2011 quality systems assessment ... - cec.health.nsw.gov.au€¦ · september 2011 to november 2011...

2011 Quality Systems Assessment Self

Assessment

Supplementary Report: Mental Health Patients at risk of suicide

Physical health of mental health patients

Management of patients with mental health co morbidity.

May 2012

2

© Clinical Excellence Commission 2012

This work is copyright. Apart from any use as permitted under the Copyright Act 1968, no part may be reproduced

without prior written permission from the Clinical Excellence Commission. Requests and enquiries concerning

reproduction and rights should be directed to the Director, Corporate Services, Clinical Excellence Commission, GPO

Box 1614, Sydney NSW 2001.

This publication is part of the Clinical Excellence Commission’s Quality Systems Assessment Series. A complete list of

the CEC’s publications is available from the Director, Corporate Services, Clinical Excellence Commission, GPO Box 1614,

Sydney NSW 2001, or via the Institute’s web site (http://www.cec.health.nsw.gov.au).

Authors

Bernadette King, Roger Kerr, Jun Bai

Clinical Excellence Commission

Board Chair: Associate Professor Brian McCaughan AM

Chief Executive Officer: Professor Clifford F Hughes AO

Any enquiries about or comments on this publication should be directed to:

Dr Charles Pain Director Health Systems Improvement Clinical Excellence Commission Locked Bag A4062 Sydney South NSW 1235

Phone: (02) 9269 5500

Email: [email protected]

http://www.cec.health.nsw.gov.au/stocktake_request.html

mailto:[email protected]

3

Table of Contents

Executive Summary ................................................................................................................................................. 4

Introduction ............................................................................................................................................................... 6

Understanding the data ................................................................................................................................................. 6

State-wide recommendations ....................................................................................................................................... 7

Suicide Risk .................................................................................................................................................................... 8

Physical Health of Mental Health Patients ............................................................................................................... 48

Patients with Mental Health co morbidity .................................................................................................................. 66

Appendix 1: Notes about the data: ....................................................................................................................... 86

4

Executive Summary

Most patients with severe mental illness are in frequent contact with primary care services, and for many this can be

their only contact with health services. There is evidence to suggest that this may not necessarily mean they always

receive good care (Phelan, Stradins & Morrison, 2001).

This supplementary report provides more detailed information from the self assessment results undertaken from

September 2011 to November 2011 relating to the management of mental health patients which included assessment

of:

Patients at risk of suicide

Physical health of mental health patients and

Management of patients with mental health co morbidity.

The 2011 self-assessment was completed by over 1,500 respondents across, and at various levels, of the health system.

At the unit level the overall response rate was 99%. All medical and surgical specialties; maternity; intensive care and

high dependency units; mental health; emergency medicine and allied health services were represented at the

department/clinical unit level.

The results provided here, unless stated otherwise, reflect data provided at the department/ clinical unit level for the

local health districts and networks. Results are presented in graph form to allow comparison of performance between

each LHD/organisation.

Some of the main findings include:

Service type

Across NSW 20% of all respondents at the clinical unit level provided services that were mental health specific;

12% adult mental health and 8% paediatric mental health specific.

In the Justice Health units there were 80% mental health specific services with 70% of those managing adult

patients.

Management of Suicide

At the clinical unit level 71% of respondents indicated that they manage at risk patients (often, sometimes or

rarely); of these 27% responded that suicide risk was managed optimally with 73% responding it was managed

variably or poorly in their department.

100% of LHDs responded yes to having guidelines in place while at the clinical unit level 79% responded yes..

At the clinical unit level 51% of respondents use a standardised screening tool when conducting a suicide risk

assessment with 28% responding that there is a system in place and functioning optimally in relation to risk

assessments being conducted in a timely manner.

In response to what discharge systems were in place and their level of functioning, 21% develop a comprehensive

care plan for at risk patients before discharge and only 24% have a system that functions optimally for clear and

timely communication with primary carer when discharge is planned/occurs

At Justice Health’s operational unit level 99% of respondents manage patients at risk of suicide often to rarely. Of

those 42% responded that at risk suicide patients were optimally managed, 57% variably.

5

All operational units have either policy/guidelines available for management of at risk patients

Physical health of mental health patients

20% of all respondents at the clinical unit level provided services that were mental health specific; 12% adult

mental health and 8% paediatric mental health specific.

In the Justice Health units there was a population of 80% mental health specific with 70% of those managing adult

patients.

95% of facilities; 82% of clinical units and 95% of Justice Health services responded that they had guidelines /

protocols regarding assessment and management of physical health needs of mental health patients

Patients with mental health co morbidity

At the clinical unit level 83% manage or treat patients with mental health co morbidity, of those 45% have

guidelines or protocols to assist in their management.

At the clinical unit level less than 60% of staff have received training in the management of patients with mental

health / challenging behaviours.

70% of clinical units responded that there are protocols in place for managing crisis situations after hours

81% of respondents at the clinical unit level have systems in place to involve the patient and family in discharge

planning while 54% contact the patients GP or Psychiatrist to arrange consultation within 24 hours following

discharge.

6

Introduction

A critical element of the QSA is the reporting of findings of the assessment activities to relevant stakeholders. The initial

rationale for the development of the QSA was to provide NSW Health with assurance about the quality of health

services and assist the CEC in identifying areas for improvement and promotion of better practice in patient safety

management. Analysis of the findings of the QSA and reporting these findings to all levels of the health system is key to

achieving the objectives of the QSA.

This supplementary report is the third reporting obligation the CEC has completed since the 2011 self assessment.

Two weeks following assessment closure the raw data (labelled and coded) was returned to each LHD / Network /

Organisation and facilities

Four weeks following assessment a ‘results’ report for each facility-level respondent (~198) was generated and

sent out to facilitate follow-up and action at facility level. These reports contained aggregated / comparative data

based on the LHD / Network

Thematic supplementary reports – Paediatrics, Sepsis, Delirium and Mental Health

It is expected that the above resources will be used by the LHD / Networks to identify areas with greatest risk and

vulnerability that apply to them and develop improvement plans to address them. Where appropriate they should also

be used by individual departments to review their data and respond to issues raised. For example at the clinical unit

level 83% manage or treat patients with a mental health co morbidity, of those 45% have guidelines or protocols to

assist in their management and less than 60% of staff have received training in the management of patients with

mental health / challenging behaviours. This issue has an impact across the whole district so it is likely the district will

need to work at each level (i.e. facility and department / clinical unit) to address this issue.

While it is expected that action is taken in response to the results the CEC acknowledge that the timeline of the QSA

assessment was for September / November 2011 and it is probable that in some cases policy / programs have already

been implemented / completed by the time this report is published.

Understanding the data In this report, charts and tables are used to provide information on department/clinical unit responses to the questions

from the 2011 QSA self assessment compared to the aggregated NSW results.

Except where noted the charts illustrate the responses for departments/clinical units from LHDs.

The report uses pie charts, summary graphs for multiple questions and tables summarising the statistical analysis

of the results.

Charts are also used to compare the responses for departments/clinical units from each peer hospital group and

the overall NSW proportion. The Peer Hospital Groups are collapsed to the main letter designation with the

exception of:

F2 Nursing Home & F3 Multi-Purpose Services facilities are mapped to F2-3

F1 – Psychiatric facilities that are mapped to F1 – MH

F4 Sub Acute, F6 Rehabilitation, F7 Mothercraft & F8 Ungrouped Non-Acute facilities are mapped to

“F4-8”

7

State-wide recommendations In May 2012 the Statewide report will be released. This report will provide an overview of results and makes

recommendation on a system wide perspective. The following recommendations come from the aggregated analysis of

all data from the self assessments.

The Mental Health and Drug and Alcohol Office work with Mental Health lead clinicians in each LHD to develop tools

and strategies to increase awareness of and skill development of all staff in recognition and assessment of patients with

or at risk of a mental health condition.

8

Suicide Risk • NSW Health staff are required to treat every suicide attempt as a significant and imminent threat.

• A suicide attempt is a major risk factor for subsequent death by suicide.

• When assistance is sought for suicidal behaviour, including suicidal threats, the response must be prompt,

effective and efficient and based on comprehensive policies, procedures and protocols which reflect evidence-

based and culturally appropriate practice.

• Individuals with co-existing drug and alcohol problems can be at greater risk of:

o increased symptoms and suicide behaviours

o greater non compliance with treatment

o more hostile and aggressive behaviours

o increased risk of violence to others

o higher rates of offending, imprisonment and homelessness

o longer psychiatric admissions

34% of departments/clinical units responding to the survey indicated that adults, children or young people who

are at risk of suicide are assessed or treated in your department at least monthly. 29% indicated they never

assess or treat patients at risk of suicide.

Figure 1: % of Departments/clinical units reporting assessing and managing patients at risk of suicide by frequency and LHD.

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

CC

LHD

ISLH

D

NB

MLH

D

NSL

HD

SCH

N

SESL

HD

SVH

N

SWSL

HD

SYD

LHD

WSL

HD

Met

ro T

ota

l

FWLH

D

HN

ELH

D

MLH

D

MN

CLH

D

NN

SWLH

D

SNSW

LHD

WN

SWLH

D

R&

R T

ota

l

JH

Metropolitan Rural & Regional Other

Often (weekly or more often) Sometimes (at least monthly but less often than weekly)

Rarely (once every three to twelve months) Never

Please estimate the frequency that patients (i.e. adults, children or young people) who are at risk of suicide are assessed or treated in your department

__ Often (weekly or more often)

__ Sometimes (at least monthly but less often than weekly)

__ Rarely (once every three to twelve months)

__ Never (answer no more questions in relation to Suicide)

9

Table 1: Count & % of Departments/clinical units reporting assessing and managing patients at risk of suicide by frequency and

LHD.

Description LHD Often (weekly or more

often)

Sometimes (at least

monthly but less often

than weekly)

Rarely (once every three

to twelve months) Never

Metropolitan CCLHD 6 12.8% 12 25.5% 21 44.7% 8 17.0%

ISLHD 8 12.7% 7 11.1% 22 34.9% 26 41.3%

NBMLHD 8 22.9% 6 17.1% 14 40.0% 7 20.0%

NSLHD 15 15.5% 16 16.5% 37 38.1% 29 29.9%

SCHN 6 6.9% 9 10.3% 20 23.0% 52 59.8%

SESLHD 10 8.0% 16 12.8% 54 43.2% 45 36.0%

SVHN 6 28.6% 3 14.3% 8 38.1% 4 19.0%

SWSLHD 28 24.8% 17 15.0% 34 30.1% 34 30.1%

SYDLHD 11 11.2% 14 14.3% 44 44.9% 29 29.6%

WSLHD 14 23.3% 6 10.0% 15 25.0% 25 41.7%

Metro Total 112 15.0% 106 14.2% 269 36.1% 259 34.7%

Rural &

Regional FWLHD 2 16.7% 3 25.0% 3 25.0% 4 33.3%

HNELHD 19 14.7% 24 18.6% 60 46.5% 26 20.2%

MLHD 8 11.9% 18 26.9% 27 40.3% 14 20.9%

MNCLHD 7 18.9% 6 16.2% 15 40.5% 9 24.3%

NNSWLHD 8 14.3% 12 21.4% 27 48.2% 9 16.1%

SNSWLHD 10 18.5% 11 20.4% 13 24.1% 20 37.0%

WNSWLHD 12 12.6% 19 20.0% 41 43.2% 23 24.2%

R&R Total 66 14.7% 93 20.7% 186 41.3% 105 23.3%

Other JH 46 79.3% 7 12.1% 4 6.9% 1 1.7%

NSW 224 17.9% 206 16.4% 459 36.6% 365 29.1%

10

Figure 2: % of Departments/clinical units reporting assessing and managing patients at risk of suicide by frequency and Peer Group.

81% of Emergency departments responding to the survey indicated that adults, children or young people who

are at risk of suicide are assessed or treated in your department at least weekly.

Figure 3: % of Departments/clinical units reporting assessing and managing patients at risk of suicide by frequency and Service

type.

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

A B C D F2-F3 F1-MH F4-F7 JH



0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Med

ical

Surg

ical

Oth

er

MH

Ob

s &

Gyn

ED

Age

d C

are

Pae

dia

tric

ICU

On

colo

gy

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ing

Nep

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11

Across NSW 73% of departments/clinical units responding to this question indicated the management of

suicide risk could be improved. 17% of rural & regional departments/clinical units responding to this question

indicated that suicide risk was managed optimally compared to 33% of units from metropolitan LHDs.

Figure 4: % of Departments/clinical units reporting how well suicide is managed by LHD.

Table 2: Count & % of Departments/clinical units reporting how well suicide is managed by LHD.

Description LHD Managed optimally - needs no

improvement Managed variably - needs some

improvement Managed poorly - needs

considerable improvement

Metropolitan CCLHD 6 15.4% 25 64.1% 8 20.5%

ISLHD 11 29.7% 23 62.2% 3 8.1%

NBMLHD 4 14.3% 15 53.6% 9 32.1%

NSLHD 17 25.0% 48 70.6% 3 4.4%

SCHN 14 40.0% 21 60.0%

0.0%

SESLHD 19 23.8% 55 68.8% 6 7.5%

SVHN 5 29.4% 11 64.7% 1 5.9%

SWSLHD 28 35.4% 47 59.5% 4 5.1%

SYDLHD 44 63.8% 25 36.2%

0.0%

WSLHD 12 34.3% 21 60.0% 2 5.7%

Metro Total 160 32.9% 291 59.8% 36 7.4%

Rural & Regional

FWLHD 1 12.5% 6 75.0% 1 12.5%

HNELHD 22 21.4% 72 69.9% 9 8.7%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

CC

LHD

ISLH

D

NB

MLH

D

NSL

HD

SCH

N

SESL

HD

SVH

N

SWSL

HD

SYD

LHD

WSL

HD

Met

ro T

ota

l

FWLH

D

HN

ELH

D

MLH

D

MN

CLH

D

NN

SWLH

D

SNSW

LHD

WN

SWLH

D

R&

R T

ota

l

JH


Managed optimally - needs no improvement Need improvement NSW - Managed optimally

How well is suicide risk managed? (tick one option & provide details)

__ Managed optimally - needs no improvement

__ managed variably - needs some improvement

__ Managed poorly - needs considerable improvement

12

Description LHD Managed optimally - needs no

improvement Managed variably - needs some

improvement Managed poorly - needs

considerable improvement

MLHD 8 15.1% 42 79.2% 3 5.7%

MNCLHD 2 7.1% 23 82.1% 3 10.7%

NNSWLHD 6 12.8% 31 66.0% 10 21.3%

SNSWLHD 4 11.8% 21 61.8% 9 26.5%

WNSWLHD 14 19.4% 50 69.4% 8 11.1%

R&R Total 57 16.5% 245 71.0% 43 12.5%

Other JH 24 42.1% 32 56.1% 1 1.8%

NSW 241 27.1% 568 63.9% 80 9.0%

Figure 5: % of Departments/clinical units reporting how well suicide is managed by Peer Group.

Figure 6: % of Departments/clinical units reporting how well suicide is managed by Service type.

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%


Managed optimally - needs no improvement Need improvement

NSW - Managed optimally

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Med

ical

Oth

er

Surg

ical

MH

ED

Age

d C

are

Ob

s &

Gyn

ICU

Pae

dia

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On

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Managed optimally - needs no improvement Need improvement

NSW - Managed optimally

13

Figure 7: % of departments/clinical units indicating the most challenging issues experienced when managing patients at-

risk of suicide for all of NSW.

69%

56%

56%

50%

45%

43%

35%

20%

16%

9%

3%

0% 10% 20% 30% 40% 50% 60% 70% 80%

Challenging behaviours such as aggression or absconding

Limitations of the physical environment

Resource/work load issue

Skill or knowledge deficits e.g. lack of familiarity with assessment/screening tools

Referrals/consultation

Discharge or transfer of care issues

Legal issues e.g. knowledge/understanding of the mental health act

Managing additional needs e.g. CALD, Aboriginal and Torres Strait Islanders, children and young people etc

Absent or unclear procedures/protocols

Other

None

NSW - % of departments/clinical units responding

From the following list please indicate the most challenging issues experienced when managing patients at-risk of suicide (tick a maximum of three)

__ None

__ Skill or knowledge deficits e.g. lack of familiarity with assessment / screening tools

__ Challenging behaviours such as aggression or absconding

__ Limitations of the physical environment

__ Absent or unclear procedures / protocols

__ Legal issues e.g. knowledge / understanding of the mental health act

__ Referrals / consultation

__ Cooperation of other agencies e.g. police, CSNSW etc

__ Managing additional needs e.g. CALD, Aboriginal and Torres Strait Islanders, children and young people

etc

__ Discharge or transfer of care issues

__ Resource / work load issue

__ other (provide details)

14

Table 3: Count & % of departments/clinical units indicating the most challenging issues experienced when managing patients at-risk of suicide by LHD.

Description LHD

Challenging

behaviours

such as

aggression or

absconding

Limitations of

the physical

environment

Resource/wo

rk load issue

Skill or

knowledge

deficits

Referrals/con

sultation

Discharge or

transfer of

care issues

Legal issues

e.g.

knowledge/u

nderstanding

of the mental

health act

Managing

additional

needs e.g.

CALD, ATSI,

children and

young people

etc

Absent or

unclear

procedures/p

rotocols

Other None

Metropolitan CCLHD 25 64% 21 54% 22 56% 21 54% 16 41% 9 23% 20 51% 6 15% 10 26% 4 10% 1 3%

ISLHD 27 73% 26 70% 18 49% 20 54% 20 54% 15 41% 17 46% 8 22% 9 24% 1 3% 3 8%

NBMLHD 22 79% 15 54% 17 61% 15 54% 13 46% 14 50% 11 39% 4 14% 9 32% 1 4% 1 4%

NSLHD 48 71% 40 59% 31 46% 32 47% 30 44% 34 50% 21 31% 11 16% 11 16% 2 3% 1 1%

SCHN 20 57% 11 31% 13 37% 19 54% 15 43% 9 26% 8 23% 6 17% 2 6% 3 9% 2 6%

SESLHD 58 73% 38 48% 48 60% 48 60% 38 48% 32 40% 36 45% 14 18% 11 14% 10 13% 2 3%

SVHN 11 65% 3 18% 10 59% 8 47% 5 29% 6 35% 4 24% 3 18% 4 24% 4 24%

0%

SWSLHD 48 61% 37 47% 44 56% 32 41% 41 52% 24 30% 22 28% 17 22% 7 9% 2 3% 4 5%

SYDLHD 41 59% 23 33% 25 36% 17 25% 11 16% 20 29% 5 7% 20 29% 4 6% 8 12% 6 9%

WSLHD 22 63% 21 60% 18 51% 13 37% 11 31% 17 49% 10 29% 8 23% 7 20% 1 3% 2 6%

Metro Total 322 66% 235 48% 246 51% 225 46% 200 41% 180 37% 154 32% 97 20% 74 15% 36 7% 22 5%

Rural &

Regional FWLHD 5 63% 6 75% 4 50% 5 63% 4 50% 4 50% 3 38% 2 25%

0% 1 13%

0%

HNELHD 77 75% 76 74% 68 66% 64 62% 54 52% 56 54% 46 45% 21 20% 16 16% 11 11% 2 2%

MLHD 40 75% 34 64% 35 66% 30 57% 32 60% 35 66% 22 42% 14 26% 8 15% 7 13%

0%

MNCLHD 20 71% 17 61% 21 75% 14 50% 12 43% 11 39% 14 50% 4 14% 6 21% 2 7% 1 4%

NNSWLHD 31 66% 29 62% 35 74% 28 60% 33 70% 24 51% 21 45% 10 21% 18 38% 6 13%

0%

SNSWLHD 29 85% 21 62% 22 65% 16 47% 18 53% 16 47% 11 32% 5 15% 3 9% 4 12% 1 3%

WNSWLHD 59 82% 51 71% 47 65% 42 58% 32 44% 42 58% 33 46% 17 24% 15 21% 10 14%

0%

R&R Total 261 76% 234 68% 232 67% 199 58% 185 54% 188 54% 150 43% 73 21% 66 19% 41 12% 4 1%

Other JH 27 47% 31 54% 16 28% 22 39% 13 23% 11 19% 6 11% 7 12% 1 2% 7 12% 1 2%

NSW 610 69% 500 56% 494 56% 446 50% 398 45% 379 43% 310 35% 177 20% 141 16% 84 9% 27 3%

15

Illawarra Shoalhaven LHD (84%) was the only metropolitan based LHD to report higher than the state average (80%) of

departments/clinical units indicating that guidelines and/or local protocols were in place to guide the safe management

of patients at risk of suicide.

Figure 8: Percentage of Departments/clinical units indicating they have guidelines and / or local protocols in place to guide the

safe management of patients at risk of suicide by LHD.

Table 4: Count & Percentage of Departments/clinical units indicating they have guidelines and / or local protocols in place to

guide the safe management of patients at risk of suicide by LHD.

Description LHD Yes, guidelines Yes, local protocols Both, guidelines and

local protocols No


ISLHD 11 29.7% 6 16.2% 14 37.8% 6 16.2%

NBMLHD 9 32.1% 6 21.4% 4 14.3% 9 32.1%

NSLHD 20 29.4% 10 14.7% 20 29.4% 18 26.5%

SCHN 7 20.0% 10 28.6% 7 20.0% 11 31.4%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

CC

LHD

ISLH

D

NB

MLH

D

NSL

HD

SCH

N

SESL

HD

SVH

N

SWSL

HD

SYD

LHD

WSL

HD

Met

ro T

ota

l

FWLH

D

HN

ELH

D

MLH

D

MN

CLH

D

NN

SWLH

D

SNSW

LHD

WN

SWLH

D

R&

R T

ota

l

JH


Yes - LHD Yes _ NSW

Do you have guidelines and / or local protocols in place to guide the safe management of patients at risk of suicide?

__ Yes, guidelines

__ Yes, local protocols

__ Both, guidelines and local protocols

__ No

16


local protocols No

SESLHD 34 42.5% 10 12.5% 20 25.0% 16 20.0%

SVHN 5 29.4% 1 5.9% 5 29.4% 6 35.3%

SWSLHD 27 34.2% 9 11.4% 24 30.4% 19 24.1%

SYDLHD 18 26.1% 7 10.1% 27 39.1% 17 24.6%

WSLHD 7 20.0% 3 8.6% 12 34.3% 13 37.1%

Metro Total 146 30.0% 67 13.8% 144 29.6% 130 26.7%

Rural &

Regional FWLHD 5 62.5% 1 12.5% 2 25.0%

0.0%

HNELHD 59 57.3% 5 4.9% 26 25.2% 13 12.6%

MLHD 23 43.4% 5 9.4% 24 45.3% 1 1.9%

MNCLHD 10 35.7% 2 7.1% 11 39.3% 5 17.9%

NNSWLHD 14 29.8% 4 8.5% 19 40.4% 10 21.3%

SNSWLHD 11 32.4% 3 8.8% 15 44.1% 5 14.7%

WNSWLHD 39 54.2% 4 5.6% 20 27.8% 9 12.5%

R&R Total 161 46.7% 24 7.0% 117 33.9% 43 12.5%

Other JH 19 33.3% 7 12.3% 30 52.6% 1 1.8%

NSW 326 36.7% 98 11.0% 291 32.7% 174 19.6%

Figure 9: Percentage of Departments/clinical units indicating they have guidelines and / or local protocols in place to guide the

safe management of patients at risk of suicide by Peer Group.

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%


Yes - LHD Yes _ NSW

17

Figure 10: Percentage of departments/clinical units indicating issues are covered in guidelines / protocols for all of NSW.

69%

62%

48%

44%

41%

39%

7%

0% 10% 20% 30% 40% 50% 60% 70% 80%

Suicide risk assessment

Drug and alcohol risk assessment

Psychiatric and psychosocial assessment

Response for crisis situations such as patient absconding

Protocols linking emergency departments and wards to 24-hour mental health services

Discharge protocols

Other


Please indicate which of the following issues are covered in your guidelines / protocols: (tick all that apply)

__ Suicide risk assessment

__ Drug and alcohol risk assessment

__ Psychiatric and psychosocial assessment

__ Response for crisis situations e.g. challenging behaviours, patient absconding etc

__ Protocols linking clinical units to 24-hour mental health services

__ Specific protocols for discharge / transfer of care / referral for outpatient care

__ other

18

Table 5: Count & Percentage of departments/clinical units indicating issues are covered in guidelines / protocols by LHD.

Description LHD Suicide risk assessment Drug and alcohol risk

assessment

Psychiatric and

psychosocial

assessment

Response for crisis

situations such as

patient absconding

Protocols linking

emergency

departments and wards

to 24-hour mental

health services

Discharge protocols Other

Metropolitan CCLHD 19 49% 17 44% 12 31% 14 36% 12 31% 10 26% 3 8%

ISLHD 22 59% 22 59% 16 43% 16 43% 13 35% 19 51% 3 8%

NBMLHD 14 50% 13 46% 11 39% 7 25% 8 29% 8 29% 2 7%

NSLHD 35 51% 36 53% 36 53% 36 53% 27 40% 22 32% 3 4%

SCHN 14 40% 10 29% 11 31% 13 37% 6 17% 5 14% 7 20%

SESLHD 53 66% 46 58% 40 50% 32 40% 19 24% 25 31% 10 13%

SVHN 9 53% 8 47% 8 47% 7 41% 5 29% 7 41% 2 12%

SWSLHD 54 68% 45 57% 46 58% 38 48% 27 34% 34 43% 3 4%

SYDLHD 43 62% 43 62% 41 59% 39 57% 32 46% 24 35% 3 4%

WSLHD 18 51% 18 51% 18 51% 15 43% 12 34% 13 37% 1 3%

Metro Total 281 58% 258 53% 239 49% 217 45% 161 33% 167 34% 37 8%

Rural &

Regional FWLHD 8 100% 7 88% 6 75% 6 75% 8 100% 5 63% 2 25%

HNELHD 85 83% 69 67% 38 37% 48 47% 48 47% 36 35% 4 4%

MLHD 49 92% 48 91% 33 62% 34 64% 45 85% 30 57% 3 6%

MNCLHD 19 68% 18 64% 14 50% 7 25% 8 29% 5 18%

0%

NNSWLHD 32 68% 32 68% 19 40% 17 36% 20 43% 20 43% 1 2%

SNSWLHD 26 76% 23 68% 12 35% 15 44% 20 59% 17 50% 3 9%

WNSWLHD 60 83% 49 68% 28 39% 29 40% 42 58% 33 46% 2 3%

R&R Total 279 81% 246 71% 150 43% 156 45% 191 55% 146 42% 15 4%

Other JH 53 93% 48 84% 41 72% 19 33% 13 23% 31 54% 7 12%

NSW 613 69% 552 62% 430 48% 392 44% 365 41% 344 39% 59 7%

19

Departments/clinical units from all rural & regional based LHDs reported higher than the NSW average (51%)

for having a standardised screening tool utilised when conducting a suicide risk assessment.

Figure 11: Percentage of Departments/clinical units indicating they have a standardised screening tool utilised when conducting a

suicide risk assessment by LHD.

Table 6: Count & Percentage of Departments/clinical units indicating they have a standardised screening tool utilised when

conducting a suicide risk assessment by LHD.

Description LHD Yes No Not applicable

Metropolitan CCLHD 14 36% 12 31% 13 33%

ISLHD 11 30% 14 38% 12 32%

NBMLHD 8 29% 13 46% 7 25%

NSLHD 24 35% 26 38% 18 26%

SCHN 9 26% 11 31% 15 43%

SESLHD 34 43% 23 29% 23 29%

SVHN 5 29% 10 59% 2 12%

SWSLHD 36 46% 32 41% 11 14%

SYDLHD 33 48% 20 29% 16 23%

WSLHD 13 37% 15 43% 7 20%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

CC

LHD

ISLH

D

NB

MLH

D

NSL

HD

SCH

N

SESL

HD

SVH

N

SWSL

HD

SYD

LHD

WSL

HD

Met

ro T

ota

l

FWLH

D

HN

ELH

D

MLH

D

MN

CLH

D

NN

SWLH

D

SNSW

LHD

WN

SWLH

D

R&

R T

ota

l

Metropolitan Rural & Regional

LHD - Yes NSW - Yes

Is a standardised screening tool utilised when conducting a suicide risk assessment?

__ Yes (provide details)

__ No

__ Not applicable

20


Metro Total 187 38% 176 36% 124 25%

Rural &

Regional FWLHD 8 100%

0%

0%

HNELHD 64 62% 23 22% 16 16%

MLHD 41 77% 8 15% 4 8%

MNCLHD 16 57% 6 21% 6 21%

NNSWLHD 32 68% 5 11% 10 21%

SNSWLHD 19 56% 9 26% 6 18%

WNSWLHD 54 75% 9 13% 9 13%

R&R Total 234 68% 60 17% 51 15%

NSW 421 51% 236 28% 175 21%

Figure 12: Percentage of Departments/clinical units indicating they have a standardised screening tool utilised when conducting a

suicide risk assessment by Peer Group.

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

A B C D F2-F3 F1-MH F4-F7

Yes NSW - Yes

21

Figure 13: Percentage of departments/clinical units indicating areas staff in contact with patients at risk of suicide have received

training for all of NSW.

33%

32%

27%

26%

19%

16%

35%

0% 5% 10% 15% 20% 25% 30% 35% 40%

The presentation of possible self-harm or suicidal behaviour in different age groups and diagnostic

categories

Assessment, treatment and follow-up of patients with possible suicidal behaviour

The implications and use of the NSW Mental Health Act 2007

How to implement suicide prevention guidelines/protocols

How to liaise with carers and families

Other

None


For staff who are in contact with patients at risk of suicide please indicate in which of the following areas they have received training

__ None

__ The presentation of possible self-harm or suicidal behaviour in different age groups and diagnostic

categories

__ How to implement suicide prevention guidelines / protocols?

__ Assessment, treatment and follow-up of patients with possible suicidal behaviour

__ The implications and use of the NSW Mental Health Act 2007?

__ How to liaise with carers and families?

__ other

22

Table 7: Count & : Percentage of departments/clinical units indicating areas staff in contact with patients at risk of suicide have received training by LHD.

Description LHD

The presentation of

possible self-harm or

suicidal behaviour in

different age groups

and diagnostic

categories

Assessment, treatment

and follow-up of

patients with possible

suicidal behaviour

The implications and

use of the NSW Mental

Health Act 2007

How to implement

suicide prevention

guidelines/protocols

How to liaise with

carers and families Other None


ISLHD 9 24% 7 19% 7 19% 8 22% 4 11% 3 8% 19 51%

NBMLHD 9 32% 7 25% 6 21% 7 25% 3 11% 6 21% 10 36%

NSLHD 13 19% 15 22% 17 25% 10 15% 18 26% 7 10% 30 44%

SCHN 15 43% 10 29% 9 26% 7 20% 11 31% 6 17% 12 34%

SESLHD 17 21% 17 21% 19 24% 13 16% 10 13% 15 19% 34 43%

SVHN 4 24% 4 24% 4 24% 3 18% 4 24% 3 18% 8 47%

SWSLHD 28 35% 28 35% 27 34% 20 25% 20 25% 10 13% 28 35%

SYDLHD 31 45% 16 23% 12 17% 14 20% 12 17% 11 16% 18 26%

WSLHD 15 43% 15 43% 13 37% 12 34% 9 26% 2 6% 17 49%

Metro

Total 151 31% 128 26% 123 25% 101 21% 99 20% 65 13% 197 40%

Rural & Regional FWLHD 6 75% 5 63% 3 38% 6 75% 3 38% 4 50% 1 13%

HNELHD 22 21% 31 30% 28 27% 19 18% 23 22% 11 11% 43 42%

MLHD 27 51% 23 43% 24 45% 29 55% 12 23% 10 19% 5 9%

MNCLHD 9 32% 5 18% 8 29% 6 21% 4 14% 4 14% 10 36%

NNSWLHD 12 26% 10 21% 11 23% 14 30% 4 9% 6 13% 20 43%

SNSWLHD 15 44% 15 44% 10 29% 12 35% 5 15% 8 24% 6 18%

WNSWLHD 16 22% 22 31% 11 15% 14 19% 10 14% 17 24% 26 36%

R&R Total 107 31% 111 32% 95 28% 100 29% 61 18% 60 17% 111 32%

Other JH 32 56% 45 79% 20 35% 29 51% 10 18% 15 26% 1 2%

NSW 290 33% 284 32% 238 27% 230 26% 170 19% 140 16% 309 35%

23

Departments/clinical units responding to this question across NSW indicated that 41% of relevant staff had

received training in the previously mentioned areas. Nepean Blue Mountains reported 17% and Mid North

Coast LHD reported 19% of relevant staff had received training in the previously mentioned areas.

Figure 14: Percentage of Departments/clinical units indicating that “All” or “Most” relevant staff that have received the

abovementioned training by LHD.

Table 8: Count & Percentage of Departments/clinical units indicating that “All” or “Most” relevant staff that have received the

abovementioned training by LHD.

Description LHD All (100%) Most (67%-

99%)

Some (34%–

66%) Few (1%-33%) None (0%) Don't know


0.0% 1 6.3%

ISLHD 2 12.5% 4 25.0% 6 37.5% 3 18.8% 1 6.3%

0.0%

NBMLHD 2 11.1% 1 5.6% 5 27.8% 6 33.3% 1 5.6% 3 16.7%

NSLHD 2 5.4% 13 35.1% 12 32.4% 6 16.2%

0.0% 4 10.8%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

CC

LHD

ISLH

D

NB

MLH

D

NSL

HD

SCH

N

SESL

HD

SVH

N

SWSL

HD

SYD

LHD

WSL

HD

Met

ro T

ota

l

FWLH

D

HN

ELH

D

MLH

D

MN

CLH

D

NN

SWLH

D

SNSW

LHD

WN

SWLH

D

R&

R T

ota

l

JH


LHD - All (100%) or Most (67%-99%) NSW - All (100%) or Most (67%-99%)

Please estimate the percentage of relevant staff that have received the abovementioned training

__ All (100%)

__ Most (67%-99%)

__ Some (34% – 66%)

__ Few (1% - 33%)

__ None (0%)

__ Don’t know

24

Description LHD All (100%) Most (67%-

99%)

Some (34%–


SCHN 1 4.5% 9 40.9% 5 22.7% 6 27.3%

0.0% 1 4.5%

SESLHD

0.0% 16 39.0% 11 26.8% 6 14.6% 2 4.9% 6 14.6%

SVHN

0.0% 4 50.0% 2 25.0% 1 12.5%

0.0% 1 12.5%

SWSLHD 6 12.0% 23 46.0% 14 28.0% 6 12.0% 1 2.0%

0.0%

SYDLHD 5 9.8% 15 29.4% 17 33.3% 4 7.8%

0.0% 10 19.6%

WSLHD 2 11.8% 6 35.3% 5 29.4% 4 23.5%

0.0%

0.0%

Metro Total 22 8.0% 97 35.1% 81 29.3% 45 16.3% 5 1.8% 26 9.4%

Rural &

Regional FWLHD

0.0% 3 42.9% 4 57.1%

0.0%

0.0%

0.0%

HNELHD 3 5.2% 17 29.3% 17 29.3% 14 24.1% 1 1.7% 6 10.3%

MLHD 3 6.5% 17 37.0% 14 30.4% 10 21.7%

0.0% 2 4.3%

MNCLHD 2 12.5% 1 6.3% 7 43.8% 4 25.0%

0.0% 2 12.5%

NNSWLHD

0.0% 8 29.6% 7 25.9% 10 37.0%

0.0% 2 7.4%

SNSWLHD 2 7.4% 10 37.0% 9 33.3% 5 18.5%

0.0% 1 3.7%

WNSWLHD

0.0% 13 28.3% 13 28.3% 15 32.6% 2 4.3% 3 6.5%

R&R Total 10 4.4% 69 30.4% 71 31.3% 58 25.6% 3 1.3% 16 7.0%

Other JH 11 20.4% 17 31.5% 13 24.1% 7 13.0% 1 1.9% 5 9.3%

NSW 43 7.7% 183 32.9% 165 29.6% 110 19.7% 9 1.6% 47 8.4%

25

Please respond in relation to your department / clinical unit

Yes,

routinely

Yes, occasionally

but not routine

No Not

applicable

Staff compliance with guidelines / protocols is audited __ __ __ __

For NSW 34% of departments/clinical units responding to this question indicated that staff compliance with guidelines /

protocols is audited.

Figure 15: Percentage of Departments/clinical units indicating that staff compliance with guidelines / protocols is audited by LHD.

Table 9: Count & Percentage of Departments/clinical units indicating that staff compliance with guidelines / protocols is audited

by LHD.

Description LHD Yes, routinely Yes, occasionally but not

routine No Not applicable

Metropolitan CCLHD 3 8% 8 21% 20 51% 8 21%

ISLHD 8 22% 5 14% 10 27% 14 38%

NBMLHD 4 14% 3 11% 17 61% 4 14%

NSLHD 6 9% 10 15% 40 59% 12 18%

SCHN 3 9% 4 11% 22 63% 6 17%

SESLHD 11 14% 14 18% 38 48% 17 21%

SVHN 3 18% 1 6% 9 53% 4 24%

SWSLHD 17 22% 16 20% 34 43% 12 15%

SYDLHD 3 4% 15 22% 22 32% 29 42%

WSLHD 8 23% 7 20% 14 40% 6 17%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

CC

LHD

ISLH

D

NB

MLH

D

NSL

HD

SCH

N

SESL

HD

SVH

N

SWSL

HD

SYD

LHD

WSL

HD

Met

ro T

ota

l

FWLH

D

HN

ELH

D

MLH

D

MN

CLH

D

NN

SWLH

D

SNSW

LHD

WN

SWLH

D

R&

R T

ota

l

Just

ice

Hea

lth


LHD - Yes NSW - Yes

26



Metro Total 66 14% 83 17% 226 46% 112 23%

Rural &

Regional FWLHD 2 25% 3 38% 2 25% 1 13%

HNELHD 10 10% 26 25% 54 52% 13 13%

MLHD 16 30% 10 19% 25 47% 2 4%

MNCLHD 2 7% 7 25% 13 46% 6 21%

NNSWLHD 8 17% 4 9% 27 57% 8 17%

SNSWLHD 3 9% 9 26% 18 53% 4 12%

WNSWLHD 9 13% 13 18% 43 60% 7 10%

R&R Total 50 14% 72 21% 182 53% 41 12%

Justice Health JH 11 20% 22 39% 14 25% 9 16%

NSW 127 14% 177 20% 422 48% 162 18%

82% of departments/clinical units responding to this question from hospitals in peer group F1 indicated that staff

compliance with guidelines / protocols is audited

Figure 16: Percentage of Departments/clinical units indicating that staff compliance with guidelines / protocols is audited by Peer

Group.

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%


Peer group - Yes NSW - Yes

27

Please respond in relation to your department / clinical unit

Yes,

routinely

Yes, occasionally

but not routine

No Not

applicable

Staff skills required to manage suicidal patients are reviewed __ __ __ __

Across NSW 36% of departments/clinical units responding to this question indicated that staff skills required to manage

suicidal patients are reviewed. Responses from seven of the ten metropolitan LHDs were below the NSW average

Figure 17: Percentage of Departments/clinical units indicating that staff skills required to manage suicidal patients are reviewed

by LHD.

Table 10: Count & Percentage of Departments/clinical units indicating that staff skills required to manage suicidal patients are

reviewed by LHD.




ISLHD 4 11% 8 22% 14 38% 11 30%

NBMLHD 4 14% 2 7% 19 68% 3 11%

NSLHD 5 7% 18 26% 34 50% 11 16%

SCHN 4 11% 8 23% 14 40% 9 26%

SESLHD 10 13% 13 16% 43 54% 14 18%

SVHN 3 18% 2 12% 9 53% 3 18%

SWSLHD 15 19% 15 19% 37 47% 12 15%

SYDLHD 3 4% 15 22% 23 33% 28 41%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

CC

LHD

ISLH

D

NB

MLH

D

NSL

HD

SCH

N

SESL

HD

SVH

N

SWSL

HD

SYD

LHD

WSL

HD

Met

ro T

ota

l

FWLH

D

HN

ELH

D

MLH

D

MN

CLH

D

NN

SWLH

D

SNSW

LHD

WN

SWLH

D

R&

R T

ota

l

Just

ice

Hea

lth



28



WSLHD 5 14% 11 31% 13 37% 6 17%

Metro Total 58 12% 101 21% 223 46% 105 22%

Rural &

Regional FWLHD 1 13% 6 75% 1 13%

0%

HNELHD 5 5% 24 23% 64 62% 10 10%

MLHD 11 21% 19 36% 21 40% 2 4%

MNCLHD

0% 5 18% 17 61% 6 21%

NNSWLHD 4 9% 7 15% 27 57% 9 19%

SNSWLHD 7 21% 10 29% 13 38% 4 12%

WNSWLHD 7 10% 23 32% 35 49% 7 10%

R&R Total 35 10% 94 27% 178 52% 38 11%

Other Justice Health 15 27% 20 36% 21 38%

0%

NSW 108 12% 215 24% 422 48% 143 16%

Figure 18: Percentage of Departments/clinical units indicating that staff skills required to manage suicidal patients are reviewed

by Peer Group.

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%



29

Figure 19: Percentage of departments/clinical units indicating the agencies where there are procedures included in guidelines for

all of NSW.

32%

27%

25%

14%

11%

11%

5%

22%

0% 5% 10% 15% 20% 25% 30% 35%

Don't know

Police

Ambulance

Other

Corrective Services NSW

Department of Community Services

Juvenile Justice

None

NSW - % of departments/clinical units

Please indicate whether your guidelines include response procedures for agencies that frequently refer patients with possible suicidal behaviour: (tick all that apply)

__ None we have no response procedures in place

__ Police

__ Ambulance

__ Corrective Services NSW

__ Juvenile Justice

__ Department of Community Services

__ don’t know

__ other

30

Table 11: Count & Percentage of departments/clinical units indicating the agencies where there are procedures included in guidelines by LHD

Description LHD Don't know Police Ambulance Other Corrective Services

NSW

Department of

Community Services Juvenile Justice None


0% 2 5%

0% 11 28%

ISLHD 19 51% 8 22% 6 16% 3 8% 3 8% 2 5% 1 3% 8 22%

NBMLHD 11 39% 7 25% 7 25% 4 14% 3 11% 4 14% 2 7% 8 29%

NSLHD 34 50% 6 9% 6 9% 11 16% 1 1% 3 4% 1 1% 17 25%

SCHN 15 43% 3 9% 2 6% 5 14%

0% 3 9%

0% 10 29%

SESLHD 34 43% 4 5% 3 4% 11 14% 4 5% 6 8% 1 1% 23 29%

SVHN 2 12% 4 24% 2 12% 5 29% 2 12% 1 6%

0% 7 41%

SWSLHD 28 35% 20 25% 16 20% 11 14% 3 4% 10 13% 1 1% 19 24%

SYDLHD 21 30% 13 19% 11 16% 17 25%

0% 5 7%

0% 15 22%

WSLHD 11 31% 11 31% 10 29% 3 9% 3 9% 2 6% 2 6% 10 29%

Metro Total 192 39% 83 17% 70 14% 74 15% 19 4% 38 8% 8 2% 128 26%

Rural &

Regional FWLHD

0% 6 75% 7 88% 1 13%

0% 2 25% 1 13%

0%

HNELHD 32 31% 41 40% 38 37% 7 7% 4 4% 7 7% 2 2% 22 21%

MLHD 13 25% 31 58% 32 60% 3 6% 7 13% 12 23% 4 8% 4 8%

MNCLHD 9 32% 8 29% 9 32% 5 18% 3 11% 5 18% 3 11% 3 11%

NNSWLHD 21 45% 11 23% 10 21% 5 11% 1 2% 2 4%

0% 12 26%

SNSWLHD 7 21% 16 47% 14 41% 9 26% 4 12% 6 18% 2 6% 6 18%

WNSWLHD 12 17% 31 43% 29 40% 9 13% 13 18% 14 19% 7 10% 21 29%

R&R Total 94 27% 144 42% 139 40% 39 11% 32 9% 48 14% 19 6% 68 20%

Other Justice

Health 0% 14 25% 11 19% 8 14% 49 86% 9 16% 14 25%

0%

NSW 286 32% 241 27% 220 25% 121 14% 100 11% 95 11% 41 5% 196 22%

31

Please indicate if you have a system in place and its level of functioning in relation to

System in

place and

functioning

optimally (i.e.

needs no

improvement)

System in place

and functioning

moderately (i.e.

needs some

improvement)

System in place

and functioning

poorly (i.e. needs

considerable

improvement)

System

not in

place

N/A

A suicide risk assessment is conducted in a timely

manner __ __ __ __ __

Figure 20: Percentage of Departments/clinical units indicating the status of their system for ensuring a suicide risk assessment is

conducted in a timely manner by LHD.

Table 12: Count of Percentage of Departments/clinical units indicating the status of their system for ensuring a suicide risk

assessment is conducted in a timely manner by LHD.

Description LHD

System in place and

functioning

optimally

System in place and

functioning

moderately

System in place and

functioning poorly System not in place Not applicable

Metropolitan CCLHD 6 15.8% 9 23.7% 5 13.2% 8 21.1% 10 26.3%

ISLHD 6 16.2% 11 29.7% 6 16.2% 6 16.2% 8 21.6%

NBMLHD 5 17.9% 6 21.4% 9 32.1% 5 17.9% 3 10.7%

NSLHD 16 23.5% 26 38.2% 6 8.8% 8 11.8% 12 17.6%

SCHN 6 17.6% 17 50.0% 1 2.9% 2 5.9% 8 23.5%

SESLHD 17 22.1% 23 29.9% 7 9.1% 9 11.7% 21 27.3%

SVHN 6 35.3% 6 35.3%

0.0% 3 17.6% 2 11.8%

SWSLHD 16 21.1% 35 46.1% 7 9.2% 8 10.5% 10 13.2%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

CC

LHD

ISLH

D

NB

MLH

D

NSL

HD

SCH

N

SESL

HD

SVH

N

SWSL

HD

SYD

LHD

WSL

HD

Met

ro T

ota

l

FWLH

D

HN

ELH

D

MLH

D

MN

CLH

D

NN

SWLH

D

SNSW

LHD

WN

SWLH

D

R&

R T

ota

l

JH


LHD - System in place and functioning optimally or moderately LHD - System in place and functioning poorly or not at all

Not applicable NSW - System in place and functioning optimally or moderately

32

Description LHD

System in place and

functioning

optimally

System in place and

functioning

moderately

System in place and


SYDLHD 17 25.4% 21 31.3% 5 7.5% 2 3.0% 22 32.8%

WSLHD 9 25.7% 14 40.0% 1 2.9% 4 11.4% 7 20.0%

Metro Total 104 21.8% 168 35.2% 47 9.9% 55 11.5% 103 21.6%

Rural &

Regional FWLHD 5 62.5% 3 37.5%

0.0%

0.0%

0.0%

HNELHD 19 18.6% 41 40.2% 20 19.6% 13 12.7% 9 8.8%

MLHD 18 34.0% 27 50.9% 3 5.7% 3 5.7% 2 3.8%

MNCLHD 3 11.5% 11 42.3% 6 23.1% 1 3.8% 5 19.2%

NNSWLHD 10 21.7% 18 39.1% 10 21.7% 2 4.3% 6 13.0%

SNSWLHD 5 14.7% 14 41.2% 8 23.5% 3 8.8% 4 11.8%

WNSWLHD 16 22.2% 31 43.1% 12 16.7% 5 6.9% 8 11.1%

R&R Total 76 22.3% 145 42.5% 59 17.3% 27 7.9% 34 10.0%

Other JH 29 51.8% 23 41.1% 3 5.4%

0.0% 1 1.8%

NSW 209 23.9% 336 38.4% 109 12.5% 82 9.4% 138 15.8%

Figure 21: Percentage of Departments/clinical units indicating the status of their system for ensuring a suicide risk assessment is

conducted in a timely manner by Peer Group.

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%




33


System in place and

functioning optimally (i.e.

needs no improvement)

System in place and functioning moderately (i.e.

needs some improvement)

System in place and functioning

poorly (i.e. needs considerable

improvement)

System not in place

N/A

Those at risk receive a psychosocial and psychiatric

assessment and follow-up care __ __ __ __ __

Figure 22: Percentage of Departments/clinical units indicating the status of their system for ensuring those at risk receive a

psychosocial and psychiatric assessment and follow-up care by LHD.

Table 13: Count & Percentage of Departments/clinical units indicating the status of their system for ensuring those at risk receive

a psychosocial and psychiatric assessment and follow-up care by LHD.

Description LHD

System in place and

functioning

optimally

System in place and

functioning

moderately

System in place and



ISLHD 7 18.9% 18 48.6% 4 10.8% 1 2.7% 7 18.9%

NBMLHD 4 14.3% 8 28.6% 11 39.3% 2 7.1% 3 10.7%

NSLHD 26 38.2% 27 39.7% 5 7.4% 2 2.9% 8 11.8%

SCHN 8 23.5% 14 41.2% 1 2.9% 1 2.9% 10 29.4%

SESLHD 21 27.3% 33 42.9% 7 9.1% 2 2.6% 14 18.2%

SVHN 6 35.3% 8 47.1% 1 5.9% 1 5.9% 1 5.9%

SWSLHD 23 30.3% 37 48.7% 4 5.3% 3 3.9% 9 11.8%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

CC

LHD

ISLH

D

NB

MLH

D

NSL

HD

SCH

N

SESL

HD

SVH

N

SWSL

HD

SYD

LHD

WSL

HD

Met

ro T

ota

l

FWLH

D

HN

ELH

D

MLH

D

MN

CLH

D

NN

SWLH

D

SNSW

LHD

WN

SWLH

D

R&

R T

ota

l

JH




34

Description LHD

System in place and

functioning

optimally

System in place and

functioning

moderately

System in place and


SYDLHD 21 31.3% 21 31.3% 4 6.0% 1 1.5% 20 29.9%

WSLHD 12 34.3% 16 45.7% 2 5.7%

0.0% 5 14.3%

Metro Total 136 28.5% 195 40.9% 45 9.4% 17 3.6% 84 17.6%

Rural &

Regional FWLHD 3 37.5% 2 25.0% 1 12.5% 2 25.0%

0.0%

HNELHD 14 13.7% 46 45.1% 22 21.6% 9 8.8% 11 10.8%

MLHD 14 26.4% 26 49.1% 9 17.0% 2 3.8% 2 3.8%

MNCLHD 2 7.7% 10 38.5% 6 23.1% 3 11.5% 5 19.2%

NNSWLHD 7 15.2% 18 39.1% 13 28.3% 2 4.3% 6 13.0%

SNSWLHD 5 14.7% 17 50.0% 7 20.6% 1 2.9% 4 11.8%

WNSWLHD 14 19.4% 33 45.8% 12 16.7% 6 8.3% 7 9.7%

R&R Total 59 17.3% 152 44.6% 70 20.5% 25 7.3% 35 10.3%

Other JH 24 42.9% 20 35.7% 8 14.3% 3 5.4% 1 1.8%

NSW 219 25.1% 367 42.0% 123 14.1% 45 5.1% 120 13.7%

35


System in place and







improvement)

System not in place

N/A

The treatment process and plan is coordinated and integrated across all aspects of service delivery with clear uninterrupted lines of clinical responsibility

__ __ __ __ __

Figure 23: Percentage of Departments/clinical units indicating the status of their system for ensuring the treatment process and

plan is coordinated and integrated across all aspects of service delivery with clear uninterrupted lines of clinical responsibility by

LHD.

Table 14: Count & Percentage of Departments/clinical units indicating the status of their system for ensuring the treatment

process and plan is coordinated and integrated across all aspects of service delivery with clear uninterrupted lines of clinical

responsibility by LHD.

Description LHD

System in place and

functioning

optimally

System in place and

functioning

moderately

System in place and



ISLHD 5 13.5% 12 32.4% 11 29.7% 1 2.7% 8 21.6%

NBMLHD 2 7.1% 5 17.9% 12 42.9% 6 21.4% 3 10.7%

NSLHD 12 17.6% 29 42.6% 18 26.5% 2 2.9% 7 10.3%

SCHN 8 23.5% 11 32.4% 4 11.8% 2 5.9% 9 26.5%

SESLHD 12 15.6% 27 35.1% 15 19.5% 7 9.1% 16 20.8%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

CC

LHD

ISLH

D

NB

MLH

D

NSL

HD

SCH

N

SESL

HD

SVH

N

SWSL

HD

SYD

LHD

WSL

HD

Met

ro T

ota

l

FWLH

D

HN

ELH

D

MLH

D

MN

CLH

D

NN

SWLH

D

SNSW

LHD

WN

SWLH

D

R&

R T

ota

l

JH




36

Description LHD

System in place and

functioning

optimally

System in place and

functioning

moderately

System in place and


SVHN 4 23.5% 7 41.2% 2 11.8% 3 17.6% 1 5.9%

SWSLHD 17 22.4% 27 35.5% 13 17.1% 9 11.8% 10 13.2%

SYDLHD 13 19.4% 20 29.9% 8 11.9% 3 4.5% 23 34.3%

WSLHD 7 20.0% 15 42.9% 5 14.3% 2 5.7% 6 17.1%

Metro Total 87 18.2% 166 34.8% 95 19.9% 40 8.4% 89 18.7%

Rural &

Regional FWLHD 2 25.0% 2 25.0% 1 12.5% 2 25.0% 1 12.5%

HNELHD 7 6.9% 40 39.2% 28 27.5% 15 14.7% 12 11.8%

MLHD 8 15.1% 21 39.6% 19 35.8% 2 3.8% 3 5.7%

MNCLHD 2 7.7% 3 11.5% 12 46.2% 4 15.4% 5 19.2%

NNSWLHD 4 8.7% 15 32.6% 12 26.1% 8 17.4% 7 15.2%

SNSWLHD 4 11.8% 12 35.3% 12 35.3% 2 5.9% 4 11.8%

WNSWLHD 9 12.5% 24 33.3% 23 31.9% 9 12.5% 7 9.7%

R&R Total 36 10.6% 117 34.3% 107 31.4% 42 12.3% 39 11.4%

Other JH 17 30.4% 27 48.2% 9 16.1% 3 5.4%

0.0%

NSW 140 16.0% 310 35.5% 211 24.1% 85 9.7% 128 14.6%

37


System in place and







improvement)

System not in place

N/A

A comprehensive care plan is developed before discharge / transition of care

__ __ __ __ __

While six of seven rural & regional LHDs reported below the state average of 51%, there was variability

between LHDs in the responses of departments/clinical units.

Figure 24: Percentage of Departments/clinical units indicating the status of their system for ensuring a comprehensive care plan is

developed before discharge / transition of care by LHD.

Table 15: Count & Percentage of Departments/clinical units indicating the status of their system for ensuring a comprehensive

care plan is developed before discharge / transition of care by LHD.

Description LHD

System in place and

functioning

optimally

System in place and

functioning

moderately

System in place and



ISLHD 5 13.5% 13 35.1% 9 24.3% 1 2.7% 9 24.3%

NBMLHD 3 10.7% 6 21.4% 11 39.3% 4 14.3% 4 14.3%

NSLHD 14 20.6% 31 45.6% 11 16.2% 3 4.4% 9 13.2%

SCHN 8 23.5% 11 32.4% 4 11.8% 1 2.9% 10 29.4%

SESLHD 15 19.5% 29 37.7% 10 13.0% 7 9.1% 16 20.8%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

CC

LHD

ISLH

D

NB

MLH

D

NSL

HD

SCH

N

SESL

HD

SVH

N

SWSL

HD

SYD

LHD

WSL

HD

Met

ro T

ota

l

FWLH

D

HN

ELH

D

MLH

D

MN

CLH

D

NN

SWLH

D

SNSW

LHD

WN

SWLH

D

R&

R T

ota

l

JH




38

Description LHD

System in place and

functioning

optimally

System in place and

functioning

moderately

System in place and


SVHN 4 23.5% 5 29.4% 3 17.6% 3 17.6% 2 11.8%

SWSLHD 19 25.0% 28 36.8% 12 15.8% 5 6.6% 12 15.8%

SYDLHD 13 19.4% 22 32.8% 5 7.5% 2 3.0% 25 37.3%

WSLHD 10 28.6% 12 34.3% 5 14.3% 2 5.7% 6 17.1%

Metro Total 98 20.5% 166 34.8% 75 15.7% 35 7.3% 103 21.6%

Rural &

Regional FWLHD 2 25.0% 3 37.5% 1 12.5% 1 12.5% 1 12.5%

HNELHD 10 9.8% 34 33.3% 28 27.5% 15 14.7% 15 14.7%

MLHD 10 18.9% 16 30.2% 16 30.2% 3 5.7% 8 15.1%

MNCLHD 1 3.8% 5 19.2% 8 30.8% 4 15.4% 8 30.8%

NNSWLHD 3 6.5% 15 32.6% 10 21.7% 10 21.7% 8 17.4%

SNSWLHD 4 11.8% 11 32.4% 12 35.3% 1 2.9% 6 17.6%

WNSWLHD 6 8.3% 21 29.2% 16 22.2% 13 18.1% 16 22.2%

R&R Total 36 10.6% 105 30.8% 91 26.7% 47 13.8% 62 18.2%

Other JH 15 27.3% 26 47.3% 8 14.5% 4 7.3% 2 3.6%

NSW 149 17.1% 297 34.0% 174 19.9% 86 9.9% 167 19.1%


developed before discharge / transition of care by Peer Group.

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%




39


developed before discharge / transition of care by Service type.

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100% M

edic

al

Oth

er

Surg

ical

MH

ED

Age

d C

are

Ob

s &

Gyn

Pae

dia

tric

ICU

On

colo

gy

Reh

abili

tati

on

Nep

hro

logy

Car

dia

c/C

ard

iolo

gy

Ort

ho

pae

dic

Pal

liati

ve C

are

Imag

ing

Mic

rob

iolo

gy



40


System in place and







improvement)

System not in place

N/A

Follow-up appointments are attended __ __ __ __ __

Across NSW 43% of departments/clinical units responding to this question indicated that the system for ensuring

follow-up appointments are attended was functioning optimally or moderately

Figure 27: Percentage of Departments/clinical units indicating the status of their system for ensuring follow-up appointments are

attended by LHD.

Table 16: Count & Percentage of Departments/clinical units indicating the status of their system for ensuring follow-up

appointments are attended by LHD.

Description LHD

System in place and

functioning

optimally

System in place and

functioning

moderately

System in place and



ISLHD 8 21.6% 12 32.4% 5 13.5% 2 5.4% 10 27.0%

NBMLHD 4 14.3% 5 17.9% 8 28.6% 4 14.3% 7 25.0%

NSLHD 11 16.2% 23 33.8% 8 11.8% 5 7.4% 21 30.9%

SCHN 5 14.7% 11 32.4% 2 5.9% 2 5.9% 14 41.2%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

CC

LHD

ISLH

D

NB

MLH

D

NSL

HD

SCH

N

SESL

HD

SVH

N

SWSL

HD

SYD

LHD

WSL

HD

Met

ro T

ota

l

FWLH

D

HN

ELH

D

MLH

D

MN

CLH

D

NN

SWLH

D

SNSW

LHD

WN

SWLH

D

R&

R T

ota

l

JH




41

Description LHD

System in place and

functioning

optimally

System in place and

functioning

moderately

System in place and


SESLHD 15 19.5% 23 29.9% 6 7.8% 5 6.5% 28 36.4%

SVHN 3 17.6% 2 11.8% 1 5.9% 2 11.8% 9 52.9%

SWSLHD 13 17.1% 22 28.9% 8 10.5% 5 6.6% 28 36.8%

SYDLHD 11 16.4% 15 22.4% 7 10.4% 2 3.0% 32 47.8%

WSLHD 8 22.9% 12 34.3% 3 8.6% 1 2.9% 11 31.4%

Metro Total 83 17.4% 133 27.9% 52 10.9% 33 6.9% 176 36.9%

Rural &

Regional FWLHD 1 12.5% 2 25.0% 1 12.5%

0.0% 4 50.0%

HNELHD 5 4.9% 35 34.3% 20 19.6% 12 11.8% 30 29.4%

MLHD 10 18.9% 17 32.1% 9 17.0% 2 3.8% 15 28.3%

MNCLHD 1 3.8% 6 23.1% 5 19.2% 3 11.5% 11 42.3%

NNSWLHD 4 8.7% 7 15.2% 10 21.7% 8 17.4% 17 37.0%

SNSWLHD 5 14.7% 13 38.2% 8 23.5% 1 2.9% 7 20.6%

WNSWLHD 6 8.3% 16 22.2% 14 19.4% 12 16.7% 24 33.3%

R&R Total 32 9.4% 96 28.2% 67 19.6% 38 11.1% 108 31.7%

Other JH 9 16.1% 25 44.6% 12 21.4% 3 5.4% 7 12.5%

NSW 124 14.2% 254 29.1% 131 15.0% 74 8.5% 291 33.3%

42


System in place and







improvement)

System not in place

N/A

There is clear and timely communication with the

primary carer and other relevant health professionals

when discharge / transition of care is planned / occurs

__ __ __ __ __

Figure 28: Percentage of Departments/clinical units indicating the status of their system for ensuring clear and timely

communication with the primary carer and other relevant health professionals when discharge / transition of care is planned /

occurs by LHD.

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

CC

LHD

ISLH

D

NB

MLH

D

NSL

HD

SCH

N

SESL

HD

SVH

N

SWSL

HD

SYD

LHD

WSL

HD

Met

ro T

ota

l

FWLH

D

HN

ELH

D

MLH

D

MN

CLH

D

NN

SWLH

D

SNSW

LHD

WN

SWLH

D

R&

R T

ota

l

JH




43

31% of departments/clinical units from Mid North Coast LHD, 32% from Nepean Blue Mountains and 33%

from Northern NSW LHD responding to this question indicated that the system to ensure clear and timely

communication with the primary carer and other relevant health professionals when discharge / transition of

care is planned / occurs was functioning optimally or moderately

Table 17: Count & Percentage of Departments/clinical units indicating the status of their system for ensuring clear and timely

communication with the primary carer and other relevant health professionals when discharge / transition of care is planned /

occurs by LHD.

Description LHD

System in place and

functioning

optimally

System in place and

functioning

moderately

System in place and



ISLHD 9 24.3% 14 37.8% 5 13.5% 1 2.7% 8 21.6%

NBMLHD 2 7.1% 7 25.0% 12 42.9% 4 14.3% 3 10.7%

NSLHD 17 25.0% 29 42.6% 9 13.2% 2 2.9% 11 16.2%

SCHN 6 17.6% 13 38.2% 2 5.9% 2 5.9% 11 32.4%

SESLHD 24 31.2% 26 33.8% 10 13.0% 3 3.9% 14 18.2%

SVHN 5 29.4% 3 17.6% 3 17.6% 2 11.8% 4 23.5%

SWSLHD 16 21.1% 28 36.8% 13 17.1% 7 9.2% 12 15.8%

SYDLHD 15 22.4% 20 29.9% 8 11.9% 1 1.5% 23 34.3%

WSLHD 9 25.7% 15 42.9% 4 11.4% 1 2.9% 6 17.1%

Metro Total 111 23.3% 163 34.2% 73 15.3% 30 6.3% 100 21.0%

Rural &


0.0% 1 12.5% 2 25.0%

HNELHD 15 14.7% 42 41.2% 23 22.5% 7 6.9% 15 14.7%

MLHD 10 18.9% 25 47.2% 11 20.8% 3 5.7% 4 7.5%

MNCLHD 3 11.5% 5 19.2% 8 30.8% 4 15.4% 6 23.1%

NNSWLHD 4 8.7% 11 23.9% 13 28.3% 8 17.4% 10 21.7%

SNSWLHD 6 17.6% 14 41.2% 8 23.5% 1 2.9% 5 14.7%

WNSWLHD 11 15.3% 20 27.8% 19 26.4% 12 16.7% 10 13.9%

R&R Total 52 15.2% 119 34.9% 82 24.0% 36 10.6% 52 15.2%

Other JH 13 22.8% 25 43.9% 9 15.8% 5 8.8% 5 8.8%

NSW 176 20.1% 307 35.1% 164 18.7% 71 8.1% 157 17.9%

44

Figure 29: Percentage of Departments/clinical units indicating they have specific guidelines for handling a suicide death by LHD.

Table 18: Count & Percentage of Departments/clinical units indicating they have specific guidelines for handling a suicide death by

LHD.


Metropolitan CCLHD 13 34% 25 66%

0%

ISLHD 14 38% 23 62%

0%

NBMLHD 15 54% 13 46%

0%

NSLHD 28 41% 40 59%

0%

SCHN 5 15% 29 85%

0%

SESLHD 22 29% 55 71%

0%

SVHN 9 53% 8 47%

0%

SWSLHD 26 34% 50 66%

0%

SYDLHD 40 60% 27 40%

0%

WSLHD 18 51% 17 49%

0%

Metro Total 190 40% 287 60% 0%

Rural & Regional FWLHD 6 75% 2 25%

0%

HNELHD 48 47% 54 53%

0%

MLHD 34 64% 19 36%

0%

MNCLHD 8 31% 18 69%

0%

NNSWLHD 15 33% 31 67%

0%

SNSWLHD 14 41% 20 59%

0%

WNSWLHD 39 54% 33 46%

0%

R&R Total 164 48% 177 52% 0%

Other JH 53 93% 2 4% 2 4%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

CC

LHD

ISLH

D

NB

MLH

D

NSL

HD

SCH

N

SESL

HD

SVH

N

SWSL

HD

SYD

LHD

WSL

HD

Met

ro T

ota

l

FWLH

D

HN

ELH

D

MLH

D

MN

CLH

D

NN

SWLH

D

SNSW

LHD

WN

SWLH

D

R&

R T

ota

l

JH


Yes NSW - Yes

Do you have specific guidelines for managing a suicide death?

__ Yes

__ No

__ Not applicable

45


NSW 407 47% 466 53% 2 0%

Figure 30: Percentage of departments/clinical units indicating the issues covered in suicide death guidelines for all of NSW.

89%

79%

70%

14%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Debriefing staff after a suicide death

Support for family and friends following a suicide death

24 hour access to specialist mental health consultation for staff

Other


Please indicate which of the following issues are covered in your guidelines: (tick all that apply)

__ Support for family and friends following a suicide death

__ Debriefing staff after a suicide death

__ 24 hour access to specialist mental health consultation for staff

__ Other

46

Table 19: Count & Percentage of departments/clinical units indicating the issues covered in suicide death guidelines by LHD

Description LHD Debriefing staff after a

suicide death

Support for family and

friends following a

suicide death

24 hour access to

specialist mental health

consultation for staff

Other


ISLHD 12 86% 12 86% 10 71% 3 21%

NBMLHD 13 87% 10 67% 3 20% 6 40%

NSLHD 25 89% 25 89% 22 79% 5 18%

SCHN 5 100% 5 100% 4 80%

0%

SESLHD 19 86% 18 82% 14 64% 4 18%

SVHN 9 100% 9 100% 8 89% 1 11%

SWSLHD 22 85% 22 85% 18 69% 4 15%

SYDLHD 35 88% 33 83% 34 85% 4 10%

WSLHD 16 89% 16 89% 14 78% 2 11%

Metro Total 167 88% 161 85% 134 71% 30 16%

Rural &

Regional FWLHD 5 83% 5 83% 6 100% 2 33%

HNELHD 41 85% 46 96% 29 60% 3 6%

MLHD 32 94% 30 88% 26 76% 4 12%

MNCLHD 5 63% 5 63% 5 63% 2 25%

NNSWLHD 14 93% 13 87% 10 67% 3 20%

SNSWLHD 13 93% 13 93% 8 57% 1 7%

WNSWLHD 36 92% 34 87% 35 90% 3 8%

R&R Total 146 89% 146 89% 119 73% 18 11%

Other JH 49 92% 15 28% 31 58% 11 21%

NSW 362 89% 322 79% 284 70% 59 14%

47

Figure 31: Percentage of Departments/clinical units indicating that all suicides that occur within one month of Emergency Department attendance or inpatient care reviewed by LHD.

Table 20: Count & Percentage of Departments/clinical units indicating that all suicides that occur within one month of Emergency Department attendance or inpatient care reviewed by LHD.



ISLHD 6 43% 1 7% 7 50%

NBMLHD 5 33% 3 20% 7 47%

NSLHD 8 29% 1 4% 19 68%

SCHN 2 40% 1 20% 2 40%

SESLHD 7 32%

0% 15 68%

SVHN 5 56%

0% 4 44%

SWSLHD 16 62% 1 4% 9 35%

SYDLHD 27 68% 1 3% 12 30%

WSLHD 9 50% 1 6% 8 44%

Metro Total 91 48% 10 5% 89 47%

Rural & Regional FWLHD 5 83%

0% 1 17%

HNELHD 24 50% 11 23% 13 27%

MLHD 14 41% 8 24% 12 35%

MNCLHD 4 50% 1 13% 3 38%

NNSWLHD 7 47% 1 7% 7 47%

SNSWLHD 8 57% 4 29% 2 14%

WNSWLHD 15 38% 13 33% 11 28%

R&R Total 77 47% 38 23% 49 30%

Other JH 42 81% 10 19%

0%

NSW 210 52% 58 14% 138 34%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

CC

LHD

ISLH

D

NB

MLH

D

NSL

HD

SCH

N

SESL

HD

SVH

N

SWSL

HD

SYD

LHD

WSL

HD

Met

ro T

ota

l

FWLH

D

HN

ELH

D

MLH

D

MN

CLH

D

NN

SWLH

D

SNSW

LHD

WN

SWLH

D

R&

R T

ota

l

JH


Yes NSW - Yes

Are all suicides that occur within one month of Emergency Department attendance or inpatient care reviewed?

__ Yes

__ No

__ Not applicable

48

Physical Health of Mental Health Patients

It is well established that mental health can have a significant impact on physical illness and disease, as well as the

poor physical health that many consumers of mental health services suffer.

Such evidence confirms the importance of bringing mental health and physical health care together to provide

holistic care for people with a mental illness.\

The physical health needs of mental health consumers can be supported through a consistent approach to the

promotion and delivery of physical health examinations and interventions

Figure 32: Percentage of Departments/clinical units indicating if mental health specific services are provided by LHD.

Table 21: Count & Percentage of Departments/clinical units indicating if mental health specific services are provided by LHD.

Description LHD Mental Health specific Both mental health and

paediatric specific None of the above


ISLHD 6 9.5% 4 6.3% 53 84.1%

NBMLHD 4 11.4% 3 8.6% 28 80.0%

NSLHD 17 17.5% 6 6.2% 74 76.3%

SCHN

0.0% 15 17.2% 72 82.8%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

CC

LHD

ISLH

D

NB

MLH

D

NSL

HD

SCH

N

SESL

HD

SVH

N

SWSL

HD

SYD

LHD

WSL

HD

Met

ro T

ota

l

FWLH

D

HN

ELH

D

MLH

D

MN

CLH

D

NN

SWLH

D

SNSW

LHD

WN

SWLH

D

R&

R T

ota

l

JH


Mental Health specific Both mental health and paediatric specific None of the above

Please indicate if the services you provide are any of the following (tick one option)

__ Adult Mental health specific

__ Both adult /children/young people mental health specific – eg Child & Adolescent Mental Health Services (CAMHS) unit

__ None of the above

49

Description LHD Mental Health specific Both mental health and

paediatric specific None of the above

SESLHD 10 8.0% 3 2.4% 112 89.6%

SVHN 4 19.0%

0.0% 17 81.0%

SWSLHD 16 14.2% 12 10.6% 85 75.2%

SYDLHD 9 9.2% 3 3.1% 86 87.8%

WSLHD 13 21.7% 5 8.3% 42 70.0%

Metro Total 83 11.1% 52 7.0% 611 81.9%

Rural &

Regional FWLHD 2 16.7% 1 8.3% 9 75.0%

HNELHD 7 5.4% 10 7.8% 112 86.8%

MLHD 7 10.4% 7 10.4% 53 79.1%

MNCLHD 5 13.5%

0.0% 32 86.5%

NNSWLHD 5 8.9% 3 5.4% 48 85.7%

SNSWLHD 3 5.6% 6 11.1% 45 83.3%

WNSWLHD 13 13.7% 9 9.5% 73 76.8%

R&R Total 42 9.3% 36 8.0% 372 82.7%

Other JH 24 70.6% 3 8.8% 7 20.6%

NSW 149 12.1% 91 7.4% 990 80.5%

50

Figure 33: Percentage of Departments/clinical units indicating they have guidelines (eg NSW health issued clinical practice

guidelines) and / or local protocols regarding the assessment and management of the physical health needs of mental health

patients by LHD.

Table 22: Count & Percentage of Departments/clinical units indicating they have guidelines (eg NSW health issued clinical practice


patients by LHD.


local protocols No

Metropolitan CCLHD

0.0%

0.0% 5 100.0%

0.0%

ISLHD 3 30.0% 1 10.0% 5 50.0% 1 10.0%

NBMLHD 1 14.3%

0.0% 5 71.4% 1 14.3%

NSLHD 8 34.8%

0.0% 7 30.4% 8 34.8%

SCHN 2 13.3% 6 40.0% 5 33.3% 2 13.3%

SESLHD 3 23.1% 2 15.4% 4 30.8% 4 30.8%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

CC

LHD

ISLH

D

NB

MLH

D

NSL

HD

SCH

N

SESL

HD

SVH

N

SWSL

HD

SYD

LHD

WSL

HD

Met

ro T

ota

l

FWLH

D

HN

ELH

D

MLH

D

MN

CLH

D

NN

SWLH

D

SNSW

LHD

WN

SWLH

D

R&

R T

ota

l

JH


LHD - Yes NSW - Yes

Do you have guidelines (eg NSW health issued clinical practice guidelines) and / or local protocols regarding the assessment and management of the physical health needs of mental health patients?

__ Yes, guidelines



__ No

51


local protocols No

SVHN 2 50.0%

0.0% 2 50.0%

0.0%

SWSLHD 6 21.4% 3 10.7% 15 53.6% 4 14.3%

SYDLHD 3 25.0% 2 16.7% 4 33.3% 3 25.0%

WSLHD 4 22.2%

0.0% 10 55.6% 4 22.2%

Metro Total 32 23.7% 14 10.4% 62 45.9% 27 20.0%

Rural &

Regional FWLHD 1 33.3%

0.0% 2 66.7%

0.0%

HNELHD 3 17.6% 2 11.8% 8 47.1% 4 23.5%

MLHD 5 35.7% 1 7.1% 6 42.9% 2 14.3%

MNCLHD 1 20.0%

0.0% 4 80.0%

0.0%

NNSWLHD 4 50.0%

0.0% 3 37.5% 1 12.5%

SNSWLHD 4 44.4%

0.0% 3 33.3% 2 22.2%

WNSWLHD 7 31.8% 3 13.6% 10 45.5% 2 9.1%

R&R Total 25 32.1% 6 7.7% 36 46.2% 11 14.1%

Other JH 7 30.4% 3 13.0% 12 52.2% 1 4.3%

NSW 64 27.1% 23 9.7% 110 46.6% 39 16.5%

Figure 34: Percentage of Departments/clinical units indicating they have guidelines (eg NSW health issued clinical practice


patients by Service type.

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

MH

ED

Oth

er

Pae

dia

tric

Med

ical

Age

d C

are

Surg

ical

Ob

s &

Gyn

ICU

Car

dia

c/C

ard

iolo

gy

Reh

abili

tati

on

Mic

rob

iolo

gy

Imag

ing

Nep

hro

logy

Ort

ho

pae

dic

LHD - Yes NSW - Yes

52

Figure 35: Percentage of departments/clinical units indicating the areas there are clear local protocols in place for all of NSW.

55%

51%

46%

1%

0% 10% 20% 30% 40% 50% 60%

Identifying and responding to medical emergencies

In what circumstances nursing or allied health staff should notify medical staff of concerns about the physical health of

consumers

Identifying and developing consumer management plans that address consumers’ needs related to chronic health

conditions and preventative health care

Other


Please indicate whether you have clear local protocols in place in relation to (tick all that apply)

__ When nursing or allied health staff should notify medical staff of concerns about the physical health of

consumers

__ Identifying and responding to medical emergencies

__ To identifying and developing consumer management plans that address consumers’ needs related to

chronic health conditions and preventative health care

53

Table 23: Count & Percentage of departments/clinical units indicating the areas there are clear local protocols in place by LHD.

Description LHD

Identifying and

responding to medical

emergencies

In what circumstances

nursing or allied health

staff should notify

medical staff of concerns

about the physical health

of consumers

Identifying and

developing consumer

management plans that

address consumers’

needs related to chronic

health conditions and

preventative health care

Other


0%

ISLHD 6 60% 6 60% 5 50%

0%

NBMLHD 3 43% 4 57% 4 57%

0%

NSLHD 8 35% 7 30% 5 22%

0%

SCHN 1 7% 1 7% 1 7%

0%

SESLHD 5 38% 6 46% 4 31%

0%

SVHN 3 75% 2 50% 2 50%

0%

SWSLHD 15 54% 15 54% 12 43%

0%

SYDLHD 8 67% 9 75% 7 58%

0%

WSLHD 12 67% 12 67% 11 61% 1 6%

Metro Total 65 48% 66 49% 55 41% 1 1%

Rural &

Regional FWLHD 1 33% 1 33% 1 33% 1 33%

HNELHD 9 53% 7 41% 7 41%

0%

MLHD 4 29% 3 21% 4 29%

0%

MNCLHD 3 60% 3 60% 2 40%

0%

NNSWLHD 2 25% 2 25% 2 25%

0%

SNSWLHD 4 44% 3 33% 2 22%

0%

WNSWLHD 14 64% 12 55% 11 50%

0%

R&R Total 37 47% 31 40% 29 37% 1 1%

Other JH 29 107% 25 93% 26 96%

0%

NSW 131 55% 122 51% 110 46% 2 1%

54

Figure 36: Percentage of Departments/clinical units indicating that all rehabilitation and recovery programs include activities

relevant to physical healthcare for mental health consumers by LHD.

Table 24: Count & Percentage of Departments/clinical units indicating that all rehabilitation and recovery programs include

activities relevant to physical healthcare for mental health consumers by LHD.

Description LHD Yes No

Metropolitan CCLHD 3 60.0% 2 40.0%

ISLHD 4 44.4% 5 55.6%

NBMLHD 3 42.9% 4 57.1%

NSLHD 10 43.5% 13 56.5%

SCHN 7 46.7% 8 53.3%

SESLHD 8 61.5% 5 38.5%

SVHN 2 50.0% 2 50.0%

SWSLHD 15 53.6% 13 46.4%

SYDLHD 9 75.0% 3 25.0%

WSLHD 14 77.8% 4 22.2%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

CC

LHD

ISLH

D

NB

MLH

D

NSL

HD

SCH

N

SESL

HD

SVH

N

SWSL

HD

SYD

LHD

WSL

HD

Met

ro T

ota

l

FWLH

D

HN

ELH

D

MLH

D

MN

CLH

D

NN

SWLH

D

SNSW

LHD

WN

SWLH

D

R&

R T

ota

l

JH


Yes NSW - Yes

Do all rehabilitation and recovery programs include activities relevant to physical healthcare for mental health consumers?

__ Yes

__ No

55


Metro Total 75 56.0% 59 44.0%

Rural & Regional FWLHD

0.0% 3 100.0%

HNELHD 9 52.9% 8 47.1%

MLHD 4 28.6% 10 71.4%

MNCLHD 3 60.0% 2 40.0%

NNSWLHD 3 42.9% 4 57.1%

SNSWLHD 2 25.0% 6 75.0%

WNSWLHD 15 68.2% 7 31.8%

R&R Total 36 47.4% 40 52.6%

Other JH 8 57.1% 6 42.9%

NSW 119 53.1% 105 46.9%

56

RELEVANT HEALTH INTERVENTIONS

See NSW Health Policy: Physical Health Care within Mental Health Services – PD2009_027 www.health.nsw.gov.au/policies/pd/2009/PD2009_027.html

Figure 37: Percentage of Departments/clinical units indicating that the relevant health interventions are discussed with the

consumer, provided /conducted if appropriate by LHD.

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

CC

LHD

ISLH

D

NB

MLH

D

NSL

HD

SCH

N

SESL

HD

SVH

N

SWSL

HD

SYD

LHD

WSL

HD

Met

ro T

ota

l

FWLH

D

HN

ELH

D

MLH

D

MN

CLH

D

NN

SWLH

D

SNSW

LHD

WN

SWLH

D

R&

R T

ota

l

JH


Yes, for 'List A' Yes, for 'List B' Both, 'List A' and 'List B' No

List A – cardiovascular health List B – potentially indirect interventions

• Smoking cessation (if relevant) • Weight control interventions, including dietary and life-style advice, if BMI > 25 or WHR >1 • Regular exercise • BP monitoring • Metabolic monitoring

• Contraceptive advice (if of reproductive age) and sexual safety advice • Visual acuity and clinical hearing evaluation; with referral to secondary care if any abnormalities • Dental review if not conducted in previous 12 months or a need is identified prior to this • Education on breast (women) or testicular self examination and symptoms of prostatism (men over 55 years) • Provision of information regarding HPV vaccination (females <27yo) • Influenza vaccination when indicated • Examination for skin malignancies • Education on risks related to alcohol and illicit drug abuse

Do you have a system in place to ensure that the issues in ‘List A’ and ‘List B’ are discussed with the consumer, provided /conducted if appropriate? (tick one option)

__ Yes, for "List A”

__ Yes, for "List B"

__ Both, "List A" and "List B"

__ None of the above

http://www.health.nsw.gov.au/policies/pd/2009/PD2009_027.html

57

Table 25: Count & Percentage of Departments/clinical units indicating that the relevant health interventions are discussed with

the consumer, provided /conducted if appropriate by LHD.

Description LHD Yes, for 'List A' Yes, for 'List B' Both, 'List A' and 'List B' No

Metropolit

an CCLHD

0%

0% 5 100%

0%

ISLHD 2 20%

0% 6 60% 2 20%

NBMLHD 1 14%

0% 3 43% 3 43%

NSLHD 4 17%

0% 7 30% 12 52%

SCHN 1 7%

0% 5 33% 9 60%

SESLHD 5 38%

0% 5 38% 3 23%

SVHN

0%

0% 1 25% 3 75%

SWSLHD 8 29% 3 11% 10 36% 7 25%

SYDLHD 3 25%

0% 6 50% 3 25%

WSLHD 4 22%

0% 10 56% 4 22%

Metro Total 28 21% 3 2% 58 43% 46 34%

Rural &


0% 1 33%

0%

HNELHD 5 29%

0% 7 41% 5 29%

MLHD 1 7%

0% 5 36% 8 57%

MNCLHD 2 40%

0% 2 40% 1 20%

NNSWLHD 2 25%

0%

0% 6 75%

SNSWLHD 2 22%

0% 2 22% 5 56%

WNSWLHD 4 18%

0% 11 50% 7 32%

R&R Total 18 23% 0% 28 36% 32 41%

Other JH 4 17%

0% 17 71% 3 13%

NSW 50 21% 3 1% 103 43% 81 34%

58

Please indicate your level of agreement with the following statements

N/A Strongly Agree

Agree Neutral Disagree Strongly Disagree

Consumers are supported to involve their families and carers in the most appropriate way for both the consumer and the family and carer

__ __ __ __ __ __

Figure 38: Percentage of Departments/clinical units responding “Strongly agree” or “Agree” to the statement “Consumers are

supported to involve their families and carers in the most appropriate way for both the consumer and the family and carer” by

LHD.

Table 26: Count & Percentage of Departments/clinical units responding “Strongly agree” or “Agree” to the statement “Consumers

are supported to involve their families and carers in the most appropriate way for both the consumer and the family and carer” by

LHD.

Description LHD Strongly Agree Agree Neutral Disagree Strongly Disagree

Metropolitan CCLHD 5 100.0%

0.0%

0.0%

0.0%

0.0%

ISLHD 4 40.0% 5 50.0% 1 10.0%

0.0%

0.0%

NBMLHD 1 14.3% 4 57.1% 2 28.6%

0.0%

0.0%

NSLHD 4 18.2% 14 63.6% 4 18.2%

0.0%

0.0%

SCHN 5 41.7% 6 50.0% 1 8.3%

0.0%

0.0%

SESLHD 6 46.2% 3 23.1% 4 30.8%

0.0%

0.0%

SVHN 1 25.0% 3 75.0%

0.0%

0.0%

0.0%

SWSLHD 13 48.1% 12 44.4% 1 3.7% 1 3.7%

0.0%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

CC

LHD

ISLH

D

NB

MLH

D

NSL

HD

SCH

N

SESL

HD

SVH

N

SWSL

HD

SYD

LHD

WSL

HD

Met

ro T

ota

l

FWLH

D

HN

ELH

D

MLH

D

MN

CLH

D

NN

SWLH

D

SNSW

LHD

WN

SWLH

D

R&

R T

ota

l

JH


LHD - Strongly agree or Agree NSW - Strongly agree or Agree

59


SYDLHD 4 33.3% 6 50.0% 2 16.7%

0.0%

0.0%

WSLHD 10 58.8% 3 17.6% 4 23.5%

0.0%

0.0%

Metro Total 53 41.1% 56 43.4% 19 14.7% 1 0.8% 0.0%

Rural &


0.0%

0.0%

0.0%

HNELHD 6 37.5% 9 56.3%

0.0%

0.0% 1 6.3%

MLHD 4 28.6% 8 57.1% 2 14.3%

0.0%

0.0%

MNCLHD 2 40.0% 2 40.0%

0.0% 1 20.0%

0.0%

NNSWLHD 1 12.5% 5 62.5% 2 25.0%

0.0%

0.0%

SNSWLHD 3 37.5% 4 50.0% 1 12.5%

0.0%

0.0%

WNSWLHD 8 36.4% 12 54.5%

0.0% 2 9.1%

0.0%

R&R Total 25 32.9% 42 55.3% 5 6.6% 3 3.9% 1 1.3%

Other JH 7 36.8% 4 21.1% 5 26.3% 2 10.5% 1 5.3%

NSW 85 37.9% 102 45.5% 29 12.9% 6 2.7% 2 0.9%

60

Q80b. Please indicate your level of agreement with the following statements

N/A Strongly Agree


Family and carers are provided with information about how the mental health system works, and fact sheets about different mental illnesses, treatments, etc

__ __ __ __ __ __

Figure 39: Percentage of Departments/clinical units responding “Strongly agree” or “Agree” to the statement “Family and carers

are provided with information about how the mental health system works, and fact sheets about different mental illnesses,

treatments, etc” by LHD.

Table 27: Count & Percentage of Departments/clinical units responding “Strongly agree” or “Agree” to the statement “Family and

carers are provided with information about how the mental health system works, and fact sheets about different mental illnesses,

treatments, etc” by LHD.



0.0%

0.0%

0.0%

ISLHD 4 44.4% 2 22.2% 2 22.2% 1 11.1%

0.0%

NBMLHD 3 42.9% 1 14.3% 3 42.9%

0.0%

0.0%

NSLHD 2 9.1% 14 63.6% 5 22.7% 1 4.5%

0.0%

SCHN 2 16.7% 4 33.3% 6 50.0%

0.0%

0.0%

SESLHD 4 30.8% 3 23.1% 5 38.5%

0.0% 1 7.7%

SVHN 2 50.0% 1 25.0% 1 25.0%

0.0%

0.0%

SWSLHD 10 38.5% 14 53.8% 2 7.7%

0.0%

0.0%

SYDLHD 5 41.7% 6 50.0% 1 8.3%

0.0%

0.0%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

CC

LHD

ISLH

D

NB

MLH

D

NSL

HD

SCH

N

SESL

HD

SVH

N

SWSL

HD

SYD

LHD

WSL

HD

Met

ro T

ota

l

FWLH

D

HN

ELH

D

MLH

D

MN

CLH

D

NN

SWLH

D

SNSW

LHD

WN

SWLH

D

R&

R T

ota

l

JH



61


WSLHD 7 50.0% 2 14.3% 5 35.7%

0.0%

0.0%

Metro Total 42 33.9% 49 39.5% 30 24.2% 2 1.6% 1 0.8%

Rural &

Regional FWLHD

0.0% 1 33.3% 1 33.3% 1 33.3%

0.0%

HNELHD 3 20.0% 8 53.3% 2 13.3% 1 6.7% 1 6.7%

MLHD 3 21.4% 8 57.1% 3 21.4%

0.0%

0.0%

MNCLHD 2 40.0% 2 40.0%

0.0% 1 20.0%

0.0%

NNSWLHD 1 12.5% 5 62.5% 2 25.0%

0.0%

0.0%

SNSWLHD 3 37.5% 2 25.0% 2 25.0% 1 12.5%

0.0%

WNSWLHD 8 36.4% 9 40.9% 3 13.6% 2 9.1%

0.0%

R&R Total 20 26.7% 35 46.7% 13 17.3% 6 8.0% 1 1.3%

Other JH 5 27.8% 3 16.7% 6 33.3% 3 16.7% 1 5.6%

NSW 67 30.9% 87 40.1% 49 22.6% 11 5.1% 3 1.4%

62

Q80c. Please indicate your level of agreement with the following statements

N/A Strongly Agree


Family and carers are provided with information and/or referrals to help them access support, information, education and advocacy

__ __ __ __ __ __


are provided with information and/or referrals to help them access support, information, education and advocacy” by LHD.


carers are provided with information and/or referrals to help them access support, information, education and advocacy” by LHD.



0.0%

0.0%

0.0%

ISLHD 4 40.0% 3 30.0% 3 30.0%

0.0%

0.0%

NBMLHD 2 28.6% 4 57.1% 1 14.3%

0.0%

0.0%

NSLHD 3 13.6% 16 72.7% 3 13.6%

0.0%

0.0%

SCHN 2 16.7% 9 75.0% 1 8.3%

0.0%

0.0%

SESLHD 4 30.8% 6 46.2% 2 15.4%

0.0% 1 7.7%

SVHN 2 50.0% 1 25.0% 1 25.0%

0.0%

0.0%

SWSLHD 10 37.0% 13 48.1% 3 11.1% 1 3.7%

0.0%

SYDLHD 5 41.7% 6 50.0% 1 8.3%

0.0%

0.0%

WSLHD 7 43.8% 5 31.3% 4 25.0%

0.0%

0.0%

Metro Total 43 33.6% 64 50.0% 19 14.8% 1 0.8% 1 0.8%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

CC

LHD

ISLH

D

NB

MLH

D

NSL

HD

SCH

N

SESL

HD

SVH

N

SWSL

HD

SYD

LHD

WSL

HD

Met

ro T

ota

l

FWLH

D

HN

ELH

D

MLH

D

MN

CLH

D

NN

SWLH

D

SNSW

LHD

WN

SWLH

D

R&

R T

ota

l

JH



63


Rural &


0.0%

0.0%

0.0%

HNELHD 3 18.8% 9 56.3% 2 12.5% 1 6.3% 1 6.3%

MLHD 4 28.6% 8 57.1% 2 14.3%

0.0%

0.0%

MNCLHD 3 60.0% 1 20.0%

0.0% 1 20.0%

0.0%

NNSWLHD 2 25.0% 4 50.0% 2 25.0%

0.0%

0.0%

SNSWLHD 3 37.5% 3 37.5% 1 12.5% 1 12.5%

0.0%

WNSWLHD 8 36.4% 10 45.5% 2 9.1% 2 9.1%

0.0%

R&R Total 24 31.6% 37 48.7% 9 11.8% 5 6.6% 1 1.3%

Other JH 5 26.3% 5 26.3% 5 26.3% 3 15.8% 1 5.3%

NSW 72 32.3% 106 47.5% 33 14.8% 9 4.0% 3 1.3%

64

Q80d. Please indicate your level of agreement with the following statements

N/A Strongly Agree


Family and carers are notified of and involved in patients discharge/transfer of care planning

__ __ __ __ __ __


are notified of and involved in patients discharge/transfer of care planning” by LHD.


carers are notified of and involved in patients discharge/transfer of care planning” by LHD.



0.0%

0.0%

0.0%

ISLHD 3 30.0% 6 60.0% 1 10.0%

0.0%

0.0%

NBMLHD 1 14.3% 5 71.4% 1 14.3%

0.0%

0.0%

NSLHD 5 22.7% 13 59.1% 4 18.2%

0.0%

0.0%

SCHN 4 33.3% 8 66.7%

0.0%

0.0%

0.0%

SESLHD 3 23.1% 8 61.5% 1 7.7%

0.0% 1 7.7%

SVHN 2 50.0% 2 50.0%

0.0%

0.0%

0.0%

SWSLHD 12 44.4% 15 55.6%

0.0%

0.0%

0.0%

SYDLHD 5 41.7% 6 50.0% 1 8.3%

0.0%

0.0%

WSLHD 9 52.9% 6 35.3% 2 11.8%

0.0%

0.0%

Metro Total 47 36.4% 71 55.0% 10 7.8% 0.0% 1 0.8%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

CC

LHD

ISLH

D

NB

MLH

D

NSL

HD

SCH

N

SESL

HD

SVH

N

SWSL

HD

SYD

LHD

WSL

HD

Met

ro T

ota

l

FWLH

D

HN

ELH

D

MLH

D

MN

CLH

D

NN

SWLH

D

SNSW

LHD

WN

SWLH

D

R&

R T

ota

l



65


Rural &


0.0%

0.0%

0.0%

HNELHD 3 18.8% 9 56.3% 3 18.8% 1 6.3%

0.0%

MLHD 6 42.9% 6 42.9% 2 14.3%

0.0%

0.0%

MNCLHD 3 60.0%

0.0% 1 20.0% 1 20.0%

0.0%

NNSWLHD 2 25.0% 4 50.0% 2 25.0%

0.0%

0.0%

SNSWLHD 3 37.5% 4 50.0% 1 12.5%

0.0%

0.0%

WNSWLHD 9 40.9% 10 45.5% 1 4.5% 2 9.1%

0.0%

R&R Total 27 35.5% 35 46.1% 10 13.2% 4 5.3% 0.0%

NSW

74 36.1% 106 51.7% 20 9.8% 4 2.0% 1 0.5%

66

Patients with Mental Health co morbidity The management of adults and children / adolescents with mental health difficulties is becoming an increasingly

common place part of work of in-patient wards. A strong partnership between the patients primary care team and

psychiatric services is required (Foster, 2009; DoH, 2011)

Figure 42: Percentage of Departments/clinical units indicating they have guidelines (eg clinical practice guidelines issued by NSW

health) and / or local protocols to guide the care for patients (adult and paediatric/young people) with a co morbid mental health

diagnosis by LHD.

Table 30: Count & Percentage of Departments/clinical units indicating they have guidelines (eg clinical practice guidelines issued

by NSW health) and / or local protocols to guide the care for patients (adult and paediatric/young people) with a co morbid

mental health diagnosis by LHD.


local protocols No Not applicable


0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

CC

LHD

ISLH

D

NB

MLH

D

NSL

HD

SCH

N

SESL

HD

SVH

N

SWSL

HD

SYD

LHD

WSL

HD

Met

ro T

ota

l

FWLH

D

HN

ELH

D

MLH

D

MN

CLH

D

NN

SWLH

D

SNSW

LHD

WN

SWLH

D

R&

R T

ota

l

JH


Yes, guidelines Yes, local protocols Both, guidelines and local protocols No Not applicable

Do you have guidelines (eg clinical practice guidelines issued by NSW health) and / or local protocols to guide the care for patients (adult and paediatric/young people) with a co morbid mental health diagnosis?

__ Yes, guidelines



__ No

__ Not applicable we never manage/treat patients who have a mental health comorbid condition

67


local protocols No Not applicable

ISLHD 10 15.9% 5 7.9% 8 12.7% 26 41.3% 14 22.2%

NBMLHD 3 8.6% 3 8.6% 7 20.0% 18 51.4% 4 11.4%

NSLHD 18 18.6% 6 6.2% 17 17.5% 44 45.4% 12 12.4%

SCHN 5 5.7% 8 9.2% 10 11.5% 28 32.2% 36 41.4%

SESLHD 16 12.8% 12 9.6% 18 14.4% 50 40.0% 29 23.2%

SVHN 4 19.0% 1 4.8% 2 9.5% 12 57.1% 2 9.5%

SWSLHD 15 13.3% 7 6.2% 18 15.9% 46 40.7% 27 23.9%

SYDLHD 8 8.2% 8 8.2% 30 30.6% 32 32.7% 20 20.4%

WSLHD 2 3.3% 10 16.7% 11 18.3% 26 43.3% 11 18.3%

Metro Total 84 11.3% 66 8.9% 127 17.0% 309 41.5% 159 21.3%

Rural &

Regional FWLHD 5 41.7% 1 8.3% 1 8.3% 3 25.0% 2 16.7%

HNELHD 37 28.7% 7 5.4% 24 18.6% 48 37.2% 13 10.1%

MLHD 13 19.4% 3 4.5% 22 32.8% 25 37.3% 4 6.0%

MNCLHD 2 5.4% 2 5.4% 7 18.9% 15 40.5% 11 29.7%

NNSWLHD 10 17.9% 3 5.4% 7 12.5% 29 51.8% 7 12.5%

SNSWLHD 8 14.8% 5 9.3% 10 18.5% 20 37.0% 11 20.4%

WNSWLHD 25 26.3% 3 3.2% 15 15.8% 35 36.8% 17 17.9%

R&R Total 100 22.2% 24 5.3% 86 19.1% 175 38.9% 65 14.4%

Other JH 10 29.4% 5 14.7% 13 38.2% 6 17.6%

0.0%

NSW 194 15.8% 95 7.7% 226 18.4% 490 39.9% 224 18.2%

68

Figure 43: Percentage of departments/clinical units indicating the issues covered in guidelines/protocols for all of NSW.

37%

31%

27%

27%

24%

24%

3%

1%

0% 5% 10% 15% 20% 25% 30% 35% 40%

Engagement of specialist mental health services/team for acute admissions

Transfer of mental health patients to another hospital for a higher level of care

Guidelines/agreements for shared care/integrated shared care between teams (i.e. treating team and Specialist …

Consultation with, and the provision of information for, the patient/family/carers

The development of individualised risk assessments

Admission criteria and inpatient processes

Other

None of these


Please indicate whether your guidelines / protocols cover the following issues (tick all that apply)

__ Engagement of specialist mental health services / team for acute admissions

__ Guidelines / agreements for shared care / integrated shared care between teams (i.e. treating team and

specialist mental health services / team)

__ The development of individualised risk assessments

__ Transfer of mental health patients to another hospital for a higher level of care

__ Admission criteria and inpatient processes

__ Consultation with and the provision of information for, the patient / family/carers

__ other

69

Table 31: Count & Percentage of departments/clinical units indicating the issues covered in guidelines/protocols by LHD

Description LHD

Engagement of

specialist mental

health

services/team for

acute admissions

Transfer of mental

health patients to

another hospital for

a higher level of

care

Guidelines/agreeme

nts for shared

care/integrated

shared care

between teams

Consultation with,

and the provision of

information for, the

patient/family/care

rs

The development of

individualised risk

assessments

Admission criteria

and inpatient

processes

Other None of these

Metropolitan CCLHD 10 24% 8 19% 8 19% 10 24% 6 14% 6 14% 1 2% 1 2%

ISLHD 15 31% 12 24% 11 22% 11 22% 10 20% 10 20% 3 6% 1 2%

NBMLHD 6 19% 9 29% 6 19% 6 19% 5 16% 4 13% 3 10%

0%

NSLHD 33 39% 21 25% 25 29% 21 25% 16 19% 18 21% 4 5% 1 1%

SCHN 18 35% 8 16% 12 24% 15 29% 8 16% 13 25% 3 6%

0%

SESLHD 32 33% 24 25% 28 29% 24 25% 23 24% 17 18% 1 1% 3 3%

SVHN 6 32% 4 21% 6 32% 5 26% 5 26% 4 21%

0%

0%

SWSLHD 34 40% 25 29% 22 26% 30 35% 26 30% 25 29% 1 1%

0%

SYDLHD 30 38% 27 35% 22 28% 15 19% 17 22% 12 15% 4 5%

0%

WSLHD 22 45% 13 27% 15 31% 15 31% 15 31% 14 29% 2 4%

0%

Metro Total 206 35% 151 26% 155 26% 152 26% 131 22% 123 21% 22 4% 6 1%

Rural &

Regional FWLHD 5 50% 3 30% 3 30% 4 40% 5 50% 3 30% 3 30%

0%

HNELHD 47 41% 44 38% 29 25% 32 28% 25 22% 34 29% 2 2% 1 1%

MLHD 25 40% 27 43% 20 32% 21 33% 21 33% 23 37% 3 5%

0%

MNCLHD 8 31% 7 27% 6 23% 6 23% 5 19% 7 27%

0% 1 4%

NNSWLHD 15 31% 14 29% 8 16% 10 20% 7 14% 8 16%

0%

0%

SNSWLHD 16 37% 13 30% 14 33% 8 19% 9 21% 7 16% 1 2% 1 2%

WNSWLHD 30 38% 33 42% 22 28% 24 31% 20 26% 23 29% 2 3% 1 1%

R&R Total 146 38% 141 37% 102 26% 105 27% 92 24% 105 27% 11 3% 4 1%

Other JH 22 65% 24 71% 15 44% 14 41% 21 62% 14 41%

0%

0%

NSW 374 37% 316 31% 272 27% 271 27% 244 24% 242 24% 33 3% 10 1%

70

Figure 44: Percentage of Departments/clinical units indicating “All (100%)” or “Most (67%-99%)” relevant staff that have received

training in relation to recognition, assessment and management of young people or adolescent children with challenging

behaviour / mental health problems by LHD.

Table 32: Count & Percentage of Departments/clinical units indicating “All (100%)” or “Most (67%-99%)” relevant staff that have

received training in relation to recognition, assessment and management of young people or adolescent children with challenging

behaviour / mental health problems by LHD.

Description LHD All (100%) Most (67%-99%) Some (34%–



0.0% 1 6.7%

ISLHD 2 9.1% 3 13.6% 2 9.1% 11 50.0% 2 9.1% 2 9.1%

NBMLHD 3 23.1% 1 7.7%

0.0% 4 30.8%

0.0% 5 38.5%

NSLHD 1 2.4% 16 39.0% 7 17.1% 10 24.4% 3 7.3% 4 9.8%

SCHN

0.0% 7 30.4% 6 26.1% 6 26.1% 1 4.3% 3 13.0%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

CC

LHD

ISLH

D

NB

MLH

D

NSL

HD

SCH

N

SESL

HD

SVH

N

SWSL

HD

SYD

LHD

WSL

HD

Met

ro T

ota

l

FWLH

D

HN

ELH

D

MLH

D

MN

CLH

D

NN

SWLH

D

SNSW

LHD

WN

SWLH

D

R&

R T

ota

l

JH


LHD - All or Most NSW - All or Most

Please estimate the percentage of relevant staff that have received training in relation to recognition, assessment and management of young people or adolescent children with challenging behaviour / mental health problems

__ All (100%)

__ Most (67%-99%)

__ Some (34% – 66%)

__ Few (1% - 33%)

__ None (0%)

__ Don’t know

71

Description LHD All (100%) Most (67%-99%) Some (34%–


SESLHD 2 4.3% 11 23.9% 14 30.4% 11 23.9% 2 4.3% 6 13.0%

SVHN

0.0% 3 42.9%

0.0%

0.0% 3 42.9% 1 14.3%

SWSLHD 4 10.0% 17 42.5% 12 30.0% 4 10.0% 1 2.5% 2 5.0%

SYDLHD 8 17.4% 9 19.6% 15 32.6% 3 6.5% 3 6.5% 8 17.4%

WSLHD 2 8.7% 7 30.4% 3 13.0% 6 26.1% 2 8.7% 3 13.0%

Metro

Total 26 9.4% 79 28.6% 61 22.1% 58 21.0% 17 6.2% 35 12.7%

Rural &

Regional FWLHD 1 14.3% 1 14.3% 2 28.6% 3 42.9%

0.0%

0.0%

HNELHD 6 9.1% 11 16.7% 16 24.2% 19 28.8% 1 1.5% 13 19.7%

MLHD 1 2.6% 16 42.1% 9 23.7% 10 26.3% 1 2.6% 1 2.6%

MNCLHD 1 9.1%

0.0% 2 18.2% 7 63.6%

0.0% 1 9.1%

NNSWLHD 2 10.0% 3 15.0% 4 20.0% 8 40.0% 1 5.0% 2 10.0%

SNSWLHD 1 4.3% 8 34.8% 8 34.8% 5 21.7% 1 4.3%

0.0%

WNSWLHD 1 2.3% 11 25.6% 15 34.9% 10 23.3% 5 11.6% 1 2.3%

R&R Total 13 6.3% 50 24.0% 56 26.9% 62 29.8% 9 4.3% 18 8.7%

Other JH 3 9.1% 8 24.2% 4 12.1% 11 33.3% 2 6.1% 5 15.2%

NSW 42 8.1% 137 26.5% 121 23.4% 131 25.3% 28 5.4% 58 11.2%

Figure 45: Percentage of Departments/clinical units indicating “All (100%)” or “Most (67%-99%)” relevant staff that have received

training in relation to recognition, assessment and management of young people or adolescent children with challenging

behaviour / mental health problems by Peer Group.

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Med

ical

MH

Oth

er

Surg

ical

ED

Ob

s &

Gyn

Age

d C

are

Pae

dia

tric

ICU

On

colo

gy

Reh

abili

tati

on

Pal

liati

ve C

are

Ort

ho

pae

dic

Car

dia

c/C

ard

iolo

gy

Nep

hro

logy

Imag

ing

Mic

rob

iolo

gy

LHD - All or Most NSW - All or Most

72

Figure 46: Percentage of Departments/clinical units indicating they have a protocol for managing crisis situations including those

occurring out of hours by LHD.

Table 33: Count & Percentage of Departments/clinical units indicating they have a protocol for managing crisis situations including

those occurring out of hours by LHD



ISLHD 20 42.55% 21 44.7% 6 12.8%

NBMLHD 13 43.33% 13 43.3% 4 13.3%

NSLHD 59 69.41% 16 18.8% 10 11.8%

SCHN 25 49.02% 12 23.5% 14 27.5%

SESLHD 45 47.87% 31 33.0% 18 19.1%

SVHN 14 73.68% 4 21.1% 1 5.3%

SWSLHD 43 51.19% 32 38.1% 9 10.7%

SYDLHD 54 69.23% 16 20.5% 8 10.3%

WSLHD 28 58.33% 17 35.4% 3 6.3%

Metro Total 320 55.36% 176 30.4% 82 14.2%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

CC

LHD

ISLH

D

NB

MLH

D

NSL

HD

SCH

N

SESL

HD

SVH

N

SWSL

HD

SYD

LHD

WSL

HD

Met

ro T

ota

l

FWLH

D

HN

ELH

D

MLH

D

MN

CLH

D

NN

SWLH

D

SNSW

LHD

WN

SWLH

D

R&

R T

ota

l

JH


Yes No Not applicable

Do you have a protocol for managing crisis situations including those occurring out of hours?

__ Yes (details)

__ No

73


Rural &

Regional FWLHD 8 80.00% 1 10.0% 1 10.0%

HNELHD 66 57.89% 37 32.5% 11 9.6%

MLHD 45 71.43% 13 20.6% 5 7.9%

MNCLHD 15 57.69% 7 26.9% 4 15.4%

NNSWLHD 25 51.02% 20 40.8% 4 8.2%

SNSWLHD 25 59.52% 12 28.6% 5 11.9%

WNSWLHD 48 61.54% 22 28.2% 8 10.3%

R&R Total 232 60.73% 112 29.3% 38 9.9%

Other JH 30 88.24% 1 2.9% 3 8.8%

NSW 582 58.55% 289 29.1% 123 12.4%

74

Figure 47: Percentage of departments/clinical units indicating processes covered in protocols for all of NSW.

39%

39%

28%

20%

16%

4%

0% 5% 10% 15% 20% 25% 30% 35% 40% 45%

Access for all clinical staff to mental health consultation/liaison support when required (i.e. 24/7). For

example Child and Adolescent Mental Health Services …

Access to mental health services, including inpatient beds, if admission/transfer required

A process to ensure effective communication of crisis management plan to all appropriate people

Mental Health Services liaison available only during 'business hours' (9am - 5pm)

Access to tele-psychiatry services

Other


Please indicate if your protocol includes a process for: (tick all that apply)

__ Access for clinical staff to mental health consultation / liaison support when required (e.g. CAMHS)

__ Mental Health liaison Services available only during 'business hours' (9am - 5pm)

__ Access to mental health services, including acute inpatient beds, if required

__ A process to ensure effective communication of crisis management plan to all appropriate people

__ access to tele-psychiatry services

__ other

75

Table 34: Count & Percentage of departments/clinical units indicating processes covered in protocols by LHD

Description LHD

Access for all clinical

staff to mental health

consultation/liaison

support when required

(i.e. 24/7). EG Child and

Adolescent Mental

Health Services

(CAMHS)

Access to mental health

services, including

inpatient beds, if

admission/transfer

required

A process to ensure

effective

communication of crisis

management plan to all

appropriate people

Mental Health Services

liaison available only

during 'business hours'

(9am - 5pm)

Access to tele-

psychiatry services Other

Metropolitan CCLHD 8 19% 14 33% 12 29% 11 26% 3 7% 1 2%

ISLHD 9 18% 15 31% 10 20% 9 18% 4 8%

0%

NBMLHD 8 26% 6 19% 4 13% 7 23% 1 3% 3 10%

NSLHD 45 53% 32 38% 27 32% 17 20% 1 1% 5 6%

SCHN 20 39% 13 25% 13 25% 3 6% 1 2% 1 2%

SESLHD 28 29% 26 27% 23 24% 13 14% 1 1% 3 3%

SVHN 8 42% 9 47% 4 21% 4 21% 1 5% 5 26%

SWSLHD 31 36% 30 35% 31 36% 17 20% 6 7% 4 5%

SYDLHD 40 51% 38 49% 22 28% 4 5% 5 6% 1 1%

WSLHD 21 43% 21 43% 18 37% 12 24% 2 4% 2 4%

Metro Total 218 37% 204 35% 164 28% 97 17% 25 4% 25 4%

Rural &

Regional FWLHD 6 60% 7 70% 5 50% 6 60% 7 70% 1 10%

HNELHD 46 40% 54 47% 28 24% 33 28% 13 11% 1 1%

MLHD 33 52% 33 52% 18 29% 18 29% 36 57% 2 3%

MNCLHD 6 23% 11 42% 5 19% 7 27% 6 23%

0%

NNSWLHD 14 29% 19 39% 10 20% 7 14% 8 16% 2 4%

SNSWLHD 14 33% 17 40% 10 23% 8 19% 13 30% 5 12%

WNSWLHD 39 50% 34 44% 30 38% 14 18% 32 41% 2 3%

R&R Total 158 41% 175 45% 106 28% 93 24% 115 30% 13 3%

Other JH 20 59% 13 38% 15 44% 7 21% 16 47% 3 9%

NSW 396 39% 392 39% 285 28% 197 20% 156 16% 41 4%

76

Figure 48: Percentage of departments/clinical units indicating barriers to the implementation of the interdisciplinary management

of patients with mental health diagnosis for all of NSW.

40%

34%

34%

33%

31%

16%

16%

0% 5% 10% 15% 20% 25% 30% 35% 40% 45%

Lack of access to education and training in the assessment and management of these patients

Lack of access to information/resources such as Clinical Liaison staff

Teams work in isolation and do not collaborate/communicate with each other

Lack of formal policy/guideline for co management of patients with mental health problems

Clinicians attitudes toward patients with mental health diagnosis and their impact on 'normal' running of …

Other

None


What do you think are the barriers to the implementation of the interdisciplinary management of patients with mental health diagnosis?

__ None

__ Lack of formal policy / guideline for co management of patients with mental health problems

__ Clinicians attitudes toward patients with mental health diagnosis and their impact on 'normal' running of depart

/ clinical unit

__ Lack of access to education and training in the assessment and management of these patients

__ Lack of access to information / resources such as Clinical Liaison staff

__ Teams work in isolation and do not collaborate / communicate with each other

__ other (provide details)

77

Table 35: Count & Percentage of departments/clinical units indicating barriers to the implementation of the interdisciplinary management of patients with mental health diagnosis for all by LHD.

Description LHD

Lack of access to

education and training

in the assessment and

management of these

patients

Lack of access to

information/resources

such as Clinical Liaison

staff

Teams work in

isolation and do not

collaborate/communic

ate with each other

Lack of formal

policy/guideline for co

management of

patients with mental

health problems

Clinicians attitudes toward

patients with mental health

diagnosis and their impact on

'normal' running of

department/clinical unit

Other None


ISLHD 25 51% 23 47% 16 33% 21 43% 13 27% 5 10% 7 14%

NBMLHD 11 35% 10 32% 14 45% 17 55% 17 55% 6 19% 1 3%

NSLHD 31 36% 29 34% 23 27% 29 34% 26 31% 15 18% 11 13%

SCHN 17 33% 14 27% 16 31% 9 18% 7 14% 9 18% 13 25%

SESLHD 37 39% 24 25% 29 30% 30 31% 28 29% 15 16% 20 21%

SVHN 11 58% 8 42% 9 47% 10 53% 3 16% 4 21% 4 21%

SWSLHD 26 30% 23 27% 21 24% 24 28% 24 28% 12 14% 17 20%

SYDLHD 9 12% 11 14% 10 13% 10 13% 13 17% 24 31% 21 27%

WSLHD 16 33% 11 22% 8 16% 15 31% 8 16% 9 18% 16 33%

Metro Total 200 34% 168 29% 165 28% 184 31% 152 26% 103 18% 114 19%

Rural & Regional FWLHD 2 20% 3 30% 6 60% 3 30% 4 40% 3 30%

0%

HNELHD 68 59% 53 46% 50 43% 49 42% 44 38% 10 9% 8 7%

MLHD 20 32% 25 40% 26 41% 13 21% 22 35% 11 17% 8 13%

MNCLHD 16 62% 11 42% 14 54% 11 42% 12 46% 3 12% 1 4%

NNSWLHD 29 59% 22 45% 21 43% 26 53% 17 35% 6 12% 4 8%

SNSWLHD 17 40% 14 33% 14 33% 12 28% 15 35% 10 23% 5 12%

WNSWLHD 45 58% 35 45% 27 35% 26 33% 32 41% 6 8% 11 14%

R&R Total 197 51% 163 42% 158 41% 140 36% 146 38% 49 13% 37 10%

Other JH 9 26% 9 26% 14 41% 9 26% 11 32% 8 24% 6 18%

NSW 406 40% 340 34% 337 34% 333 33% 309 31% 160 16% 157 16%

78 2011 Quality Systems Assessment- Mental Health

When a patient with a co morbid mental health condition is discharged / care transferred please indicate the frequency that the following activities occur

Always (100%)

Mostly (67%-99%)

Sometimes (34%-66% )

Seldom (1%-33%)

Never (0%)

N/A

The patient's relevant health provider (e.g. GP, private psychiatrist) is contacted to arrange a consultation with the patient 24 hours post discharge

__ __ __ __ __ __

Figure 49: Percentage of Departments/clinical units indicating the status of their system for ensuring the relevant health provider

(e.g. GP, private psychiatrist) is contacted to arrange a consultation with the patient 24 hours post discharge by LHD.

Table 36: Count & Percentage of Departments/clinical units indicating the status of their system for ensuring the relevant health

provider (e.g. GP, private psychiatrist) is contacted to arrange a consultation with the patient 24 hours post discharge by LHD.

Description LHD

System in place and

functioning

optimally

System in place and

functioning

moderately

System in place and


Metropolitan CCLHD 4 10% 7 17% 3 7% 10 24% 18 43%

ISLHD 4 9% 14 30% 6 13% 8 17% 15 32%

NBMLHD 1 3% 5 17% 11 37% 4 13% 9 30%

NSLHD 7 8% 28 33% 12 14% 10 12% 28 33%

SCHN 5 10% 12 24% 2 4% 6 12% 26 51%

SESLHD 14 15% 19 20% 10 11% 13 14% 38 40%

SVHN 7 37% 4 21% 5 26% 2 11% 1 5%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

CC

LHD

ISLH

D

NB

MLH

D

NSL

HD

SCH

N

SESL

HD

SVH

N

SWSL

HD

SYD

LHD

WSL

HD

Met

ro T

ota

l

FWLH

D

HN

ELH

D

MLH

D

MN

CLH

D

NN

SWLH

D

SNSW

LHD

WN

SWLH

D

R&

R T

ota

l

JH



LHD - Not applicable NSW - System in place and functioning optimally or moderately


Description LHD

System in place and

functioning

optimally

System in place and

functioning

moderately

System in place and


SWSLHD 7 8% 28 33% 5 6% 18 21% 26 31%

SYDLHD 10 13% 25 32% 7 9% 15 19% 21 27%

WSLHD 8 17% 17 35% 5 10% 5 10% 13 27%

Metro

Total 67 12% 159 28% 66 11% 91 16% 195 34%

Rural &

Regional FWLHD 2 20% 3 30% 1 10%

0% 4 40%

HNELHD 9 8% 32 28% 19 17% 31 27% 23 20%

MLHD 9 14% 20 32% 9 14% 7 11% 18 29%

MNCLHD 2 8% 5 19% 4 15% 8 31% 7 27%

NNSWLHD 2 4% 11 22% 10 20% 14 29% 12 24%

SNSWLHD 3 7% 12 29% 7 17% 6 14% 14 33%

WNSWLHD 11 14% 20 26% 9 12% 15 19% 23 29%

R&R Total 38 10% 103 27% 59 15% 81 21% 101 26%

Other JH

0% 8 32% 10 40% 6 24% 1 4%

NSW 105 11% 270 27% 135 14% 178 18% 297 30%



Always (100%)

Mostly (67%-99%)


Seldom (1%-33%)

Never (0%)

N/A

Family / carer are notified/involved in patient's discharge planning

__ __ __ __ __ __

Figure 50: Percentage of Departments/clinical units indicating the status of their system for ensuring the family / carer and

notified/involved in patients discharge planning by LHD.

Table 37: Count & Percentage of Departments/clinical units indicating the status of their system for ensuring the family / carer

and notified/involved in patients discharge planning by LHD.

Description LHD

System in place and

functioning

optimally

System in place and

functioning

moderately

System in place and



ISLHD 14 30% 15 32% 4 9% 2 4% 12 26%

NBMLHD 4 13% 16 53% 4 13% 1 3% 5 17%

NSLHD 18 21% 41 48% 5 6% 2 2% 19 22%

SCHN 22 43% 15 29%

0%

0% 14 27%

SESLHD 32 34% 24 26% 6 6%

0% 32 34%

SVHN 7 37% 5 26% 6 32%

0% 1 5%

SWSLHD 24 29% 33 39% 4 5% 3 4% 20 24%

SYDLHD 26 33% 27 35% 4 5% 4 5% 17 22%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

CC

LHD

ISLH

D

NB

MLH

D

NSL

HD

SCH

N

SESL

HD

SVH

N

SWSL

HD

SYD

LHD

WSL

HD

Met

ro T

ota

l

FWLH

D

HN

ELH

D

MLH

D

MN

CLH

D

NN

SWLH

D

SNSW

LHD

WN

SWLH

D

R&

R T

ota

l

JH





Description LHD

System in place and

functioning

optimally

System in place and

functioning

moderately

System in place and


WSLHD 16 33% 16 33% 3 6% 2 4% 11 23%

Metro Total 171 30% 205 35% 40 7% 18 3% 144 25%

Rural &

Regional FWLHD 4 40% 3 30%

0%

0% 3 30%

HNELHD 34 30% 45 39% 13 11% 6 5% 16 14%

MLHD 16 25% 27 43% 7 11% 3 5% 10 16%

MNCLHD 4 15% 9 35% 8 31% 3 12% 2 8%

NNSWLHD 8 16% 18 37% 9 18% 6 12% 8 16%

SNSWLHD 8 19% 12 29% 7 17% 2 5% 13 31%

WNSWLHD 15 19% 31 40% 10 13% 4 5% 18 23%

R&R Total 89 23% 145 38% 54 14% 24 6% 70 18%

Other JH 3 13% 6 25% 5 21% 6 25% 4 17%

NSW

263 27% 356 36% 99 10% 48 5% 218 22%



Always (100%)

Mostly (67%-99%)


Seldom (1%-33%)

Never (0%)

N/A

The patient is provided with interim discharge summary

__ __ __ __ __ __

Figure 51: Percentage of Departments/clinical units indicating the status of their system for providing the patient with an interim

discharge summary by LHD.

Table 38: Count & Percentage of Departments/clinical units indicating the status of their system for providing the patient with an

interim discharge summary by LHD.

Description LHD

System in place and

functioning

optimally

System in place and

functioning

moderately

System in place and



ISLHD 10 21% 14 30% 5 11% 5 11% 13 28%

NBMLHD 5 17% 16 53% 4 13%

0% 5 17%

NSLHD 25 29% 30 35% 3 4% 4 5% 23 27%

SCHN 12 24% 19 37% 2 4% 2 4% 16 31%

SESLHD 36 38% 16 17% 5 5% 4 4% 33 35%

SVHN 6 32% 5 26% 4 21% 1 5% 3 16%

SWSLHD 20 24% 29 35% 6 7% 7 8% 22 26%

SYDLHD 25 32% 21 27% 4 5% 8 10% 20 26%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

CC

LHD

ISLH

D

NB

MLH

D

NSL

HD

SCH

N

SESL

HD

SVH

N

SWSL

HD

SYD

LHD

WSL

HD

Met

ro T

ota

l

FWLH

D

HN

ELH

D

MLH

D

MN

CLH

D

NN

SWLH

D

SNSW

LHD

WN

SWLH

D

R&

R T

ota

l

JH





Description LHD

System in place and

functioning

optimally

System in place and

functioning

moderately

System in place and


WSLHD 17 35% 18 38%

0% 2 4% 11 23%

Metro

Total 165 29% 177 31% 36 6% 39 7% 161 28%

Rural &


0% 3 30% 2 20% 3 30%

HNELHD 28 25% 44 39% 13 11% 13 11% 16 14%

MLHD 7 11% 22 35% 11 17% 10 16% 13 21%

MNCLHD 3 12% 8 31% 6 23% 5 19% 4 15%

NNSWLHD 7 14% 9 18% 11 22% 12 24% 10 20%

SNSWLHD 5 12% 13 31% 8 19% 3 7% 13 31%

WNSWLHD 10 13% 20 26% 14 18% 7 9% 27 35%

R&R Total 62 16% 116 30% 66 17% 52 14% 86 23%

Other JH 4 14% 13 45% 8 28% 1 3% 3 10%

NSW 231 23% 306 31% 110 11% 92 9% 250 25%



Always (100%)

Mostly (67%-99%)


Seldom (1%-33%)

Never (0%)

N/A

The patient / family is provided with written treatment plan and information on where and how to seek further help post discharge if required

__ __ __ __ __ __

Figure 52: Percentage of Departments/clinical units indicating the status of their system for providing the patient / family with a

written treatment plan and information on where and how to seek further help post discharge if required by LHD.

Table 39: Count & Percentage of Departments/clinical units indicating the status of their system for providing the patient / family

with a written treatment plan and information on where and how to seek further help post discharge if required by LHD.

Description LHD

System in place and

functioning

optimally

System in place and

functioning

moderately

System in place and



ISLHD 12 26% 12 26% 5 11% 5 11% 13 28%

NBMLHD 3 10% 11 37% 7 23% 1 3% 8 27%

NSLHD 13 15% 33 39% 10 12% 6 7% 23 27%

SCHN 13 25% 17 33% 3 6% 1 2% 17 33%

SESLHD 19 20% 26 28% 6 6% 9 10% 34 36%

SVHN 4 21% 4 21% 4 21% 5 26% 2 11%

SWSLHD 17 20% 34 40% 2 2% 9 11% 22 26%

SYDLHD 16 21% 28 36% 3 4% 10 13% 21 27%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

CC

LHD

ISLH

D

NB

MLH

D

NSL

HD

SCH

N

SESL

HD

SVH

N

SWSL

HD

SYD

LHD

WSL

HD

Met

ro T

ota

l

FWLH

D

HN

ELH

D

MLH

D

MN

CLH

D

NN

SWLH

D

SNSW

LHD

WN

SWLH

D

R&

R T

ota

l

JH





Description LHD

System in place and

functioning

optimally

System in place and

functioning

moderately

System in place and


WSLHD 15 31% 14 29% 5 10% 3 6% 11 23%

Metro

Total 118 20% 187 32% 51 9% 58 10% 164 28%

Rural &

Regional FWLHD

0% 2 20% 2 20% 2 20% 4 40%

HNELHD 11 10% 43 38% 24 21% 19 17% 17 15%

MLHD 8 13% 20 32% 17 27% 7 11% 11 17%

MNCLHD 2 8% 7 27% 8 31% 5 19% 4 15%

NNSWLHD 4 8% 8 16% 13 27% 13 27% 11 22%

SNSWLHD 5 12% 12 29% 4 10% 7 17% 14 33%

WNSWLHD 11 14% 21 27% 13 17% 11 14% 22 28%

R&R Total 41 11% 113 30% 81 21% 64 17% 83 22%

Other JH 3 11% 8 29% 6 21% 8 29% 3 11%

NSW 162 16% 308 31% 138 14% 130 13% 250 25%


Appendix 1: Notes about the data:

In this report, charts and tables are used to provide information on department/clinical unit responses to the questions

from the 2011 QSA self assessment compared to the aggregated NSW results.

Except where noted the charts illustrate the responses for departments/clinical units from LHDs.

The report uses pie charts, summary graphs for multiple questions and tables summarising the statistical analysis

of the results.

A small number of pie charts are used in the report to graphically summarise the responses for all of NSW to

classification questions. These questions are used to include or exclude units from subsequent questions.

Figure x: % of Departments/clinical units reporting that children/young people were assessed and treated and the SPOC had been

implemented (Q.6; NSW)

In the chart below, responses for the block of six questions on the paediatric Between the Flags

program for all NSW are summarised.

.

Figure X: % of “Strongly agree” or “Agree” responses to questions on the Paediatric Between the Flags Program for

departments/clinical units reporting that children/young people were assessed and treated (Q.7x; NSW).

Yes, 67% No, 14%

Not applicable, 19%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90%

100%

Q7a. Executive support

important part of success

Q7b. Clinical lead critical to

uptake & acceptance

Q7c. Blue zone assists early

detection

Q7d. Yellow zone assists

early detection

Q7e. Red zone assists rapid

response

Q7f. Overall BTF Benefits patient

safety

2

The count of responses is

provided in the text of the

report.

1

This chart summarises the responses to the group of statements from Question 7

in the 2011QSA, LHD Department/Clinical Unit self assessment. The results are

aggregated at the NSW level.


The section of the report that reviews each question in detail makes use of 3 types of chart to

summarise the department/clinical unit responses. The chart below is used to compare the responses

for departments/clinical units from each LHD, Metropolitan and Rural based LHDs and the overall

NSW proportion. A list of Metropolitan and Rural & Remote LHDs is available at

http://www.health.nsw.gov.au/services/index.asp

Figure X: % of Departments/clinical units responding “Strongly agree” or “Agree” by LHD.

The chart below is used to compare the responses for departments/clinical units from each peer

hospital group and the overall NSW proportion. The Peer Hospital Groups are collapsed to the main

letter designation with the exception of:

F2 Nursing Home & F3 Multi-Purpose Services facilities are mapped to F - Other

F1 – Psychiatric facilities that are mapped to F1 – MH

F4 Sub Acute, F6 Rehabilitation, F7 Mothercraft & F8 Ungrouped Non-Acute facilities are

mapped to “Other”

A list of NSW Peer Hospital Groups 2011/12 is available at

http://www.health.nsw.gov.au/hospitals/peer_groups.asp

Figure X: % of Departments/clinical units responding “Strongly agree” or “Agree” by Peer Hospital Group.

0% 10% 20% 30% 40% 50% 60% 70% 80% 90%

100%

CC

LHD

ISLH

D

NB

MLH

D

NSL

HD

SCH

N

SESL

HD

SWSL

HD

SYD

LHD

WSL

HD

Met

ro T

ota

l

FWLH

D

HN

ELH

D

MLH

D

MN

CLH

D

NN

SWLH

D

SNSW

LHD

WN

SWLH

D

R&

R T

ota

l



0%

20%

40%

60%

80%

100%

A B C D F - Other F1 - MH Other

Peer group - Strongly agree or Agree NSW - Strongly agree or Agree

This line shows the

aggregate result for all

NSW (77%)

3

Aggregate result

Metropolitan LHDs

Aggregate result for

Rural/ Regional LHD

4

http://www.health.nsw.gov.au/services/index.asp

http://www.health.nsw.gov.au/hospitals/peer_groups.asp


The chart below is used to compare the responses for departments/clinical units from each

aggregated service type and the overall NSW proportion. The aggregated service types are derived

from the response to Question 88 from the Department/Clinical Unit Self assessment. The primary

respondent for the self assessment was asked to indicate the main type of service their

department/clinical unit provides. A table showing the mapping of these responses is provided in

Appendix A of this document.

Figure X: % of Departments/clinical units responding “Strongly agree” or “Agree” by Service type.

Tables used in the report.

This table summarises the statistical analysis made for a group of questions.

The P-Value indicates if there is a statistically significant association between the variables (in this case) of LHD

location and response to the question. Using an -level of 0.05 for this test, the conclusion is the variables are

associated.

Table X: Summary of metropolitan and rural/regional Department/clinical unit self assessment responses regarding the level of

agreement with the SPOC/BTF statements.

Metropolitan Rural & Regional P-Value

BTF SPOC implemented % 70.3 91.3 <0.001

Agree on BTF clinical leader benefits % 64.7 66.2 0.78

Agree on BTF blue zone benefits % 53.9 73.7 <0.001

Agree on BTF yellow zone benefits % 72.9 81.3 0.06

Agree on BTF red zone benefits % 68.6 79.7 0.02

Agree on BTF benefits % 71.7 81.8 0.02

BTF NSW CPGs utilised always/often % 42.9 77.3 <0.001

0% 10% 20% 30% 40% 50% 60% 70% 80% 90%

100%

Med

ical

ED

Surg

ical

Pae

dia

tric

Ob

s &

Gyn

Oth

er

Mic

rob

iolo

gy

MH

Ort

ho

pae

dic

ICU

Car

dia

c/C

ard

iolo

gy

Imag

ing

On

colo

gy

Nep

hro

logy

Pal

liati

ve C

are

Reh

abili

tati

on

Service type - Strongly agree or Agree NSW - Strongly agree or Agree

5

6

7

7


This table summarises the responses for LHDs or clinical units to a single question. The responses for the

question are arranged across the top of the table with the values arranged in columns.

Table X: Count and % of Departments/clinical units reporting that children/young people were assessed and treated and the SPOC

implantation status by LHD.


Not applicable - our department

does not manage or treat

children


ISLHD 7 41.2% 6 35.3% 4 23.5%

NBMLHD 11 73.3% 3 20.0% 1 6.7%

NSLHD 18 47.4% 8 21.1% 12 31.6%

SCHN 66 75.9% 9 10.3% 12 13.8%

SESLHD 14 33.3% 15 35.7% 13 31.0%

SVHN 0 N/A 1 100.0% 0 N/A

SWSLHD 18 42.9% 8 19.0% 16 38.1%

SYDLHD 10 43.5% 4 17.4% 9 39.1%

WSLHD 11 64.7% 2 11.8% 4 23.5%

Metro Total 160 54.4% 59 20.1% 75 25.5%

Rural & Regional FWLHD 8 100.0% 0 N/A 0 N/A

HNELHD 61 82.4% 5 6.8% 8 10.8%

MLHD 40 97.6% 1 2.4% 0 N/A

MNCLHD 10 71.4% 0 N/A 4 28.6%

NNSWLHD 28 84.8% 5 15.2% 0 N/A

SNSWLHD 23 59.0% 4 10.3% 12 30.8%

WNSWLHD 52 77.6% 6 9.0% 9 13.4%

R&R Total 222 80.4% 21 7.6% 33 12.0%

NSW 382 67.0% 80 14.0% 108 18.9%

Similar tables have been provided for peer hospital groups and aggregated service types where applicable.

8

91

Offices

Level 13, 227 Elizabeth Street

SYDNEY NSW 2000

Correspondence

Bernadette King

QSA Program leader

Locked Bag A4062,

Sydney South NSW 1235

Tel 61 2 9269 5500

Fax 61 2 9269 5599

[email protected]

www.cec.health.nsw.gov.au

mailto:[email protected]

http://www.cec.health.nsw.gov.au/

2011 quality systems assessment ... - cec.health.nsw.gov.au€¦ · september 2011 to november 2011...

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