1

Caring for our Community

DieticiansAcross Australia there is an increasing trend in the number of women with weight gain prior to and during pregnancy. This can result in complications such as gestational diabetes, large babies and increased likelihood of caesarean section. At WGHG Dietitians, Obstetricians and Midwives joined forces to develop the Positive Pregnancy Program (PPP). Instead of the traditional education approach, women are supported with individualised, tailored health coaching and the results have been outstanding. When compared to similar women not on the program the PPP women have

• averaged 4 kg less weight gain during their pregnancy.

• 1/4 the number of caesarean sections

• less that 1/4 the number of large babies and

• 1/2 the incidents of gestational diabetes

Quality of Care News 2011

COOINDA LODGEA G E D C A R E R E S I D E N C E

R E S I D E N T I A L A G E D C A R E S E R V I C E S

R E S I D E N T I A L A G E D C A R E

We s t G i p p s l a n d H e a l t h c a r e G r o u p

W E S T G I P P S L A N D

C a r i n g f o r o u r C o m m u n i t y

C a r i n g f o r o u r C o m m u n i t y

H E A L T H C A R E G R O U PW E S T G I P P S L A N D

W E S T G I P P S L A N D

C a r i n g f o r o u r C o m m u n i t y

H E A L T H C A R E G R O U P

H E A L T H C A R E G R O U P

W E S T G I P P S L A N DH E A L T H C A R E G R O U P

WEST GIPPSLAND HEALTHCARE GROUP

C a r i n g f o r o u r C o m m u n i t y

W E S T G I P P S L A N D H E A L T H C A R E G R O U P

W E S T G I P P S L A N D H E A L T H C A R E G R O U P

W E S T G I P P S L A N D H E A L T H C A R E G R O U P

Transition Care Program…There is nothing Graham Robinson enjoys more than being at home with his wife Ruth and son Allan and taking in the view of his 16 1/2 acre Westbury property. It is the goals that he set through the Transition Care Program that have allowed him to be back at his home of 30 years.

On the 16th of June 2010 Graham suffered a stroke and was admitted to West Gippsland Hospital. He then broke his hip in November 2010 and was cared for in the hospital after his surgery. Upon being assessed by Allied Health it was suggested he take part in the Transition Care Program. The Transition Care Program aims to assist older people, who, after a hospital stay, may require extra time to complete their recovery. Story continues Page 8

Governance Program is built on a framework that complies with the Department of Health’s Clinical Governance Framework.

The program ensures that the right people are doing the right thing at the right time in the best and right way. This involves:

• Ensuring an effective and safe workforce• Monitoring the effectiveness of care• Managing clinical risks• Involving consumers in their own care

This year WGHG’s Clinical Governance Program was reviewed by the Victorian Managed Insurance Agency ( VMIA) as part of a broader review of all risk management processes.

The results of the review rated WGHG as the top performing hospital among 14 other hospitals reviewed across the State.See full story Page 8 - 9

Quality Care With Ever Increasing Demand…The Board of Directors of WGHG is accountable for ensuring a process of continual improvement in the quality of services, and safeguarding high standards of care. The Board monitors these matters as part of the organization’s Clinical Governance Program. At WGHG the Clinical

Allied Health assistant Nina Blaney farewells Graham Robinson before he goes home

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From the new CEO…

On behalf of the West Gippsland Healthcare Group (WGHG) it gives me great pleasure to present the 2010/11 Quality of Care Report.

As I am sure you are aware, I am only relatively new to the role of CEO, having taken over from Ormond Pearson

in November 2011. The report provides a great overview of the services provided at WGHG and I am pleased and proud to have the opportunity to continue the excellence in health provision that the Community deserves and expects. As this report relates to activities that occurred during Ormond’s tenure, it is appropriate that we use Ormond’s words to introduce the Report.

Dan WeeksChief Executive Officer

From the previous CEO…

The past year continued to present many challenges. The Emergency Department saw continued growth with 19,098 attendances, 1,622 more than last year, a 9% increase.

The Elective Surgery waiting list continued to grow despite the efforts of our Elective Surgery Access Coordinator, operating theatre team and surgeons to focus on increasing access to these services. At the end of June there were 610 patients on the Elective Surgery waiting list, 96 more than the same time last year.

The number of babies born at the hospital remained comparable to past years with 820 babies born.

This report features new programs commenced in the past year in response to needs identified by us in the community. These include the Transition Care Program and the Positive Pregnancy Program.

I commend to you the outstanding work undertaken by our staff in collaboration with the Ramahyuck District Aboriginal Cooperative in Drouin to develop health programs for Aboriginal members of our community.

I would also like to take this opportunity to congratulate our staff for the very positive manner in which they address

the many challenges of delivering high quality health services to meet the growing demands of our community. Their energy, enthusiasm and focus on continuous quality improvement is outstanding.

The leadership of our Board of Directors, the community perspective provided by the Community Advisory Council and the tireless efforts of our wonderful volunteers is also acknowledged.

It has been my pleasure to lead West Gippsland Healthcare Group over the past 13 years. The support shown to me and this wonderful organisation throughout this time has been outstanding. I am truly grateful for it.

Ormond PearsonChief Executive Officer 1998 - 2011

About your Health Service

VisiOn To improve the health and wellbeing of our community.

MissiOn West Gippsland Healthcare Group is committed to the provision of high quality, integrated health care that meets the changing needs of individuals and our community.

WE ValuE: Our Customers; Our Community; Our Staff; Leadership; Improving Performance

What We DoHOspital (aCutE)AnaesthesiaBreast SurgeryCommunity Rehabilitation CentreDay SurgeryDental SurgeryDiabetes EducationEar Nose and Throat SurgeryEmergencyEndoscopyGeneral MedicineGeneral PracticeGeneral SurgeryHaemodialysisHigh DependencyMidwiferyNeurologyObstetrics/GynaecologyOncologyOphthalmologyOrthopaedic SurgeryPaediatricsPaediatric SurgeryPlastic SurgeryPost Acute CarePre-admissionRheumatologyStomal TherapyUrology and Urodynamics sub-aCutECognitive Dementia and Memory Service (CDAMS)ContinenceGeriatric Evaluation and Management (GEM)Hospital Admission Risk Program (HARP)Interim CarePalliative Care

agED CarEAged Care AssessmentAndrews House Aged Care FacilityCooinda Lodge Aged Care facilityHome & Community Care ServicesRespite Care COMMunity HEaltH sErViCEsAboriginal LiaisonAdolescent HealthAsthma EducationVictorian Bushfire Community Support ServiceCounsellingDiabetes EducationEmergency ReliefFalls PreventionFamily CounsellingHealth Education/PromotionRural Allied Health ServiceSelf Help and Support Group FacilitationWomen’s and Men’s HealthYouth Services alliED HEaltHCardiac RehabilitationChronic Obstructive Airways Disease (COAD) ProgramDiabetesNutrition and DieteticsOccupational TherapyPharmacyPhysiotherapyPodiatrySocial WorkSpeech Pathology

HOME nursing sErViCEDistrict Nursing ServiceHospital in the HomePalliative Care Nursing/Volunteers suppOrt sErViCEsAdministrationEngineeringEnvironmental ServicesFinanceFood ServicesHealth InformationInfection ControlInformation TechnologyLibraryOccupational Health and SafetyPayrollPublic RelationsQuality & Customer ServiceStaff DevelopmentSupply

businEss unitsConsulting SuitesMeals on WheelsSalary PackagingWarragul Linen Service

DiagnOstiC sErViCEs(Contract Services)BreastScreenEndoscopyLung Function TestingMedical ImagingPathologyStress Electro CardiographsStress Echo Cardiographs

Our service area… Who we care for

West Gippsland Healthcare Group (WGHG) is a customer focused health service providing hospital, residential and community health care to 40,000 people in the rural, urban residential, agricultural and industrial areas located within the Baw Baw Shire and beyond.

We employ 1,141 staff, treated 11,064 hospital patients, provided 87,872 outpatient services and cared for 147 aged care residents during the year.

While most people in the Shire speak English, 5.3% of our population is from multi-cultural and non-English speaking backgrounds. In addition to this 1.5% of our population is Aboriginal.

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Blood SafetyEach year West Gippsland Healthcare Group gives many blood and blood product transfusions in the care of acutely ill patients. These blood and blood products are a vital resource so making sure they are used appropriately is important. There are also are many safety aspects to the procedure for giving transfusions. To ensure the safe and effective use of blood and blood products WGHG has a comprehensive blood safety program which is monitored by the multidisciplinary Blood Transfusion Committee.

The program ensures;

• Best practice policies and procedures are in place to safely and appropriately store, order and administer blood and blood products

• Staff are trained and deemed competent in storage, transportation and transfusion administration procedures, documentation and techniques

• Patients and their families are provided with up to date information about blood transfusions

• Medical records are periodically audited to check that all appropriate steps are documented

• Where patients have reactions, such as a fever or other symptoms, that these are investigated and reported to the Blood Transfusion Committee for review

• Where there are significant reactions to blood transfusions that these are reported to the state-wide Serious Transfusion Incident Reporting( STIR) system at the Department of Health

• Each request for a transfusion is audited to ensure there is appropriate documentation and the resource is not wasted.

Infection ControlReflecting on infection control over the years there have been many challenges and changes to the way we do things. While ‘super-bugs’ that are resistant to antibiotics have been around for some time in the past they were predominately found in hospitals where the environment was constantly exposed to antibiotics. We are now seeing these resistant bugs emerging in the community. This means that we have to be more vigilant in checking people for these bugs and implementing strategies to limit their spread.

A clean hospital is important to reduce the risk of people developing infections. Some ‘superbugs’ that are difficult to treat, live in dust or on equipment and surfaces and can easily spread to people via hands or equipment.

Our infection control team makes sure work surfaces, environments and new equipment are easy to clean and maintain.

Infection Control Consultant Coralie Tyrrell is making sure WGHG policies and procedures meet the new Australian Guidelines for the Prevention and Control of Infection in Healthcare released in 2010.

The new Guidelines now recognise that the control of infection should not just focus on diseases but also that the risks vary between different types of organisations and the settings in which people are cared for, such as Aged Care facilities, specialised hospital settings or in their own home.

Patient Safety

Hand Hygiene Millions of normally harmless micro-organisms live on everyone’s hands. These ‘bugs’ spread far and wide by contact happily moving from objects to people and back again just by touch. When people are sick or have had surgery these ‘bugs’ can take the opportunity to multiply and cause infection.

It has long been known that clean hands are the key to preventing this spread and reducing infections. Over time the way we keep our hands clean, educate staff and monitor our practices has changed.

• Hand washing supplemented with special alcohol based hand rub solutions

• Educate staff on hand hygiene, not just hand washing

• We use observational audits and techniques and a team approach to provide ongoing support and advice on areas that can be improved

To ensure cleaning standards are met, regular cleaning audits are conducted. High risk areas such as an operating room require a higher level of cleanliness than an area such as a corridor. Monthly internal audits and external cleaning audits are conducted annually by Department approved auditors. WGHG consistently scores above the desired target.

100%

95%

90%

85%

80%

75% 06-07 07-08 08-09 09-10 10-11

Cleaning standard score

94.292.4

95.295.095.2

Acceptable Score

80%

70%

60%

50%

40% Ward 2 Ward 3 ED Hospital State Average

Hand Hygiene audit - Department Compliance

6965

6265

69

DoH Compliance Target

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WgHg Medication safety self assessment

Ten areas of medication management are audited covering areas such as patient information, how staff are educated, risk management processes and medication ordering and storage. The results can then be compared to previous results and the National average results.

total score 2011 65% total score 2008 58% national average 56%

A medical safety self assessment conducted this year demonstrates WGHG significantly exceeds the National average for medication safety, an excellent result.

Patient SafetyFalls prevention

The Falls Prevention program aims to prevent falls and minimise the injuries they cause to hospital patients, aged care residents and clients in community based settings. Based on the Victorian Quality Council best practice model, the program was implemented five years ago and has significantly reduced the number of reported falls.

The program has five steps:1. Risk screening2. Risk assessment3. Care plan to reduce risks4. Process to manage a fall if it occurs5. Process to reassess and modify care plans.

The program is ongoing and regular evaluations and audits monitor staff compliance to screening and assessment steps. The program continues to enable adequate screening and assessment of patients with preventative strategies being a major focus. Building up personal physical strength is one of these strategies. Two years ago a functional maintenance plan was implemented for patients in the Medical Ward. Research shows that without exercise people resting in a hospital bed can lose significant muscle strength within days significantly increasing their risk of falling. Plans are for this to be extended to other areas of the hospital.

Patients identified at risk of falling can and have been referred to a number of programs including:• Strength and Balance• Community Rehabilitation Centre• Strength and Conditioning Program.

The Community Services Physiotherapists provide a 14 week ‘Make a Move’ program in a community based setting for patients requiring further assistance.

Other falls prevention and injuries minimisation strategies include:• Lowering beds so they are closer to the floor• Where possible, locating patients in a room close to the nurses

desk for closer observation• Regularly checking on a patient’s need• Using alarms to alert staff when patients are getting out of bed

without help• Using yellow arm bands to alert staff of someone at high risk of

falling• Applying hip protectors• Ensuring items needed are close at hand• Reviewing medications• Referrals to dieticians, podiatrists and eye specialists• Encouraging exercise• Auditing staff skills in patient screening and assessment• Reporting falls to ensure occurrence and contributing factors

can be analysed

Though since the implementation of the Falls Prevention program, total falls have decreased by approximately 80 demonstrating implemented strategies are effective, falls with major outcomes have not significantly reduced over the last five years but stayed static with the increased number of patients treated in hospital.

Falls with no adverse

outcome

Falls with minor

outcome

Falls with major

Outcome

TotalFalls

0 25 50 75 100 125 150 175 200

number of Falls West gippsland Hospital

20112010200920082007

Falls with no adverse

outcome

Falls with minor

outcome

Falls with major

Outcome

TotalFalls

0 50 100 150 200 250 300 350 400 450 500 550

number of Falls residential age Care (raC)

20112010200920082007

Despite the 20 high care bed growth in December 2007 at Andrews House, the total number of falls in Aged Care has reduced by more than half in the last five years since the implementation of the Falls Prevention program and the falls with major outcomes has remained static.

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Patient SafetyMedication safety

Medication management is taken very seriously. The large volume and diversity of medication administered at different times by a variety of different methods in a busy setting makes it a high risk area. Because of the risk, medication management is approached covering a range of aspects including;

• Policies, procedures, protocols and guidelines are reviewed regularly

• Education programs at orientation and throughout the year are conducted to keep staff informed and up to date

• Nursing staff competency to correctly calculate medication doses is checked annually

• Numerous audits to determine staff are complying with policies

• All staff actively encouraged to report and discuss medication errors

• Errors are analysed to identify why they occur and opportunities to improve

• Medication management processes are checked against national standards for medication management

• Reporting to the Board Standards committee and The Drugs and Therapeutics committee.

Over the last two years the number of medication errors at West Gippsland Hospital has decreased by 37%. One of the most effective processes for reducing errors has been the bi-weekly INSPIRED meetings. This meeting of Nurses, Doctors, Pharmacy staff and Physicians provides a learning environment and engages junior staff in the review of errors and issues in relation to medication management. Summaries of meeting discussions are circulated to other staff via the INSPIRED newsletter highlighting lessons learned which this year include:

• using correct abbreviations

• not using brand names when prescribing medications

• the potential impact of unplanned interactions between medications.

pressure injuries

Pressure injuries are caused when tissue over boney parts of the body is starved of blood due to pressure or friction. The injuries can range from a reddened area to deep sores that affect the underlying tissues. The sick and elderly are very vulnerable and pressure injuries can begin to occur very quickly.

Once the deeper tissues are damaged they can take a long time to heal and in some cases can lead to more serious complications.

All patients and aged Care residents are assessed for the risk of developing a pressure injury and the need to implement pressure relieving strategies as part of the care plan.

Some people come in to our hospital or aged care facilities with pressure injuries. In these cases the focus of care is on healing the injury while preventing the development of new ones.

As part of our patient safety program all pressure injuries are reported on the incident reporting system. This includes those that people come in with and those that occur while in hospital (Hospital acquired ) or the nursing home.

A review of hospital acquired pressure injury incidents this year found that while staff were very good at assessing the risk of pressure injury there were sometimes delays in implementing pressure relieving strategies.

To identify why these delays occurred and problem solve, nursing staff from all areas participated in a series of workshops and came up with a number of practical ideas such as easily identifiable central store containers for equipment.

pressure ulcer stagesStage 1 Redness with intact skin Stage 2 Abrasion, blister or shallow crater on the skin surfaceStage 3 Deep crater on the skin surfaceStage 4 Full thickness skin loss and muscle or bone damage

Reported medication incidents have reduced by 37% at West Gippsland Hospital in the past two years.

0 25 50 75 100 125 150 175 200

Medication incidents West gippsland Hospital

2011

2010

2009

121

135

191

While nine more medication incidents were reported in Residential Aged care this year, there has been a 25% reduction in reported incidents in the last two years.

0 10 20 30 40 50 60 70 80

Medication incidents residential aged Care

2011

2010

2009

60

51

80

2011

2010

2009

4 6 8 10 12 14 16 18 20

14

8

19

Hospital acquired pressure injuries

Whilst there has been a increase, numbers of reported incidents are low and nearly all were stage 1 or 2 There was one hospital acquired stage 3 pressure ulcer reported

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Managing Demand

The Emergency DepartmentExtensions for the Emergency Department are well under way and it can’t come soon enough. In 2010/11 we again report a record number of attendances at our emergency department. There were 1620 more Emergency department attendances for the year compared to the year before, an increase of 9%.

This large increase in demand within the confines of our current ED has placed enormous pressure on staff to meet the waiting time guidelines set down by the Department of Health. As a result, the improvements to waiting times made the previous year have not been able to be maintained.

Beds in the wards are in high demand as we try and get more people in for surgery and cope with the Emergency Department admissions. Unfortunately this often means that patients can be kept in the Emergency Department for more than 24hours waiting for a bed to become available. This is not only undesirable for patients but also reduces the capacity of the Emergency Department to see new patients and compounds the issue.

In 2010/11 93 people waited in the Emergency Department more than 24 hours. This is 17 more than 2009/10 but still 29 less than in 2008/09 when 122 people waited more than 24 hours

The extensions to the department will provide an additional 8 cubicles and 2 more treatment areas to see patients but the issues of finding a bed for admissions will continue to be a major challenge.

With this increase in demand there are times when the Emergency Department is critically overloaded. During these times a two tiered response plan is initiated. The hospital does not go on ‘Ambulance by-pass’ but it does notify the ambulance service so that it can make appropriate choices regarding which hospital to take patients, particularly those from outside the Baw Baw Shire. Other strategies include bringing in additional medical and nursing staff, reviewing the elective surgical operating list and reviewing patients who are scheduled for discharge in the next 24 hours. During this response the department is monitored half hourly until the situation improves.

In 2010/11 the response was triggered 20 times compared to 18 times in 2009/10

pneumatic tube

Installation of a pneumatic tube system has made a big difference in getting results for pathology tests back to our Emergency Department.

Instead of pathology specimens waiting to be collected and delivered by hand in batches they are now packaged, placed immediately in a pneumatic system and whisked around the hospital to pathology in matter of seconds. What used to take 2 to 3 hours now takes between 1 and 2 hours. Not only has it meant tests getting to pathology quicker but it has freed up time for the porters to help with other patient tasks.

percentage of peopleseen within target timeframes

2007/08 2008/09 2009/10 2010/11

Category 1 100% 100% 100% 100%Category 2 90% 87% 87% 66%Category 3 69% 71% 72% 61%Category 4 63% 66% 64% 57%Category 5 90% 90% 85% 82%

Category 1 is most urgent and Category 5 is least urgent.

20000

19000

18000

17000

16000

15000

14000

13000

12000 06-07 07-08 08-09 09-10 10-11

Emergency Department attendances by year

15,545

16,49717,058

17,478

19,098

250

200

150

100

50

0 06-07 07-08 08-09 09-10 10-11

patients With ED length of stay Over 24 Hours

213

149122

7693

Nurse Unit Manager Sue Colby and Senior Medical Officer Greg Shuttleworth plan patient management in the Emergency Department

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Current accreditation ratings

• 20/20 accreditation score for our Home and Community Care ( HACC) services

• Full Aged Care accreditation rating with full compliance to all 44 criteria for Andrews House and Cooinda Lodge

• Full accreditation for our hospital and community services • Full accreditation with International Standards Organisation

AS:NZS ISO 9001:2008 for the Warragul Linen Service.• Community services registration under the Children, Youth and

Families Act, 2005• Full food safety certification.• Baby Friendly Hospital Initiative Accreditation

We are pleased that our ongoing continuous quality improvement and safety systems have enabled us to be recognised by the awarding of these accreditations.

Midwifery

improvement tools aimed at identifying areas for improvement and implementing solutions. The training has assisted staff right across the organisation to implement many improvement initiatives that have allowed staff to work more efficiently and improve service delivery. The major project ‘Losing Wait’ focused on the management of the elective surgery processes and in particular reducing the amount of time a patient waits when having elective surgery which then impacts on the number of people that can be operated on.

Elective SurgeryManaging the demand for elective surgery continues to present many challenges.

While we increased the number of elective surgical admissions in 2010/11 by 2.6% (39) The number of people being added to the wait list has increased by 252 and as a result our elective surgery waiting list has grown from 487 June 2009/10 to 610 June 2010/11

Whilst we did not meet the target of reducing the overall waiting list we are pleased to report that we met admission targets. 100% of Category 1 patients (the most urgent) were operated on within 30 days, we exceeded the target number of admissions by 44 and doubled the number of joint replacement operations.

Significant Department of Health funding has enabled WGHG to introduce a range of tools and new ways of thinking about how we manage a patient’s journey during their stay. The project has provided many staff across the organisation with intensive training on the use of data, observations and a range of quality

Accreditation processes are in place to ensure that healthcare organisations meet industry standards and continually improve their systems and processes.

WGHG undergoes several mandatory accreditation processes which are conducted at regular intervals from 1 to 2 years depending on the type of survey.

During 2010/11 WGHG was mid cycle for the hospital and community services accreditation while our aged care services have undergone several spot checks to maintain accreditation.

All recommendations from the previous surveys have been actioned. These were minor and include things such as

• Reviewing the use of close circuit TV to assist with security • Development of policies for staff when travelling or considering

travelling to see clients during extreme or catastrophic fire danger.• Reviewing storage in the operating theatre.

Managing Demand

Accreditation Update

Twins Gus and Fred Irving

900

800

700

600

500

3500

3000

2500

2000

1500

06-07 07-08 08-09 09-10 10-11

06-07 07-08 08-09 09-10 10-11

number of births

total Operations performed (Elective & Emergency)

724

2888

817

3130

779

3207

870

3321

820

3327

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What WgHg does to get the right people (credentialing staff)…

New staff appointees undergo rigorous selection to ensure they have the correct qualifications, experience and credentials to undertake the tasks they are employed to do.

Current staff have their qualification registration checked annually.

Last year WGHG completed a project to develop and implement best practice on credentialing and defining the scope of practice for Allied Health staff. This year the project was presented at the National Quality and Safety Conference in Perth.

• 100% of doctors are credentialed according to best practice guidelines

• 100% of doctors have current registration with the Medical Board of Australia

• 100% of nurses have current practicing certificates

• 100% of staff have appropriate police checks including Working With Children checks

What WgHg does do to ensure the right thing is done, at the right time in the best and right way (best practice)...• Staff are guided by up to date policies, procedures and

protocols A large range of policies, procedures and guidelines have been revised in the light of the latest literature and research.

• Each department is closely managed in relation to staffing needs and staff rostering is organised to ensure an appropriate mix of skill and experience.

- During 2010/11 senior medical hours in the Emergency Department were further increased providing, support to newer medical staff.

- Social Worker hours have been increased to provide additional services to District Nursing and Palliative Care

• Orientation programs are in place to provide important information to all new staff. General orientation was provided for all 119 new staff members and the 45 new nurses were provided with an additional nursing orientation

• Experienced staff supervise students.

• 238 nursing staff have completed a program which builds skills in supervising and guiding new staff.

• Medical Education Officer hours have been extended to provide additional support for junior medical staff.

• A formal medical education program has been established in the Emergency Department to provide additional learning opportunities.

• New graduate staff are mentored by senior staff to guide them through their first year in the workplace. Ten graduates completed their first ( graduate) year in 2011.

• Extensive ongoing education keeps staff up to date with best practice. During 2011 there were 3477 staff attendances at 286 different education events.

• Staff complete compulsory annual training in their area of expertise. These competencies include:

- Hand hygiene - Manual handling - Drug dose calculations - Basic life support - Falls - Fire safety - Neonatal resuscitation for midwives - Food safety - all staff trained

In 2010/11 the new clinical skills training area was completed. The area replicates ward areas, and is fitted with advanced computerized simulation dolls. A 2 way mirror allows educators to put staff into simulated real life situations and has greatly enhanced learning opportunities. One of the first projects to use the new area is a project in partnership with Monash University Gippsland which is building nursing staff skills in the early recognition of a deteriorating patient.

Clinical Governance

Transition Care Program - from front page...

Graham and Ruth visited Andrews House where Graham would be staying and were quite impressed with the facility. He was transferred to Andrews House on the 15th of December and together with the staff and his family, Graham set about achieving his ultimate goal of going home. Ruth said the care given to Graham at Andrews House was marvellous. “The staff were all very caring and committed to helping Graham achieve his goal of going home. If something wasn’t working they were prepared to try something different.”

Communication was a very important part of Graham’s Transitional Care Program. Andrews House nursing staff kept in contact with the doctor to make sure all of Graham’s medical needs were taken care of. Allied Health visited Graham three times per week to assist him with his range of rehab activities. This was helping to achieve the goal of Graham and his family being able to manage his transfer to home.

Graham was transferred to the home based Transition Care Program on the 24th March 2011. He and his family were very happy that this goal had been reached .A follow up visit found that Graham and his family were managing really well and that Allan was helping his father with the exercises set by Allied Health. Graham was enjoying his home cooked meals and had moved into the bedroom on the north side of the house that overlooked his beloved farm. He was discharged from the home based Transition Care Program on the 13th of April 2011.

The Transition Care Program is a new state and federally funded program that commenced in October. Two beds are provided at Neerim District Health Services, one at Andrews House and two in community based settings eg. in the client’s own place of residence. All clients in this program have an individual, goal oriented plan to help them optimise their functional capacity with the help of Allied Health support staff, and achieve their long term care plans of either living in their pre hospital environment or accessing longer term, permanent care.. The program will be further expanded in 2011/12.

Staff working in the Clinical Skills area

9

Clinical Governance

involving consumers in their own care

another important risk management strategy is actively involving patients and their families. being informed and involved helps consumers understand the importance of changes in their care and increases the opportunities for them to provide valuable information to the nursing and medical staff.

patients and their families can also keep an eye out for potential risks and mistakes. Examples of these are ensuring that staff remember to wash their hands, or questioning a tablet they have been given that looks different to previous medication.

What WgHg does to manage clinical risks or the things that go wrong…

WGHG has a comprehensive clinical risk management program which involves:

• A commitment by the Board and Executive to a ‘safety first’ environment.

• Encouraging staff to report clinical risks and incidents, to learn from them and prevent them from occurring again.

• Investigating incidents, identifying underlying causes and implementing strategies to reduce risks.

• Where possible, utilising technology to design out or minimize errors.

• Having in place and constantly revising programs to manage known clinical risks (such as Infection Control risks).

• Regular reviews of policies, procedures, guidelines and protocols to ensure they reflect current best practice.

• A weekly meeting of the Clinical Risk and Evaluation (CARE) Committee to discuss clinical incidents, complaints and issues. Risks identified are then directed to the most appropriate committee or persons for action. Strategies aimed at risk prevention are identified, implemented and reported to the monthly Clinical Quality Committee.

The CARE Committee discussed an average of 27 issues per month (compared to 28 in 2009/10). Where a serious incident occurs, the CARE committee recommends a higher level of

investigation be carried out, such as an in-depth review or root cause analysis. During these processes every detail of the incident and events leading up to the incident are analyzed to identify causes. The team then develops recommendations to prevent similar incidents occurring in future.

The work of this committee has resulted in a range of recommendations being implemented to reduce risk. Some of the improvements during 2010/11 have been:

• Implementation of a range of strategies to improve access to pressure relieving devices.

• Targeted education campaigns to improve staff knowledge eg management of the deteriorating patient.

• Strengthening of a number of policies and procedures to reduce confusion.

• Improvements to a number of forms strengthening documentation.

What WgHg does to ensure patients, residents and clients are provided with the best and most effective care…

To ensure clinical effectiveness WGHG:

• Enrols in projects to implement best practice.

• Supports staff in learning about best practice.

• Fosters and encourages ideas to improve care delivery.

• Involves staff in planning and redesigning systems and processes that improve the way things are done for example the Redesigning Care Project

• Involves patients and families in their care

• Constantly reviews documentation to ensure care is accurately documented and communicated.

• Monitors a large number of audits and clinical indicators that measure clinical performance, compares them to standards, and reports to the Clinical Quality Committee, Standards Committee and Board. This helps to ensure improving performance and provision of best practice care.

50

40

30

20

10

0 06-07 07-08 08-09 09-10 10-11

Common Clinical incidents

4245

37

27 26

1513

22

13 127 11 33

6 7

% Falls% Medication% Behavioural

The table above shows the percentage of the most common types of clinical incidents reported.

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Closing the gap…

With particular thanks to the staff at Ramahyuck Aboriginal Clinic in Drouin our strengthening links with the aboriginal community are starting to make a real difference to the number of aboriginal people accessing our services.

A large number of aboriginal people have diabetes however, as they were not visiting the Diabetes Educator, there has been a gap in their care. With the help of the Ramahyuck practice nurse and her workers the number of aboriginal people visiting the Diabetes Educator more than doubled during 2010/11.

A number of Aboriginal women over 50 had breast screening completed for the first time.

Referrals to other services such as the continence service have increased.

To promote better health and wellbeing our health promotion team has trained six aboriginal health workers in a ‘Living Strong’ program. This is the first time this training has been provided in Victoria and the six health workers are now keen to get started and deliver healthy lifestyle programs within their own community.

Reaching Everyone

responding to cultural needs…

WGHG has a whole of health service approach to responding to cultural needs.

A Cultural responsiveness plan addresses the six standards of the Department of Health Cultural responsiveness framework. It is reviewed annually by the Consumer Advisory Council. The Consumer Advisory Council is a sub-committee of the Board of Directors and is involved in strategic and annual planning. It has established links with the Gippsland Multicultural Service which is used annually to advise on the development and review of the organisation’s cultural diversity framework.

As less than 5.3% of our patient population come from culturally and linguistically diverse backgrounds (CALD) WGHG does not have dedicated cultural staff. Using the Cultural Diversity Policy, Interpreter Policy and resource kit we ensure staff are aware of how to access resources, interpreter services and translated written health material as they are required.

Clinical assessment tools include cultural considerations so staff can plan patient, resident or client needs.

Incident and complaint reporting processes identify issues where there has been a lack of interpreter services. During 2010/11 no issues were identified.

Each year the patient feedback is evaluated and population demographics are reviewed to identify training requirements

In 2010/11we made a commitment to providing annual training sessions on accessing interpreter services.

Data from the Victorian Patient Satisfaction Monitor ( Wave 19) showed

1% required an interpreter and 98.5% of CALD consumers indicated that their cultural or religious needs were respected by the health service as good or very good.

Other activities include

• A project in the Emergency Department to understand more about why aboriginal people often leave the ED without being seen.

• The development of strategies to help improve their experiences in ED through better communication and understanding.

• The Community Health nurse is working with young aboriginal students to build self esteem

• Cross cultural training at orientation and access to resources to assist staff

• Asking all admitted persons whether they are of Aboriginal or Torres Straight Islander decent and referring them to the Aboriginal Liaison Officer where appropriate.

• Provision of a locally designed aboriginal discharge booklet to assist in discharge planning and communication

“As an organisation, we feel privileged to have been the first group in Victoria to have received the ‘Living Strong’ Training. We would highly recommend the training to other Aboriginal Organisations who wish to deliver healthy lifestyle programs within the Community.”

Rebecca Mazengarby Regional ‘Close the Gap Coordinator’

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You and your care…WGHG is committed to working in partnership with consumers at many different levels. Part of this commitment involves using various strategies to meet the consumer participation indicators required by the Department of Health as part of their ‘Doing it with us not for us policy.’ For 2010/11 WGHG achieved 100% of the objectives set under the 5 required standards

standard 1 - Demonstrating commitment – 8/8 objectives met

• A community participation policy is in place and this year has been revised to align with the Departments Consumer Participation framework.

• WGHG contributes to the implementation and monitoring of the local primary care partnership strategic plans.

• WGHG has a variety of approaches to record and monitor consumer participation .

• WGHG has a cultural responsiveness plan that meets the six requirements

• The WGHG program for improving care for Aboriginal and Torres Straight Islander patients program meets the 4 key result areas.

• A Disability action plan has been developed.

• Processes in place to consult and involve consumers.

• WGHG works with staff to build the capacity of workers to support consumer participation at multiple levels.

standard 2 - Consumers, and, where appropriate, carers are involved in informed decision-making about their treatment, care and wellbeing –all targets exceeded• Victorian patient satisfaction score for consumer participation

index. WGHG… 83.2% .( Target 75% State average 81%)

• The number of women who said they thought they were given an active say in making decisions about what happened during their labour and/or birth WGHG 100% (Target 90%)

standard 3 - Evidence-based, information provided to people is helpful.• 87.43 % of patients responding to the Victorian Patient

Satisfaction Monitor rated as good to excellent ,the quality of written information on how to manage your condition and recovery at home. (Target 75%)

• Written information produced by WGHG met all the requirements of the Checklist for Assessing Written Consumer information. (40/40 100% Target 85%)

standard 4 - Consumers, carers and community members are active participants in the planning, improvement, and evaluation of services and

programs.WGHG meets 6/6 of the dimensions required (100%) the target is 75%

A Consumer Advisory Council meets monthly and provides a forum to regularly seek consumer input in relation to people’s experiences, service delivery and strategic planning.

The council:

• Reviews consumer related policies

• Provides commentary and advice on written patient information

• Reviews the results of the Victorian Patient Satisfaction Monitor

• Provides advice on improving the organisation’s website

• Assists in monitoring the progress on the Cultural Diversity Plan

• Participates in organisational planning days

• Provides a link to the Aboriginal community

• Participates in the Ethics Committee

• Advises on a variety of quality activities such as consumer surveys and projects.

The Council is currently undertaking a major project to provide written information to the carers and families of patients who are being transferred suddenly to Melbourne hospitals. The booklets will provide helpful information such as directions, where and how much it costs to park. How to advocate for themselves in relation to coming from a rural area and the need to coordinate outpatient appointments and discharge arrangements.

standard 5 - the organisation actively builds the capacity of consumers, carers and community members to participate fully and effectively.Members of the Consumer Advisory Council are developing an orientation program for new members. They are also provided the opportunity to attend Health Issues Centre workshops and conferences> The organisation is a member of the Health Issues Centre which provides a large range of resources for our Consumer Advisory Council

A consumer participation kit provides a guideline to assist staff in consumer participation.

Being involved and understanding your care is important. The more you understand what is happening to you the better you are able to cope with your treatment.

Good communication is the key to involving people in their care. We encourage everyone to discuss their care with the team looking after them. For patients with complex needs we assist this process by arranging more formal meetings with family members and the health care team.

Getting You Involved

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1.COMMunity HEaltH sErViCEsDrouin - Baw Baw Healthand Community Care CentreYoung Street Drouin 3818ph 03 5625 0200fax 03 5625 0204email bbhcc@wghg.com.au

2.COMMunity HEaltH sErViCEsWarragul Community Services31-35 Gladstone Street Warragul 3820ph 03 5624 3500fax 03 5624 3555email wgcsd@wghg.com.au

3.HEaD OFFiCEWest Gippsland Hospital41 Landsborough Street Warragul 3820ph 03 5623 0611fax 03 5623 0896email info@wghg.com.au

4.Warragul Linen ServiceLey Street Warragul 3820ph 03 5623 4056fax 03 5623 5074email info@wls.com.au

5.agED CarECooinda LodgeWest Gippsland Hospital SiteLandsborough Street Warragul 3820ph 03 5623 0769fax 03 5623 0896email cooinda.clerk@wghg.com.au

6.agED CarEAndrews HouseSchool Road Trafalgar 3824ph 03 5637 4100fax 03 5633 1018email ah.office@wghg.com.au

7.COMMunity HEaltH sErViCEsTrafalgar Community Services9 Contingent Street Trafalgar 3824ph 03 5624 3500email traf.chs@wghg.com.au

8.COMMunity HEaltH sErViCEsRawson Community Health CentrePinnacle Drive Rawson 3825ph 03 5165 3236fax 03 5165 3268email rawson.chs@wghg.com.au

How Happy Are You?

Consumer Feedback Form The Quality of Care Report is designed to inform our community about the serviced provided by the West Gippsland Healthcare Group. We value your feedback so we can ensure our Report meets your needs in the future. Please tick appropriate boxes:

Age: q 15-35 q 35-50 q 50-65 q Over 65 Gender: q Male q Female

How much of the report did you read? q All q Some q A little q None

Was the Report easy to understand?

q Very easy q Easy q Not easy but not difficult q Difficult q Very difficult

Did you find the report informative? q Yes q No

Please tell us what you liked about the report and any other comments you may have:

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Please return in person to main reception, West Gippsland Hospital, 41 Landsborough Street Warragul 3820 or post to the address above. Alternatively, you may complete the form at:

www.wghg.com.au

Patient Satisfaction Monitor Many WGHG departments and services conduct surveys to gather your thoughts and ideas on the quality of services they deliver. One major survey is the Victorian Patients Satisfaction Monitor (VPSM). This is an independent survey collated every six months by an external body appointed by the Department. The survey provides data on our performance and is then compared to all other Victorian Hospitals.

While our results have always been very positive there is always room for improvement and last year we targeted written health information . It was pleasing to see our latest score for clarity of information achieved the biggest improvement. The overall score for treatment and related information jumped from 78.5 in wave 18 to 82. in wave 19 and is above the state average of 80.

areas we need to improve this year...Relate to the quality and temperature of food, waiting room comfort and facilities for storing belongings, Explanation of hospital routines.

best performing areas...• Courtesy of nurses

• Being treated with respect

• Personal safety

• Helpfulness of staff in general

• Cleanliness of room

Please tell us...When things do not appear to go as they should please tell us. We encourage people to let us know if things have not been as planned. It provides us with the opportunity to investigate what happened and try to ensure it does not happen again.

To help us determine where issues are occurring, prioritise them and ensure they are responded to, all complaints are registered.

This year we registered 64 complaints, 31 less than last year.

All complaints are investigated by a senior member of the management team.

There are many ways for you to tell us your concerns or what you particularly liked. Speak to one of our staff members , fill in a compliment or complaint brochure available at all our sites, write us a letter or email us at info@wghg.com.au.

Victorian patient satisfaction Monitor (VpsM)2006/07 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79.92007/08 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80.42008/09 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78.22009/10 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81.02010/11 WAVE 19 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82.0State average WAVE 19 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79.0

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