Southern NSW Local Health District Quality Awards 2018

Southern NSW Local Health District
                              Quality Awards 2018
                                            Finalists 2018

          The annual SNSWLHD Quality Awards are designed to recognise and
      celebrate the tremendous commitment and innovation of staff to improve what
                        we do in all aspects of our health service.

         We are pleased to present the following projects as finalists in the 2018
         Quality Awards. We thank all of those staff who entered submissions and
              congratulate those who have been selected to receive awards.

        Following the Awards, selected projects will be submitted to the 2018 NSW
                  Health Innovation Awards and NSW Premier’s Awards.

Artists impression of the Goulburn Base Hospital redevelopment

Category - Patients as Partners
This award acknowledges projects/programs which promote collaboration
between the patient and the health care team to improve health.

Finalists

Breastfeeding Babies for Mothers – Goulburn Maternity Ward
Team: Erin Petty, Kathy Staines, Lynn Wenham, Kristy Wilson (consumer)

This project aimed to provide consistent, planned and current breastfeeding
practices at Goulburn Maternity Ward to decrease confusion and anxiety for
mothers and increase the rate of exclusive breastfeeding rates. The project
had increase in exclusive breastfeeding rates from 62% in Oct-Dec 2017 to
83% in Jan-Mar 2018 and an increase in satisfaction by mothers.

Consumer Rounding within Acute Mental Health Inpatient Units (MHIPU)
Team: Dr Pavan Bhandari, Tim Leggett, Anne Francis, Robert ‘Butch’ Young,
Cherie Puckett, Erin Evans, Anita Bizzotto, Peta Kleinig

This project initiated a regular Consumer Rounding meeting between
MHDA senior leaders, and consumers admitted to the acute MHIPUs within
SNSWLHD to engage consumers in their care. The feedback loop ensures
all consumers are aware that we take seriously the perspective, “You said,
we listened and we did together”. Significant value has been identified in
the feedback that has been received, and actions to improve the quality and
process of care introduced as well as improving the consumer experience.
Some examples include: introduction of exercise physiology services based
upon consumer feedback, the development of a mobile device policy, ensuring
all consumers are aware of who is treating them and their relevant roles,
ensuring all staff wear welcoming name badges, ensuring a wider variety of
activities are available to consumers, and that staff ensure any change in
treatment is clearly articulated to the consumer.

Consumers Shaping our Service - MHDA
Team: Sandra Morgan, Butch Young, Richard Bell, Vanessa Capstick,
Members of the SNSWLHD MH Consumer Participation Group (CPG),
Gabrielle Mulcahy

This project aims to strengthen the engagement of consumers and the mental
health service so that they can work together to provide effective, recovery-
based, consumer centred care. The CPG is a well-established and thriving
model operating across 6 sites in SNSWLHD. Recent achievements include:
•       Driving the access to mobile devices in inpatient units, and access to

lockers
•       Involvement in clinical service plan processes and redesign
        processes (e.g. Including Mental Health Inpatient Unit Models of care,
        and the infrastructure of services)
•       Consultation on draft MHDA procedures and documents designed for
        the information and support of consumers
•       Participation in NSW Seclusion and Restraint Review (2017) and
        provision of advice to SNSWLHD MHDA regarding key initiatives
•       Hosting 2 regional consumer and carer forums (2014 in Batemans
        Bay; and 2016 in Queanbeyan, held jointly with Coordinare)
•       Monitoring Action & Change processes derived from Consumer
        satisfaction (YES) surveys for each local service.

This group operates on the reliance of consumer staff and volunteers. The
achievements of this group and contribution to working in partnership with
MHDA are to be commended.

Connections Program - Eurobodalla Cancer Care Centre (ECCC)
Team: Michele Polach (Oncology Social Worker and Program Manager), Tracy
Blake (NUM Oncology), Trina Castell-Brown (Physiotherapist), Gai Gibson,
Karena Durden, Tracey Rich (Occupational Therapists), Clare Hofsteede,
Caitlin Jamieson (Dieticians), Dang Nyguen, David Quinn (Pharmacists),
Lyndel Stuckey, Jen O’Donnell (Social Worker and Mindfulness Facilitator),
Ben Wright (Finance Support)

The Connections Program is an eight week program for people affected by
cancer. Its aim is to empower patients and carers to be experts in their cancer
journey and take an active role in decision making with regard to their health
care.

‘Dry July’ funding enabled the ECCC to offer the ‘Connections’ program in
2017 – 2018. It is the first psychoeducational group, both developed and
implemented in SNSWLHD to meet the biopsychosocial needs of people
affected by cancer living in the Eurobodalla.

The program design involves joint facilitation and information sharing from
SNSWLHD Allied Health service providers and community sector partners
during each session. This offers new opportunities for communication and
partnerships between Allied Health professionals and the Community Sector.

The ‘Connections’ program built increased community and consumer
interest over the past 12 months, with participant numbers and referrals from
health and community increasing steadily with each group with evaluations

demonstrating that the psychoeducation model supports people affected by
cancer to self-manage in a supportive and cost/resource effective way.

Never Stop Quitting - empowering mental health consumers to quit
South East Regional Hospital Mental Health Unit (SERH MHIPU)
Team: Anita Bizzoto (NUM), Dr Tanya Ahmed (Psychiatrist), Erin Evans (CNC),
Clancy Tucker (A/CNC), staff of SERH MHIP

People living with mental illness smoke more cigarettes per day than those
without mental illness and the smoking rates are much higher than the
average smoking rates in Australia at 70-80% compared to 22% (Benowitz
1998). Smoking also interacts with many medications making it difficult for
consumers to manage the symptoms of the mental illness effectively.

Our aim was to increase knowledge in healthy lifestyle choices specifically
focusing on empowering consumers with the knowledge and resources to
cease smoking. The in-patient mental health environment provides an ideal
opportunity for consumers to reduce their use of nicotine. The MHU staff can
then walk beside the person as they use and reflect on the various strategies
that are demonstrated to be effective in mitigating the symptoms of nicotine
withdrawal. Consumers can be linked in with key health promotion services
such as Quitline & Quit Buddy programs. Collaboration and partnership
with non-clinical psycho-social mental health service providers enables a
supported transition for the consumer back into their home and community
environments.

Anecdotally, several consumers and staff have made changes to their smoking
behaviours. Some have reduced their use of nicotine, others have completely
Quit with no intention of smoking again. Community Mental Health Clinicians
report that these changes in behaviour are being sustained in the community
over time.

Consumers are making requests that staff destroy their tobacco prior to
discharge from the MHU in order to assist them in continuing their smoke-free
lifestyle when they return home. Carers and families report that they are proud
of the smoke-free choices that their loved one is making.

Consumer feedback:
The staff are really well trained. We talk about it at the morning meeting. They
have new ways and tips for using the NRT (nicotine replacement therapy)
that I never knew. Like putting the 24hrs patch on at night so ya not hanging
out first thing in the morning. That was great for me, didn’t affect my dreams.
But everyone was different so we all used the NRT in different ways. We chat

about how we were doing at the morning meeting, share stories, staff and
patients, all quitting at the same time. That really helped, the daily catch up.
Some nurses were quitting too so we all opened up. It was really encouraging.
It wasn’t like we were being told to quit, it was like being shown how to quit.
There is a big difference.

Patient’s experience of perioperative care - a quantitative research project
(SERH)
Team: Uta Conway, Tollan Conway, David Schmidt, Nadine Quennell

The aim of this project was to identify the patients’ perceptions of the care they
experience during their Perioperative journey, including day surgery, in theatre
and in the recovery room in at South East Regional Hospital Bega and utilise
findings for service improvements. 346 patients returned their questionnaire
(45% response rate) which was co-designed with the Consumer Consultation
Committee.

Improvements made as a result of the research study:
•      Patient’s reported feeling cold led to increased pre-warming measures
       in day surgery and awareness by recovery staff
•      Some patients felt their privacy was not respected. This led to
       changes in admission and handover practices
•      Patients were mostly satisfied with pain management which is
       a positive finding and not consistent with reports in the literature or the
       anticipated result by the Consumer Consultation Committee
•      Patients identified that the provision of information could be improved
       especially relating to discharge information, wound care and who to
       call in case of adverse events. Family members want to be informed
       of the patient’s journey especially if there are delays to surgery times.

To date findings from this research study have been presented as a poster
presentation at the 2017 Rural Research Conference at Wagga and oral
presentations have been provided at the 2018 Bega Health Research Forum
at Bega and the 2018 Patient Experience Symposium in Sydney.

Four Minutes, Anywhere, Anytime - Queanbeyan Video DOTS
Team: Dot Nicholson (Nurse Manager), Denise Smillie (Specialist TB Nurse),
Catherine McKenna (TB CNC), Queanbeyan Community Nursing Team

The human impact of tuberculosis (TB) on a patient is significant. Despite
treatment being free to the patient the illness still imposes significant financial
risk for the individual. Risks include shame, loss of jobs, using significant sick
leave, social isolation and fear of possible visa ramifications, discrimination
and language barriers.

Daily supervision of taking of medications ensures compliance with treatment
regimens rendering confidence there is minimal risk of disease relapse. Face
to face delivery of Directly Observed Treatment Short course (DOTS) by a
nurse is intrusive for patient work/life balance, creates issues of compliance
due to availability of both parties and is a resource intensive service delivery
model.

The Queanbeyan TB Service inviting patients to use Video Directly
Observed Treatment Supervision (VDOTS) in April 2017. The aim of VDOTS
implementation is to reduce both the human and service delivery cost of daily
TB treatment supervision for patients in the Queanbeyan community.

Twelve months on we can report 100% patient engagement and high levels
of patient satisfaction with the redesigned model of care.As patient needs
change we adapt services throughout the six month daily reatment regimen.

VDOTS is truly a patient centred model of care. Patients set appointment
times and they can be anywhere of their choosing in the world at medication
time and they self-determine privacy and confidentiality. VDOTS has occurred
for six clients in India, New Zealand and Philippines and across Australia.
Babies aren’t woken, truckies stop by the road, students continue studies and
nurses continue other work wherever they they’re working.

The Silent 12: Reducing avoidable hospital readmissions – Eurobodalla
Team: Andrea White (ADDONM), Lynn Wilson (AHNM), Kathryn Harris (Allied
Health Manager), Sharon Howell (NUM Critical Care), Ruth Snowball (CH
Manager), Brigid Crosbie (Care Navigator)

The Silent 12 program was established to reduce avoidable, unplanned
representations to hospital within the Eurobodalla area and to identify people
at risk of re-presentations and readmission to hospital.
A multidisciplinary team reviewed the presentations and current support
services of the top 12 patients at risk for readmission. A key health worker
was allocated for each patient and individual care plans addressing medical
and psychosocial issues were developed in collaboration with patients, with
copies kept in the emergency departments. Support services were increased
and modified according to individual needs. For the 12 patients admitted to the
program:
•        ED presentations reduced from a total of 223 to 50 (77% reduction)
•        Admissions reduced from a total of 154 to 32 (79% reduction)
•        Total days in hospital reduced from a total of 234 to 22 (90%
         reduction)
Routine six monthly audits are now conducted to identify those with increasing
care needs and implementation of care plans in partnership with patients at an

earlier stage. Regular care plan reviews occur to ensure they remain current
and effective.

The Silent 12 Program focuses on keeping people well, safe and at home. A
partnership between vulnerable patients at risk of readmission and a broad
multidisciplinary team is fostered to ensure a more focused and structured
plan of care is developed and shared.

Patients who frequently present to ED are treated as experts in their own
care. They are provided with formal links to primary carers, allied health, and
community services and are supported to manage their own health conditions
via the development of a collaborative, patient centred, specific care plan.
Plans are shared with ED teams to provide consistency for patients. Thus,
care can be delivered more effectively, in a more timely manner and with a
greater understanding of a patient’s individual needs.

Category – Integrated Health Care
Integrated care involves the provision of seamless, person centred care
across different health settings, focused on preventing illness and deterioration
of health and delivering flexible, continuous and appropriate care in the right
place at the right time. This award recognises innovative partnerships which
promote an integrated approach to care.

Finalists

Fit for Interview - Improving referral criteria for mental health services from
hospital emergency departments
Team: Lynda Cumberland (RN MH TECS), Chantel Ashkar, Andrew Burke,
Joanne Finlayson, Julie Bender, Glenn Kelly, Victoria Martinez, Elsie Te Puni,
Tsitsi Foroma, Shaji Porunnoli, Colin Moore, Denise Bool, Henry Luciap, Fiona
Keddie, Annette Laird, Stephen Bateman and Belinda Travers

This project aimed to reduce the number of inappropriate referrals from
Emergency Departments to the MH Triage and Emergency Care Support
(TECS) service. TECS receive requests from the ED for MH consultation or
advice when a person presents with an acute mental health risk issue. TECS
can provide face to face, video or telephone consultation to determine the
least restrictive option of care available to the consumer.

As Mental Health resources are often under pressure, the identification of
accurate information to determine appropriate referrals to MH services is a
priority in order to maximise the effectiveness of clinician time available. It
was identified by MH clinicians that inappropriate referrals occurred from the

Hospital ED for several reasons.
•       Consumer not fit for MH interview,
•       Consumer not consenting to MH interview,
•       Consumer has no acute MH/risk issues present.

The project team aimed to formalise the process between the ED staff and
TECS to better qualify the need for appropriate MH referrals.

The results following a six week period of intensive collaboration demonstrated
a reduction of inappropriate referrals from ED to TECS from 22% to 8%.
The audio recordings of the consultation and referral process demonstrates
communication between MH services and ED services has improved as a
result which supports mutual respect between the teams.

Overcoming Barriers to Discharge – Sub Acute Rehabilitation Unit (SARU)
Moruya
Team: Jason Mook (NUM), Michelle Allan (CNE), Melissa Smith, Susan Gadd,
Sherry Piltz, Alison Pongho, Elena Renfrew, Perla Smith, Marie Traynor (RNs),
Kathy Booth, Michael Christensen, Brenda Scott, Belinda Morrison, Suzanne
Smithers, Jemima Moreton, Vicki Walsh, Robyn Caffetto, Yanoula Hambesis
(EENs), Rosie Scott (Physiotherapist)

The aim of this project was to improve the communication processes relating
to care discussion within the Multidisciplinary team (MDT) in Eurobodalla
SARU to focus on identifying and addressing barriers to discharge. This
project focused on utilising the information that nursing staff from all shifts
could contribute to the discharge planning process.

The outcome is that nursing staff are now critically analysing the barriers
and focusing referrals to the wider MDT in a collaborative manner. The
average length of stay for patients has reduced from 18.6 days in September
– November 2017 to 15.5 in February – April 2018 (December and January
excluded due to Christmas closure). The team’s approach to focus on
barriers to discharge demonstrates an integrated approach which allows for a
seamless progression from Acute to Sub Acute and Community.

Project to develop a palliative care bereavement support model for SNSWLHD
Team: Jacky Clancy (Palliative Care Program Manager/CNC), Christine
Ashley (Project Officer)

The aim of this project was to develop a palliative care bereavement support
model which is sustainable and suitable for implementation by a rural palliative
care service.

Current literature and standards emphasise the importance of families and
carers having access to bereavement support services and it is identified as
meeting the highest standards of palliative care to the community. This gap
in SNSWLHD service provision was identified by palliative care nurses, with
funding being successfully sought to develop a model for the LHD.

A project officer and expert advisory group were appointed in April 2017 to
develop a model in consultation with health professionals and the community.
This consultation was extensive and included surveys, workshops, community
grief forums, interviews with carers and presentations to palliative care
researchers at the Australian Health Services Research Institute.

The project has resulted in the production of a bereavement support model
purpose designed for use by a palliative care service in a rural setting. The
model provides a seamless, person-centred approach to supporting the
bereaved in SNSWLHD. It encourages self-awareness by promoting and
supporting individual capacity in managing personal bereavement, and has
been developed in conjunction with end-users and bereaved carers to ensure
it is fit for purpose.

Eurobodalla Birth Partners – Women having a known midwife for continuity of
care
Team: Marshia Radin (Consumer), Claudia Stevenson (MUM Project Lead),
Wendy Pryke (CME), Angela McClelland (Midwife) Judith Hallam (Manager
Redesign & Innovation) Lisa Kennedy GM, Dr Belinda Doherty (DMS), Leanne
Ovington (DoNM), Dr Michael Holland (O&G), Amanda Gear (LHD CMC),
Dr Michelle Mitchell (ABA), Jackie Jackson (SNSWLHD Aboriginal Health
Manager)

The Eurobodalla Maternity service aims to move towards the NSW Health
towards Normal Birth Policy PD 2010_045 (TWNB) which promotes a known
carer program for women and staff through access to a midwifery continuity of
care program. This model aims to provide a woman with the same midwife (or
small group of midwives) throughout her pregnancy, labour, birth and postnatal
period until transfer of care to Child and Family Health Nurses at around 4 – 6
weeks post birth.

The Eurobodalla Birth Partners project reviewed the model of care being
delivered and emphasised the woman’s need, ensuring patient centred care
occurs in the right place at the right time. The team developed foundation
steps to guide change in a midwifery service model of care. The maternity unit
partnered with child and family nursing to increase and improve postnatal care
services.

The size of the service makes it difficult to implement a midwifery group
practice model found elsewhere and the team needed to be innovative
in designing an alternative model which incorporated the principles of
continuity of care whilst maintaining a safe service for all women. In late 2017
stakeholders agreed on a continuity service model with a small group of
midwives that would be considered for implementation in the future.

Accessible and Collaborative Renal Care through a Network
Team: Linda McCorriston (Renal CNC), Robyn Facchini and Jan Diaresco
(Renal Outreach CNSs), Tuija Kostiainen (Moruya Renal NUM), Checille
Naig (Bega Renal NUM), Lynn Nichols (Cooma Renal NUM), Tracy Sampson
(Goulburn Renal NUM), Barbara Harvie (Queanbeyan Renal NUM)

Our ability to safely deliver specialist renal care within our health service is
limited by the lack of a tertiary hospital in the District. In 2012, SNSWLHD and
The Canberra Hospital executives collaboratively formed an integrated Renal
Network. The aim of this Network is to provide a seamless and integrated
renal service to residents of Southern NSW. The objectives were to deliver
safe and effective renal care, provide timely access to specialist renal
services, and to reduce the need for NSW residents to travel to the ACT for
renal care.

SNSWLHD Renal Services now incorporates five satellite haemodialysis
inpatient units and renal outreach outpatient services throughout our District.
Home dialysis services are accessible across the Network, inclusive of home
dialysis training at Bega Valley and Eurobodalla, supporting home based
dialysis and reducing the burden of travel. The introduction of the sharing of
CV5 (ACT renal electronic medical record) with SNSWLHD renal team has
enabled standard treatment pathways and accessible, timely patient health
record information, inclusive of the prescription and administration of dialysis-
related medications. CV5 provides internal referral pathways, which allows
clinical staff to efficiently manage their tasks. An improvement in productivity
has been demonstrated by the shared procurement strategy, enabling the
purchase of dialysis equipment and consumables, at a reduced price per
treatment. This has also enabled dialysis machine connectivity to CV5, so
renal health professionals can view dialysis information in real time

The success of the Network has been achieved by all interdisciplinary teams
working in equitable partnerships and ensuring that planning across the
Network includes our consumers. This collaborative approach has been driven
by the Health District’s renal nursing team.

Stepping On – Integrated Health Promotion Project
Team: Trina Castell-Brown (Stepping On Coordinator), Monica Alcock (Health

Promotion Officer), Niccola Follett (Falls Prevention Coordinator) and Lorraine
Dubois (Manager Population Health).

The Stepping On program is an evidenced based, multidisciplinary falls
prevention program for community dwelling older adults 65+ and has been
operating in SNSWLHD since June 2011. Over the period of the program the
average number of participants completing the program had continued on a
downward trend. In the period July 2014 – June 2015 completion rates had
fallen to an average of n7.2, jeopardising achieving target KPI’s and new
funding agreements.

In August 2015, SNSWLHD Health Promotion commenced the Integrated
Health Promotion (IHP) Project, a quality project with the aim to improve and
maintain completion rates (n8) for Stepping On programs at all sites. The
project was focussed on: identifying and reviewing current practices related
to recruitment, referral and retention of Stepping On participants; developing
strategies to retain participants in the program and implementing systems to
ensure consistent program implementation across all sites.

As a direct result of the IHP project, completion rates have significantly
improved and been maintained. The completion rate improved from 7.2 in the
year ending June 2015 to 10.54 from July 2017 – Dec 2017. Other significant
improvements include increased number of participants, increased use of
Allied Health Assistants in the program (thereby freeing up valuable Allied
Health professionals time) and improved links with internal and external
referral services which has raised the profile of the Stepping On program.

Consultation and collaboration with internal and external stakeholders
has generated referrals to this valuable program as well as resulting in an
empowered workforce.

Patient centred care to reduce unplanned readmissions with 28 days –
Nursing and Midwifery Directorate
Team: Anka Radmanovich, Melissa Tinsley, Judith Hallam, Maria Wilson,
Jane Cotter, Wendy Grealy, Yonca Lloyd, Janice Dalton, Charmaine Johnson,
Christine Sullivan, Uta Conway, Philippa Gately, Lucille Ingram

The research study was conducted to understand contributors for readmission
within 28 days from a patient’s perspective. This is an area that is poorly
understood at present. 50 readmitted patients and 64 non-readmitted patients
were interviewed using a structured template.

The results indicate that patients experiencing unplanned readmission within
28 days have been in hospital longer, received less information on what to

look for in the event of a deterioration, experience difficulty in attending follow-
up appointments and have a Care Navigator involved in their care. Those who
were readmitted experienced more negative emotions on their initial discharge
and were most likely to be readmitted due to pain, or complications from a
procedure or their original condition.

These results have identified a number of recommendations for improvement
including:
•       Discharge information to be concise, specific and easily understood
        and involve the consumer. Information on what to look for in event of
        deterioration to be highlighted.
•       Post discharge phone calls for all patients within 3 days of discharge.
•       HealthDirect phone numbers (in form of fridge magnets) to given to all
        patients on discharge to ensure ready access to health advice.
•       Mental Health Access Line number to be displayed on main page of
        Staffnet for easy access for all clinicians.

Category - Supporting our People
Developing and supporting our people and culture is a priority for SNSWLHD.
By supporting the people working for in our District, positive interactions in the
workplace are inspired and health outcomes are improved.

Finalists

Bega Valley Health Service Mentoring Program: A project to provide an
additional layer of support for nurses transitioning to practice and specialty
Team: Tracey Doran-Robertson (RN), Uta Conway, Nicole Tate (DoNM)

The aim of this program was to improve support and guidance to newly
graduated nurses to help them cope with the perpendicular learning curve that
is the first year of nursing, whilst practicing and upholding the CORE values. It
is well documented that without adequate support for these new nurses, there
is an increase in sick leave, ‘burn out’ and resignations.

Coupled with the Australian Mentoring Centre and University of Wollongong,
this team developed a structured program to provide an appropriate mentor to
the nurse (mentee), with regular contact, constructive support and network of
structured assistance.

The results have manifested in confident, supported staff, with more wishing to
join the program every day. Six years of consistently overall positive feedback
and re-uptake of mentor/mentee roles.
The main impact is the move toward better staff retention. Fewer newly
graduated nurses express a desire to move to other areas (while participating

in the program) – feedback indicates a 5% reduction from 2017 to 2018. More
are looking to progress to Post-Graduate studies (32% of current mentees/
mentors with several considering the Clinical Nurse Specialist pathway).
Ultimately, the greatest impact is on improved patient care. A more engaged
and confident staff allows for a better level of practice and care provision.
Staff feel more rewarded by their work as they see and hear positive events
rather than negative. There is a short term and long term plan of expansion
in progress, to broaden the scope of the program to include (eventually) all
grades of nurses and disciplines.

Empowering NM/NUM/MUM through Facilitated Development
Team: Dot Hughes (Nurse Manager Initiatives and Projects), SNSWLHD
Nurse Unit Managers, Nurse Managers and Midwifery Unit Managers

Effective functioning of The Nurse/Midwifery Unit Manager and Nurse
Manager positions are pivotal for the coordination of patient care, staff
leadership and management to ensure high quality, patient centred care.

In 2015 a qualitative study of 46 NUM/MUM/NMs in SNSWLHD was
undertaken using focus groups to identify issues and barriers to performing
the role well and to identify ideas for role support and development.

In response to these identified issues, an action learning program was
implemented with the aim to empower nurse managers to develop positive
workplace cultures, which would subsequently engage staff to achieve
improved patient outcomes. Four projects were chosen by the nurse
managers for development and improvement and which would be shared
among the wider group. These included mentoring, induction for new
nurse managers, clinical nurse educators to support nurse managers and
succession planning for nurse managers.

All four projects have been completed and are available for sharing across the
LHD. Further work is in progress to sustain and spread the change.

Planning the Planner – Improving Leave Management Eurobodalla Health
Service
Team: Andrea White (A/DDoNM), Leanne Ovington (DoNM), Fiona Cummings
(CSO)

SNSWLHD leave management states that the management of annual leave
is a vital element to maintaining the wellbeing of employees, optimal service
delivery for the organisation and minimisation of financial risks.

The aim of the project was to improve current systems for annual leave

planning for staff and reduce excess leave balances in the Eurobodalla
nursing team. This was prompted by the LHD aim to reduce excess leave
which identified that the existing system in Eurobodalla to plan and monitor
staff leave was resource intensive and inefficient for NUMs and other
managers; there was a lot of manual collating of plans and cross referencing
against the new reports provided each month.

Nursing Managers and clinical support officers collaborated to develop an
improved system which has provided current and accurate leave management
information which is accessible by managers and staff.

Implementing the new planner has resulted in continuous and sustained
improvement of the number of staff with excess leave and excess annual
leave days for the 17/18 financial year in the Eurobodalla. The planner will
be rolled out to further departments in the Eurobodalla to provide a generic
system for all managers to plan their workforce’s leave. The template and
instructions on using the planner has been shared with the clinical operations
team within SNSW LHD and can be easily adapted for all sites.

Supporting our Managers – MHDA
Team: Gabrielle Mulcahy (Governance Manager MHDA), Danielle Hansen (EA
to Executive Director MHDA), Netty Swinburne-Mepham

New managers usually hit the ground running, and find themselves navigating
a range of complex systems and processes. In the absence of a formal
on-boarding system for managers, we decided to try and make this process
a little easier for new MHDA managers.We wanted to make sure they had the
right knowledge and skills, at the right time.

So we developed and have maintained a simple checklist, listing key
resources that they will likely need to access in their roles. We have trialled
this for nearly 12 months, and the feedback is positive.

It is now being used to also support new MHDA staff in other senior roles
(not just management). Although well-received, the checklist has highlighted
the need for a formal orientation program/guide to be developed for new
managers within MHDA, and also at an LHD level.

It is but one small step, but we have now given every MHDA manager another
tool to help them to do their job.

Category - Health Research and Innovation
This award aims to recognise collaboration between researchers, policy
makers, service users, health managers and clinicians in research. This

collaboration is critical and can lead to findings that are more likely to be
innovative and positively inform health decisions.

Finalists

Developing a standard approach to managing Central Venous Access Devices
(CVADs)
Team: Sherri-Leigh Bayliss (Intensive Care CNC), Judy Ryall (Nurse Manager
Leadership and Development), Kristy Wilson (CNE Goulburn), Linda
McCorriston (Renal Services CNC), Melissa Mudie (Oncology Services CNC)

In 2014 a Working Party was formed to improve patient safety by minimising
CVAD associated complications such as air embolism and Central Line
Associated Blood Stream Infections (CLABSI) and reducing variation in clinical
practice. The Working Party consisted of CNCs from specialities that provide
care and management of CVADs (Critical Care, Renal and Oncology and a
Clinical Nurse Educator representative).

Since 2015 there has been significant changes to the way CVADs are
cared for in SNSWLHD reflecting evidence-based practice and products. A
standardised training framework has been developed and delivered increasing
the number of competent clinical staff with trainers available in each site (92
assessors across the LHD). Products are now being used that optimise patient
safety. Patients with implanted ports are now able to have these accessed
safely in our larger EDs with staff confident and competent in care.

The CVAD Working Party meets regularly to discuss changes to evidence and
update procedures and clinical products as required to ensure we remain in
line with current best practice standards.

Golden Angels - enhancing dementia and delirium acute care
Team: Cath Bateman (CNC Dementia Delirium (Acute)), Annaliese Blair,
Katrina Anderson, Maria Zylinski, Peter Davis, Brigid Crosbie, Kirsten Herbert,
Chantelle Tiskins

The project was a collaboration between the Commonwealth Department of
Health as a funder and policy maker, researchers at the Cognitive Decline
Partnership Centre (CDPC) and within the Aged Care Evaluation Unit, the
Agency for Clinical Innovation (ACI), SNSWLHD decision makers, clinicians,
health information managers, consumers/families and volunteers.

Prevalence of dementia and delirium in older hospitalised adults is increasing,
and with it, increased risk of falls, functional decline, prolonged length of
stay, premature residential placement and death. In rural hospitals, the lack

of access to geriatricians and other specialists contributes to these negative
outcomes. The Dementia and Delirium Care with Volunteers© program
recruits and trains volunteers in rural hospitals to provide one-to-one practical
assistance and emotional support for inpatients with dementia/delirium. The
aim of the program is to reduce patient distress and adverse incidents.

The outcome of this project was that the Dementia and Delirium Care with
Volunteers© program was successfully and consistently implemented
in all sites. Across all sites, patients in the volunteer group had reduced
readmissions within 28 days and 1:1 specialling rates. The volunteer group
were less likely to be prescribed PRN psychotropic medication.
Family carers reported improved hydration and nutrition, reduction in patient
distress, increase in patient happiness, reduction in family care burden and
provision of respite. Staff reported high satisfaction with the program and
that the volunteers contributed to safer outcomes for patients, assisted with
nutrition and hydration and reduced staff burden (Blair et al., 2018).

A business case for funding to sustain the program through establishment
of volunteer coordinator positions has been supported to commence in the
2018/19 financial year. This will ensure sustainability of the program.

Category – Patient Safety First
Providing world-class clinical care where patient safety is first is a key priority
for NSW Health. NSW Health has a shared vision that Patient Safety is
everybody’s business. This award acknowledges a commitment to putting
patient safety first every day.

Finalists

A Better Bedside Handover – Bombala MPS
Team: Julie Mann (Nurse Manager Bombala)

This project aimed to focus on the clinical handover processes within the
MPS to improve team skills and communication and ensure compliance with
National Standard 6 Clinical Handover.

Through a collaborative approach with staff including a staff survey and
staff meetings, an improved clinical handover process was implemented.
This included a more concise, productive bedside handover that follows a
consistent format. Audit results are improved, more effective communication
exists between staff along with improved relationships.

Observational audit of clinical emergency response systems (CERS) across
Southern NSW LHD
Team: Sherri Leigh Bayliss (ICU CNC), Rowena Mitchell Acting ICU CNC,
CNE SERH, CNS, SNSWLHD CNE’s

Recognising patients whose condition is deteriorating and responding to their
needs in an appropriate and timely way are essential components of safe
and high quality care. Serious adverse events such as unexpected death and
cardiac arrest often follow observable deterioration in a patient’s condition.

The aim of this project was to investigate CERS processes in Southern NSW
LHD facilities and ensure that a responsive and reliable system was available
at each site to identify and manage patient deterioration including systems for
escalating care, personnel and equipment available and staff competence and
ability to work in a team.

2016 an observational audit of the CERS in SNSWLHD was undertaken
to test processes in each site. The project design included mock clinical
scenarios where a patient deteriorated (usually to cardiac arrest). Following
each scenario the audit team debriefed, completed notes and developed initial
recommendations. The recommendations informed Action Plans which were
developed locally and implemented by the site.

In late 2017 and early 2018 the observational audit was repeated across
SNSWLHD using the same method and tools. The 2017 observational audit
showed that significant progress had been made at most sites with regard
to staff knowledge and confidence in detecting, assessing and managing
a deteriorating patient. All participating staff (almost without exception)
agree that these exercises are valuable in noting gaps in knowledge and
skill, learning to work together as a team and improving management of the
deteriorating patient. This project was presented to the Clinical Excellence
Commission (CEC) Between the Flags Advisory Group and at the ANZICS
Deteriorating Patient conference and generated a great deal of interest.

Improving responses to BTF yellow zone alerts in the general ward setting –
Batemans Bay
Team: Rebekah O’Reilly (Ward NUM), Tracey Elkins (GM Quality Systems),
Carolyn Hallam (RN), Phillipa Stiller (EEN), Belinda Mcauley (RN), Kim
Nightingale (EEN), Anita Ashby (RN), Dr Luke Mitchell (GP VMO)

Data from SAC 1 and 2 investigations within the LHD during 2016 indicated
that failure to recognise and respond to clinical deterioration was a
contributing factor in the occurrence of these incidents. In Batemans Bay
ward, the data showed less than 20% of yellow zone alerts in eMR were

being actioned and responded to with the appropriate Clinical Review form
being completed. A team of nursing staff and doctors sought to understand
why the nursing group were not documenting Clinical Reviews and address
these issues. The team held individual coaching sessions, in-services and
ward meetings to disseminate the change ideas around how to attend Clinical
Reviews correctly and engage as many people on the ward to perform Clinical
Reviews immediately with their patients. The team implemented changes to
handover processes to check Care Compass at each handover as a reminder
to the staff member to ensure no unresolved Clinical Review alerts remained.
Doctors were encouraged and educated on the use of the altered calling
criteria and improving the documenting of Resuscitation Plans.

The results showed an increase in the Clinical Review forms completed
(as a percentage of total yellow zone alerts) from 16% in October 2016 to
45% in December 2017. Additionally an improvement in the percentage of
Rapid Response forms completed (as a % of red zone alerts) increased from
23% in October 2016 to 89% in April 2018. Total number of yellow alerts
generated dropped from 262 to 173 per month, and the total number of red
alerts generated dropped from 50 to 26 per month which may indicate that we
are managing our alerts more effectively and preventing further alerts being
generated. Most importantly there was no SAC 1 or 2 incidents during 2017
and 2018 YTD at Batemans Bay relating to failure to recognise and respond to
deteriorating patient.

CT and ultrasound service development Eurobodalla
Team: Phil Carter (Manager, Medical Imaging Eurobodalla), Leanne Ovington,
Lisa Kennedy, Dr Belinda Doherty, Ben Wright, Linda Brown, Aaron Sanders

Previously CT and ultrasound were provided in Moruya in private rooms,
resulting in acutely ill patients traveling off-site from the hospitals to a private
facility that did not always have appropriate medical support. Additionally,
after-hours access to CT was very limited.

A new and full operational Medical Imaging service was available in the
Eurobodalla at Moruya from September 2017 through funding from the
Ministry of Health. Patients are now able to access CT services 24/7. As a
result CT usage has increased as more patients are getting the services they
need in the Eurobodalla and not being transferred to the ACT after hours and
on weekends.Direct clinical benefits to patients have included:
•        several lung biopsies on patients who have been able to have their
         study done locally and in a shorter timeframe than was available in the
         ACT, reducing the discomfort and out of pocket expenses for patients
         with a new cancer diagnosis.

•       Stroke patients now have quicker access to diagnosis with patients
        being identified as FAST positive by NSW Ambulance going direct to
        CT making diagnosis and transfer to the ACT faster. This has resulted
        in at least 1 patient receiving successful thrombolysis
        in the ACT within the 4 hour timeframe. With time this will improve and
        puts Eurobodalla (with the highest number of stroke presentations in
        the LHD) in a position in the future to be able to offer better stroke
        services with the potential for thrombolysis to be done locally.
•       Trauma patients are receiving a full diagnostic workup enabling more
        appropriate timely transfer. Those with normal CT can be kept locally
        rather than transferring to a tertiary centre. With time this will help
        decrease patient flows to the ACT.
•       Access to a bulk-billed CT and US service for the community is
        proving very popular and helping us achieve an improved revenue
        outcome that is growing each month.

Mrs Dean’s Story – A consumer collaboration to reduce injury at Batemans
Bay
Team: Niccola Follett (Falls Prevention Coordinator), Christine Ewin
(Consumer), Rebekah O’Reilly (NUM Batemans Bay Inpatient Ward)

Providing relevant and meaningful education to clinical staff is a challenge
that requires innovation and creativity. In an effort to improve compliance with
admission procedures for patients with fall and delirium risk, an engaging and
emotional consumer story outlining the journey of a 76 year old who suffers a
serious fall in hospital was bought to life.

The passionate account, given by Mrs Dean’s daughter Christine has received
much accolade on a local and state wide platform. The story is a real life
reflection of the published statistics related to the morbidity and mortality
of older people who fall in our community and hospitals. It offers the face
of a mother and grandmother to the journey of patients that require close
screening and observation when they come into our care.

Mrs Dean’s story was creatively produced into a short film in 2017 to assist
in educating clinical staff from across Southern NSW and other Local Health
Districts in NSW. This has been widely used in staff training provided by the
Southern NSW LHD Falls Prevention Coordinator in the past year with over
150 clinicians attending face to face sessions at their sites. The collaboration
between the Falls Prevention Coordinator, NUM and the Consumer has
been embraced by the SNSWLHD Chief Executive, the Clinical Excellence
Commission and NSW Falls Prevention Network. The story was presented
in the plenary session at the NSW Falls Prevention forum in Sydney in 2017.

Evaluation reports from this forum attended by over 300 health professionals
from across NSW identified that the ‘patient story was excellent…motivating
and moving…poignant and absolutely reinforced reasons why we need to
bring changes to current processes.

The team at Batemans Bay have used this story as a carriage to highlight
the patient safety improvements they have made in implementing of a range
of best practice fall prevention strategies. The outcomes of which have
resulted in the site having not experienced a fall with serious injury for three
consecutive years.

A New Culture for Patient Safety – Goulburn Hospital
Team: Rebecca Moon (Team Leader – A/NUM GBH ICU), Cassandra O’Brien,
Kathleen Manfred, Jennifer Roberts, Jojy Joseph (RNs ICU), Phoebe Dobb
(CNE, ICU), Kristy Wilson (CNE GBH), Debbie Oxford-Willson (QI Advisor)

Goulburn Hospital has had a number of SAC 2 incidents in the last few years
relating to failure to recognise and respond to patient deterioration as per the
local Clinical Emergency Response System (CERS) policy. This project aimed
to put patient safety first by ensuring that within 12 months, 100% of patients
in ICU who breach the CERS calling criteria are escalated as the CERS
protocol.

The results were that 100% of red zone alerts were escalated and 100% of
forms were completed; 77% of yellow zone alerts were reviewed appropriately;
and 55% of Clinical Review forms were completed.

The project team from ICU collaborated with the surgical ward staff which
resulted in a more collaborative relationship between both nursing areas.

The project will continue with PDSA cycles to commence for other secondary
drivers including increasing the use of computers, increasing the awareness
of the In-Charge role, improving documentation of Altered Calling Criteria and
Resuscitation Plans and maintaining a focus on staff education.

Be My Buddy – Queanbeyan Inpatient Unit
Team: Lauren Rodger (Essentials of Care Coordinator), Pauline Murtagh (QI
Advisor), Kassandra Packwood (NUM – IPU/COU), Ljiljana Cvetkoska, Leone
Bell, Jessica Cahill, James Heslop

Staff working the afternoon and night shifts were leaving work late (usually
by about 30mins) every shift due to bedside handover taking too long. This
was a daily complaint made by staff and causing increasing frustration and
resentment.

This project aimed to ensure that 100% of Bedside Handovers between all
shifts takes a maximum of 30mins to complete and a team nursing model of
care on the In-Patient Unit at Queanbeyan Hospital was implemented.

The results of the project to date demonstrate improved compliance with the
Clinical Handover audit in QARS, reduced number of Rapid Response alerts
generated in EMR, reduced incidents in IIMS and reduced sick leave.

The project was presented at the Essentials of Care Showcase in May 2018.

Confident Nurses for Safe Patients – Goulburn Hospital
Team: Kristy Wilson (CNE), Kerry Sebo (NUM Surgical Ward), Sarah
Honeysett (CNS, Surgical Ward), Katherine Withers (RN Surgical Ward),
Rebecca Moon (A/NUM ICU), Ainslie Humphries (Consumer/RN Surgical
Ward), Debbie Oxford-Willson (QI Advisor), Judy Ryall (GBH DoNM)

Goulburn Hospital has had a number of SAC 2 incidents in the last few years
relating to failure to recognise and respond to patient deterioration as per the
local Clinical Emergency Response System (CERS) policy. This project aimed
to put patient safety first by ensuring that within 12 months, 90% of patients in
Surgical Ward who breach the Between the Flags calling criteria are escalated
as per the CERS protocol and documented appropriately.

The results were that 100% of red zone alerts were escalated and
documented in eMR. 78% of yellow zone alerts were escalated and
documented in eMR. Response times to initiate care following a Clinical
Review activation reduced from 34 minutes in January 2017 to 13 minutes in
January 2018. There has been a noted increase in both yellow and red zone
triggers for “Concerns by staff” which is encouraging. The overall culture of
managing patient deterioration has been impacted hugely.
The work being carried out on the Surgical Ward has also been completed
on the Medical Ward and Sub-Acute Rehabilitation Unit. DETECT has had a
revamp for GBH which now includes a session on REACH and how to locate
local and District CERS procedures.

Ring, Ring, Why don’t you give me a call? Queanbeyan Theatres
Team: Tahnee Bell (CNS OT), Della Trute (NUM OT), Pauline Murtagh (QI
Advisor), Surgical Bookings and Admission staff, Harry Williams (HSM
Queanbeyan - sponsor)

The project was initiated as post-operative concerns and complaints were not
being recognised in a timely manner. The project team aimed to reduce post-
operative complaints by 80% from patients using the Queanbeyan Hospital
Operating Theatres Service.

The team clarified post-operative instructions by introducing a standard
process for post-operative follow up phone calls with patients and medication
management was improved through medications and scripts being tailored to
Day Surgery patients.

The results were that concerns and complaints from patients following theatre
procedures were reduced significantly. Plans to sustain change include phone
calls are now imbedded into the daily practice of staff in the operating theatres;
auditing of eMR and feedback forms and if concerns are raised we follow up
in timely manner; we continue to collect the returned surveys from patients
and store these in the patient record after documenting; and we continue to
provide training to new, existing and visiting staff to ensure that the good work
continues.

Category – Collaborative Team
This award aims to emphasise the need for people to work together across
boundaries to implement projects/programs which promote improvement in
the health of our community and our health systems.

Finalists

Allied Health Assistant Teleconference Network – Ambulatory and Integrated
Care Cluster
Team: Jenni Devine (Allied Health Assistant Coordinator)

Representing a small portion of the health workforce in SNSWLHD and
without a professional governing body, the Allied Health Assistants (AHAs)
were lacking guidance and direction for workplace skill enhancement and
professional development. Some AHAs were also feeling isolated in their role
and expressed a desire for an increased sense of team and collaboration with
their peers.

From this, the AHA Teleconference Network (AHATN) was developed
to support, enhance collaboration and provide informal professional
development. Through teleconference sessions held 2nd monthly, the district
AHAs are able to collaborate, share workplace knowledge and experiences
with other AHAs and learn from the wider health service team of allied health
professionals (AHPs) and others who join the teleconferences as guest
presenters.

This capacity for collaboration supports the AHAs in their integral work as part
of the health service.

Sticking to CORE values- Designing individual and team work plans to
improve consumer care – Bega Valley Community MHDA
Team: Danielle Neves/ Fiona Burns, Sukalpa Goldflam, Simon Grealy, Chris
Groninger, Jacqui Keogh, Ben Laycock, Paul Merrick, Els Paijmans, Rebecca
Perry, Brendan Rombouts, Rochelle Watch, Brianna Armstead, Tricia Atkin,
Nea-Ann Bax, Caron Copas, Julie Caldeira, Jocelyn France, Matt Pritchard,
David Shepherd, Jeanette Westmore

This project aimed to build the Bega Valley Community Mental Health Drug
and Alcohol team’s understanding of organisational goals. By asking clinicians
to link individual personal performance and appraisal development goals to
strategic and services plan goals in their individual PPAD’s, opportunities for
developing team goals were identified.

This exemplifies the values of collaboration. Team members were willing to
share individual PPAD goals with other team members in order to develop
team work plans and this exemplifies openness and respect. Team members
were empowered to think innovatively by considering strategic direction when
developing their individual personal performance and appraisal development
plans.

Innovation also emerged. The Older Persons’ team used this model of work
planning to explore goals to improve relationships with GP’s and knowledge
of services. The Child and Adolescent Mental Health Team used this model
of work planning to improve distress-tolerance activities provided by a local
school and developed a model of regular case conferencing with school
counsellors to promote better care for child and adolescent consumers
engaged with these tertiary services. One adult clinician identified the need to
engage in training and service delivery for young women with eating disorders
and was able to develop a work plan that drew on relevant goals from the
clinical services plan.

Life is Highway … but life on the country road is better – Bombala MPS
Team: Rhonda Stewart (SNM Bombala/Delegate), Julie Mann, all staff
Bombala MPS

As a pilot site for the Living Well in an MPS Collaborative, Bombala MPS has
spent the last 12 months exploring strategies to improve the quality of life for
our Residents within the MPS.

The overall outcome has been the change in the culture of care towards our
residents – we are involving them more in decisions about their care and
lifestyle. We are recognising that Bombala MPS is their home and the model

of care should reflect that principle. We are giving them choices in many more
aspects of their life and we are trying to make their rooms and spaces reflect
a home like environment. We are facilitating a closer connection with the
community through working with schools and other community groups and
improving access for residents to private providers for services eg exercise
physiologists, hairdresser.

Creating a Control Centre – Eurobodalla
Team: Leanne Ovington (DoNM), Phil Carter (Manager Medical Imaging
Eurobodalla), Ken Russell (Capital Works and Sustainability Manager), Ian
Johnson (Capital Works and Accommodation Support Officer)

Eurobodalla Health Service received capital funding from the Ministry
of Health for development of the medical imaging service including the
installation of a CT in Moruya Hospital. It was identified it was imperative for
this to be located near the emergency department, which then impacted on
multiple other areas of the service. The aim was to provide improved spaces
for all impacted staff, ensure WHS requirements, increase productivity and
staff satisfaction were met.

The project team drafted multiple options for relocating services and
consultation with all stakeholders occurred. The important part of the
consultation process was stating the case for change, informing stakeholders
of benefits and listening to the requirements for all focusing on the areas
which did not currently meet needs.

The outcomes of the capital works at Moruya Hospital are improvement
to patient care by ensuring appropriate, safe patient flow between ED and
radiology, collaboration with the nursing administration team leading to better
decision making, and improved patient flow. The clinical staff station allows
improved medication handling. All staff affected by the relocation in space
gained an improved work area resulting in more appropriate storage of
medical records, increased efficiency of staff, opportunity for team building and
better accessibility of managers for staff.

This project was a one off capital works funded project however the principles
of collaborating as a team, involving all stakeholders, listening to the issues
and thinking outside the square to create solutions are transferable to all
projects.

Once More Unto the Breach - Emergency Treatment Performance (ETP),
Monaro Cluster
Team: Nicola Yates (GM Monaro), Harry Williams (A/HSM Queanbeyan),
Rhonda Stewart (A/HSM Cooma), Heather Fairfax (NUM ED Queanbeyan),

Joann Caldwell (NUM ED Cooma), Heather Scroope (NM Delegate), Dr Daniel
Smith (Director ED Queanbeyan), Dr Deepak Puri (Emergency Medicine
Queanbeyan)

The Monaro Cluster was formed in January 2017, bringing four hospitals
and four very different emergency departments together, each with their own
challenges and issues, with a shared KPI target of 86.7% ETP to be achieved
against a state target of 81% and an LHD target of 85%. In addition 2017 was
the busiest winter to date with presentation numbers rising over 10% above
same time last year in some sites with a corresponding increase in acuity
evidenced by rising triage numbers in categories 1, 2 and 3.

In April 2017, a weekly 30 minute ETP breach meeting was introduced in the
Monaro Cluster to bring together Emergency Medicine Doctors and Nurse
Managers with Health Service Management to review the previous weeks
breach data obtained from Firstnet and examine the reason why patients were
staying longer than 4 hours in the emergency department.

The results of this collaboration for Monaro are:
•       Sustained small improvements in ETP performance achieving 87%
        YTD against a stretch target of 86.7% in the face of an 8% YTD
        increase in ED presentations
•       Transfer of Care Performance is significantly improved, achieving
        97.1% YTD, up 7% on last year’s achievement, whilst dealing with a
        3.4% increase YTD in ambulance arrivals and a significant increase in
        Triage 1, 2 and 3 presentations indicating higher acuity as well as
        complexity.
•       Costs have been reduced with both Cooma and Queanbeyan being
        approximately 8% cheaper per encounter than their C2 peers
•       An overall reduction in representation and readmission rates
        indicating that the quality of care provided is also maintained and in
        some cases improved, despite the increased volume and acuity that is
        being managed in a more timely manner.
•       Acute Length of Stay also continues to decrease
This project enabled us to enhanced collaboration and improve team work by
bringing different clinical disciplines together with managers across four sites
to work collaboratively on improving performance through a focus on timely
and appropriate clinical care delivery.

Rising to the Challenge - Eurobodalla Generalist Community Nursing Team
Team: Ruth Snowball (Eurobodalla CH Manager), The Eurobodalla community
nursing team including: Bern Lambert, Edwina Fynmore, Liz Craze, Jessica
Jackson, Kylie Belcher, Sharon Richards, Kris Lenehan, Larissa Cottier,