Excellence in Clinical Leadership
Clinical Leadership Program Projects 2008

The Clinical Excellence Commission________1

Clinical Leadership Program______________2

Selected Project Summaries______________6

Past Participant Testimonials____________33

List of 2008 CLP Projects______________34

Acknowledgements___________________44

Clinical Excellence Commission

PO Box 1614

Sydney NSW 2001

Tel: (02) 9382 7600

Fax: (02) 9382 7615

www.cec.health.nsw.gov.au

This work is copyright. It may be reproduced in whole 
or part for study or training purposes subject to the 
inclusion of an acknowledgement of the source.

It may not be reproduced for commercial usage or sale.

Reproduction for purposes other then those indicated 
above require permission from the Clinical Excellence 
Commission.

The CEC Clinical Leadership Program has no association 
with the Royal College of Nursing, United Kingdom (RCN, 
UK) Clinical Leadership Programme, represented in 
Australia by the Royal Adelaide Hospital.


I 

Clinical Leadership Program


The Clinical Excellence Commission

The Clinical Excellence Commission (CEC) 
is committed to making healthcare in 
NSW demonstrably better and safer for 
patients and a more rewarding workplace 
for healthcare workers. To achieve this will 
require effective and supportive clinical 
leadership at all levels of the system, where 
those in positions of leadership have both the 
skills and support to carry out their roles in a 
compassionate, safe and effective manner. 

The CEC Clinical Leadership Program was 
initiated in 2006, and this booklet reports 
on the continuation of the process with the 
results of the 2008 program. The importance 
of investing in clinical leadership programs 
has been noted in recent reports, both the 
statewide Garling report and the National 
Health and Hospitals Reform Commission 
report. Recognition of the link between 
leadership, patient safety and governance 
is also supported, where it is recognised 
that patients and staff are at the heart of 
healthcare. 

I am pleased to commend this booklet to 
wide use, in the hope that, in addition to 
highlighting the benefits of the Clinical 
Leadership Program to the NSW health 
system, the projects detailed herein will 
encourage others to apply the findings or 
develop them further. 

Professor Clifford Hughes AO

Clinical Professor

Chief Executive Officer

Clinical Excellence Commission



I

Clinical Excellence Commission

The continuation into 2008/09 of the 
successful Clinical Leadership Program 
(CLP), initiated in 2006, is marked again with 
the publication of this booklet. 

The aim of the program remains to build 
a cohort of effective clinical leaders who 
progressively become the Ôcritical massÕ 
needed for patient-centred system change. 

The Clinical Leadership Program is offered in 
two different modes: statewide and modular. 
The statewide program is a multidisciplinary 
program, targeting clinicians at a middle 
management level. It is delivered by local 
area facilitators within an area health service. 
The modular program targets senior clinician 
managers, and is delivered as five intensive 
modules in Sydney. Participants attend 
modules which focus on the personal and 
professional attributes of effective leaders.

Both programs require the completion of 
a clinical service challenge which provides 
the opportunity for participants to apply the 
skills and learning they have gained from 
the program. The challenge also enables 
the strengthening of links between effective 
governance, core leadership competencies, a 
culture of safety and quality and continuous 
improvement.

Clinical Practice Improvement (CPI) 
methodology is a key learning area of the 
program as it provides the model upon which 
the clinical service challenge can be based. 
This methodology requires the participants to 
identify a problem in their clinical area which 
directly impacts on patient care. 

Publication of this booklet has a twofold 
purpose. One is to present some of 
the clinical projects, their methods and 
outcomes; the other is to encourage the 
sharing and application of the projects more 
broadly throughout the health system. 


Clinical Leadership Program



There is a list of all projects undertaken by 
the 2008 cohort of both the statewide and 
modular CLP participants in this booklet. All 
participants are to be congratulated on their 
achievements; there was a broad scope of 
issues addressed. The projects chosen for 
inclusion in this booklet were selected due to 
the quality of the participantsÕ submissions 
to the CEC. 

The CEC acknowledges the contribution 
and cooperation of the participants, 
their facilitators, managers, the Clinical 
Governance and Clinical Redesign Units 
within area health services, and the 
considerable expertise provided by an 
extensive external faculty of trainers. Our 
thanks go to all for their involvement.

Ms Bernie Harrison

Director, Organisation Development & Education

Clinical Excellence Commission

Overview of CPI methodology


Aims statement

Project team

Problem Identification

Ongoing monitoring

Outcomes

Future plans

Conceptual Flow of process

Customer Grid 

Data 

- Fishbone

- Pareto chart

- Run charts

- SPC charts 

Annotated run 
chart

SPC charts

Plan a change

Do it in a small test

Study its effects

Act on the results 


If you would like more information about the Clinical Leadership Program or would like further details about 
any of the projects please contact: Clinical Excellence Commission, GPO Box 1614, Sydney NSW 2001; 
Ph: 02 9382 7600; Fax: 02 9382 7615; Email:clps@cec.health.nsw.gov.au; ww.cec.health.nsw.gov.au



Thirty senior clinician managers successfully 
completed the Modular program in 2008.

A clinical service challenge was completed 
by each participant as part of the program 
and this has served to equip them as 
advocates for patient safety along with 
assisting them to integrate health system 
improvement into their everyday clinical 
practice. 

The clinical service challenge areas 
encompassed a broad array of topics, 
ranging from improving clinical treatment 
(in areas such as psoriasis, transfusion 
medicine, pregnancy, delirium, alcohol 
withdrawal) to system-wide enhancements 
including clinical governance teams, 
workforce flexibility, models of care, strategic 
planning and Junior Medical Officer (JMO) 
rotation periods. 

Participants presented a summary of their 
projects to fellow participants and CEC 
representatives prior to graduation. 

The Modular program


2008 Modular Clinical Leadership Program - Presentation Day, 8th November 2008.
Back row L-R: Greg Hugh (GWAHS), Frank Moloney (GWAHS), Michael Golding (SESIAHS), James Donnelly (SESIAHS), 
Doug Andrews (NCAHS), Stuart Turner (HNEAHS), Pablo Fernandez-Penas (SWAHS). 

Middle row L-R: Christine Packer (GSAHS), Liz Mullins (Program Facilitator), Katherine Brown (SESIAHS), 
Wendy Cox (Director CGU SESIAHS), Leonie Watterson (NSCCAHS), Joanne Ging (NSCCAHS), Frances Monypenny 
(NSCCAHS), Kathryn Carmo (CHW), Mark Cross (SSWAHS), Helen Gillespie (NSCCAHS), Kevin Quan (GWAHS). 

Front row L-R: Wolfgang Weninger (SSWAHS), Michael Peregrina (NSCCAHS), Patricia Saccasan-Whelan (GSAHS), 
Mark Dexter (SWAHS), Bernie Harrison (CEC), Bruce Barraclough (CEC Board), Teresa Pudo (CEC), Kay Wright (CEC).



Over 170 people successfully completed the 
program in 2008. 

The Statewide program is delivered at 
an area health service level by local 
facilitators. As a part of the program, 
participants undertake a Clinical Practice 
Improvement project and present this to 
area management, sponsors and CEC 
representatives at the end of the program.

Projects undertaken in the statewide CLP 
involve working with a project team to 
develop an improvement initiative at the 
local level. 

The range of projects undertaken by the 
2008 cohort represented a broad range 
of topics, from specific clinical areas to 
broader system and workforce development 
initiatives. 

A list of all projects undertaken by the 
Statewide and Modular cohorts is provided 
in the back section of this booklet, with 
a selection of projects showcased in the 
following pages.

The Statewide program


South Eastern Sydney Illawarra Area Health 
Service - Southern Network, Statewide 
2008 CLP participants (TRACS Project). 
Left to Right: Sarah Foulstone, Susan Dileva, Rebekah 
Reurich, Maren Jones, Coral Levett (CLP facilitator), 
Helen Troy, Anthony Arnold, Anne Lees, Verica Marin, 
Sue-Ellen Hogg.

The ChildrenÕs Hospital Westmead, 2008 
CLP participants and program leaders.
Front row: Colleen Leathley (CEC Statewide Coordinator), 
Helen OÕGrady CHW CLP Program Manager, Bernie 
Harrison (CEC Director), Sonya Bubnij (CHW CLP 
Facilitator). Middle Row: Sarah Clarke, Tracey Marshall, 
Margaret Kelly, Chrissy Ceeley, Claire Blackburn, Gloria 
Tzannes, Erin Sheehan. Back Row: Jan Hancock, 
Amy Walker, Frank Horn (CHW Director of Workforce 
Development / CLP Program Sponsor). 



Getting on TRACS: Investigating issues affecting the 
occupancy levels of the Illawarra Transitional Aged Care 
Service (TRACS)

______________________________________7

Youth Mental Health Ð Getting It Right

_____________________________________10

Paediatric Pain Management: No Laughing Matter - 
Nitrous Oxide (N2O) administration to Paediatric Patients

_____________________________________12

Improving client attendance rates at the Brain Injury 
Clinic (BIC)

_____________________________________15

One Step at a Time

- Improving access to podiatry services

_____________________________________16

Drying out with Dignity: medically supervised alcohol 
withdrawal in the Shoalhaven, an Aboriginal Health 
solution

_____________________________________19

Paediatric Ambulatory Care Service

_____________________________________21

Following Up: To call or not to call? Streamlining follow-
up calls to parents and carers of children with asthma

_____________________________________24

Palliative Care Pathway for 
End of Life Care

_____________________________________26

Tweed Valley Aged Care Assessment Team (ACAT) 
Waiting Times Project

_____________________________________28

Nutrition Assistant in a Rural Health Service: optimising 
nutrition

_____________________________________31

Selected

Project Summaries 

Clinical Leadership

Program - 2008



Clinical Leadership Program - Project Summaries

Getting on TRACS: Investigating 
issues affecting the occupancy 
levels of the Illawarra 
Transitional Aged Care Service 
(TRACS)

Verica Marin RN TRACS, Anthony Arnold 
Chief Radiation Therapist, Sue Ellen Hogg 
Speech Pathologist, Susan Dileva Regional 
Operations Manager, Sarah Foulstone Social 
Work, Anne Lees CNC, Rebekah Reurich 
Social Work, Helen Troy Physiotherapist, 
Maren Jones Physiotherapist, Coral Levett 
Facilitator

South Eastern Sydney Illawarra Area Health 
Service (SESIAHS) 

Problem/Background

In 2007 the Illawarra Transitional Aged Care 
Service (TRACS) had a bed occupancy rate of 
59%. This compared poorly with an average 
of 79% occupancy across similar programs 
throughout NSW. The Southern Hospital 
Network (SHN) participants of the Clinical 
Excellence CommissionÕs Clinical Leadership 
Program selected TRACS as the team project 
for 2008.

Aim

The aim was to achieve and maintain a 
100% usage rate of the community based 
TRACS based in the Illawarra, within six 
months.

Problem identified

The TRACS program provides clients aged 
65 and older with individually tailored therapy 
in their own homes from six to twelve 
weeks. Statistical data for 2007 showed 
that TRACS operated at 59% utilisation that 
year. This compared poorly with an average 
of 79% usage across similar programs 
throughout NSW (SESIAHS Transitional Care 
KPI Occupancy data). Due to the low level 
usage, no additional funded places were 
provided for TRACS in 2008.

Investigation of the extent of the insufficient 
utilisation problem was done through surveys 
of clinical staff and referrers; discussions 
with stakeholders; and a fishbone analysis 
of issues identified by the project team. The 
findings assisted the project team to direct 
their strategies and make recommendations. 
Valuable guidance and support was obtained 
from the SHN executive and the Clinical 
Practice Improvement unit. Issues identified 
were prioritised by the project team using a 
Pareto analysis.



Changes made

The following table shows the problems identified in the areas of systems, communication and 
process, with the solution implemented to redress the deficit in each case.

Systems Issues

1. Lack of program data available 

 

2. Lack of clear referral criteria 

 

Communications Issues

3. Confusion and lack of information 
available to staff 

4. Information pamphlets were outdated 
and not readily available

5. Need to increase TRACS profile 

6. Feedback mechanism issues following 
the referral process 

Process Issue

7. Intra-team and stream reporting issues

Implemented Solutions

a. Reconfiguration of the Community Health 
Information Management Enterprise (CHIME) 
data system enabling access to relevant 
statistical information

a. Clear referral criteria determined and 
approved by key stakeholders

b. Referral criteria clearly documented with 
a supporting flowchart.

Implemented Solutions

a. Education strategy developed 

a. Existing pamphlet updated

a. Inclusion in the SHN daily bed 
management teleconference

b. Promotion of TRACS as a patient pathway 
at case management meetings

a. Standard template and system for 
providing feedback to referrers developed

Implemented Solution

a. Scheduled meetings between 
TRACS team leader and management 
communicating program outcomes and 
initiatives. 



Clinical Leadership Program - Project SummariesI9

Measurement / process measures

The outcomes of the project were immediate 
and evident, with data confirming the 
increased profile of the TRACS among staff 
and stakeholders.The project culminated 

in an occupancy rate of 94.5% for JuneÐ

November 2008.This represents a % 
improvement from the previous 2-month 
period, and is well above the state average 
of 79%.

Furthermore,TRACS has recently been 
offered additional funded places to expand 
the service.

Through identifying causal and systemic 
issues that had been impacting on the 
TRACS program, improvements in access 
to this service were obtained.These 
resulted in improved primary health care 
in the community and optimal utilisation of 
resources.

Plans to sustain change

Strategies for sustaining the change 
achieved through this project include:

¥A four-tiered strategy for ongoing 
education involving:

oScheduled TRACS education sessions
oProvision of resource packs about TRACS 
to referral hospitals
oCirculation of TRACS occupancy rates on 
a daily basis
oEstablishment of a TRACS intranet site
¥Dissemination of a quarterly report to 
stakeholders

¥Ongoing benchmarking of project 
outcomes.

These strategies have been incorporated into 
the TRACS current business plan.


ÒYou begin with the end in mind,
by knowing what you dream about 
accomplishing, and then figure out how to 
make it happenÓ

Jim Pitts, Northrop Grumman Corporation.


Youth Mental Health 
Ð Getting It Right 

Mr Adrian Cobbold Clinical Nurse Consultant 
- Children & Young PeopleÕs Mental Health, 
Central Coast Children and Young PeopleÕs 
Mental Health (CC CYPMH)

Northern Sydney Central Coast Area Health 
Service (NSCCAHS) 

Problem/Background

In 2007 NSW Health allocated funding 
to NSCCAHS to establish and evaluate a 
prototype Youth Mental Health (YMH) model 
on the Central Coast (CC). This model was 
aimed at improving access to mental health 
services for 12Ð24 year olds experiencing 
moderate to severe mental health disorders 
or problems, and extending the existing 
services within CC CYPMH. 

Given that this was a pilot project, the CC 
YMH model was formally evaluated in order 
to make recommendations to other area 
health services for the reorientation of their 
current service provisions in line with the 
YMH approach. However, data collection 
during the first six months of the CC pilot 
indicated that referrals in the 18Ð24 year 
age group remained relatively low (despite 
high levels of referrals in the 12Ð17 year age 
group) and the potential of the project was 
not being fully reached. 

Aim

The aim of the CC YMH pilot was to increase 
the number of early intervention referrals 
of young people (aged 18Ð24yrs) by 75% 
(from the initial six month referral date) by 
December 2008.

Problem identified

The mechanisms used to identify the 
problem were as follows: 

¥ A planning session with YMH staff 
after six months of the initial CC YMH pilot 
project being implemented. This supported 
the previous evidence of low referral rates, 
and staff were keen to contribute ideas for 
increasing access to the services.

¥ Through evaluation questionnaires, users 
and potential users of the service reported 
dissatisfaction with and limitations to the 
existing service model.

¥ Feedback from CC Adult Mental Health 
services indicated that the existing model 
was restricted and the referral criteria were 
unclear and confusing.

Changes made

In February 2008 some of the recommended 
changes from the planning session were 
started within the CC YMH team. A decision 
was made to focus more on an intensive 
case management and assertive outreach 
model. Despite this shift, the original criteria 
remained unchanged.



In June 2008 it remained apparent that there 
were still low referrals rates (in the 18Ð24 
year age group) and inappropriate referrals, 
which led to the clinical improvement project 
team meeting over June and July 2008 to 
complete a Cause & Effect Diagram, Pareto 
Chart and Intervention Action Plan. 

Outcomes from this stage of the clinical 
improvement process resulted in prioritising 
the areas highlighted for change and setting 
out actions required to address the identified 
issues. Two of the main changes centred on:

¥ Conducting a major collaborative review 
with internal and external key stakeholders 
before amending the CC YMH inclusion 
criteria and clearly defining the early 
intervention focus 

¥ Developing and implementing a 
structured communication strategy aimed 
at effectively promoting the service with 
stakeholders.

Measurement/ process measures

Amendments to the CC YMH criteria 
have resulted in the desired outcome 
of substantially increasing the number 
of suitable referrals into the project and 
improving outcomes beyond expected 
targets. 

The quantitative data collected to 
date provides evidence of sustained 
improvements, showing:

¥ A dramatic increase of over 150% in 
the number of referrals of 18Ð24 year olds 
accepted into the CC YMH model 

¥ A significant downward slide of over 
150% in inappropriate referrals 

¥ Clients remaining engaged for longer, 
with a 75% increase in the average episode 
of care.

These findings were reinforced by the 
qualitative evidence of positive change 
including:

¥ Increased job satisfaction and retention 
rates for CC YMH staff following clarification 
to teams of the CC YMH model and the 
staffÕs roles and responsibilities, thus 
assisting team cohesion and functioning 

¥ Improved partnerships and awareness of 
pathways through hospital departments and 
other agencies, following the establishment 
of clearer expectations and guidelines.


Adrian Cobbold and Sue Leonard - Project ÔYouth 
mental health - getting it rightÕ



2 IClinical Excellence Commission

Plans to sustain change

In order to promote the CC YMH service 
criteria and pathways, and sustain project 
reporting key performance indicators, it 
is recognised that regular and ongoing 
in-service education to identified referral 
sources is required.

Other required action has also been 
identified and begun, to assist with the CC 
YMH model progression, i.e. file audits to 
determine typical client intervention profiles 
and standardised client/carer satisfaction 
surveys.

It is hoped that the formal evaluation of the 
process used to develop an effective CC YMH 
clinical model will be used to inform other 

health services planning to engage this Ôat 
riskÕ population.


ÒDonÕt let anyone tell you that you canÕt 
make a difference. If we all work on our little 
parts of the planet we will change the world.Ó
Tara Church, Quin Emanuel Urquhart Oliver 
& Hedges LLP

Paediatric Pain Management:
No Laughing Matter - Nitrous 
Oxide (N2O) administration to 
Paediatric Patients

Belinda Porter RN/CNE Emergency 
Department, Port Macquarie Base Hospital 
Emergency Department

North Coast Area Health Service (NCAHS)

Problem/Background

There are many misconceptions surrounding 
the management of pain and anxiety 
in paediatric patients which has led to 
inadequate pain relief being delivered during 
a diagnostic or therapeutic procedure.
Nitrous Oxide (N2O), is commonly used in 
Emergency Departments (ED) as a safe 
form of analgesia as it produces rapid, short 
duration analgesia without complete loss of 
consciousness in most cases (Harrop, 2007).

Various paediatric studies have been 
conducted which conclude that the 
performance of minor invasive procedures 
using N2O leads to a less distressing 
experience along with fewer adverse effects 
and shorter recovery times than that for 
those children who receive other parenteral 
forms of sedation (Hsu, 2008).

Aim

The aim of this project was that within 

two months, 100% of ÔeligibleÕ paediatric 


patients would receive non-parenteral 
sedation (specifically N2O) during minor 
laceration repair in Port Macquarie Base 
Hospital (PMBH) ED in order to improve their 
experience.

Problem identified

Retrospective data on paediatric patients, 
who had required a minor invasive procedure 
and presented to the ED in PMBH, was 
collected for the month of March 2008.

Benchmarking with other EDs within NSW 
showed that N2O is used regularly for 
children presenting with similar injuries. 
The data for PMBH showed that 0% of their 
patients received N2O as a form of sedation 
or analgesia. Therefore, a change in practice 
was required. 

A multi-disciplinary team was assembled 
comprising: the ED nursing unit manager (the 
project team leader or change agent); the 
ED medical director; the ED nurse educator, 
PMBH paediatric clinical nurse consultant 
and two ED registered nurses who have a 
paediatric background and an interest in 
improving the care of paediatric patients. A 
literature review revealed that administration 
of N2O is a safe and effective method of pain 
relief in paediatric patients.

Clinical Practice Improvement methodology 
was used to identify the causes of non 
administration of analgesia in paediatric 
patients. The team also decided that the 
most appropriate measure would be to 
collect information about the administration 
of N2O to appropriate clients. 

The team constructed a flow diagram 
of the process of pain management in 
place for paediatric patients presenting to 
the ED with conditions requiring a minor 
invasive procedure. Next, the team held 
a brainstorming session on issues arising 
from paediatric pain management. From 
this process, a cause and effect diagram 
was constructed and it appeared that 
there had been previous failed attempts 
to implement the administration of N2O as 
common practice. It was also noted that the 
N2O delivery device was not available on a 
permanent basis in the ED. This had led to 
difficulties in accessing it when needed. As 
a result, it was not used regularly and staffÕs 
knowledge of the use of N2O and the delivery 
device had diminished. 

Staff also thought, incorrectly, that patients 
needed cardiac monitoring during the 
administration procedure and this led to 
the problem of these beds often being 
inaccessible when needed. Therefore 
N2O was not seen as a simple solution 
to analgesia in the paediatric group of 
ED patients, and was thus omitted from 
paediatric pain management.

A Pareto chart was then constructed which 
emphasised that two major changes needed 
to occur in order to initiate a change and 
introduce the use of N2O into common 



practice of managing paediatric pain. The 
two changes identified were:

¥ education and accreditation in the 
administration of N2O and the use of the 
delivery device

¥ the permanent relocation of the N2O 
delivery device to the ED. 

Changes made

In response to the findings of the project 
teamÕs investigations, the following changes 
were made:

¥ Negotiation with the Paediatric ward staff 
occurred to ensure that the N2O machine is 
located in the ED on a permanent basis for 
improved access 

¥ Information about the use of N2O was 
posted around the ED. This included the 
criteria for use in paediatric patients, and a 
brief outline of the policy. A photo of the N2O 
tubing and set up was also placed on the 
delivery device

¥ Education sessions were provided to 
doctors and nurses in August, one month 
before the Ògo liveÓ date of the project. 

Measurement/ process measures

Monitoring of the change in practice showed 
that initiating education and implementing 
the use of N2O into the management of 
laceration repair in the Express Community 
Care Centre (ECCC) would also be of major 
benefit to the paediatric patients who attend 
PMBH with a minor laceration. 

It was also concluded that ongoing education 
for nurses and doctors would help improve 
the usage of N2O, and the purchase of a 
N2O machine for the ED would increase the 
likelihood of paediatric patients receiving 
adequate pain management during a minor 
laceration repair.

Plans to sustain change

The planned actions to be taken to sustain 
the change achieved by this project are:

¥ Purchase of a nitrous oxide machine for 
the ED and the ECCC

¥ Ongoing education for nurses and doctors

¥ Usage of N2O in the ED to be included in 
the orientation process for new staff.



Improving client attendance 
rates at the Brain Injury Clinic 
(BIC)

Janice Hancock Brain Injury Service 
Coordinator, Brain Injury Unit

The ChildrenÕs Hospital Westmead (CHW)

 


Problem/Background

Attendance at Brain Injury Clinic (BIC) is 
essential for multiple reasons, including 
monitoring of the clientÕs condition, 
evaluation of the clientÕs progress, evaluation 
of the familyÕs coping mechanisms, 
identifying new issues, and ensuring optimal 
care for the client. Non-attendance at BIC 
can therefore jeopardise optimal care for 
the client and the family. Brain Injury Service 
(BIS) staff identified non-attendance at BIC 
as an issue for further investigation. The rate 
of non-attendance was 33% for the first 
three months of 2008. Staff were concerned 
that patients who need assessment and 
intervention, and their families, were not 
receiving adequate care.

In order to increase attendance rate at BIC 
two main issues required review. These were:

¥ The process for making appointments, 
including communication between clients 
and their families and the BIS

¥ ClientsÕ and their familiesÕ beliefs and 
opinions about the importance of the clinic 
and why they do or do not attend clinic.

Aim

The aim of the project was to increase 
attendance of clients and families at 
scheduled appointments at the BIC of The 
ChildrenÕs Hospital at Westmead to 90% by 
December 2008.

Problem identified

Surveys of families who attended clinic 
and of those who failed to attend clinic 
were conducted using a paper survey for 
attendees and phone call enquiries for 
non-attendees. The surveys were developed 
in consultation with the Rehabilitation 
Department Parent Advisory Committee.

The data collected enabled the project team 
to identify issues related to non-attendance, 
and identify strategies to increase attendance. 

Rates of attendance were monitored using 
existing outcome clinic reports.

Changes made

Strategies used to implement necessary 
changes to redress the identified problems 
included reviewing the content of the 
current clinic letters and information sent to 
parents and developing a plan for changes 
to signage and maps directing clients and 
visitors to the Rehabilitation Department.

In addition, to promote ongoing monitoring 
of the use of the clinic, the procedures for 
collecting demographic information during 
outpatient appointments were modified.



Measurement/ process measures

A positive change in attendance rates to BIC 
was recorded with the rate of attendance at 
the end of the project at 90.4% compared 
with 67% at the beginning of the year.

Feedback from families surveyed, which was 
primarily positive, was provided to staff of the 
BIS and wider Rehabilitation Department.

Plans to sustain change

The plan for sustaining the positive 
increase in attendance at BIC includes the 
implementation of procedures to: 

¥ Regularly monitor the attendance rates 
at BIC

¥ Continue to review the levels of 
satisfaction of clients and families who 
attend BIC. This will include surveying 
attendeesÕ satisfaction with the service and 
reviewing communication procedures for 
arranging appointments.

This implementation will continue in 
2009/2010 as part of reviewing the 
DepartmentÕs family-centred practice.

One Step at a Time

David Cooper Podiatrist, 

Hastings / Macleay Podiatry services

North Coast Area Health Service (NCAHS)

Problem/Background

Clients with foot ulcers or infections were 
waiting up to four weeks to receive what 
should have been urgent podiatry treatment. 
The improved ÔPodiatry Practice GuidelinesÕ 
state that treatment for such conditions 
should be initiated within two working days 
from referral.

This problem is an issue for:

¥ All professions involved in the treatment 
of these clients 

¥ The clients themselves, who are at risk of 
developing chronic conditions

¥ The Health Department, due to the 
financial management implications of chronic 
health conditions.

Aim

The aim of the project was that within 4 
months, 80% of podiatry clients referred 
with a foot ulcer or infection would be able to 
access Hastings / Macleay Podiatry services 
within two working days from referral.

Problem identified

The investigation and analysis stages of the 
project involved a multi-disciplinary team 
in conjunction with Podiatry services which 



Clinical Leadership Program - Project SummariesI 7

included Community Nursing,Wound Clinic 
and administration staff.

Waiting times of very high risk clients and 
patients with ulcers were measured and 
compared to the benchmarks set out in the 

ÔBetter practice guidelines for managing 
appointments in podiatry servicesÕ.Analysis 

showed that only 7% of clients with an 
active ulcer or infection, and only 9% of very 
high risk clients, were being seen within 
benchmark waiting times.

The main factors identified as causing the 
access block were (in order):

¥Administration procedures not being 
clearly defined

¥Podiatry staffing levels
¥No podiatry intake forms
¥Limited podiatry clinical hours
¥Poor appointment book management.
As improving podiatry staffing levels was 
deemed to be outside the scope of this 
project, the first focus was to measure the 
number of work hours allocated to direct 
clinical contact.The number was determined 
to be the maximum that could be achieved 
without:

¥An increase in podiatry staffing levels
¥Ceasing outreach clinical services to 
allow travelling time to be reallocated to 
extended clinical hours at major centres

¥Ceasing other vital clinical services 
such as community education sessions and 
orthotic therapies.


Given this, the other aspects of the problem 
regarding administration and bookings 
became the issues for redress in attempting 
to fulfil the project aim.

Changes made

An intervention plan was implemented 
that involved three components of process 
alteration to redress issues identified in the 
problem analysis.

The first was a review of administration 
procedures comprising:

¥Consultation with administration staff to 
identify the specific current problems

¥Involvement of administration staff in the 
development of new intake procedures

¥Implementation of a flow chart for 

administration staff to follow to assess the 
urgency of referrals

¥ Individual training of administration staff 
in the new procedures.

The second was in relation to the lack of 
intake forms, wherein two steps were taken:

¥ A review of other servicesÕ intake forms 
was conducted

¥ Consultation was undertaken with 
administration staff in the development of an 
appropriate intake form for podiatry services 
at Hastings / Macleay.

The third process undergoing alteration was 
the appointment book management. The 
review here identified: 

¥ An increase in the number of urgent 
appointments available on each clinical day

¥ Longer waiting times for assessment of 
low risk diabetic clients

¥ The establishment of a waiting list for 
all assessments not deemed an ÒActive 
ProblemÓ, a ÒVery High RiskÓ or a ÒLow RiskÓ 
or ÒDiabeticÓ.

Measurement/ process measures

The new procedures resulting from these 
reviews were instrumental in achieving an 
increase in Active Problem clients seen by 
the Podiatry service within benchmarks from 
17% to 47%. This increase was obtained 
even with an increase of 250% in the 
number of referrals. The average length of 
waiting time fell from 8.7 to 3.3 working 
days. 

There was an increase in Very High Risk 
clients seen by the Podiatry service within 
benchmarks from 9% to 62.5%. The average 
length of waiting time fell from 46.2 to 12.4 
days.

The greatly decreased length of delay in 
receiving treatment from referral means 
that clients that are requiring urgent care 
are receiving this on more occasions than 
not. This results in quicker healing times, 
with less development of chronic conditions, 
both of which are of cost benefit to the 
Health Service. Clients are receiving a better 
standard of health care with higher levels of 
client satisfaction. 

Plans to sustain change

The improvements made continue to be 
maintained through:

¥ The development of clearly defined intake 
procedure flow charts and intake forms 

¥ Training of all new and casual 
administration staff in the intake procedures

¥ Continual education of staff in the major 
referral sources.

In addition, the podiatry serviceÕs waiting 
times are continually monitored with incident 
reporting measures taken when breaches of 
benchmarks occur.



Drying out with Dignity: 
medically supervised alcohol 
withdrawal in the Shoalhaven, 
an Aboriginal Health solution

Clinical Associate Professor Katherine 
Brown Clinical Stream Director, Population 
Health & Primary Care

South Eastern Sydney Illawarra Health 
Service (SESIAHS) 

Problem/Background

Aboriginal people with co-morbidities in 
Shoalhaven need to access a medical 
withdrawal service locally. Health 
professionals and advocates for Aboriginal 
health considered that a new facility was 
needed for this purpose.

 

Australian data indicates that:

¥ Alcoholism is 11 times higher in 
Aboriginal people 

¥ 45% of Aboriginal people who drink do 
so at risky levels compared with 12% of the 
general population 

¥ Aboriginal male drinkers are five times 
more likely to die and nine times more likely 
to be hospitalised than non-Aboriginal male 
drinkers

¥ Aboriginal female drinkers are four times 
more likely to die and 13 times more likely to 
be hospitalised than non-Aboriginal female 
drinkers.

 

Aim 

The aim of the project is that SESIAHS 
Southern Hospital network will provide a 
functioning sustainable system for medically 
supervised withdrawal from alcohol for 
clients with co-morbidities.

Problem Identified

Aboriginal people comprise 3.8% of 
ShoalhavenÕs population. Shoalhaven has 
the highest death rate in SESIAHS. Aboriginal 
deaths are 1.6 times higher than the 
SESIAHS average, with avoidable deaths 
being 2.4 times higher. Alcohol causes 13% 
of drug related deaths. 

There were 149 Aboriginal people admitted 
to Shoalhaven District Memorial Hospital 
for alcohol related problems in 2007. 84 
admissions related to mental & behavioural 
disorders associated with alcohol, while 27 
related to withdrawal from alcohol. 


A/Prof Katherine Brown and Prof Bruce Barraclough, 
CEC Board Chairman at the CLP Modular presentation, 
November 2008.



There were 67 presentations to Shoalhaven 
Hospital by Aboriginal clients needing 
alcohol withdrawal treatment. Co-morbidities 
included cardiovascular, respiratory and renal 
diseases. 

Many Aboriginal people prefer to receive care 
close to land and family. Access to skilled 
medical staff who can provide hospital-based 
care is problematic, and separate access to 
a community facility is required for clients 
with social rather than medical problems. 

Aboriginal service providers and community 
members had identified the problem 
and sought assistance in meeting their 
communitiesÕ needs. 

Changes made

In the absence of a specialist in Addiction 
Medicine, the Clinical Stream Director for 
Population Health and Primary Health Care 
suggested appointment of a lead clinician 
to take responsibility for medical withdrawal 
from alcohol for patients with co-morbidities. 
The local infectious disease physician 
was approached, as he already treated 
marginalised populations for hepatitis C. 

Protocols for medical withdrawal from 
alcohol were obtained from Langton Centre 
in Sydney. All patients requiring admission for 
medically supervised withdrawal from alcohol 
are assessed by the Shoalhaven Drug and 
Alcohol team. Admissions are planned and 
discussed with the admitting medical team. 
Clients needing social support in addition to 
treatment are not admitted to prevent such 
social support requirements becoming the 
focus for hospital staff. Clinical backup is 
provided from the Langton CentreÕs Addiction 
Medicine physicians. Local support during 
the admission is provided by a CNS in 
Addiction Medicine. Outpatient follow-up is 
provided by the Drug and Alcohol service on 
discharge.

Measurement/process measures

Establishment of the program has resulted 
in improvements in the local management 
of alcohol withdrawal clients, measured in 
terms of the reported progress from the 
various service representatives involved.

The lead clinician reports the following:

¥ elective admission means the 
detoxification process is smoother for the 
client

¥ unnecessary admissions have been 
avoided

¥ clients have benefited from involvement 
of the Drug and Alcohol service throughout 
the process

¥ other physicians are now willing to 
undertake these admissions if the lead 
clinician is unavailable. 

Aboriginal Health services report that:

¥ the lead clinician is very supportive

¥ planned intake has increased acceptance 
from staff and clients



¥ withdrawal is now seen as a health issue, 
not a nuisance.

Southern Network Drug and Alcohol Service 
reports that this process has improved their 
relationship with Shoalhaven Hospital.

Plans to sustain change

The implemented change is planned to be 
sustained through:

¥ Maintenance of intensive support from 
the local Drug and Alcohol services

¥ Maintenance of links with the specialist 
Addiction Medicine service in Sydney until 
local specialist support is available south of 
Sydney.

Paediatric Ambulatory Care 
Service

Mr Michael Peregrina Divisional Manager & 
Dr. Joanne Ging Clinical Director,

Division of WomenÕs & ChildrenÕs & Family 
Health, Hornsby Ku-ring-gai Health Service

North Sydney Central Coast Area Health 
Service (NSCCAHS) 

Problem/Background

The capacity of the paediatric inpatient unit 
at Hornsby Ku-ring-gai Health Service (HKHS) 
was reduced from 18 beds to 12 beds with 
the opening of the new ward in November 
2006.

This created potential for access block, long 
waits in the Emergency Department (ED) 
and reduced capacity for elective surgery. 


Dr. Joanne Ging - Paediatrician / Nicole Page- Clinical 
Nurse Specialist / Debbie Skinner- NUM Paediatric 
Ward / Dr. Anna Gill- Paedaitrician / Michael Peregrina- 
Divisional Manager



Furthermore,

¥ Paediatric ED presentations have 
increased since 2005 (4965) to 2007 (6978) 
by 28%

¥ Paediatric separations increased by 23% 
in the same period

¥ Paediatric patients who did not wait 
increased by 24%

¥ With reduction of inpatient beds from 
2005 to 2007, access block of paediatric 
beds has increased from 2.8% to 6.7%.

Aim

The aim of the project was to reduce access 
block in the Paediatric Ward within 18 
months to ensure that all children and their 
families are able to access and be supported 
by a model of care that is appropriate to their 
needs using existing resources.

Problem identified

With a 10% increase in paediatric 
presentations to ED and the reduction of bed 
numbers at Hornsby Ku-ring-gai Hospital 
(HKH) Paediatric Ward, a potential for access 
block was identified, particularly during the 
winter peak. A small working party was 
formed to develop strategies to minimise 
access block during winter. In order to use 
existing resources to develop new paediatric 
models of care a project team was formed, 
and using CPI methodology, a cause and 
effect diagram and a Pareto chart were 
developed. 

Two possible interventions were identified. 
These were: (a) introduction of a Paediatric 
Ambulatory Care Service and (b) changing 
the theatre admission times for surgical 
patients. It was determined that the first of 
these would be the target for this project.

Changes made

The HKH PACS opened in July 2007. PACS 
was implemented at neutral cost. The model 
of care currently incorporates:

¥ daily acute review clinics

¥ telephone support.

Planning for service implementation 
included:

¥ Development of a ÒdashboardÓ to capture 
the service-related data 

¥ Consultation with Wyong Hospital PACS 
staff prior to implementation at HKHS. 
Ideas were shared between Wyong PACS 
and HKHS wherever possible and the units 
worked together to develop shared forms, 
guidelines, referral criteria and policies. 

The HKHS PACS clinic is run by a 
paediatrician and a registered nurse five 
days per week. Children are referred to the 
service by the ED, GPs, paediatricians and 
the childrenÕs hospitals. Children who are 
on the borderline for admission, especially 
overnight, can have treatment started 
including intravenous antibiotics which can 
be continued at home and reviewed the next 
day. Children can also be discharged earlier 
from the ward with treatment completed as 
outpatients. 



Measurement/ process measures

In the 10 months since HKHS PACS 
commenced operation there has been:

¥ 1890 non-admitted patient occasions of 
service (phone calls and clinic visits)

¥ Parent satisfaction surveys conducted 
showing very positive results with high levels 
of praise and satisfaction with the care given, 
i.e.,

 ¥ 100% of parents reported that PACS 
met their childÕs needs

 ¥ Parents commented that follow up 
phone calls were good as it gave them an 
opportunity to ask questions

 ¥ Reports received stated that staff 
were friendly, calm, efficient

 ¥ 100% of respondents reported they 
would recommend this service

¥ Simplifications of the clinic, allowing 
quick and easy access to a personalised 
service 

¥ Coordination of services

¥ At least two bed days saved per day

¥ Thursday access block improvements.

This project, together with PACS (Wyong 
Hospital), was a finalist in NSW 2008 
Quality Health Awards for the ÒCreate better 
experiences for people using health servicesÓ 
category.

Plans to sustain change

The HKHS PACS was established and is 
operating within existing resources and 
demonstrates a cost-effective, sustainable 
model of care. 

There is ongoing collaboration between 
Wyong and HKHS in the development of 
services. This collaborative approach in 
developing standard forms, guidelines and 
procedures shows potential for collaboration 
and support for similar service development 
on a wider scale across NSW. Consideration 
should be given to developing PACS (short 
stay units, outreach care and telephone 
support) to complement traditional inpatient 
models of care. 



Following Up: To call or not to 
call? Streamlining follow-up 
calls to parents and carers of 
children with asthma 

Tracey Marshall CNC Asthma Education

Respiratory Function Unit

The ChildrenÕs Hospital Westmead (CHW)

Problem/Background

The Asthma Education Service (AES) provides 
a Monday to Friday Service from 7.30am to 
5pm and is primarily responsible for follow-
up calls regarding children with a diagnosis 
of asthma. The purpose of the follow-up 
call is to ensure that the families of children 
who are discharged outside business hours 
receive an offer of educational support.

Aim

The aim of the project was to develop the 
criteria for which childrenÕs families should 
receive a follow-up phone call in regards 
to asthma education and management 
issues. The follow-up calls are for children 
whose asthma management is complex or 
where asthma education issues have been 
identified.

Problem identified

In past years the AES has provided follow-up 
phone calls for children with asthma who 
have been discharged outside business 
hours. The follow-up call is based on clinical 
judgment, but in order to ensure safety, 
quality and equality the aim of the project 
was to establish the set criteria for making 
follow-up calls. In order to achieve this, 
a multi-disciplinary team approach was 
adopted to develop the criteria that would 
guide the process of performing follow-up 
calls. 

Changes made

There were two main changes adopted as a 
result of this project:

¥ the development of AES criteria for 
follow-up calls

¥ the development of a new template to 
provide consistency in the type of questions 
that parents are asked in follow-up calls.

The Ôdischarge asthma patientÕs follow-upÕ 
template was developed and implemented. 
All calls are now documented in a software 
system using Powerchart which allows other 
health professionals to document follow-up 
calls for this group of children. 

 

Key stakeholders were engaged using a 
variety of strategies such as team meetings, 
progress reports and updates on the 
dedicated CHW Asthma webpage. 

Changes were implemented over a six month 
period.

The utility and efficacy of follow-up calls was 
evaluated by a parent survey in June 2009.

 



Clinical Leadership Program - Project SummariesI 2 

Measurement/ process measures

For May to July 2007, the AES performed 
99 follow-up calls.The results from May to 
July 2008 showed there were 7 follow-up 
calls during this time. Eight children did 
not meet the draft criteria, mainly due to a 
diagnosis of wheeze, and one return call was 
made to a parent from a past admission.The 
follow-up calls were made within 72 hours of 
discharge of the patient.

In addition, due to the revised procedure,
all follow-up calls were documented. 69 
of the calls were documented either in the 

phone consult or in the ÔDischarged asthma 
patientsÕ follow-upÕ template.

The remaining two of the total 7 calls were 
only documented in the patient diary.This 
was because no Medical Record Number 
was available at the time of the call.

The length of calls ranged from five to 0 
minutes.

The Clinical Indicator Comparative Report 
(CHW) for 2002 to 2008, in September 2008 
showed that:

¥The re-admission rate for children with 
asthma from January to June 2008 is down 
to 2. % as compared with the rate for the 
same period in 2007 of .8% 

¥The development of the criteria for follow-
up calls resulted in no harm or increase in 
re-admissions even though fewer follow-up 

Tracey Marshall, CNC Asthma EducationRespiratory Function Unit


calls were made from mid-May to mid-July 
as compared with the same period in 2007.

Plans to sustain change

The CHW is investigating implementing the 
criteria in other paediatric services such as 
the Asthma Education Service at Sydney 

ChildrenÕs Hospital.The Òfollow-up phone 
criteriaÓ will form the basis for development 

of inpatient consultation criteria.


Ó Leaders are people who modelgood practice, challenge poor practiceand inspire others.Ó

Health Foundation


Palliative Care Pathway for 
End of Life Care

Caroline Short CNC Palliative Care, 

Cessnock Community Health

Hunter New England Area Health Service 
(HNEAHS) 

Problem/Background

Care for the dying is important and, from 
the palliative care perspective in particular, 
how that care is delivered is a measure 
of the success, not failure of health care 
professionals.

According to Costello (2001), a culture of 
death avoidance has led to care that is 
often unplanned, sub-standard, and which 
excludes patients, carers and families from 
end of life discussions and decision-making. 
This occurs despite the publicÕs reliance 
on health professionals to care at this most 
significant time in patientsÕ and carersÕ lives.

This may have far reaching consequences 
for health teams, as well as families and 
society generally (Ellershaw & Ward 2003).

 

Evidence suggests that this problem is 
extensive throughout hospitals in the 
developed world (Costello 2006; Gomes 
& Higginson 2006). These problems are 
attributed to reliance on medical models of 
care amid the complexity of a death-denying 
society.

Aim

The aim of this project was to improve end 
of life care for dying people by increasing the 
ability of hospital nurses to diagnose dying in 
80% of expected deaths in the last few days 
of life. The timeline for meeting the project 
aim was within three months.

Problem identified

Inability to recognise the signs of imminent 
death in palliative care patients resulted 
in formal and informal complaints from 
relatives. This problem was also identified 
through anecdotal evidence and requests 
for further education from hospital nurses, 
and through bereavement visit feedback 
from carers. In 2002, a Palliative Care Ôcarer 
satisfaction surveyÕ also demonstrated that 
there was an opportunity for improvement.

 

A pre-project file audit was conducted in 
Cessnock District Hospital to establish the 
extent of the problem using the Liverpool 
Care Pathway (LCP). This tool recognises the 
challenges of the prevailing Ôdeath-denying 
attitudesÕ and promotes excellence in end of 
life care in any setting.

Changes made

The project implemented an end of life 
pathway and associated education and 
procedures suited to the lower Hunter 
environment. This strategy had the potential 
to increase nursesÕ abilities to diagnose 
dying and enable the implementation of 
improved end of life care for dying people.



Measurement/ process measures

Evaluation of the end of life pathway project 
clearly showed that the end of life care 
for dying people had improved. This was 
demonstrated by an increase in the ability of 
hospital nurses to diagnose dying in 85% of 
expected deaths in the last few days of life, 
up from 45% in the pre-project audit.

End of life pathway commencement is 
dependent on recognising the determinants 
that are indicative of terminal status. The 
greatest improvement was in the ability 
to recognise patientsÕ inability to swallow 
tablets. 

The following results were also achieved:

¥ A 30% improvement in cessation of 
inappropriate interventions 

¥ Improved referral to palliative care 
services for people with chronic disease

¥ Improved documentary evidence of good 
practice and symptom control, e.g., a 20% 
improvement in pain management and 
appropriate use of analgesia and a 15% 
reduction in nausea and vomiting through 
improved anticipatory use of antiemetic

¥ Nursing staff utilised the end of life 
pathway to address the Ôplan of care of 
the dyingÕ with carers and families. They 
were able to reassure relatives of the best 
practice, evidence-based care contained in 
the pathway. 

¥ Nursing staff developed skills in an area 
where they were previously anxious

¥ The end of life pathway prompted staff to 
provide grief brochures and to discuss the 
grieving process. This has initiated further 
requests for education and skill development 
in the area of grief and bereavement, to 
assist in ÔnormalisingÕ the process.

Plans to sustain change

Following the success of the pilot project 
at Cessnock district hospital, the end of 
life pathway project has been extended to 
Singleton and Kurri Kurri hospitals within the 
lower Hunter cluster.

The palliative care team continues to 
provide ongoing support and developmental 
education to the hospital resource nurses 
and other nurses. Auditing and variance 
analysis has continued. 


Community and hospital nurses working together to 
improve end of life care. NSW Rural Nurse Workshop 
March 2009. Trish Ling; Caroline Short; Michelle Wiehe; 
Anne Scott; Louise Ball; Emma Wesseling; Debborah 
Olsen; Kate Stuart.



28 IClinical Excellence Commission

The project materials have been developed 
so that they can be used in other facilities of 
the HNEAHS.

Ongoing evaluation and variance analysis 

is occurring in conjunction with the UKÔs 

Liverpool Care Pathway Collaborative, and 
this will allow for international benchmarking.


ÒLeadership is ultimately about 
creating a way for people to contribute to 
making something extraordinary happen.Ó

Alan Keith, Genetech

Tweed Valley Aged Care 
Assessment Team (ACAT) 
Waiting Times Project

Siobhan Laffey Integrated Care Coordinator,
Tweed Valley Aged Care Assessment Team

North Coast Health Service (NCAHS

Problem/Background

¥
tional Guidelines from the Commonwealth 
Department of Health and Aging recommend 
that:Category 3 clients (in the community) 
are to be assessed within 3 months of refer¥
ral to the Aged Care Assessment Team.

Tweed Valley Aged Care Assessment Team 
data indicated 66. % of Category clients 
in the community setting were assessed 
according to these guidelines.

Prior to undertaking the project, the 
prioritising of ACAT clients was conducted 
by the clinical team members rostered onto 
the daily intake roster.Anecdotally, when 
a person contacted the administration 
officers at ACAT they were ready to give 
all the information required for referral for 
service.This information was held by the 
administration staff pending the availability 
of a clinician to progress the intake and 
allocate a suitable category. In some 
instances it could take several weeks for the 
clinician to make contact with the client for 
categorisation to occur.


From the initial contact with the ACAT the 
client data was recorded on the minimum 
data set (MDS) indicating they had been 
referred to the service and were awaiting 
assessment. This data reflected a lengthy 
timeframe between initial contact with 
the service and subsequent conduct of 
assessment.

Aim

The aim of the project was to reduce the 
average waiting time for assessment by 
Tweed Valley Aged Care Assessment Team 
(ACAT) by 30% for community based clients, 
within six months.

Problem identified

Utilising the principles of Clinical Practice 
Improvement, the team set about identifying 
the components that influence an efficient 
prioritisation of an ACAT Client. The Pareto 
chart identified the two key areas for 
improvement, i.e. the referral tool for ACAT 
assessment and the intake process. 

To check the accuracy of the waiting list 
at the starting point of the project, 120 of 
the 183 existing referrals were contacted 
for updates on their requests and need 
for assessment. As a result, 52 referrals 
withdrew, leaving 132 referrals remaining. 

A workload tool was provided by an external 
consultant and used to equitably distribute 
the referrals among the team members. 

Changes made

The senior administration officer role was 
redesigned to undertake the position of 
intake officer. This created one point of 
contact for all referrals to ACAT.

Daily clinical supervision by the CNC and 
clinical staff was available to the intake 
officer to provide support on complex 
referrals. 

Allocation of clients/referrals was changed to 
fortnightly instead of weekly. 

The addition of opportunistic delegation as 
needed, and a weekly case conference for 
complex matters requiring multi-disciplinary 
team input, resulted in an increase in the 
delegation of assessments from once a week 
to three times a week. 

Prioritisation of the clients now occurs on 
first point of contact with the service.


Siobhan Laffey, Integrated Care Coordinator, 

Tweed Valley Aged Care Assessment Team



Measurement/ process measures

The data collected at the completion of the 
six months from July to September 2008, 
and reported by the NSW Evaluation Unit, 
demonstrated an improvement of 23% in 
time to assessment for Category 3 clients 
in the community, however the increase in 
referrals affected the full achievement of the 
mission statement. The rate of assessment 
of Category 3 community clients within the 
targeted three month timeframe improved 
from 66.3% of all referrals in the period 
January to March, to 89.2% in the period 
July to September 2008. 

Further exploration of the data demonstrated 
that the average number of assessments 
conducted per full time equivalent (FTE) over 
the duration of the project increased from 12 
to 24. This represents 100% improvement 
in the number of assessments conducted 
for community clients within the Category 3 
Guidelines. 

The redesigned intake system and intake 
tool resulted in an improved data collection 
method which will more accurately reflect 
the correct prioritisation of clients. The 
waiting times from referral to first clinical 
intervention will result in greater satisfaction 
to community clients.

 

Data from the most recent quarterly report 
(March 2009) indicates 98.7% of Category 
3 clients in the community setting are seen 
within the Commonwealth GuidelinesÕ 
timeframe. This demonstrates a continued 
improvement in the initial project outcome 
and the achievement of the original project 
aim.

Plans to sustain change

The improvement on waiting times has been 
sustained through the following:

¥ Monthly waiting list reports to 
management to assist with informed 
decisions regarding service needs

¥ NSW Evaluation Unit quarterly reports

¥ Weekly team meetings to review 
workload allocation

¥ Education of GPs and residential 
aged care facilitiesÕ staff regarding the 
requirements for referral to ACAT

¥ Continuation of the PDSA cycles to 
improve other areas affecting waitlist 
efficiency.



Nutrition Assistant in a Rural 
Health Service: optimising 
nutrition

Ms Elizabeth Scott Dietetics Adviser,

Orange Base Hospital

Greater Western Area Health Services 
(GWAHS) 

Problem/Background

Patient malnutrition is a significant health 
issue and results in poor health outcomes, 
while impacting significantly on costs (by a 
factor of approximately two). 

According to the literature, patients with 
malnutrition will stay in hospital significantly 
longer. Also, all patientsÕ nutritional status 
declines with Length of Stay (LOS).

Malnutrition screening was introduced at 
Orange Base Hospital (OBH) in 2002 but 
due to the limited resources, intervention 
for all patients, including those who were 
malnourished, was also limited. Also, no 
systematic intervention existed for patients 
with Fractured Neck of Femur (#NOF), a 
group known to have significantly improved 
medical outcomes with early nutrition 
intervention.

Aim

The aim of this project was to evaluate 
the effectiveness of enhanced nutrition 
intervention for patients with #NOF and 
patients identified at risk of malnutrition, 
using a nutrition assistant.

Problem identified

A project conducted in GWAHS in 2002 
showed that the prevalence of malnutrition in 
health facilities was 29%, a level consistent 
with other Australian hospitals. 

After introducing malnutrition screening, 
a significantly increased workload was 
experienced within the dietetics department. 
Inpatient occasions of service more than 
doubled in 2004Ð2007 within existing 
resources. Anecdotally it was observed 
that three to five patients with #NOF were 
admitted weekly to OBH with no systematic 
nutritional intervention possible. It was 
projected that increased LOS and increased 
costs would result if this problem was not 
addressed.

Changes made

A proposal regarding the identified issues 
was written and it was agreed to trial 
one full time equivalent (FTE) position of 
nutrition assistant. This position was trained 
and supervised by dietitians and focused 
on nutrition intervention for target patient 
groups. 

The nutrition assistant supervised and 
monitored patientsÕ intake according to 
protocol developed by the dietitians. This 
involved:



¥ Provision of a high protein/high energy 
diet together with routine nutritional 
supplements (charted on the patientÕs 
medication chart) 
¥ Education of the patient regarding good 
nutrition and its role in recovery; and timely 
discharge

¥ Monitoring and coaching of intake, 
together with dietary adjustments 

¥ Continuous liaison between the nutrition 
assistant and dietitian. 

The nutrition assistant telephoned these 
patients at one week, one month and two 
months post discharge for ongoing support. 

Measurement/ process measures

Information was gathered at the beginning of 
the project and after implementation of the 
enhanced nutrition intervention for the target 
groups. 

The following data was collected:

¥ Age & gender

¥ Occasions of service for nutrition 
intervention

¥ 3 day protein and energy intakes

¥ Length of stay 

¥ Re-admissions within two months

¥ Living situation two months after 
discharge

¥ Patient satisfaction with food service

¥ Patient satisfaction with clinical nutrition 
services

The age and gender demographics for the 
initial group (n=28, 76.9±9.3 years, 50% 
male) and the group who experienced the 
intervention (n=24, 74.6±14.4 years, 29% 
male) were not significantly different. 

Nutrition interventions increased from 2.6 
(range 0-11) in the baseline group to 5.3 
(range 2-11) in the intervention group. As 
a result of enhanced nutrition intervention, 
nutritional intakes significantly increased, 
that is protein levels went from 43% to 95% 
of requirements and kilojoules went from 
40% to 86% of requirements. 

 

Improved nutritional intake provided real 
life impacts with improvements in patient 
outcomes. 

Median LOS reduced from 26 (range 4-98) 
days before the intervention to 17.5 (5-66) 
days after implementation (Mann-Whitney 
U test, p=0.125). Although this does not 
demonstrate a reduction of statistical 
significance, clinically significant outcomes 
were achieved in terms of patient care

Re-admissions to OBH within two months 
were reduced by 40%.

The project showed that at two months after 
discharge, the number of those patients 
returning home increased from 25%, in the 
baseline group to 58.8% in the group with 
improved nutrition.



Patient satisfaction increased in regard to 
both clinical nutrition services and food 
services.

These results help address concerns and 
recommendations raised in the Garling 
Report regarding malnourished patients. 

Plans to sustain change

Enhanced nutrition intervention for these 
patients helped GWAHS achieve the 
following identified NSW Health Òdashboard 
indicatorsÓ:

¥ Reduction in bed days for patients over 
75 years 

¥ Reduction in avoidable admissions for 
selected Diagnostic Related Groups.

Due to the demonstrated outcomes of the 
project, sustainable access funding was 
gained. This enabled inclusion of one FTE 
nutrition assistant position in the Orange 
Dietetics Department. The improved nutrition 
support will provide the opportunity for 
improved patient outcomes and efficiencies 
of service for the hospital. 


What the 2008 participants said about the program

ÒThe program has taught me to treat 
leadership as a skill set that can be developed 
and improved rather than innate ability.Ó

ÒThe program has given me a set of tools I 
can use. I am now planning a major service 
change and am mapping out my strategy, 
engaging stakeholders and setting timelines 
far more effectively than I would have a 
year ago.Ó

ÒI would encourage anyone interested in 
doing the program to participate if they 
are looking to improve their interpersonal 
and leadership skills, inspire and motivate 
themselves and their team.Ó

Some other words from participants:

Excellent, challenging, intriguing

Innovative, hard work, life changing

Professional, inclusive and inspiring



34 I

Clinical Excellence Commission

CLP Project List

2008

The ChildrenÕs Hospital at Westmead

_____________________________________35

Greater Southern Area Health Service

_____________________________________35

Greater Western Area Health Service

_____________________________________36

Hunter New England Area Health Service

_____________________________________37

Justice Health

_____________________________________38

North Coast Area Health Service

_____________________________________39

Northern Sydney Central Coast Area Health Service

_____________________________________40

South Eastern Sydney Illawarra Area Health Service

_____________________________________41

Sydney South West Area Health Service

_____________________________________42

Sydney West Area Health Service

_____________________________________43



Clinical Leadership Program - List of Projects

The ChildrenÕs Hospital
at Westmead

Statewide CLP

Out of hours management of burn patients 
presenting to CHW

Sarah Clarke 

Improving client attendance rates at Brain 
Injury Clinic*

Jan Hancock 

Fighting fits with fats

Tracy Harris 

Following Up - to call or not to call? 
Streamlining follow-up calls to parents & 
carers of children with asthma*

Tracey Marshall 

Aseptic Non Touch Technique (ANTT) and 
Central Venous Access Devices (CVADs)

Erin Sheehan 

Investigating readmission rates to CHW 
of children with recurrent respiratory 
illness due to dysphagia, and the level of 
engagement of Speech Pathology in the 
management of these children

Gloria Tzannes 

Modular CLP

Sharing the turf: introducing a point of care 
ultrasound in the newborn intensive care 
unit 

Kathryn Carmo 

Greater Southern Area Health 
Service

Statewide CLP

Transitional Aged Care Service - 
multidisciplinary care

Catherine Barkley 

Monitoring of physiotherapy service 
provision in the Eurobodalla

Tracey Bates 

Reduce length of stay for joint 
replacements 

Catherine Blacker 

Falling in and out of Hospital 

Fay Fox 

Integrated Community Health progress 
notes

Skye Gray 

Mandatory Risk Assessments 

Julie Henderson 

ACE- Acute Care of Elderly, BatemanÕs Bay 
Hospital

Elizabeth Huppatz & Gaynor Jamieson 

WWBH Paediatric Clinical Pathways 
Working Group

Lesley Jeffries 

* see project summary



Clinical Excellence Commission

Access to Pathology Service 

Karen Keith 

Orthopaedic Occupational Therapy 
Services

Linda McCormack 

Keeping our eye on the goal: managing 
goals with families 

Jane Murtagh 

Outreach and how do we do it better

Robert Parker 

Management and prioritisation of 
Occupational Therapy community caseload 
and waiting list

Lisa Reade 

Management of inpatient hyperglycaemia

Debbie Scadden 

Improving referral feedback mechanisms 
within Community Health

Karen Solah 

Modular CLP

Development of an oncology shared care 
model 

Christine Packer 

Mental Health Medical Assessment Guide 
For Emergency Departments

Patricia Saccasan Whelan 

Greater Western Area Health 
Service

Statewide CLP

Spirometry Testing within CAPACS and 
ambulatory care for clients with COPD

Nicole Baines 

The Patient Safety Culture SurveyÉ
emerging approaches in safety analysis

Carolyn Coleman 

Point of Care Troponin Testing

Vicki Conyers 

Paediatric Medications

Karyn Fahy 

Documentation / Care Plans for Agency / 
Casual Staff

Liz Greaves 

Transfer of Patients from Base Hospital 
to District Hospitals and Multi-Purpose 
Services (MPS)

Christine Hayes 

Adolescent Vaccine Program

Kerry Inder 

Falls @ Blayney

Jackie Kelly 

ÔStopping the LeakÕ

Louise Linke 



Effectiveness of occupational therapy 
group work on symptom reduction in acute 
inpatient psychiatric setting

Claire Lynch 

Acute Hospital Inpatient Admissions for 
clients of the remote SectorÕs Lower 
Western Mental Health and Drug and 
alcohol service

Derek Moore 

Redesign the storage areas to include a 
separate triage area at Gilgandra MPS

Jo Peterson 

The GLUCOSE Solution

Kerry Porter 

Forbes Health Service Orientation Manual

Patricia Rousell 

Nutrition Assistant in a Rural Health 
Service: optimising nutrition*

Elizabeth Scott 

Positive outcome therapy for the aged

Caroline Squires 

Circle of Care Project 

Max Stonestreet 

Pain relief post Caesar 

Renee Walker 

MenÕs Health

Andrew Whale 


Leadership Our Responsibility? 
Our Legacy?

Deb Wilden 

Modular CLP

Root Cause Analysis in Mental Health: 
Is it useful?

Greg Hugh 

Anaesthetics pre-consent information

Frank Moloney 

Rural Critical Care Advisory Service (CCAS) 
Kevan Quan 

Hunter New England Area 
Health Service

Statewide CLP

Improving team communication through 
regular team meetings 

Jane Bourke 

Maternity unit escalation plan 

Sally Cameron 

Accreditation and implementation of the 
HNEAHS Advanced Life support program 
Ð a leadership project 

Karen Chronister 

* see project summary



Supporting clinical mentors and trainee 
Paramedics 

Peter Elliott 

Correct position of drug additive labels 
on opioid syringes for patient controlled 
analgesia and continuous infusions 

Annette Keegan 

Forensic Medicine Services 

Tim Lyons 

Bring equity to the Bush. The effective 
collaborative use of multidisciplinary teams 

Fiona Lysaught 

Management of urgent orthopaedic surgery

Jennifer Muir 

Phone calls to the ED at Singleton District 
Hospital

Ann Relf 

Identifying and communicating risk within 
the context of an acute mental health 
inpatient unit

Derek Roberts 

Palliative care pathway for end of life care*

Caroline Short 

ÒThe prescription black holeÓ How to 
share prescription information between 
GPs & Mental Health Services

Kate Simpson 

Improve service communication to improve 
consumer outcomes

Gail Stevens 

Mental Health rehabilitation project

Gabrielle Williams 

 

Modular CLP

Developing a response service for inpatient 
paediatric patients: ÒPAED METÓ call

Helen Goodwin 

Bloodwatch program with the CEC 

Murray Hyde Page 

Reducing waiting time for inpatient cardiac 
ultrasound

Stuart Turner 

Justice Health

Statewide CLP

Triage: ÒI dare you to see meÓ

Garry Clarke; Maxine McCarthy; Kerri Davidson; 
Julie Skinner; Kathrin King 

Modular CLP

ÒGrowing your ownÓ Ð development of a 
forensic psychiatry program

Anthony Samuels 



North Coast Area Health Service

Statewide CLP

Letting Go of the Rope: What happens 
to the cancer patient when no further 
treatment can be offered? 

Nicole Abercrombie 

FRAGILE: Handle with Care. Effective 
Coordination of services for complex 
situations

Eric Belling 

A Fraction of the Time: Reducing total 
clinic time at Port Macquarie Base Hospital 
fracture clinics 

Anthony Best 

One Step at a Time: To improve access to 
podiatry services for clients with high risk 
or active problems*

David Cooper 

Hastings Macleay Mental Health 
Operational Guidelines 

Matthew Eldridge 

Improving Cognition Management in 
long-term care

Lynn Forsyth 

Blood Sugar Level readings in all patients 
who have experienced altered level of 
consciousness 

Steve Fraser 

The 3 C Project: Cleaner, Clearer, 
Colonoscopies

Kathy Hanson 

Improving Discharge Processes Ð CHHC 
Mental Health Inpatient Unit 

Clare Harber 

Preventing emotional decline

Carolyn Heise 

Sooner rather than later 

Deborah Huxstep 

ÔThatÕs my BabyÕ - Social Work Referrals 
for women presenting at Tweed Heads 
Hospital with early pregnancy concerns

Janelle Jacobson 

Establishing a key worker for clients in the 
Acute Care Service, Richmond Community 
Mental Health 

Liz Joblin 

Discharge planning from a Mental Health 
Unit 

Michael Martin 

Tweed Valley Aged Care Assessment Team: 
Waiting Times Project* 

Siobhan Laffey 

After hours medication access

Helen Lourens 

* see project summary



ÒPaediatric Pain Management, No Laughing 
MatterÓ Nitrous Oxide administration to 
Paediatric Patients*

Belinda Porter 

Time to Triage

Emma Smith 

Improving the care of women with 
gestational diabetes

Ann Tippett 

Modular CLP

Improving mental health clinical 
governance (building teams)

Doug Andrews 

Reducing the wait in emergency

Martin Chase 

Northern Sydney Central Coast 
Area Health Service

Statewide CLP

Improved access and care Ð clozapine 
clinic trial (IMPAACCCT)

David Archer 

Achieving unique client goals through 
collaborative community care planning

Sandra Brown 

Improve the dispensing processes of the 
Level 1 Pharmacy

Pauline Calder 

Improving fluid balance recording practices 
on a paediatric ward

Kathy Chapman 

Assessment of patients with cognitive 
deficits

Lois Clarke 

Youth Mental Health: Getting it right* 

Adrian Cobbold and Sue Leonard 

Access to emergency surgery at RNS 

Rosemary Cullen 

PRN Medication and over sedation
Ð 2008 review 

Paul Dimond 

Domestic Violence Assist 

Ronald Gibbs 

Medication storage & handling in radiation 
oncology

Tracey Gray & Eunice Chan 

Famous Last Lines - Documentation
in the Emergency Department 

Susan Hair 

To improve the elective patient journey 
from admission to discharge

Karen Jones and Kylie Whitehorn 

Improving referral processes for Coral Tree 
Family Service (statewide tertiary child and 
adolescent mental health service)

Bob King 



Improving the provision of medication to 
patients on the wards

Sally Nicolson 

Gosford Home Based Treatment Team 
(GHBTT) discharge process

Leilani Ormsby 

Getting discharged patients off the ward 
faster

Mark Pratt 

Intensive Care Infection Control Working 
Party: Royal North Shore Hospital

Rebecca Riordan & Leila Kuzmiuk 


Risk management planning for a workforce 
shortage of experienced haemodialysis 
nurses

Lucy Spencer 

Modular CLP

ÒAre we there yet?Ó A Paediatric Service 
Clinical Challenge - The Pregnancy 
Journey*

Joanne Ging & Michael Peregrina 

The management of delirium in the older 
patients in Manly and Mona Vale Hospitals 
Helen Gillespie & Frances Monypenny 

Improving training services for 
management of the acutely deteriorating 
patient 

Leonie Watterson 

 

South Eastern Sydney Illawarra 
Area Health Service

Statewide CLP

Improving the nutritional status of hospital 
inpatients

Janet Bell and Dominique Grognard 

Designing a Paediatric Nursing Care Plan 
which meets the needs of the chronic/
long-term patient

Helen Bullot 

Equitable access to bereavement 
counselling

Sara Burrett 

Implementation of antenatal services 
review recommendations 

Louise Everitt 

Introducing a ward culture of critical 
inquiry to improve outcomes

Jocelyn Guard 

Oral intake safety in elderly clients Ð a 
multidisciplinary approach 

Jai Gupta 

Improving practice management for 
patients with foot ulcers at the STG 
podiatry clinic

Sally-anne Jakowlew 

* see project summary



Psychosocial care for patients with a 
cancer diagnosis in the outpatient setting

Judy Jeffery 

Protected Engagement Time (PET) in 
Mental Health Units 

Mark Koh 

Improved reporting in the prevention 
and management of pressure sores for 
Community Health clients

Jacqueline Little 

Improving the recording of information into 
the IIMS system

Jane Newman 

Introduction of ÒLife-jetÓ a new recovery 
based care planning tool and its use within 
Team and Primary Nursing. 

Mark Perree 

A home-visit service to Cultural and 
linguistic diverse (CALD) clients in the St 
George Child and Family Health Service. 

Robinson Jacky 

Getting on TRACS: Investigating issues 
affecting occupancy levels of the Illawarra 
Transitional Aged Care Service* 

Southern network participants: 

Maren Jones; Verica Marin; Sue-Ellen Hogg; 
Helen Troy; Sarah Foulstone; Anthony Arnold; 
Susan Dileva; Rebekah Reurich; Anne Lees

Prevention of falls with implementation of 
Assistant in Nursing in Nursing trial

Julie Spencer 

Client safety and satisfaction Ð preparing a 
patient for tendon rehabilitation 

James Stormon 

Modular CLP

Drying out with Dignity - medically 
supervised alcohol withdrawal in the 
Shoalhaven, an Aboriginal Health solution*

Katherine Brown 

Increasing workforce flexibility in 
Psychology: Feasibility at Sydney 
ChildrenÕs Hospital

James Donnelly 

Triple Zero Project at The Sutherland 
Hospital Emergency Department

Michael Golding 

Sydney South West Area

Health Service

Modular CLP

MHOAT Outcome measures and clinical 
significance 

Mark Cross 

Improvement of care for patients with 
severe psoriasis 

Wolfgang Weninger 

 



Sydney West Area

Health Service

Statewide CLP

Improving Social Work documentation, 
reducing risks 

Pauline Barber & Rachel Oates 

Reduce waiting times for clients after initial 
base mammogram completed on the same 
day 

Harj Bariana 

Pain management in the Emergency 
Department

Ann Dudley 

Mentorship 

Liz Eglington 

Caring for the deferred patient 

Rebecca Galvin & Tina Van Weelderen 

Post natal group based education program 
for S4EP 

Susan Gawthorne 

Cardiac monitoring study 

Pauline Higgs 

WAAT Referral Process (WAARP) 

Richard Hoskins 

Hand Hygiene compliance in Intensive Care 
Unit

Brenton Hughes 

Continuity of care and support following 
discharge from Mental Health inpatient 
Unit

Katrina Knight & Kathi Boorman 

Developing a sustainable process to 
monitor and improve patient outcomes 

Lisa Newling 

Reducing waiting times without reducing 
care

Linda Robinson 

Acute post partum pain management of 
perineal trauma following vaginal birth 

Julie Ann Swain 

SWOT; Springwood Hospital Occupational 
Therapy Service Project 

Kathy Sweeny 

The optimal management of perineal tears

Talat Uppal 

Modular CLP

Complex pre-surgical epilepsy evaluations 
in SWAHS

Mark Dexter 

Dermatology at Westmead. Model of care 
and strategic plan 

Pablo Fernandez Pe–as 

 

* see project summary



Acknowledgements

CLP Modular Area Health Service Program Sponsors - 2008

Frank Horn___________________________________________The ChildrenÕs Hospital at Westmead

Joe McGirr___________________________________________Greater Southern

Jenny Coutts_________________________________________Greater Western

Nigel Lyons__________________________________________Hunter New England

Bronwen Ross________________________________________Justice Health Service

David Hutton / Jane Boot_________________________________North Coast 

Phillipa Blakey________________________________________North Sydney Central Coast

Sue Browbank________________________________________South Eastern Sydney Illawarra

Paul Gavel___________________________________________Sydney South West

Charles Pain__________________________________________Sydney West

CLP Statewide Area Health Service Program Sponsors/Contacts - 2008

Graeme Malone_______________________________________Ambulance Service of NSW

Val Johnson__________________________________________The ChildrenÕs Hospital at Westmead 

Maggie Crowley_______________________________________Greater Southern 

Jenny Coutts_________________________________________Greater Western

Allan Parsons_________________________________________Hunter New England

Alison Stevens________________________________________Justice Health Service

Katie Willey__________________________________________North Coast

Lynda-Mary Wood_____________________________________North Sydney Central Coast

Kim Olesen__________________________________________South Eastern Sydney Illawarra

Charles Pain, Sue Whitby_________________________________Sydney West 

CLP Statewide Facilitators / Program Managers Ð 2008

Helen OÕGrady, Sonya Bubnij______________________________The ChildrenÕs Hospital at Westmead 

Amanda Baker________________________________________Greater Southern 

Rachelle Ellem, Julie Swain_______________________________Greater Western

Nicole Byrne, Alison Fielder_______________________________Hunter New England

Michelle Eason________________________________________Justice Health Service

Margot Tugwell, Christine Lee______________________________North Coast

Raichel Green, Claire Nabke-Hatton_________________________North Sydney Central Coast

Mary Lambell, Louise Van Baarle___________________________North Sydney Central Coast

Karen Patterson, Jacqui Cross_____________________________South Eastern Sydney Illawarra

Ketty Rivas, Coral Levett_________________________________South Eastern Sydney Illawarra

Richard Tewson, Loretta Martin_____________________________Sydney West 

CLP Program Leaders 2008

Clinical Excellence Commission

Bernie Harrison, Teresa Pudo,
Colleen Leathley

Compiled and edited by

Teresa Pudo, Bernie Harrison, 

Kay Wright, Brid Morahan


If you would like more information about the Clinical 
Leadership Program or would like further details about 
any of the projects please contact: 

Clinical Excellence Commission

GPO Box 1614

Sydney NSW 2001


Ph: 02 9382 7600

Fax: 02 9382 7615

Email:clps@cec.health.nsw.gov.au

www.cec.health.nsw.gov.au



Excellence

 in Clinical Leadership

Clinical Leadership Program Projects 2008