Kerang District Health Quality of Care Report 2012 - 2013

Cover i mage

RN 1 Jeecinta Lightbody seen here with long term patient ,Joyce MacLean in the Chemotherapy Unit..

Edition 2012 - 2013

2

Contents

Welcome 3

Maintaining and enhancing standards 4

Improving care 8

Listening to our consumers 11

Doing it with us, not for us 12

Caring in our community 13

3

Welcome We are pleased to present our 2012 -13 Quality of Care Report

Quality and safety underpins every service and

program that Kerang District Health provides to our

community. Both the Board of Management and

Executive Directors are responsible for ensuring that

we have robust systems and processes that support

safe and good quality care to achieve optimal

outcomes for our patients. Each and every member of

staff should be committed to improving the way we

work for the benefit of our consumers, their families

and carers.

The Quality of Care Report is Kerang District

Health’s report to the community on our quality and

safety systems, processes and outcomes. This

information is presented using text, tables, statistics,

stories and consumer comments to illustrate how we

monitor quality and safety. It identifies how we

improve the health care we provide to our

community, and how we consult with consumers to

meet their needs.

Once you have read this report, please do not hesitate

to let us know how we can improve our service and meet the needs of our consumers. By listening to you,

we will further make this health service one that

belongs to the community. We hope that you enjoy reading this Quality of Care Report.

Robert Jarman

Chief Executive Officer

Distribution of our Quality of Care Report

Kerang District Health Quality of Care Report is

distributed at our Annual General Meeting, and will

be available on our website:

www.kerangdistricthealth.org.au. It will also be

widely distributed in Kerang through a letter box

drop, and to the outlying districts through the mail

delivery system. Copies are also available at the

hospital and medical clinics.

We welcome your feedback on the Quality of Care

Report or your suggestions for new areas to be

included in next year’s report. Please fill out the

enclosed feedback form and send it back to us.

Last year fifteen consumers provided feedback on the

report with the overall opinion summarised in the

words of one consumer, “a thorough, comprehensive,

detailed report on the care and running of our

hospital.”

In this report you will find information on the Victorian

Patient Satisfaction Monitor, a Department of Health

survey that reports on patient satisfaction and Kerang

District Health’s own feedback initiative that gathers

comments from consumers across the health service.

We encourage you to contact us if you are thinking

about volunteering at Kerang District Health, or about

getting involved as a consumer.

Victorian Patient Satisfaction Monitor Indices Results for Wave 23,

July 20 to Dec 2012 Index (20-100 scale)

KDH

Wave 23 score

KDH

Wave 22 score

Category D (like

sized hospitals)

Wave 23 average

Overall Care (OCI) 85.9 87.1 86.0

Access and Admission (AAI) 84.8 89.5 84.5

General Patient Information (GPII) 89.7 89.7 89.1

Treatment and Related Information (TRII) 86.1 87.1 85.7

Complaints Management (CMI) 87.6 88.4 87.1

Physical Environment (PEI) 83.4 84.9 84.8

Discharge and Follow-up (DFI) 84.6 85.5 83.9

Consumer Participation Indicator (CPI)

86.9 88.6 86.6

4

Maintaining and

enhancing standards Health Service Accreditation

As an independent organisation and the main accrediting

body for health services in Australia, the Australian Council

on Healthcare Standards (ACHS), assesses health services

against a set of comprehensive standards

In October last year Kerang District Health took part in a

Periodic Review Assessment by ACHS to assure our

community that we are performing well and are able to

provide safe, high quality care. We performed well in this

accreditation survey, gaining an MA (marked

achievement rating (above average) for all standards. As

part of the survey, ACHS made recommendations on

areas where further improvement could be achieved,

and in October 2013 a self-assessment on our progress

towards meeting the recommendations was submitted to

ACHS.

Residential Aged Care Accreditation

All residential aged care facilities across Australia, such as

Glenarm, must be accredited in order to receive

Australian Government funding. The Aged Care Standards

and Accreditation Agency (ACSAA) is the independent

body that manages this process.

Quality & Safety in Residential Aged Care

Each quarter, Kerang District Health reports to the

Department of Health on five key aspects of the clinical care

provided to our residents in Glenarm. These are called

Quality Indicators in Public Sector Residential Aged Care

Services. This process enables us to identify possible

improvements to be actioned, and to measure and report

on our efforts for improvement. The areas we report on

include: pressure ulcers, falls and falls with fractures,

restraint, nine or more medications, and unplanned weight

loss.

Right Kerang District Health Public Sector Residential Aged

Care Quality Indicators 2012 – 2013. (state averages in

brackets)

INDICATOR Per 1,000 bed days.

GLENARM Aged care facility

1.

Pressure ulcers – Stage 1 Pressure ulcers – Stage 2

Pressure ulcers – Stage 3

Pressure ulcers – Stage 4

1.17% (0.60%) 0.49% (0.62%)

0.19% (0.11%)

0.00% (0.60%)

2.

Prevalence of falls Prevalence of falls with fractures

7.69% (7.35%)

0.19% (0.12%)

3.

Incidence of physical

restraint

3.79% (1.10%)

4.

Incidence of resident prescribed nine or more

medicines

5.84% (4.17%)

5.

Unplanned weight loss

0.78% (0.82%)

.

Above : Ruby enjoys knitting as one of the activities in

Glenarm Nursing Home

5

Maintaining and

enhancing standards National Safety & Quality Health Standards

The Australian Commission on Safety and Quality in

Healthcare has developed 10 National Health Standards for safety and quality in the Acute setting. These standards were implemented on 1 January 2013. They are evidence-based improvement strategies to address the gaps between current and best practice that the Department of Health has identified as

affecting a large number of patients.

The primary aims of the National Health Standards are: to protect the public from harm and to improve the quality of health service provision.

Each criterion has a series of items and actions that are required in order to meet the Standard.

Kerang District Health has conducted a gap analysis

against each of the criterion in the standards to identify

areas that require work to improve clinical practice.

Each action within a Standard is designated as either Core or a Developmental Action.

There are a total of 256 actions – 209 core actions and 47 developmental actions. Core, are critical for safety and quality, and Developmental, are aspirational targets.

To pass accreditation an organisation must pass all the core actions.

At Kerang District Health accreditation will be carried out by ACHS – Australian Council on

Healthcare Standards and follows the same process of: Self-Assessment Periodic Review, Self-Assessment and Organisation Wide Survey.

Kerang District Health Organisation Wide Survey date is 02 - 04 Sept 2014.

1 Governance for Safety and Quality in Health Service Organisations - the quality framework required for health service organisations to implement safe working systems

2 Partnering with Consumers - to create a consumer-centred health system by including consumers in the development and design of quality health care. 3 Preventing and Controlling Healthcare Associated Infections - to prevent infection of patients and to manage infections effectively when they occur . 4 Medication Safety - to ensure clinicians safely prescribe, dispense and administer appropriate medicines to informed patients.

5 Patient Identification and Procedure Matching - to identify patients and correctly match their identity with the correct treatment. 6 Clinical Handover - the effective clinical communication whenever accountability and responsibility for a patient’s care is transferred. 7 Blood and Blood Products - the safe, effective and appropriate management of blood and blood products. 8 Preventing and Managing Pressure Injuries – to prevent patients developing pressure injuries and implementing best practice management when pressure injuries occur. 9 Recognising and Responding to Clinical Deterioration in Acute Health Care - to respond quickly and effectively to patients when their clinical condition deteriorates. 10 Preventing Falls and Harm from Falls - to reduce the incidence of patient falls and implement best practice management when falls do occur.

6

Maintaining and

enhancing standards Safety and Quality framework at KDH

The framework at Kerang District Health is based on the

Victorian Government Clinical Governance Policy Framework

which is built on the four domains of quality and safety –

Consumer Participation, Clinical Effectiveness and

Appropriateness, Effective Workforce, and Risk

Management.

The Management Quality Risk Committee oversees clinical

governance of the health service and monitors quality and

safety. Two Board of Management members, the Chief

Executive Officer, Corporate Services Director, Director of

Nursing, Quality Coordinator, Nurse Unit Managers and

Department Heads attend the meeting. Departmental

Operational Quality meetings are held each month, to

facilitate the transfer of information and discussion of

audit results. Staff are encouraged to suggest how

improvements can be made to both clinical and non-

clinical processes.

An organisational Continuous Improvement Plan is linked

to the KDH Strategic Plan 2012 - 2015. Departmental

plans have also been developed and are linked to the KDH

Strategic plan. The Accreditation Action Plan /Status

report includes recommendations from the previous ACHS

Periodic Review, and gaps identified against all of the

actions required to meet the National Safety and Quality

Standards.

Consumer participation

We are required by the new National Safety and Quality

Standards to develop a Consumer Participation Strategy

that aims to build strong partnerships with our community,

to enable them to have greater input into health care. This

occurs when consumers are meaningfully involved in

decision-making about their care and treatment, or when

providing input about service delivery, health policy or

planning.

Currently we have many initiatives that gather data on

patient experience, but the new standard requires for

consumers to be more involved in being part of finding the

solutions to aspects identified for improvement.

During 2013 Kerang District Health will be seeking

consumers to be members of the Consumer Participation

Committee and they will be offered training in how to fulfil

this role.

Clinical effectiveness

Clinical effectiveness is crucial for providing appropriate

and timely care, and to ensure that patients are

informed and involved in decisions about their care.

One strategy we use for measuring clinical effectiveness

is to compare patient outcomes with those of other

hospitals. We take part in the ACHS Clinical Indicator

benchmarking program where our results are compared

to other like sized hospitals for a number of clinical

areas.

Regular clinical audits are undertaken to identify

issues that need improvement. Any aspect identified

for improvement has an action entered onto the

departmental quality plan, and reaudits occur to

ensure that the change in practice is being adhered to

until it becomes embedded as routine practice.

Effective workforce

We check the qualifications, registration, work history

and references of medical, nursing and allied health

applicants before they start work at Kerang District

Health, We also check their scope of practice according to

their qualifications and experience. This is to ensure that

all clinical staff have the right skills and qualifications to

provide safe health care. Annual checks are also conducted

on registrations for all clinicians.

We invest in ongoing education and professional

development through our Personal Development Days,

online resources and online ELearning courses. All staff

undertake mandatory training each year to remain

competent.

7

Maintaining and

enhancing standards Risk management

Risk management is the process of identifying what,

where, when, why and how something could happen

that may adversely affect patients or systems.

We use the Victorian Health Incident Management System

(VHIMS), a state-wide electronic system for reporting and

managing incidents, adverse events and near misses.

Each incident is investigated by the Nurse Unit Manager

or Department Head to improve practice and to prevent

similar events happening again.

The Incident Review Panel reviews all incidents each

month. It brings together the key staff involved in the

investigations and the implementation of recommended

actions. Informed discussion occurs with journal entries

made into VHIMs to update the record. Trends are

identified and implemented strategies are reviewed for

effectiveness.

KDH Top Risks at 30 June 2013

Risk Risk Score

1 Medical Emergencies (Ref: 2) High -12

2 Foetal Emergencies (Ref: 3) High -12

3 Management of acute Psychotic

episodes (Re: f5)

High -12

4 Obstetric Emergencies (Ref: 4) Medium - 9

5

Maintenance of Accreditation Status with Aged Care Standards

Accreditation Agency (Ref: 9)

Medium - 9

6 Risk of Litigation (Ref: 16) Medium - 9

7 Possibility of injury in use of

Wheelchair lifter on Bus (Ref: 61)

Medium - 9

Facts and figures

In 2012 – 2013 Kerang District Health had a

total of 1,811 separations - 918 overnight

separations, and 893 same day separations.

There was a total of 4,124 bed days - 3,231

overnight bed days and 893 same day bed days.

The total overnight daily average of patients was

11.53 patients, with the average length of stay

3.49 days.

There were 311 minor surgical procedures and

107 major surgical procedures conducted during

the year.

There were 50 births for the year, with a total of

171 new born days recorded.

There were 2,830 outpatient attendances.

Glenarm had a total of 10,273 bed days.

District nurses recorded 8,661 visits.

Day Centre program recorded 2,700 contacts.

Mobile Day Activity program recorded 836 contacts.

The Exercise program recorded 3,106 attendances.

There were 1,565 Men’s Shed attendances.

There were 30 staff incidents and 36 staff hazards

recorded on VHIMS, with 26 days lost to workers

compensation.

There were 1,230.58 sick days taken, and 229.76

carer’s leave days taken.

There were 12,028.42 annual leave hours taken, and

108,617 annual leave hours accrued; 2,070 long

service leave hours taken, and 226,361 long service

leave hours accrued across the health service.

8

Improving care Medication safety

The Management Quality Risk committee oversees

medication management at Kerang District Health. Staff are encouraged to report any errors involving

medications, including near misses, as this enables us to develop new initiatives to ensure that the

prescribing, dispensing and administering of

medications is made safer for our patients.

Information about the medications patients are

currently using is an important part of the admission

process; as is providing written information to patients

about their medications upon discharge from hospital.

Some of our doctors are now providing a printed sheet

outlining the medication dose, time to be taken, the

purpose of the medication and possible side effects to

their patients upon discharge, and the feedback from

our local survey supports this initiative.

Client feedback

We have recently introduced a pharmacy review of the

patient’s medications upon discharge, as another

means of ensuring that the patient is fully informed

about the medications that they are to take, and to

reconcile any new medications with medications on file

at the local pharmacy. This also allows the patient or

their carer to ask any questions and have them

answered by the pharmacist.

We have widen the scope of the audits conducted on medications to cover PRN medications, outpatients card

medications, legibility of orders, and the standard compliance medication audit.

In response to a recommendation from the Accreditation Periodic Review the Director of Medical

Services wrote to all our doctors regarding results of medication and medical documentation audits, to urge

greater compliance with GP’s signing and ceasing medications, and also noting the time of

history/examination of patients in the progress notes.

In addition an audit tool was developed to review the

overall degree of legibility of the doctors’ handwriting

covering the following criteria: 1 = notes can be read by a nurse new to the

organization or a non-nurse. 2 = writing can be read by staff familiar with the script.

3= writing creates concern and requires follow up

with a staff member who is familiar with the script. In the first audit, 10 histories were reviewed with an

overall compliance rate achieved of 82%.

Notes are now being typed which alleviates issues with

legibility, and student Doctors are now writing progress notes and having them co-signed by the GP.

In order to address the non-signing of medications all

medication charts are collected at the end of each shift and checked for compliance to legal requirements, and

this has improved compliance in this area.

High alert medications including drugs of addiction have been identified and include medicines with a low

therapeutic index; and medicines that present a high

risk when administered by the wrong route or when other system errors occur.

To improve this Kerang District Health follows the PINCH acronym:

P - Potassium

I - Insulin N - Narcotics

C - Chemotherapy H - Heparin

We have listed the medicines and developed risk

mitigation strategies to prevent errors from occurring.

Medications were given to me on a Medications were given to me on a Medications were given to me on a Medications were given to me on a printed sheet explaining what time to printed sheet explaining what time to printed sheet explaining what time to printed sheet explaining what time to take them and what they were for take them and what they were for take them and what they were for take them and what they were for ---- this this this this is an excellent idea.is an excellent idea.is an excellent idea.is an excellent idea.

In 2012 In 2012 In 2012 In 2012 –––– 2013 there were2013 there were2013 there were2013 there were::::

48 medication errors for Glenarm ; 48 medication errors for Glenarm ; 48 medication errors for Glenarm ; 48 medication errors for Glenarm ;

82. for Acute ward, an82. for Acute ward, an82. for Acute ward, an82. for Acute ward, and d d d

1 for District Nursing recorded on 1 for District Nursing recorded on 1 for District Nursing recorded on 1 for District Nursing recorded on VHIMs,VHIMs,VHIMs,VHIMs,(Victorian Incident (Victorian Incident (Victorian Incident (Victorian Incident Management System) Management System) Management System) Management System) as well as the as well as the as well as the as well as the errors identified by the visiting errors identified by the visiting errors identified by the visiting errors identified by the visiting pharmacistpharmacistpharmacistpharmacist,,,, who who who who conducts weekly conducts weekly conducts weekly conducts weekly audits audits audits audits on on on on files of patients who are on 9 files of patients who are on 9 files of patients who are on 9 files of patients who are on 9 or more medications. or more medications. or more medications. or more medications.

9

Improving careFalls prevention

Falls occur in all age groups; however the risk of falls

and harm from falls varies between individuals due to

factors such as eye sight, balance, muscle strength,

bone density and medication use. Falls remain a

significant issue in the safety of patients in Australian

hospitals, and although the risks are well documented

impaired mobility is also a major falls risk and is not

age defined.

In 2012 Kerang District Health developed an organisational wide policy on the Prevention of Falls and Fall Related Injuries with Falls Prevention made a

quality project across the health service focusing on a review of falls risk screening in Acute, District Nursing

and Day Centre. Work has been conducted on ensuring appropriate tools are in use with the orange sticker

used to flag prevention strategies in patients identified

as a high risk of falls.

Education of staff on changed strategies and audits on patient files for compliance to risk assessment and care

planning are conducted.

In 2013 the falls project continues and has a focus on

care planning and prevention strategies in line with best practice. Staff are using an escalation criteria for

patients who are in the high falls risk category, and when rated on the higher scale, staff are documenting

hourly checks, offering fluids, toilet break, and change

in position for patients.

Also simple strategies such as reducing clutter in patient rooms, ensuring that the bed is in a low

position, that the light is left on in the bathroom, and

that the patient’s glasses or waking aid are within reach are put in place – every little bit helps.

Falls risk status has been included on the Nursing Care

Plan with prevention actions to be noted.

Pressure injuries The chances of acquiring a pressure injury are increased when people are ill and admitted to hospital.

Pressure injuries can result in a longer stay and

prevention is a priority at Kerang District Health.

Pressure injuries are defined as any lesion caused by unrelieved pressure resulting in damage of the skin and

underlying tissue – they cause pain, distress and debility for patients and residents.

Risk minimization strategies are put in place such as the use of electronic air mattresses, and a soft mattress

in theatre. Surgical patients whose procedure is to last more than three hours are given gel pads to relieve

pressure areas.

In May 2013 a Pressure Injury and Prevention

Management Manual was adopted and is to be implemented with training for staff to be arranged.

Audits of current patients to assess Pressure Area/Skin Integrity occur to check if patients have been assessed using the Braden Scale Assessment Tool.

The audit conducted in January 2013 showed overall

compliance was 86% with the following noted: 6 clients were checked with 5 noted to have skin

issues. 3/5 had issues noted on the history /examination.

3/5 had the braden scale assessment conducted.

4/6 had evidence in the care plan of wound management strategies with 2/6 n/a.

5/6 had evidence that the care plan was being followed 3/6 had evidence of reassessment if the health status

had changed e.g fall or decline in condition with 3/6 n/a.

In 2012 In 2012 In 2012 In 2012 –––– 2013 2013 2013 2013 Glenarm haGlenarm haGlenarm haGlenarm had d d d 79797979 falls reported onto falls reported onto falls reported onto falls reported onto VHIMsVHIMsVHIMsVHIMs,,,, and and and and Acute ward recorded Acute ward recorded Acute ward recorded Acute ward recorded 29292929 falls on VHIMs.falls on VHIMs.falls on VHIMs.falls on VHIMs. (Victorian Health Incident Management (Victorian Health Incident Management (Victorian Health Incident Management (Victorian Health Incident Management System)System)System)System)

The The The The above overall compliance result of above overall compliance result of above overall compliance result of above overall compliance result of 86% showed an increase of 30.6% in 86% showed an increase of 30.6% in 86% showed an increase of 30.6% in 86% showed an increase of 30.6% in compliance to the previous audit results compliance to the previous audit results compliance to the previous audit results compliance to the previous audit results of 55.5%.of 55.5%.of 55.5%.of 55.5%.

In 2012 In 2012 In 2012 In 2012 –––– 2013 Glenarm 2013 Glenarm 2013 Glenarm 2013 Glenarm recordedrecordedrecordedrecorded 40 40 40 40 pressure area/skin integrity injuriespressure area/skin integrity injuriespressure area/skin integrity injuriespressure area/skin integrity injuries reported onto VHIMs and Acute ward reported onto VHIMs and Acute ward reported onto VHIMs and Acute ward reported onto VHIMs and Acute ward recorded recorded recorded recorded 10101010 pressure arepressure arepressure arepressure area injuriesa injuriesa injuriesa injuries on on on on VHIMs.VHIMs.VHIMs.VHIMs.

10

Improving carePreventing infections Monitoring the rates of infections in our patients and

finding ways to reduce those rates is an important part of keeping our patients safe during their hospital stay.

Kerang District Health is part of the state wide program to monitor patients for infections following surgery.

Last year our results were above the state average and in line with regional rates.

We monitor any blood stream infections caused by staphylococcus aureus (golden staph) as part of the

national program

Kerang District Health participates in the National Hand

Hygiene strategy with audits conducted twice yearly. Our latest results achieved an overall compliance rate

of 87% which is well above the Department of Health’s benchmark of 70%

All staff and visitors are encouraged to use the alcohol

hand gel. Wave 23 of the Victorian Patient Satisfaction

Survey results indicated that 81.8% of Acute patients indicated they observed hospital staff cleaning their hands between patients all of the time. A clean hospital is not just a pleasant place to recover

from illness or injury, but cleanliness plays a vital role in reducing the risk of patients developing an infection

during their stay. Our external cleaning audits for 2012 and 2013 showed that we successfully met the

Department of Health cleaning standards in all risk categories with overall compliance rate for the audit

conducted in October 2012 of 99%.

In order to prevent the spread of influenza the

Department of Health supplies Fluvax to Kerang District Health staff and aged care residents.

The graph below shows the number of staff who received fluvax

Blood safety

Blood safety

Informed consent for a blood component transfusion

means the Doctor and patient (or carers) discuss the risks, benefits and alternatives to having a transfusion.

As a result of the discussion the patient or carer will: • understand what medical action is

recommended and why.

• be aware of the risks and benefits associated

with the transfusion.

• appreciate the risks of receiving and possible

consequences of not receiving the recommended therapy.

• be given the opportunity to ask questions.

• give consent for the transfusion.

• receive two brochures Blood – who needs it? and A Blood Transfusion.

We participate in the Blood Matters clinical audit

program run by the Australian Red Cross Blood Service. We also carry out our own audits to ensure we comply

with best practice and that we are compliant with informed consent.

The audit in March of all transfusions for January

and February 2013, showed overall compliance of

95.7% with the following noted:

7/7 had a signed consent form.

7/7 signed consent by Doctor.

6/7 had the pathway completed as required.

5/7 had the cross match form signed by 2 people.

7/7 were transfused when the HB was less than

100g/l

7/7 had signs and symptoms of the need for a

transfusion, or ongoing bleeding noted.

7/7 had blood administered in < 30 minutes from

the time it left Pathology.

....

Our policies on blood and blood Our policies on blood and blood Our policies on blood and blood Our policies on blood and blood transfusions have been reviewed to transfusions have been reviewed to transfusions have been reviewed to transfusions have been reviewed to ensure that they meet legislative ensure that they meet legislative ensure that they meet legislative ensure that they meet legislative rerererequirements and follow best practice quirements and follow best practice quirements and follow best practice quirements and follow best practice guidelines.guidelines.guidelines.guidelines.

An analysis of the results indicated An analysis of the results indicated An analysis of the results indicated An analysis of the results indicated that 1 normal saline was not double that 1 normal saline was not double that 1 normal saline was not double that 1 normal saline was not double signedsignedsignedsigned,,,, and on one occasion only 1 and on one occasion only 1 and on one occasion only 1 and on one occasion only 1 nurse signed nurse signed nurse signed nurse signed the cross match form.the cross match form.the cross match form.the cross match form.

11

Listening to our consumers The Victorian Patient Satisfaction Monitor (VPSM) is

a survey that monitors and reports on patient

satisfaction with public hospital services throughout

Victoria. This information is reported to the

Department of Health. For Kerang District Health, it

enables us to compare our patients’ satisfaction

with similar hospitals and the State.

The most recent report, for VPSM Wave 23, is for the

period July 2012 to December 2012. There were 128

consumers who completed the surveys for Kerang

District Health during this period. The Overall Care

Index (OCI) identifies patient satisfaction with the care

provided by a health service, and achieved a rating of

86%. VPSM reports the OCI to the Department of

Health.

In July an Action Plan was devised to improve areas

identified for improvement:

• Weekend discharge plans to improve.

• Information for discharge especially written

medication information and discussion around this with the patient to occur.

• Planning discharge at all levels with ward staff

using the Nursing Admission Tool to improve. • Explanation to patients about waiting and service

times if delays expected to occur.

• Doctors to prepare before blood transfusions and

iron transfusions, documents including cross match or scripts, consent and orders in order to

prevent delays

• Post op patients now to get 1.5 - 2 rounds of

sandwiches.

•

Sample verbatim responses July to Dec 2012

Local surveys

To complement the VPSM feedback, Kerang District

Health conducts a phone survey to 10 random patients

each month and seeks feedback on admission, care

provided, including consumer input into the planning of the care, cleanliness of the room and bathroom, meals ,

discharge planning and services provided.

On two occasions during the year we have also sought on the spot comments from consumers across the health service, using a feedback card in inpatient areas and in District Nursing.

Our Midwifery surveys collect feedback on antenatal care, care during delivery, breastfeeding, comfort of the room, cleanliness of the bathroom, satisfaction with the meals offered, and domiciliary mid care. Overall ratings were excellent with the following comments received from some of our patients:

Helping us to improve

Complaints and compliments help us understand how

best to improve our services. The complaints we

receive can relate to communication, the

environment, food services, and timeliness of care –

and any other aspects of care raised by patients,

carers or families.

All comment, complaint and suggestion forms are forwarded to the Chief Executive Officer. Each form is registered with a brief summary outlining the nature of the complaint, what the investigation found and what the outcome was, provided to the monthly Management Quality Risk meeting.

In 2012 – 2013 the complaints were reviewed to identify any trends, and it was identified that the complaints against staff tended to be about the manner and language used in communicating with the patient or carer, rather than about the care. In 2012 – 2013 there were 30 complaints received by the health service. These were investigated and action taken as required.

Being able to relax knowing that I was Being able to relax knowing that I was Being able to relax knowing that I was Being able to relax knowing that I was in the best place for min the best place for min the best place for min the best place for my wellbeing and y wellbeing and y wellbeing and y wellbeing and care.care.care.care.

Friendliness of the staff and their Friendliness of the staff and their Friendliness of the staff and their Friendliness of the staff and their commitment to providing appropriate commitment to providing appropriate commitment to providing appropriate commitment to providing appropriate care.care.care.care.

I am an outpatient receiving I am an outpatient receiving I am an outpatient receiving I am an outpatient receiving chemotherapy and I cannot fault the chemotherapy and I cannot fault the chemotherapy and I cannot fault the chemotherapy and I cannot fault the staff I have contact with on staff I have contact with on staff I have contact with on staff I have contact with on each weekeach weekeach weekeach week

We were very happy with all the care We were very happy with all the care We were very happy with all the care We were very happy with all the care provided fromprovided fromprovided fromprovided from the knowledgeable and the knowledgeable and the knowledgeable and the knowledgeable and supportive midwives.supportive midwives.supportive midwives.supportive midwives.

All midwifery staff were friendly All midwifery staff were friendly All midwifery staff were friendly All midwifery staff were friendly and full of information guiding a and full of information guiding a and full of information guiding a and full of information guiding a new mother through a new experiencenew mother through a new experiencenew mother through a new experiencenew mother through a new experience....

12

Doing it with us, not for us The DOH policy “Doing it with us not for us” (2010 –2013) is a key way of measuring our success

1.The governing body is committed to consumer, carer and community

participation appropriate to its diverse

communities. Target indicator = 75%

Kerang District Health has appointed an Aboriginal Liaison Officer in 2013.

A Cultural Responsiveness Plan exists and we are required to report our progress on cultural responsiveness to the Department of Health against six requirements. VPSM – Wave 23 overall care index score of 86%

VPSM – Wave 23 How well cultural /religious needs were met = a score of 4.14 out of a possible score of 5.0

2.Consumers, and where appropriate,

carers are involved in informed decision–making about their treatment,

care and wellbeing at all stages and with appropriate support.

Target indicator VPSM = 75%

Maternity Services = 90%

Wave 23 Victorian Patient Satisfaction Monitor results for Consumer

Participation Index were 86.9% and KDH received a mean score of 4.26 compared to the state wide mean of 4.02. for “the way staff involved you in

decisions”. Wave 23 VPSM results for General Patient Information KDH received a score

of 89.7.

Annual Maternity Satisfaction Survey indicated 100% for care in labour ward

and post birth care and involvement. In 2012 a number of staff received training on patient centered care.

3.Consumers, and where appropriate, carers are provided with evidence-

based, accessible information to support

key decision making along the continuum of care.

Target indicator - = 85%

Wave 23 Victorian Patient Satisfaction Monitor results for “treatment and related information” Kerang District Health received an overall score of 86.0

on par with category D hospitals average score of 86.0

We use the telephone translation services for people requiring an

interpreter.

4.Consumers, carers and community members are active participants in the

planning, improvement, and evaluation of services and programs on an ongoing basis. The target indicator = 75% for

public hospitals covering the 6 specified

areas.

Boards of Management members are involved in Strategic Planning.

Community members are involved in the development of the some service

programs.

Board of Management members are members of the Management

Quality/Risk Committee – they receive audit reports, adverse events data,

key performance indicators on falls, pressure ulcers, aggression incidents

medication safety, complaints and triage urgency cat 1 – 5.waiting times,

All Board of Management members receive the minutes of the Management

Quality/Risk meeting, KPIs and accreditation reports.

Members on the Community Participation Register are involved in the

development and review of written consumer information.

Members on the Community Participation Register are involved in the development and review of the annual Quality of Care Report.

5.The organization actively contributes

to building the capacity of consumers,

carers and community members to

participate fully and effectively. The

target = 75% for public hospitals.

Early in 2013 the Quality Coordinator and a Board of Management member

attended a training day at the Health Issues Centre Melbourne and returned to Kerang District Health and conducted training for senior staff on consumer

participation.

13

Caring in our community Julie’s story

Norm and Julie Foster moved from Melbourne to

Kerang in September 2012 to enjoy a “tree change”

for their retirement. Not feeling well Julie attended

Fitzroy Street Clinic and saw Dr Harry Vanrensburg

who ordered tests and regrettably, in December 2012

diagnosed that Julie was suffering from Mesothelioma.

After various invasive procedures Julie commenced

chemotherapy treatment at Kerang District Health in

March 2013, where she completed six sessions of

chemotherapy over eighteen weeks, with the sessions

taking five hours each time. Half way through the

treatment regime Julie had a scan and received a ray

of hope, as the results showed that the tumour had

shrunk. At the end of the six sessions Julie says that

she is feeling “pretty good”, and added that she had

put herself on a high antioxidant diet.

Julie was asked how she had come into contact with

exposure to asbestos, and revealed that she had been

exposed as a nine year old girl when she played in the

backyard alongside discarded building materials, while

her father renovated their family home.

Again, as a nineteen year old bride, she assisted her

husband by sweeping up and cleaning the site as he

renovated their bathroom and kitchen. Both buildings

sadly contained asbestos sheeting and as she aptly

states:

” in those days we unaware of the dangers”.

Norm and Julie have been amazed at the quality of

care received at Kerang District Health, and also at

Swan Hill District Health and Bendigo Health Care,

where the care received and the transfer of

information has been exceptional. Julie says that

“everyone right down to the tea lady has a smile and a

greeting at all three facilities.”

A palliative care nurse visits once a month and Julie

welcomes her visit. She admits that she has been dealt

a death sentence, but you only have to speak with this

lady for a short time, to realise that she has an

inspirational, positive attitude and spirit. In her own

words she is “striving to live longer than her initial

prognosis.” which she has achieved twice over, and

continues to amaze her family and the clinicians

involved in her care.

Lauren’s story

After attending antenatal care Lauren Edwards presented to Kerang District Health for an elective

caesarean section in April 2013.

On admission she was warmly welcomed and shown to her room, where a nurse verified her paperwork.

Lauren was second on the surgery list, but she said it

felt like she waited for an eternity, before going to theatre and being prepared for her caesarean section.

Finally at 2.20 her baby daughter was born weighing

3146.85gms. Lauren and John named their daughter

Arlie.

There is always a small risk of developing an infection post operatively, and unfortunately Lauren developed

a post-operative infection which was treated with antibiotics over a five day period. Lauren recovered

well and was happy with the care she received from

nursing and medical staff, and especially the care of her baby daughter.

“ Everyone was outstanding, particularly the way the nurses cared for my daughter when I was unwell. All

staff, even down to the girls delivering the meals were always pleasant and courteous”.

In September 2010 Kerang District Health changed

to a Shared Care Model of Care for maternity

services, which is a team approach between the

Midwifery team and GP Obstetrician in the care of

the woman having an uncomplicated pregnancy.

Responsibility is shared for a woman’s care,

including communication, a shared Maternity record,

and Management of results and abnormal findings.

The focus is on education, preparation, involvement

and active birth, providing an opportunity for women

and their families to participate fully in pregnancy and

birth.

Our staff are committed to providing an integrated

service of the highest quality.

14

Caring in our community Men’s Shed setback

In December 2012 the Kerang District Health Men’s

Shed building was damaged by fire which forced its

closure for over five months. The fire destroyed

benches, equipment, electrical wiring, the main roller

door, and a vital beam in the workshop. It took time

for the insurance claim to be processed and to get

repair work authorised, but by April 2013 construction

work within the Burgoyne Street facility was in full

swing. Work to replace the roller door, roof panels and

electrical wiring that was damaged in the blaze was

almost completed. Members had commenced building

work benches to replace ones that were destroyed,

and were looking forward to moving back into the

workshop after five months of waiting. “All the

tradesmen involved in the project were fantastic” said

Harry Sambrooks coordinator of the program.

Despite not having a work space members remained

active by converting a portable classroom from Kerang

South Primary School into a meeting and tea break

room, where they discussed ideas on how to fix the

workshop, or share a joke. The fact that the members

could still come together was important.

Today the Men’s Shed is fully operational with the

existing members enthusiastic about the repaired

workshop, and new members continuing to join the

group.

The Men’s Shed program operates each Tuesday,

Wednesday and Thursday with anyone interested in

further information encouraged to contact Harry on

5452 1198.

Below: Carl Peterson and Rex Bradley are enjoying being back

with their tools in the repaired Men’s Shed.

15

Caring in our community Tony’s success

Anthony (Tony) Morosoli is a 72 year old gentleman

who suffered a heart attack in 1998; he had stents

inserted in 1999, and suffered a stroke in 2001.

In March 2012 he underwent a triple bypass operation

and commenced at the Kerang District Health

Rehabilitation Exercise Program mid-year after an

initial physio assessment. Tony commenced with a

limited program of

8 repeats of most

exercises using

low weights, and

taking lots of rest

periods between

exercises. His

balance was not

good, so he

required

assistance and

encouragement

from the program

workers.

As the weeks

passed Tony was

able to repeat the

exercises more

often and have

fewer rest

periods. Weights

were slowly

increased and

after three

months the

program became

more achievable

for Tony and his

confidence and

general health

improved. He is now able to do things that could not

do before, such as gardening and walking his dog Max

over the Railway footbridge.

The program has now been tailored to maintain Tony’s

strength and fitness, which has resulted in him

enjoying a better quality and happier lifestyle with his

wife. He attends sessions on Tuesday and Thursday

and along with improving his health, he enjoys the

social aspect of the program and has met many new

people.

Tony’s physio update shows a significant improvement

to his strength, balance and general stamina.

For further information on the exercise programs are

contact Karyl on 5450 9203. the programs are held n

each Tuesday and Thursday. Consumers can be

referred by their General

Practitioner or they may

self-refer. All participants

are required to have an

initial physio assessment

to determine the type of

program required.

Day Centre activities

are held on Monday

Wednesday and Friday

and cater for elderly

members of the

community who enjoy

activities, musical

entertainment, and the

company of others.

Participants can be

picked up at their home

and returned in the

afternoon by the Kerang

District Health Day

Centre bus.

The Mobile Planned

Activity Program is held

on Tuesday and

Thursday. On Tuesday

Kerry our bus driver

collects participants who

travel to Quambatook

for activities with local

residents and share a meal at the Quambatook hall.

On Thursday Kerry operates a service for clients who

require assistance with shopping, and medical

appointments. Again, clients share lunch together and

are collected from their home and returned in the

afternoon. This service is particularly focused on

country clients who may no longer wish to drive.

Above: Tony Morosoli busy at the Exercise Program