Bed day savings achieved in
accordance with the CSF and
demand modelling.
DSD
There is clear and timely
communication between hospitals,
GPs and non-inpatient services.
• Standardised GP referral process
established.
ED MS
• Standardised discharge letter for
GPs established.
ED MS
Patients access services in
accordance with the CSF and models
of care.
• Comprehensive community
education programme regarding
reconfiguration of services across
NMAHS.
M COMM
Staff and patients in rural and remote
areas have consistent and reliable
access to experts.
• NMAHS Telehealth Strategic Plan
is developed and implemented.
ED MS
• Strategies for up skilling regional
staff implemented.
ED MS
Page 16 of 44
Strategic Goal 1.3: Enhance access to services
Outcomes
Deliverables
Responsibility
Gaps in service access are identified
promptly.
• System in place to monitor access
to services and identify priority
areas for action.
ED CP&R
Criteria for access to NMAHS services
are clearly documented.
• Access criteria developed for two
services per annum.
ED MS
• Needs assessment for adult eating
disorders services completed
collaboratively with CAHS and
Centre for Clinical Interventions
(CCI).
ED SCGG
• Adult Rehabilitation Services
• Options developed for delivering
adult rehabilitation services across
NMAHS.
ED CP&R
• Aged Care Services
• Plan developed for provision of the
required health services for the
aged population.
ED CP&R
• Breastscreen and other screening
services
• Options developed for delivering
screening services across the
NMAHS.
ED WNHS
• Disability Access & Inclusion Plan
implemented.
• Disability Access & Inclusion Plan
implemented.
ED PHAC
• Elective Surgery
• Elective access program
implemented.
ED SCGG
• Mental Health Services
• Options developed for delivering
adult and older adult mental health
services for the Joondalup
catchment.
ED MHS
• Programs developed in
collaboration with the Department
of Corrective Services to increase
access to specialist services for
mentally ill offenders.
ED MHS
• Development and implementation
of a specialist metropolitan youth
mental health services program.
ED MHS
Patients have improved access to
services, including:
• Adult Eating Disorder Services
Page 17 of 44
ED MHS
ED CP&R
Outcomes
Deliverables
Responsibility
• Neuroscience Services.
• Review of requirements for State
Neurosciences Centre completed
and action plan developed.
ED CP&R
• Oral Health Care
• Submission funding for Oral
Health for eligible patients.
ED PHAC
• Outpatient Services
• New model(s) for outpatients
delivery established across the
NMAHS.
ED SCGG
• Consistent process in place for
outpatient referrals across the
NMAHS based on acuity and
service level requirement.
ED SCGG
• Elective access program in place.
ED SCGG
• Strategies implemented to
improve access to Youth Mental
Health Service
ED MHS
• Strategies implemented to
improve access to adolescent and
young adult cancer services.
ED SCGG
• Youth Health Services
Page 18 of 44
Strategic Goal 1.4: Provide seamless service delivery within NMAHS
and integration with other AHSs
Outcomes
Deliverables
Responsibility
Adolescents and young adults
transition smoothly from CAHS to
NMAHS services.
• Transition processes agreed with
CAHS and implemented.
ED SCGG
Optimise the delivery of services for
country patients attending NMAHS.
• Service delivery models
incorporate the needs of country
patients in the metro services.
ED CP&R
• MOU (Memorandum of
Understanding) established with
WACHS.
ED CP&R
• MOUs established with all AHSs
(Area Health Services) for those
services that are cross-boundary.
All
Services provided across AHS
boundaries are well coordinated.
Page 19 of 44
Strategic Priority 2 – Quality and Safety
Strategic Goal 2.1: Deliver high quality, reliable and safe health care
to every patient, every time, everywhere
Outcomes
Deliverables
Safety and quality standards are met
and maintained across the NMAHS.
• Annual Safety & Quality
Performance Reports developed
for NMAHS.
• Area-wide Quality Improvement
Audit on at least two topics each
year.
Patients presenting at NMAHS
Emergency Departments are assessed
and admitted, discharged or
transferred within target time periods.
Clinical leaders promote and facilitate
continuous improvement.
NMAHS buildings and facilities are
safe and fit for purpose.
Page 20 of 44
Responsibility
ED SQ&P
ED SQ&P
• Annual NMAHS Safety & Quality
Operational Plan developed.
ED SQ&P
• Achieve key targets for safety &
quality.
All
• Four Hour Rule targets achieved
at SCGH, SDH, JHC and KEMH.
- SCGH
ED SCGG
- SDH
ED SKHS
- JHC
ED CM
- KEMH
ED WNHS
• Evidence Based Leadership
framework established at:
- NMAHS (AEG & Area
Functions)
DSD
- SCGG
ED SCGG
- SKHS
ED SKHS
- PHAC
ED PHAC
- Area Mental Health Service
ED AMHS
- WNHS
ED WNHS
• Priority areas within the Facilities
Maintenance Plan are addressed.
ED FM
Strategic Goal 2.2: Achieve or exceed all required standards of
service and care
Outcomes
Deliverables
Responsibility
NMAHS sites / services maintain
accreditation status with relevant
organisations.
• ACHS accreditation maintained by
NMAHS member sites and
services.
ED SCGG
ED SKHS
ED WNHS
ED MH
ED PHAC
- Public Health & Ambulatory
Care achieve ACHS
accreditation status by 2014.
National Safety and Quality Standards
are met and maintained across the
NMAHS.
Page 21 of 44
• NATA accreditation maintained by
PathWest.
ED PW
• NMAHS hospitals achieve
accreditation against the new
National Safety and Quality Health
Service Standards, to be
introduced in 2013.
ED SCGG
ED SKHS
ED WNHS
ED MH
• Area-wide Quality Improvement
Audit on two topics each year.
ED SQ&P
Strategic Goal 2.3: Deliver care in accordance with quality,
standardised evidence based practice
Outcomes
Deliverables
Services across the NMAHS and
statewide services managed by the
NMAHS, are provided in line with
evidence based practice.
•
Page 22 of 44
Area wide framework established
for incorporating evidence into
clinical practice.
Responsibility
ED SKHS
• Processes established for
incorporating evidence into clinical
policies, guidelines and pathways.
ED SKHS
• Priority areas for implementing
consistent evidence based
practice identified.
ED SKHS
• At least one evidence based
clinical guideline developed and
implemented each year.
ED SKHS
Strategic Goal 2.4: Ensure patient safety through the management of
clinical risks
Outcomes
Deliverables
Responsibility
There is a reduction in preventable
clinical incidents.
• SQuIRe PLUS Program
implemented and targets achieved
in the areas of:
ED SQ&P
- Clinical Deterioration
- Clinical Handover
- Surgical Safety Checklist
- Falls
- Medication Reconciliation
- Acute Myocardial Infarction
compliance
- Pressure Ulcers
- Hand Hygiene
- Central Venous Catheter
related Blood Stream Infections
- Surgical Site Infections
- Venous Thromboembolism
prophylaxis
Data is collected, analysed and used
to identify clinical risks and improve
patient safety.
Patients affected by adverse events
are provided with prompt, accurate and
empathetic communication.
Page 23 of 44
• An electronic clinical incident
reporting and management
system is implemented across
NMAHS sites and services.
ED SQ&P
• Clinical incident data is used to
identify and address clinical risks.
ED SQ&P
• WA Hospital-Acquired Infection
(HAI) Surveillance data is used to
identify and address patient safety
issues and trends.
ED SQ&P
Process of Open Disclosure and
transparent communication
established at all NMAHS sites and
services.
ED SQ&P
Strategic Priority 3 – Community and Partnerships
Strategic Goal 3.1: Engage with our community
Outcomes
Deliverables
Responsibility
Members of the community are
involved in planning, developing and
reviewing services provided by the
NMAHS.
• NMAHS community engagement
plan developed and implemented.
ED PHAC
• CAC Terms of Reference and
processes reviewed.
ED SQ&P
• Community representation
established on key NMAHS
strategic and operational groups.
ED SQ&P
• NMAHS Aboriginal Health Forums
established to facilitate input into
service planning and delivery by
Aboriginal members of the
community.
ED PHAC
• Links established with CALD
community members to ensure
input to service planning and
delivery.
ED PHAC
• Carer engagement strategy
implemented.
ED SQ&P
• Annual reporting to the WA
Carer’s Council and WA Carers
Advisory Council.
ED SQ&P
• Governing Council decisions and
advice are considered in NMAHS
planning and performance
monitoring.
Office of CE
• Framework and education for the
role of volunteers developed and
implemented.
ED WF
Members of the community are
supported to contribute practically to
the NMAHS as volunteers.
Page 24 of 44
Strategic Goal 3.2
Deliver well coordinated, need-specific and
culturally sensitive health services to indigenous
Australians
Outcomes
Deliverables
Responsibility
Health needs of Aboriginal people are
identified, prioritised and addressed.
• Position of Director Aboriginal
Health NMAHS established.
ED PHAC
• Specialist Aboriginal mental health
services provided.
ED MHS
• Care pathways and patient flows
developed in collaboration with
Aboriginal Medical Services.
ED PHAC
ED MS
• Aboriginal health workers
appointed as part of mainstream
services.
All operational EDs
• Reconciliation Action Plan
implemented.
ED PHAC
• NMAHS Aboriginal Health Forums
established to facilitate input into
service planning and delivery by
Aboriginal members of the
community.
ED PHAC
Health services for Aboriginal
community members are well coordinated and culturally secure.
Page 25 of 44
Strategic Goal 3.3
Work innovatively with the community and
partners to reduce dependency on hospital care
Outcomes
Deliverables
Responsibility
Patients’ access primary care services
from community based providers.
• Collaboration with Medicare
Locals, General Practice
Networks, Local Governments and
NGOs to promote primary care
services.
ED PHAC / ED MHS
Promote, develop, support and initiate
actions which ensure healthy
environments and sustainable
communities.
• Patient prevalence of lifestyle
related chronic disease across the
population:
ED PHAC
- Increase healthy eating
- Increase physical activity levels
• Capacity and capability of the
community based NGO workforce
developed for:
ED SCGG / ED MHS
- aged care
- mental health
Patients receive care in their homes
whenever possible.
Page 26 of 44
• Recommendations of the Stokes
Review implemented for HITH and
RITH programs.
ED SCGG
Strategic Goal 3.4: Work innovatively with all partners to ensure
seamless care, close to home
Outcomes
Deliverables
Responsibility
Patients receive well coordinated care
that is provided as close as possible to
where they live.
• Funded strategies within Mental
Health 2020 implemented in
collaboration with the Mental
Health Commission.
ED MHS
• Links with local government
established.
ED PHAC
• Consistent consumer-focussed
documentation developed for use
across Government and nonGovernment providers.
M COMM
• Consistent and efficient discharge
planning and documentation
developed and implemented.
ED MS
• Recommendations of the Stokes
Review into MHS referral,
admission, transfer and discharge
practices to be implemented.
ED MHS
Patient care information is shared
promptly and appropriately between
service providers.
Page 27 of 44
Strategic Priority 4 – People and Workplace Culture
Strategic Goal 4.1: Build and maintain a flexible, motivated and
skilled workforce to meet current and future
needs
Outcomes
Deliverables
Responsibility
The NMAHS attracts and retains
skilled and knowledgeable staff.
• Develop and implement NMAHS
Workforce and Diversity Plan.
ED WF
• NMAHS workforce attraction and
retention strategy developed and
implemented.
ED WF
• Develop and implement Mental
Health Workforce Transition Plans
to support infrastructure projects
and major clinical reform.
ED WF
• Develop succession planning
framework for key clinical,
technical and management roles.
ED WF
• PathWest Workforce Plan
implemented.
ED PW
• Build on the metro/WACHS
service interface to develop a
staffing model that helps recruit
and retain the rural workforce
(including specialist skills).
ED MS
• Analyse and report on refreshed
WRM data.
ED WF
• Complete workforce profiling for all
NMAHS sites.
ED WF
• Develop NMAHS Workforce
Supply Model.
ED WF
The NMAHS workforce reflects the
diversity of the community.
• NMAHS Aboriginal Employment
Strategy implemented.
ED WF
The NMAHS workforce adapts and
responds constructively to changes in
the health service environment.
• Process implemented for the
systematic identification and
assessment of opportunities for
role redesign and flexibility.
ED WF
NMAHS continues to develop the
Workforce Requirements Model
(WRM) in partnership with other key
stakeholders.
Page 28 of 44
ED MHS
Outcomes
Deliverables
Responsibility
NMAHS staff maintain up to date
knowledge and skills.
• Evidence based training programs
developed and implemented.
ED NS
• Training programs are targeted to
fill identified workforce shortages
and gaps.
ED MS
ED NS
ED WF
• An appropriate and effective
medical credentialing/recredentialing system is in place at
all sites.
ED MS
ED NS
Ensure SKHS staff are supported
through transition to the MHC in
partnership with the key stakeholders.
• Develop and implement a
Workforce Transition Plan for
SKHS.
ED WF
ED SKHS
Develop NMAHS-Wide Strategy for
resource (workforce) development
across the area.
• Strategies for competing in the
workforce marketplace are
identified and implemented.
ED WF
ED MS
ED NS
Page 29 of 44
ED MS
Strategic Goal 4.2: Ensure a healthy and safe workplace environment
and culture where staff are motivated and treated
fairly and with respect
Outcomes
Deliverables
Responsibility
Harassment and bullying are not
tolerated within the NMAHS.
• Training initiatives implemented
for the prevention and
management of workplace bullying
and harassment.
ED WF
NMAHS staff feel supported and
valued.
• Evidence based programs
identified to support positive
workplaces and teams.
ED WF
NMAHS sites are safe working
environments.
• Smoke free workplace achieved.
All EDs
• Strategy and process established
to identify and address OSH
priorities.
ED WF
• Safety and Risk Climate Survey of
NMAHS Staff completed every two
years. Areas for improvement
identified and addressed.
ED SQ&P
Page 30 of 44
Strategic Goal 4.3: Develop the leadership and management capacity
and performance of our staff
Outcomes
Deliverables
Responsibility
Strong leadership is evident across all
areas and all levels of the NMAHS
workforce.
• NMAHS Leadership Development
program promoted across all staff
areas.
CE
• Medical Leadership Program
established for current and future
medical leaders within NMAHS.
D SDH
• Establish the NMAHS Aboriginal
Leadership and Cultural
Workforce Committee.
ED PHAC
• NMAHS Manager’s Toolkit
implemented across all sites and
services.
ED WF
• Mentoring and coaching programs
developed and implemented.
ED WF
Managers at all levels of the NMAHS
are skilled and confident in their
management responsibilities.
Page 31 of 44
Strategic Goal 4.4: Enhance and maintain culture and processes to
support ethical and professional conduct by all
staff
Outcomes
Deliverables
Responsibility
The NMAHS maintains high standards
of ethical conduct across all areas.
• The WA Health Integrity and
Ethical Governance Framework
implemented.
ED SQ&P
• Integrity and ethical conduct
training and teaching delivered to
ensure improved accountability
across the organisation.
ED WF
Potential misconduct is promptly
identified and addressed.
• Processes established for
reporting, investigating and
managing potential misconduct.
ED WF
The NMAHS is recognised by the
Aboriginal community as culturally
secure.
• Implement Cultural Respect
Framework.
ED PHAC
• Secure formal partnerships with
stakeholders.
ED PHAC
• Evaluate NMAHS against
performance measures for cultural
security.
ED PHAC
Page 32 of 44
ED WF
Strategic Goal 4.5: Strengthen teaching, training and research with a
focus on improved health outcomes
Outcomes
Deliverables
Responsibility
All NMAHS staff have access to
relevant education and training
programs.
• Teaching and training plan
developed and implemented to
support reconfiguration and
service delivery models for MHS.
ED MHS
• WA Health Safety & Quality
Education and Training
Framework implemented.
ED SQ&P
• Training programs offered using a
variety of formats including elearning and video conferencing.
ED WF
• Process established for
prioritisation of research into key
clinical areas.
ED SCGG
• Increased number of research
funding grants obtained.
ED SCGG
• Implement Research Governance
Policy.
Operational EDs
• Increased number of peer
reviewed publications:
ED SCGG
SCGH is recognised for its research
and academic programs.
- State Health Research
Advisory Council
- National Health and Medical
Research Council
Page 33 of 44
Strategic Priority 5 – Resourcing for Sustainability
Strategic Goal 5.1: Ensure optimal use of resources across the NMAHS
Outcomes
Deliverables
Responsibility
Internal distribution of funding is
aligned with NMAHS strategic
objectives.
• Framework for the internal
distribution of funding developed
and in place for financial year
2012/13.
ED F
• The development of triennial
budgets rather than annual
budgets.
ED F
• An ABF/ABM budget and financial
management awareness program
developed and implemented for
3rd and 4th tier staff across
NMAHS.
ED F
NMAHS managers understand and
operate within the ABF/ABM budget
and financial management framework.
• ABF/ABM budget and financial
management education program
implemented for all tier 3 and tier 4
staff.
ED F
Maximise resource utilisation.
• Integrated NMAHS KPI reporting
system developed to enhance/
optimise resource use.
ED F
Additional funding is sought in line with
NMAHS strategic objectives.
• Clear framework and prioritisation
process established for
applications for additional funds.
ED F
NMAHS workforce is available to
support all sites and services as
required.
• Area wide staff appointments
made where appropriate.
ED WF
ED MS
NMAHS physical resources are
maintained in good working order.
• Maintenance program in place.
ED FM
Sustainability is a fundamental driver in
improving NMAHS facility design,
construction, operations and
maintenance.
• Sustainability issues considered in
the prioritisation of construction,
operations and maintenance.
ED FM
Page 34 of 44
Strategic Goal 5.2: Manage financial resources to achieve a
sustainable financial position
Outcomes
Deliverables
Responsibility
NMAHS Finance and Business staff
provide effective financial management
and business support for service
delivery.
• Professional development and training
programs in place for all NMAHS
Finance and Business staff.
ED F
Relevant, timely and accurate finance
and business information is available
to managers across NMAHS.
• Intranet/portal facility for provision of
finance and business information to
desk tops and mobile devices across
NMAHS developed.
ED F
Own source revenue enhancement
opportunities are applied to achieve
NMAHS strategic priorities.
• Process in place for identifying,
prioritising and progressing revenue
enhancement opportunities.
ED F
IT systems support NMAHS business
needs.
• Process in place for collaboration with
HIN.
ED F
• NMAHS requirements communicated
to HIN to inform development and
implementation of new systems
including:
ED F
- Clinical costing
- Patient billing
- New systems progressively
implemented.
NMAHS complies with statutory
requirements.
NMAHS operates within budget.
Accurate and up to date data is
available for use in financial planning
and management.
Page 35 of 44
• Process in place to review and revise
relevant policies, procedures and
processes.
ED F
• OAG annual audit recommendations
implemented.
ED F
• Processes in place to monitor
performance against budget.
ED F
• Strategies identified for managing
budget over runs.
ED F
• Strategies implemented to ensure
activity coding is up to date.
ED F
• Audit program in place to monitor
integrity of relevant data sets.
ED F
Strategic Goal 5.3: Deliver our infrastructure programme
Outcomes
Deliverables
NMAHS infrastructure supports
reconfiguration and service delivery
models.
• Complete construction of:
Responsibility
- Joondalup Health Campus
development
ED CP&R
- Midland Health Campus
development
ED CP&R
- QEII MC redevelopment
Stage 1
ED CP&R / ED SCGG
- SCGH Mental Health Unit
ED CP&R / ED MH
- OPH Mental Health Unit
ED CP&R / ED MH
- Laboratory services at:
Page 36 of 44
-
QEII (commissioning 2012)
ED CP&R / ED PW
-
FSH (commissioning 2014)
ED PW
Strategic Goal 5.4: ICT requirements to support service delivery
across NMAHS sites are identified and prioritised
Outcomes
Deliverables
Responsibility
ICT requirements to support service
delivery across NMAHS are identified
and prioritised.
• Process in place for identifying
and prioritising ICT requirements.
ED PW
Technology supports the delivery of
services at NMAHS sites.
• Technology Plan developed to
support reconfiguration and
service delivery models including:
ED F
- Medical technology
- IT
- Communication technology
• Laboratory Information System
(LIS) implemented by 2013.
ED PW
• NMAHS involved in the
development of an electronic
medical record.
ED F
Technology supports the training and
support of rural patients and health
services.
• Telehealth clinical application
enhancement implemented.
ED MS
Technology supports communication
between the NMAHS and other health
service providers.
• Systems implemented to facilitate
information exchange with PPP.
ED F
• Systems and agreed protocols for
the exchange of information with
the Mental Health Commission.
ED F
• ICT programs implemented for:
ED PHAC
- School Dental Services
- Ambulatory Care Services for
use in community/homes.
Page 37 of 44
ED MHS
Strategic Goal 5.5: Plan for future physical infrastructure
requirements
Outcomes
Deliverables
The infrastructure needs of the
NMAHS beyond 2015 are identified,
prioritised and planned.
• Future infrastructure plan
developed including:
- OPH
ED CP&R / ED SCGG
- Mirrabooka
ED CP&R
- Graylands
ED CP&R / ED MHS
- KEMH
ED CP&R / ED WNHS
- QEII
ED CP&R / ED SCGG
- Dental
ED CP&R / ED PHAC
• SDH decommissioned.
• Other infrastructure requirements
eg North of North.
Page 38 of 44
Responsibility
ED SKHS
Enabling Strategies
A number of enabling strategies are detailed below. The commonality across each of these
strategies is achieving the best patient outcomes. In recognition of this, community and
consumer engagement is a significant driver in developing and delivering these strategies.
NMAHS will develop a number of strategies to complement and enable the implementation of
the strategic priorities.
1.
Clinical Services Plan (CSP)
In line with the CSF, NMAHS will revise and update its current CSP to delineate how
primary, secondary and tertiary services will be delivered across the Area Health
Service.
2.
Workforce Plan
It is vitally important that we have the right mix of staff, in the right place to deliver
services as outlined in the NMAHS CSP and the CSF. Further, the workforce plan will
ensure that workforce requirements are achievable and sustainable into the future.
3.
Safety and Quality Plan
The NMAHS Safety and Quality plan will outline a shared vision for enhancing the
safety and quality of health care. Guided by the Western Australian Strategic Plan for
Safety and Quality in Health Care 2008-2013 and any future edition, the Safety and
Quality Plan for NMAHS will build on our current clinical governance practices to further
improve our health services and minimise clinical risk.
4.
Reconciliation Action Plan
The Reconciliation Action Plan details strategies that focus on relationships, respect
and opportunities for Aboriginal people to receive the right services, provided by the
right staff in the right locations.
5.
Community Participation Plan
The Community Participation Plan will be the blueprint for engaging the community,
including consumers and carers, in meaningful and effective engagement. This plan
builds on the extensive community participation already occurring across NMAHS,
including patient satisfaction surveys and community representation on various
committees and working groups.
6.
Transition Plan
The Transition Plan will detail the requirements to achieve the planned service
reconfiguration and implementation of the CSF within NMAHS and across the whole of
health system.
Page 39 of 44
Implementation
NMAHS’s mission, vision and values will drive the implementation of this Strategic Plan. The
successful implementation will require a whole of organisation focus with there being an
alignment of leadership and management capability with the strategic priorities, supporting and
enabling staff performance and responsibilities to achieve the desired outcomes. It is
imperative that all services, programs, and staff have clarity and insight as to the
organisation’s vision and strategic priorities to achieve this vision to inform decision making
and manage competing demands.
The Plan’s Strategic Priorities and Outcomes will be delivered through:
•
•
•
WA Health Operational and Business Plans
NMAHS Operational Plans
Directorate or Divisional Business Plans
As shown in the diagram below.
WA Health Strategic Intent
WA Health Operational Plan
NMAHS Strategic Plan
NMAHS Operational Plan
Service/Directorates Division
Strategic Plan
Service/Directorates Division
Operational Plans
It is vital that the Strategic Plan remain flexible and current over the three year period until
2015. To ensure this, the outcomes and deliverables to achieve the five Strategic Priorities will
be reviewed annually at the NMAHS Area Executive Group and with the Governing Council.
Page 40 of 44
Glossary
Abbreviation
Meaning
ABF / ABM
Activity Based Funding / Activity Based Management
ACHS
Australian Council on Healthcare Standards
AHS
Area Health Service
AHU
Aboriginal Health Unit
CAC
Carers Advisory Council
CAHS
Child and Adolescent Health Service
CALD
Culturally and Linguistically Diverse
CE
Chief Executive
CM
Contract Management
COMM
Communications
CP&R
Clinical Planning and Redevelopment
CSF
Clinical Services Framework
CSP
Clinical Services Plan
D
Director
DSD
Director Strategic Development
ED
Executive Director
F
Finance
FM
Facilities Management
FSH
Fiona Stanley Hospital
HIN
Health Information Network
HITH
Hospital in the Home
ICT
Information Communication Technology
JHC
Joondalup Health Campus
KEMH
King Edward Memoral Hospital
KPI
Key Performance Indicator
M
Manager
MHS
Mental Health Service
MOU
Memorandum of Understanding
MS
Medical Services
Page 41 of 44
NATA
National Association of Testing Authorities
NGO
Non-governmental Organisation
NMAHS
North Metropolitan Area Health Service
NS
Nursing Services
OAG
Office of the Auditor General
OPH
Osborne Park Hospital
PHAC
Public Health and Ambulatory Care
PPP
Public Private Partnership
RITH
Rehabilitation in the Home
PW
Pathwest
QEII MC
Queen Elizabeth II Medical Centre
SCGG / SCGH
Sir Charles Gairdner Group / Sir Charles Gairdner Hospital
SDH
Swan District Hospital
SKHS
Swan Kalamunda Health Service
SQ&P
Safety, Quality and Performance
SQuIRe
Safety and Quality Investment for Reform
WF
Workforce
WACHS
WA Country Health Service
WNHS
Women and Newborn Health Service
Page 42 of 44
NMAHS Organisational Chart
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