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PAGE 1 QUALITY OF CARE NEWS
Wuman njinde...welcome.Improving care for Aboriginal people
Quality of Care News
2009 Regional Health Service of the year
Peta McGregor Emergency Department nurse and Dot Mullett Aboriginal Hospital Liaison Officerstanding beside the Aboriginal land map in the Emergency Department corridor at WGH.
CEO Ormond Pearson, artists Lionel Rose Junior and Dale Hayes and Education CentreGippsland ‘Brayakoloong’ Art Project Coordinator Maryanne Meyer with artwork painted speciallyfor the West Gippsland Hospital.
Strengthening relationships between our health service andour Aboriginal community is an important step in starting tobridge the health gap for Aboriginal people.
The Department of Human Services (DHS) Improving Carefor Aboriginal People (ICAP) program was establishedin July 2004. It amalgamated different funding programsand focused on cultural change in health servicesthrough improving health care and identification ofaboriginal people under four key areas identifiedfor improvement. Relationships with Aboriginalcommunities, culturally aware staff, discharge planningand primary care referrals.
These four areas provide the framework for the workWGHG has been implementing to assist in bridging the gap.
In general Aboriginal people are reluctant to present tohospital and have limited contact with doctors. For an Aboriginalperson, attending the hospital’s Emergency Department is adaunting experience tinged with fear. Waiting in the waiting room oftenbecomes emotionally overwhelming and many leave without being seenby a doctor.
Those who do come often have complex medical needs and are verysick having had little preventative medical intervention. The average lifeexpectancy for an Aboriginal person is 20 years less than that of the generalAustralian population and across Victoria about half the Aboriginal deathsare of persons under 55 years.
For this reason, it is very important that our staff have an understandingof the Aboriginal culture and the feelings they have towards hospital. InMarch this year WGHG was one of four pilot sites selected by DHS torun a funded project Improving Experiences of Aboriginal People in theEmergency Department. Peta McGregor was appointed project officerand a steering group was established. Drouin residents Linda Mullett andKaylene McKinnon are members of our Community Advisory Council (CAC)and provide us with a direct link to the Aboriginal community. Both werepivotal in working with Peta in rolling out a series of cultural awarenesseducation sessions for doctors and nurses in our Emergency Department
and developing and trialling a consumer brochure and informationsheets aimed specifically at Aboriginal people.
The cultural awareness education sessions provided staff with: � a moving first hand account of the local Aboriginal
community life in the 1930’s to the 1960’s through storiesand an award winning film produced about Jackson’s Track� current health issues within the community � strategies to help break down barriers; and � an opportunity to ask questions of Aboriginal elders.
Comments during the sessions went a long way to breakingdown barriers and build an understanding between nursesand the Aboriginal community.
Also under the guidance of Linda and Kaylene, we havebeen working towards making the hospital more welcoming
to Aboriginal people.
Transfers of the blue wren, the totem of the local Aboriginal peoplehave been placed at all entrances to West Gippsland Healthcare
Group buildings and paintings by local artists have been purchasedand placed throughout West Gippsland Hospital.
To improve the care provided to Aboriginal patients after they are dischargedfrom hospital, a health record booklet was developed this year for Aboriginalpatients to take home. This provides a record of their health managementplans, details of referrals to General Practitioners and other healthprofessionals and will improve communication to all health providersinvolved in their care.
Under-identification of Aboriginal patients continues to hamper planningof health services based on a complete picture of Aboriginal health. TheAboriginal Hospital Liaison Officer provides orientation to staff to ensure theyare aware of the mandatory requirements for all Victorian hospitals to ask if apatient is of Aboriginal or Torres Strait Islander descent.
In another popular project, the Community Kitchens program was extendedthis year with the commencement of a group for young Aboriginal people.The program teaches participants about preparing healthy, budget friendlymeals in a welcoming, social environment. The knowledge they gain willnot only benefit the participants but also their families. And they love it!
PAGE 2 QUALITY OF CARE NEWS
TRIVIA QUESTION 1:
About your health service
On behalf of the West Gippsland Healthcare Group (WGHG)team, welcome to our 2009 Quality of Care Report.
This Report provides us with the opportunity to inform youof how we monitor, compare and act to improve the safetyand quality of our services. It details highlights as well asareas we need to improve.
The Report is prepared by a team of staff and Community Advisory Councilmembers who:� review minimum reporting guidelines� listen to feedback� collate data from across West Gippsland Healthcare Group; and� work with staff in all departments to provide ideas for stories and photos.
Each year Quality of Care Reports from around the State are reviewed by apanel of experts who provide feedback on a variety of criteria. Their commentstogether with your feedback are used to continually improve our Report.
At WGHG we strive to ensure every one of our stakeholders has the opportunityto hear about our health service. It is for this reason this publication isdistributed to every household in the Baw Baw Shire through the local freenewspaper and available to read at doctors’ surgeries and in waiting roomsat all WGHG facilities.
Our sincere appreciation is expressed to our Community Advisory Councilmembers, staff and the community for their contribution to making this Reportan informative, valuable and enjoyable publication for our stakeholders.
I would also like to take this opportunity to congratulate our staff for the verypositive manner in which they address the many challenges of delivering highquality health services to meet the growing demands of our community.Their energy, enthusiasm and focus on continuous quality improvement isoutstanding.
Ormond PearsonChief Executive Officer
Hospital (acute)AnaesthesiaBreast SurgeryCommunity Rehabilitation CentreDay SurgeryDental SurgeryDiabetes EducationEar Nose and Throat SurgeryEmergencyEndoscopyGeneral MedicineGeneral PracticeGeneral SurgeryHaemodialysisHigh DependencyLibraryMidwiferyNeurologyObstetrics/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 and Community Care ServicesRespite Care
Community ServicesAboriginal LiaisonAdolescent HealthAsthma EducationBushfire Recovery CounsellingCounsellingDiabetes EducationEmergency ReliefFalls PreventionFamily CounsellingHealth Education/Promotion
Community Services (cont’d)Rural Allied Health ServiceSelf Help and Support Group FacilitationSustainable Farm FamiliesWomen’s and Men’s HealthYouth Services
Allied HealthCardiac RehabilitationChronic Obstructive Airway
Disease (COAD) ProgramDiabetesNutrition and DieteticsOccupational TherapyPharmacyPhysiotherapyPhysiotherapyPodiatrySocial WorkSpeech Pathology
Home Nursing ServiceDistrict Nursing ServiceHospital in the HomePalliative Care Nursing/Volunteers
Support ServicesAdministration
Support Services (cont’d)EngineeringEnvironmental ServicesFinanceFood ServicesHealth InformationInfection ControlInformation TechnologyLibraryOccupational Health and SafetyPayrollPublic RelationsQuality and Customer ServiceStaff Development UnitSupply
Business UnitsConsulting SuitesMeals on WheelsSalary PackagingWarragul Linen Service
Diagnostic Services (Contract Services)BreastScreenEndoscopyLung Function TestingMedical ImagingPathologyStress Electro CardiographyStress Echo Cardography
To improve the health and wellbeing of our community.
Vision
Our Services: What we do
From the CEO
West Gippsland Healthcare Group is committed to the provision of high quality,integrated health care that meets the changing needs of individuals and ourcommunity.
Mission
Our service area.. .who we care for
West Gippsland Healthcare Group is a customer focused health organisationproviding hospital, residential and community health care to 38,500 people inthe rural, urban residential, agricultural and industrial areas located within theBaw Baw Shire and beyond.
We employ 1,064 staff and treated 10,910 hospital patients, provided 80,485outpatient services and cared for 225 aged care residents during the year.
While most people in the Shire speak English, 5.3% of our population arefrom multi-cultural and non-English speaking backgrounds. In addition to this1.5% of our population is Aboriginal.
Caring for our migrant communityEven though only a small percentage of our population come from culturallyand linguistically different (CALD) backgrounds, we recognise the importanceof equipping our staff to understand what is needed to provide the appropriateservices and care for people from other cultures.
WGHG has an established cultural diversity policy promoting the benefitsof cultural diversity. Each year we develop a Cultural Diversity plan with theassistance of the Community Advisory Council and the Gippsland MulticulturalResource Centre. The plan involves gathering data on our local population,skilling staff, and engaging people from culturally diverse backgrounds tocontribute to the WGHG planning processes.
Our organisation has established links with the Gippsland MulticulturalResource Centre and is planning to develop connections with new migrantsfrom diverse backgrounds and provide them the opportunity to input directly intoservice planning
Staff have access to a kit which is regularly updated and provides informationon access to interpreter services, translated information, and important culturalinformation for each cultural group. They also attend cultural training daysappropriate to their service to ensure they are responsive to cultural needs.
Access to interpreters is an important part of cultural responsiveness. This year,data from the Patient Satisfaction Monitor showed that we must provide furtherstaff training to ensure patient access to interpreters.
One strategy that is proving to be very effective is the visit to West GippslandHospital by participants in the English as a second language course conductedby the Education Centre in Warragul. Participants enjoy a tour of the WGH siteand are provided with information as to where to come in an emergency, whatthey should bring with them and what is provided to them as hospital patients.Information packages containing brochures, contact numbers and interpreterservices are provided as well as an opportunity to have any questionsanswered.
How many face washers are cleaned in the Warragul Linen Service each year? ANSWER ON PAGE 12.
PAGE 3 QUALITY OF CARE NEWS
Water recycling.. .it’s a triple treat!
West Gippsland Healthcare Group is committed to minimisingthe impact we have the on the environment. Where possible,
systems are in place to improve water and energy conservationand waste recycling and management. One component of our
water recycling program is highlighted in this Report.
Special Projects
750,000 litres of water is recycled each year fromthe Haemodialysis Unit. This water is caught and
pumped to a water storage area located in the roofat West Gippsland Hospital.
Frank Gallagher is one of14 patients who attendthe Haemodialysis Unitthree times per week toundergo a process ofbeing connected to amachine that performsthe function of the kidneyto clean the blood.
The water is then redirected for use in theCentral Sterilising Services Department located
on Level 2 at the Hospital.
Approximately 60,000pieces of equipmentare sterilised at WestGippsland Hospitalevery year.
The water is again redirected back to the storage tanksin the roof and used for a third time to flush toilets
across West Gippsland Hospital.
West Gippsland Hospitalhas 67 toilets flushedusing recycled water.
The saving...a massive4,832 kilolitres of waterper year! Congratulations toWGHG Engineering ServicesManager Peter Jayaweera andhis team for their innovation indeveloping this system.
It’s all about the kids!
Coming to hospital can be adaunting experience. Even formost adults it’s difficult. Imaginewhat it’s like when you’re a smallchild. That’s why at West GippslandHospital we do as much as we canto allay fears and to make it loads offun.
One way we do this is by offeringtours of our Emergency Department(ED), Operating Theatre RecoveryRoom and the Paediatric Ward forkindergarten groups and prep gradeclasses from the Baw Baw Shire.
Our tours begin at the ED. Doctorsand nurses greet the kids, show themaround, visit the ambulance bay even
apply back slab plasters on eachsmall arm in the treatment room!It’s then off to the Recovery Roomto meet Dan, the Theatre Manager,who shows the kids where they willwake up if they ever need to have anoperation.
The play room and treatment room inKid’s Ward is next. Here there’s loadsof distraction with dinosaurs, robots,colourful murals and even a driveablefour wheel drive.
Of course, there will always be themonitoring, medicine and mash, butat least the kids will have somethingto look forward to when they knowthey have to come to hospital.
Students listen attentively as Operating Theatre Nurse Unit Manager Daniel Scholtes tells the kidswhat they can expect when they wake up after an operation.
ED nurse Trish Blair shows St Paul’s Anglican Grammar Junior School students the vital signs monitorin the treatment room.
TRIVIA QUESTION 2: How many toilet rolls are bought each year? ANSWER ON PAGE 12.
PAGE 4 QUALITY OF CARE NEWS
Patient Safety
Falls preventionThe falls prevention program atWGHG aims to minimise the risk offalling for all patients and residents.
There are factors however that canincrease the risk of someone falling.These include:� people who are unwell� people recovering at home after
being discharged from hospital; and� old age and frailty.Falls prevention strategies provide asafety net for those at risk by earlyidentification, personalised care plansand investigation of falls aimed atfurther prevention.
These five steps are:
1. Risk screenAll patients over 65 and all aged careresidents are screened by staff at theirinitial entry or point of contact. The riskscreen tool identifies people requiringa more detailed assessment.
2. Risk assessmentIf the risk screen indicates a positiverisk of falling, a more detailed riskassessment is completed. Auditsconducted in September and Marchresulted in an average of 99% ofpatients identified as being at riskundergoing a more detailedassessment.
3. Care plan to reduce risksOnce the assessment is completed,
Time out!Did you know that our operatingtheatre team calls ‘Time Out’ evenbefore an operation begins?The reason.. .it is the final stage ofa thorough checking process toensure the correct operation isbeing performed on the correctpart of the body, at the correct site,and on the correct patient.
While ultimately it is the surgeon’sresponsibility to make sure thecorrect operation is performed,the surgeon, anaesthetist andnursing team come together tocheck these details against the
written consent given by thepatient. Adopting this teamapproach significantly minimisesthe risk of the wrong operationbeing performed.
We are pleased to report that theoperating theatre team achieved100% compliance for ‘Time Out’audits this year and the correctoperation was performed on everypatient who underwent surgery atWest Gippsland Hospital.
A total of 3,207 operations wereperformed for the year, 77 morethan last year.
an individualised care planimplements measures to preventa fall or reduce injury from falls.
4. Process to manage a fallif it occurs
Should a patient or resident continueto fall, after the implementation ofmeasures in Step 3, an investigationis conducted to identify opportunitiesto prevent further falls.
5. Reassess and modify care plansThe patient is then reassessed andthe care plan adjusted to includeadditional or changed preventionstrategies.
After leaving hospital, patients at riskof falling are referred to appropriateservices including physiotherapy,podiatry or to an optometrist.Working with a physiotherapistcan improve strength and balancewhich aids in reducing the risk offalling.
Despite an increase in the number ofhigh care residents in our aged carefacilities, there was an18% decreasein falls. Falls with a minor outcomeincreased and are investigated as partof the falls prevention plan. While fallswith a minor outcome did increaseby 15%, the percentage of fallsresulting in a major outcomeremained steady at 2%.
0
Number of Falls West Gippsland Hospital
20
40
60
80
100
120
140
160
180
Falls
with
noad
vers
eou
tcom
e
135
180
136
94
Tota
lfa
lls15
9
200
160
130
Falls
with
min
orou
tcom
e
22
17
2428
Falls
with
maj
orou
tcom
e25 3
2007
2008
2006
2009
2007
2008
2006
2009
0
Number of Falls Residential Aged Care (RAC)
50
100
150
200
250
300
350
400
450
500
Falls
with
noad
vers
eou
tcom
e
386
272
465
339
Tota
lfa
lls45
5
376
519
453
Falls
with
min
orou
tcom
e
61101
50
102
Falls
with
maj
orou
tcom
e
852 4 12
Note: Andrews House atTrafalgar extendedfrom 30 residentsto 50 residentsin 2007 withan increasednumber of highcare residents.
The graph shows anoverall decrease in thenumber of falls at WestGippsland Hospital overthe last four years.
Surgeon Mr Paul Ah-Tye (right) and the theatre team stop for ‘Time Out’ before commencingan operation.
� Be actively involved in your own health care� Speak up if you have any questions or concerns� Learn more about your condition or treatments� Keep a list of all the medicines you are taking� Make sure you understand the medicines you
are taking� Get the results of any test or procedure� Talk about your options if you need go into hospital� Make sure you understand what will happen if you
need surgery or a procedure� Make sure you, your doctor and your surgeon
all agree on exactly what will be done� Before you leave hospital, ask your health care
professional to explain the treatment plan you willuse at home.
TRIVIA QUESTION 3: How many babies were born at West Gippsland Hospital in 2008/2009? ANSWER ON PAGE 12.
PAGE 5 QUALITY OF CARE NEWS
Patient Safety
Medication safety
Taking the pressure off you
The prescription, dispensing andadministration of medications arehigh risk areas. While no medicationerror brought harm to any patientor resident this year, medicationmanagement is taken very seriously.Of all incidents reported across theGroup, medication errors remain oneof the most reported with an averageof one reported every day.
The reporting of medication errorsfollowed by the close analysis ofwhy they occurred is very important.This enables us to implementstrategies to prevent future errorsand to improve medication safetyoverall. All staff are activelyencouraged to report all medicationincidents. This year 364 incidentswere reported, 149 more than lastyear with the majority relating toerrors in documentation.
As a proportion of the overallnumber and variety of medicationsadministered at different times andin varying ways throughout the day,the number of reported medicationerrors is relatively small.Documentation related errors arethe highest recorded, with 126 errorsin documentation reported this year.
Examples of these types of errorsinclude:� writing the letter ‘u’ instead of the
whole word ‘unit’� prescribing a product name like
panadol rather than the medicationname paracetamol
� unclear hand writing which isdifficult to read and understand.
This year, a comprehensive reviewwas undertaken of insulin, heparinand administration of oral drugs, allconsidered to be high riskmedications. As a result: � medical and nursing guidelines
for insulin were reviewed to ensurebest practice
� high dose insulin syringes wereremoved from the general wardsto reduce the risk of high dosesof insulin being given by mistake
� the ‘PINCH’ strategy was introducedand promoted as a reminder tostaff to stop and consider the riskbefore prescribing or administeringhigh risk drugs
� orange oral dispensers wereintroduced this year to replaceclear dispensers to reduce the riskof liquid based oral drugs beinggiven intravenously. The intravenousattachment does not connect to theorange dispenser.
Pharmacist Kenneth Ch’ngshows the new orangeoral dispensers introducedthis year to avoid oraldrugs being administeredintravenously.
Laying in the hospital bed canbring some risks.
Who would have thought thatstaying still can be harmful?
It can result in developing apressure area. Pressure areascan occur when there is notmuch movement, and pressureis placed on a specific part of thebody.
So our elderly, and the less mobileare at risk. Preventing pressurearea points is part of our patientsafety program.
Factors such as the inability tomove, poor nutrition, smoking,age and illness increase thechance of someone developinga pressure area.
Pressure ulcers used to be calledbedsores, and range from areddened area, to a deep ulcerthat eventually affects muscleand bone.
Some people come into hospitalor into an aged care home with a
Pressure Ulcer Stages
Stage 1 Redness with skin in tact
Stage 2 Abrasion, blister or shallow crater on the skin surface
Stage 3 Deep crater into skin surface
Stage 4 Full thickness skin loss and muscle or bone damage
Percentage of Inpatients withdocumented Risk Assessment:
April 2009 - WGH
WGH (Group B Hospital) 100%
State average 81%
Other Group B Hospitals 82%
pressure area. In this case, the mainfocus is to heal any pressure areasalready present, while also avoidingthe development of new pressureareas.
The severity of a pressure areais measured in four stagesdemonstrated in the table above.
The following practices help us tominimise the risk of pressure ulcers:� A pressure ulcer prevention policy
guides staff� Nursing staff and Personal Care
Workers trained to identifyand assess people at risk
� Regular assessment of allCooinda Lodge and AndrewsHouse residents
� Classifying all pressure areasaccording to severity scale
� Commencement of immediatetreatment and managementstrategies using latest techniquesand products
� Specialist wound managementprogram provided by highly trainedClinical Nurse Specialists
Pressure area data is reported to DHS.Three measurements are reported:� Patients with a documented
assessment of risk� Pressure areas acquired in hospital� Pressure areas acquired in Cooinda
Lodge and Andrews House.
Our data is then compared with otherhealth services from across the State.
Hospital acquired pressure areas
2
4
6
8
10
12
STA
GE
1
STA
GE
2
STA
GE
3
STA
GE
4
0
2006/07
2007/08
2008/09
The number of hospital acquired pressure areasincreased slightly this year prompting anincreased focus on education for nursesand orientation of new staff.
Pressure areas on residents in ourresidential aged care facilities aremeasured differently than in thehospital setting. Some residentscome into our care with existingpressure areas.
These are measured as well aspressure areas acquired while inour care. Both Andrews Houseand Cooinda Lodge reported lownumbers of pressures areas thisyear with results rating similar toother aged care facilities whenmeasured as a rate per thousandbed days.
Pressure Areas - ResidentialAged Care 2008-2009
0.20
0.40
0.60
0.80
1.00
1.20
STAGE 1
1.21
0.65
0.51
STAGE 2
0.67
0.45
0.34
STAGE 3
0.09
0.11
0.17
STAGE 4
0.04
Cooinda Lodge
Andrews House
State Average
0
The graph above shows the rate of pressureareas on residents per thousand bed days.
TRIVIA QUESTION 4: What is the most common first name of staff? ANSWER ON PAGE 12.
PAGE 6 QUALITY OF CARE NEWS
Accessing our health service
The Emergency DepartmentLast year we reported that we werebursting at the seams and this yearhas seen no change in the trend.
The Emergency Department hasagain broken attendance recordsand seen an increase in the numberof presentations. A total of 17,058patients were seen this year, 561more than last year, a 3% increaseand a 9% increase over the last 2years.
This demand places staff andthe physical environment underenormous pressure to meet thestringent DHS acceptable waitingtimes for patients guidelines. It isnot uncommon for all cubicles, thecorridor and waiting room to be fullat any one time.
While demand has increased, wecan report:� waiting times for category 3 patients
improved with 2% more patientsseen within the required time frame
� continued improvement in waitingtimes for category 4 patients with3% more patients seen within therequired time frames
� 90% of category 5 patients seenwithin the required time frame
� 3% less category 2 patients wereseen within the 10 minute timeframe than last year, however thisis still 2% better than previous years.
The length of time a patient stays inthe Emergency Department until abed becomes available in a hospitalward is an ongoing concern. Thisdifficulty in getting a bed is related tothe increase in presentations and thehigh occupancy rate in the hospitaland other related issues.
In an effort to cope with the increasingdemands and to reduce waiting timesfor patients, the EmergencyDepartment and the Medical Wardare working together to redesign andimprove the patients experience andcare journey for patients requiring
Percentage of patients for admission to Ward
2006/07 2007/08 2008/09 State average
Admitted within 12 hours 78% 81% 81% 87%
Admitted within 8 hours 64% 68% 67% 75%
Percentage of patients seen within the recommended time
Most urgent Category 1 100% 100% 100% 100%
Category 2 85% 90% 87% 86%
Category 3 67% 69% 71% 79%
Category 4 62% 63% 66% 73%
Least urgent Category 5 84% 90% 90% 89%
The table above shows the percentage of people attending the Emergency Department in eachtriage category that were seen within recommended time frames.
admission. Data has been collectedto enable staff to analyse where timecan be saved. A redesigning careproject worker has been appointedand trained in techniques that identifyareas where we can improve workflow and reduce waiting times forpatients.
Other improvements include:� The establishment of a safe room
to care for patients with challengingbehaviors
� Increased nursing and seniormedical staff hours
To address unsafe capacity levels,a tiered critical capacity processwas implemented this year to providean early warning and to alert seniorstaff to expedite actions to assist inrelieving pressure on the departmentduring peak times
Planning has commenced on therefurbishment of the Mary Sargentbuilding to improve capacity for dayprocedures and free up bed capacity.
Improving the managementof people with Chest PainLast year we reported on the workbeing done through the AcuteCoronary Syndrome Project toimprove the management of peoplewith chest pain.
This project won the National Healthand Medical Research Council,
Emergency Department Attendances
14,000
14,500
15,000
15,500
16,000
16,500
17,000
15,5
5420
07
16,4
9720
08
17,0
5820
09
14,9
4920
06
15,0
7420
05
0
The table above shows the percentage of people that required admission to a hospital bed that werefound a bed within 12 hours and 8 hours of attending the Emergency Department.
Waiting List as at 30 June 2009
Urgency Count of Waiting Episodes
1 25
2 282
3 331
Total 638
The table shows the number, in three categories,of people on the elective surgery waiting list asat 30 June, 2009 and the average waiting timesfor surgery. Category 1 patients are the mosturgent and should receive surgery within 30days, Category 2 within 90 days and Category 3within 365 days.
National Institute of Clinical Studies“Evidence in Action Prize” for bestpractice evidenced basedassessment process at the NationalConference College of EmergencyNurses. Nurse Unit Manager SueColby was invited to sit on theDepartment of Human Services statesteering committee for improving theassessment of people with chest painin the Emergency Department.
We continued the project, this yearand achievements include:� revision of the chest pain worksheet
to provide staff with prompts toensure care is delivered in a timelymanner and improvedocumentation
� improvements to dischargedocumentation
� a new data base as beenestablished to collect additional data
� the number of measures to monitorperformance and adherence to bestpractice have been increased andstrengthened so we can target moreareas for improvement.
In a separate but related project,WGHG participated with 48 otherhospitals, in a national projectfocusing on the dischargemanagement of patients withacute coronary syndrome. Projectinitiatives include: � surveying General Practitioners
to identify issues with dischargemanagement
� surveying patients to identifyissues associated with medicationmanagement and their ability toattend cardiac rehabilitation.
WGHG results indicated that weprovided good discharge informationand follow up. Two areas targeted forimprovement were: � to improve the documentation
of risk factors
DHS pleased withelective surgery progressManaging the elective surgerywaiting list continues to presentmany challenges. Irrespectiveof the challenges, our staffcontinue to identify areas tomake the operating theatre listsmore efficient and to reduceelective surgery waiting times.This has been achieved byoffering extra theatre time tosurgeons to perform surgery,performing routine generalsurgery in the morning insteadof the afternoon so patientscan be admitted as day casesrather than staying overnightand by extending the lengthof lists to operate on morepatients in a day.
The DHS allocated anadditional 409 WIES this yearof which 139 were for theCommonwealth Governmentelective surgery initiative toreduce the length of electivesurgery waiting lists.
This funding coupled withstrategies contributed to anoverall reduction in the waitinglist with 638 patients listed atthe end of the year, 16 less thanlast year. This is an excellentresult considering 3,207operations were performed thisyear, 77 more than last year.
We are pleased to report thatall revised elective surgerytargets set by DHS were metwith 100% of all category one(the most urgent) patientswaiting less than therecommended 30 days forsurgery and a 50.9% reductionin ‘long wait’ patients to the endof December.
Total Operations Performed 2008/2009
500
1,000
1,500
2,000
2,500
3,000
3,500
3,13
020
08
3,20
720
09
2,88
920
07
2,94
320
06
3,10
720
05
0
The table shows an additional 77 operationswere performed this year.
TRIVIA QUESTION 5: How many meals were prepared this year by the Food Services Department? ANSWER ON PAGE 12.
� communication to GeneralPractitioners regarding whathappened during the patientsstay in hospital, and what referralswere made to other services.
Infection Controlstaff KarenneNielsen (left) andCoralie Tyrrell(right) take anovel approach to‘testing’ staff handhygiene practices.Medical studentsSarah Cain (left)and Jet Driver(right) prepare toplace their cleanedhands under theultra violet light toreveal how wellthey cleaned theirhands.
PAGE 7 QUALITY OF CARE NEWS
Infection Control
Hand hygiene
Managing H1N1(swine flu)
Cleaning standardsHand hygiene is the most importantcomponent of preventing infection.Our staff focus on cleaning theirhands thoroughly with audit resultsindicating consistent performanceabove expected targets.
The Victorian Quality Council handhygiene project implemented atWGHG in 2007 continues and isan integral part of the infectioncontrol program. With the supportof the Infection Control team, handhygiene principles, education andperformance are demonstrated:� as part of the staff orientation
program
Having a clean hospital isimportant to reduce the risk ofpeople developing infections.Some superbugs, that aredifficult to treat, live in dust andcan easily spread to peopleon hands and equipment, so it isimportant that we make sure ourhospital is as clean as possible.To ensure cleaning standards aremet, regular cleaning audits are Graph below, shows for the past five years,cleaning standards have remained wellabove benchmarks set by DHS.
conducted. High risk areas suchas the operating room aremeasured differently as theyrequire a higher level of cleanlinessthan for example corridors. Inaddition to these regular internalaudits, audits are conducted byexternal auditors with the resultsreported to DHS.
Pictured above, Environmental Servicesstaff Dianne, Elaine, Sue, Margaret, Reneeare part of a highly trained team who ensurewe achieve outstanding results in periodiccleaning audits.
� by conducting regular awarenesscampaigns
� by completing regular audits andcomparing results with targets setby DHS
� by reporting audit results backto staff and advising whereimprovements can be made.
Hand hygiene audits involveobserving the number of times staffuse hand hygiene products suchas special alcohol hand rubs, againstthe number of opportunities for handhygiene eg the use of alcohol handrubs before and after touchinga patient or the equipment besidetheir bed.
Hand Hygiene Compliance
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Ward 2
64% 67
%
75% 79
%
77%
Ward 5
57% 59
%
EmergencyDepartment
71%
68%
HighDependency
Unit
85%
81%
81%
Ward 3
73%
73%
70%
Average
70%
69%
February 2008
March 2009
November 2007
0
COMPLIANCE SET BY DHS: 55% The graph shows theoverall results of handhygiene audits in thedifferent departments.All departments werewell above the targetof 55% set by DHSwith an overall averageimprovement of 7%.
Cleaning Standard Score
20%
40%
60%
80%
100%
2007
95.5
0%
2008
95%
2009
95.2
0%
2006
92.4
0%
2005
SCORE SET BY DHS: 80%
91.4
0%
0
SCORE SET BY DHS: 85%
With the dire warnings aboutthe potential severity of theH1N1 epidemic earlier this year, acomprehensive management planwas activated to manage thesituation. Strategies implementedincluded:� a patient screening system to
identify potential H1N1 cases� any identified patients were
isolated to protect exposure toother patients, staff and thepublic to reduce the risk offurther spread
� a hospital room was alsodedicated to streamline direct
admission for patients at riskof having H1N1 to limit andminimise the risk of exposureto other patients, staff andpublic in the EmergencyDepartment
� public posters were updatedregularly and alcohol handrubs were provided at mainentrances for public use
� Infection Control staff meetingregularly with the Executiveteam for updates and to monitorand plan for the potential impacton the Emergency Departmentworkload and staffing levels.
Infection Control Clinical Nurse Specialist Coralie Tyrrell points out the poster reminding thepublic to clean their hands during the H1N1 pandemic earlier this year and is happy that visitorBrian Brewer is applying the alcohol hand rub as he enters West Gippsland Hospital.
TRIVIA QUESTION 6: How many operations were performed this year? ANSWER ON PAGE 12.
PAGE 8 QUALITY OF CARE NEWS
Getting you involved
CommunityAdvisory Council
At WGHG we are committed toworking with patients, their families,carers and the community toimprove the delivery of health care.
WGHG works in partnership withconsumers at many different levelsand a consumer participationpolicy has been in place for anumber of years.One way this is achieved isthrough the Community AdvisoryCouncil. The Council meetsmonthly and actively seeksconsumer input in relation topeople’s experiences, servicedelivery and strategic planning.This is achieved by:� reviewing consumer related
policies� reviewing and recommending
changes to written patientinformation
� reviewing patient satisfactionsurveys
� reviewing patient care pathways� improving the web page� development of a cultural
diversity plan� organisation planning by
participation in the Boardplanning day
� development of this Report� improving relations with the
Aboriginal community� participation on the Ethics
committee, Hospital AdmissionRisk Program, RedesigningCare project and ImprovingCare for Aboriginal Peopleproject.
As part of the formal, periodicaccreditation process, externalsurveyors from the AustralianCouncil of Healthcare Standards(ACHS) review how we involveconsumers. We are pleased toreport all requirements are metby the Group and an ‘extensiveachievement’ rating was awardedfor how well our consumers andpatients are informed of theirrights and responsibilities.
The surveyors verified that weseek input from consumers,carers and the community inthe planning, delivery andevaluation of the health serviceand also make provisionfor consumers and patientswith special needs andfrom culturally and linguisticallydiverse backgrounds.
Community Advisory Council members (L-R) Theresa Walker-Hassett, Laele Pepper,Angela Greenall, Bev Dowie, CEO Ormond Pearson, Richard Morris, Michael McGuire,Linda Mullett and Kaylene McKinnon. Absent: Rosemary Joiner.
Your care and youBeing involved in and understandingyour daily care is important. The moreyou understand what is happening toyou the better you are able to copewith your treatment. To help youunderstand, specific informationrelating to your care it is recorded,and updated daily, in your ‘PatientCare Pathway’.
The Pathway provides guidance onwhat we do for you each day eg anyspecific dietary requirements, yourmobility or tests required to beundertaken. Pathways are writtenin patient friendly language and
mirror the Pathways used by nursesto plan and record your care.
For patients with complex needs,formal meetings are held with familymembers and the medical teamlooking after you.
Patient satisfactionDepartments regularly conductsurveys to gather your thoughtson the types and quality of servicesthey deliver. One survey type thatwe rely upon is the Victorian PatientSatisfaction Monitor (VPSM), anindependent survey conductedthroughout the year by an externalbody appointed by the DHS.
The survey provides data on ourperformance and is then comparedto all other Victorian Hospitals.
Victorian Patient SatisfactionMonitor WGHG results
2006/07 79.9%
2007/08 80.4%
2008/09 78.2%
State average 77.6%
Consumer participation Indicator -VPSM
WGHG 81% satisfaction
State average 79% satisfaction
Outstanding achievements include:� response time of nurses - 96%� helpfulness of staff in general - 99%
Areas we need to improve:� providing access to interpreters� improving discharge information.
These areas are targeted for furthereducation and review in the comingyear.
Measuring your satisfaction as tohow we involve you in your care isalso achieved using the consumerparticipation indicator of the VPSMby asking the following questions:� Did you have the opportunity to
ask questions about your conditionor treatment?
� Were you happy with the way staffinvolved you in decisions about yourcare?
� Did you find hospital staff listen toyour health concerns?
Our results are above the stateaverage and support the importancewe place on consumer participation.
Please tell usAt times when things don’t seemto go as they should, we want youto tell us. This provides us with theopportunity to look into whathappened, work out why, and tryto ensure it doesn’t happen again.We like being told and we encourageit.
Some people may seem like they’recomplaining, but it does help us toimprove systems and processes.We would rather know about anyconcerns, so we can prevent themfrom occurring again.
When you make an officialcomplaint, it is reported to ourexecutive management team andregistered on a formal data base.This is so that any trends can beestablished. This year 95 complaintswere registered.
There are many ways for you to tellus your concerns. Please speakto one of our staff members, fillin a Compliment and Complaintbrochure available at all of our sites,write us a letter, or email us [email protected].
All complaints are investigatedand followed up, where possible,with the complainant and seniormanagement and/or the mostappropriate person.
Of course you’re also welcometo tell us what you liked too!
For a copy of our Compliments and Complaintsbrochure, please telephone 5623 0631.
TRIVIA QUESTION 7: How many loaves of bread were eaten this year? ANSWER ON PAGE 12.
Kids-Life! MEND (Mind,Exercise, Nutrition, Do It!)
PAGE 9 QUALITY OF CARE NEWS
Improving Care
Kids-Life! MEND (Mind,Exercise, Nutrition, Do It!)
Bev’s story
Accreditation update
Improving carefor older people
The Hospital Admission Risk Program(HARP) was introduced last year toimprove health outcomes for clientswho meet specific criteria and havechronic health conditions. By workingwith them, General Practitioners andother support people, clients areassisted to better self manage theircondition and thus reduce hospitaladmissions and presentations.
An extension to this program thisyear is the Improving Care for OlderPeople (ICOP) project. The ICOPproject includes improved staffknowledge of person centredcare through education and thecommencement of the FunctionalMaintenance Program on theMedical Ward. Delivered inconjunction with allied health staff,clients are encouraged to remainactive and prevent functional declinewhile in hospital.
The program uses exercises andactivities that help keep patientsactive during their stay in hospitaland is delivered in addition to thephysiotherapy programs that arepart of the planned care providedto patients.
Activities are supervised by an AlliedHealth Assistant, usually on a oneto one basis with some group
Physiotherapy assistant Adele Whelanassists patient Maureen Davies to dowalking exercises as part of the inpatientfunctional maintenance program.
sessions where it is appropriate.Family and friends are alsoencouraged to help with activitiesand exercises. They can be assimple as going for a walktogether, doing a puzzle ordiscussing the latest news.
Progress is monitored during thepatients stay in hospital and ismeasured against a ‘six minutewalk’ test and the ‘time to up andgo’ test which measures how longit takes for a patient to get up andstart walking.
Drouin resident Bev Miller knows onlytoo well the benefit of the continuingcare journey at West GippslandHospital.
Following a routine mammogramearly in 2009, Bev was diagnosedwith breast cancer for the secondtime. For Bev, this started a journeythat saw her utilising a number ofour services in the hospital andcommunity settings.
Bev underwent surgery the followingweek at the hospital to have thebreast removed and was immediatelyreferred to the McGrath breast carenurse, located at the Warragul DistrictNursing Clinic, for follow up care
and support. After going home fromhospital, Bev was visited regularlyat home by the District Nurses whochanged her wound dressings andmade sure she was going along okay.
A side effect of breast surgery canbe the retention of fluid known aslymphoedema which can be helpedby massage. Bev experienced thisside effect and attended thelymphoedema massage clinic alsorun by the District Nursing Service.
Visiting Oncologist, John Scarlett, wasBev’s next port of call for follow upand review as well as ongoing threemonthly check ups with the surgeon.
We are pleased to report Bev is ‘doingreally well’ and is anactive member of theWest Gippsland WeInsist on GoodSupport (WIGS)Cancer SupportGroup. McGrath Breast CareNurse Annette Houlahanchats with patient Bev Millerfollowing her surgery forbreast cancer.
Kids-Life! MEND (Mind, Exercise,Nutrition, Do It!) is a fun programoffered FREE to families withchildren aged between two and12 who are interested in becomingmore healthy and active.
The program teaches childrenand their parents the importanceof good nutrition and the benefitsof being active through lots of fungames and activities. Families canattend either a group or individualprogram, depending upon theirneeds.The benefit of the individualsessions is the tailored approachto suit each unique family. Somesessions include picnics in thepark, playing games in your ownneighbourhood, home visits afterschool and some in schoolsessions. Each family works
towards a healthier lifestyle withnutritious foods, active living andimportantly developing the selfconfidence and self esteem ofthe children and family.
MEND (Mind, Exercise,Nutrition, Do It!) is a 10 weekgroup program with two sessionsper week for children and theirparents to attend together. Allreports from participants whorecently completed their 10 weekprogram are that they are noweating better, their relationshipswith each other had improvedand their physical activity hadincreased significantly.Pictured above, new friends! Childrenwho recently completed the MEND(Mind, Exercise, Nutrition, Do It!) programduring one of their pool based exercisesessions.
If you would like more information about the Kids-Life! Programplease telephone the Community Services Division on 5623 4500
and ask for the Kids-Life! Coordinator. Bookings are now being takenfor Term 1 next year. Remember it’s FREE!
Accreditation processes are in placeto ensure that healthcareorganisations meet industry standardsand continually improve their systemsand processes. The achievement of asuccessful accreditation is mandatoryfor all health services and aged carefacilities. Accreditation surveysare conducted at regular intervalsdepending on the type of survey.
Each accreditation survey identifiesareas for improvements which arereviewed at the next survey. This yearwe have been focussing onimprovements to our patient flowthrough Emergency Department andimproving some of our documentationin preparation for the periodic reviewin October.WGHG has also been at the forefrontof evaluating National AccreditationMethodology. This year weparticipated as one of 20 healthcareorganisations nationally in a project toevaluate the potential of “short notice”surveys.
The project, while designed to identifythe benefit of short notice surveymethodology, provided theopportunity to identify gaps inour quality improvement processes.Two days notice is provided to healthservices undergoing short noticesurveys. We are pleased to reportthat our robust continuous qualityimprovement systems supportedour current accreditation status andall evidence that was requiredmet all requirements.
The Warragul Linen Service issurveyed annually and holdsAS:NZS ISO 9001:2008 certification.Cooinda lodge and Andrews Houseunderwent full accreditation withthe Aged Care Standards Agencyin December and successfullyachieved compliance with the 44criteria surveyed. West GippslandHospital and the CommunityServices Division are fullyaccredited by the AustralianCouncil of Healthcare Standards.
TRIVIA QUESTION 8: How many litres of milk are consumed in one week? ANSWER ON PAGE 12.
PAGE 10 QUALITY OF CARE NEWS
Clinical GovernanceClinical governance is the processwhere the Board of Directors monitorthat we have the right people doingthe right thing at the right time in thebest and right way. It involves:� ensuring an effective and safe
workforce;� monitoring clinical effectiveness;� managing clinical risks; and� consumers in their own care.
Right peopleNew staff undergo rigorous selectionto ensure they have the correctqualifications, experience andcredentials to undertake the tasksthey are employed to do. Currentstaff have their credentials andregistration checked annually.
100% of nurses have currentpracticing certificates
100% of doctors are credentialedaccording to best practiceguidelines
100% of doctors have currentregistration with the Medical Boardof Australia
100% of staff have satisfactorypolice checks including workingwith children checks
A new project commenced this year isthe credentialing and defining scopeof practice for staff in Allied Healthareas.
Right thing,right time,right wayOur staff are guided by policies,procedures and protocols that areregularly reviewed reflecting bestpractice and supported by the latestliterature and research.
Staff rostering is organised and takesinto consideration an appropriate mixof skill and experience.
Orientation programs provideimportant information to all newstaff. General orientation was providedfor 121 new staff members this yearand 68 new nurses were providedwith additional nursing orientation.
Experienced staff supervise andmentor students. 120 staff completeda preceptorship program to build skillsin supervising and guiding new staffand 32,000 hours of student clinicalplacement were undertaken this year.
New graduate staff are mentoredby senior staff to guide them throughtheir first year in the workplace. Tennurse graduates completed theirgraduate year this year.
Extensive ongoing education extendsscope of practice and keeps staffup to date with best practice. Duringthe year there were 2,566 staff
attendances at 182 different educationtopics.
Staff take compulsory annual trainingin their area of expertise. 350 nursescompleted a total of 2,640 differentcompetency tests, a significantincrease on last year. Thesecompetencies include:� basic life support� drug dose calculations� hand hygiene� manual handling� falls� neonatal resuscitation for midwives� fire safety� food safety.
The best care...how we do itTo ensure clinical effectiveness we:� enrol in projects to implement best
practice� support our staff to learn about best
practice � foster and encourage ideas to
improve care delivery� involve staff in planning and
redesigning systems and processthat improve the way we do things
� undertake a large number of auditsand clinical indicators that measureand monitor our clinicalperformance, compared tostandards, and report these to theClinical Quality Committee,Standards Committee and Board.This helps ensure we are improvingperformance and aiming for bestpractice care
� constantly review ourdocumentation to ensure care isaccurately documented andcommunicated
� involve patients and family in theircare.
Managing risks Our comprehensive clinical riskmanagement program which includes: � a commitment by the Board of
Directors and Executive teamto a safety first environment
� encouraging staff to report clinicalrisks and incidents, to learn fromthem and prevent them fromoccurring again
� investigating incidents,identifying underlying causesand implementing strategies toreduce risks
� utilising technology to designout or minimise errors
� regular reviews of policies,procedures, guidelines andprotocols to ensure they reflectcurrent best practice
� having in place and constantlyrevising programs to manageknown clinical risks (such asInfection Control risks)
� a weekly meeting of the ClinicalRisk and Evaluation (CARE)Council to discuss clinicalincidents, complaints and issues.
Risks identified are then directedto the most appropriate committeeor persons for action. Strategiesaimed at risk prevention areidentified, implemented andreported to the monthly ClinicalQuality Committee.
Clinical Risk and EvaluationCouncil (CARE)CARE discusses an average of26.5 issues per month. This yearsaw a 38% reduction in the numberof complaints discussed and a 50%reduction in the number of issuesrelated to policies and procedures.However analysis of data shows anemerging trend pointing to the needto prevent delays in caremanagement.
The work of CARE has resulted ina range of recommendations beingimplemented to reduce risk. Someof these improvements are:� setting up an “early warning critical
capacity process” to implementactions to improve access toservices in the EmergencyDepartment at times when thedepartment is critically overloaded
� revising processes to improveour response when a patient’scondition is deteriorating
� revising consent policies � revising medication protocols� a range of targeted education
campaigns to improve staffknowledge eg improving themanagement of arterial lines.
Serious incidents have a high levelof investigation, including root causeanalysis. During this process everydetail of the incident and eventsleading up to the incident areanalysed to identify causes. The teamthen develops recommendations toprevent the incident occurring again.
This year we completed two RootCause Analyses. Recommendationsincluded:� improvements to operating suite
count sheets� development of a formalised
process of self-assessment incompetence and confidence inrelation to scope of practice
� revision of nursing roster systemto reduce times of extended shiftswhen overtime is worked in theoperating room.
Development of formal guidelinesoutlining conditions where referralto a paediatrician is mandatory.
RISKMAN incident recordingA new electronic risk managementsystem, RISKMAN, was introducedthis year to record all reportedincidents. It provides real timereporting to managers and othersenior staff responsible forinvestigating incidents usingautomated electronic alerts. The staffmember who generated the incidentreport is able to see an outcome ofthe investigation and the action taken.Details are recorded on each incidentenabling us to get more refinedreports and quickly discoveremerging trends.
The most common types of incidentsreported are falls, medication andaggressive behaviour incidents. Werecognise that it is difficult to ensurethat every incident is reported but wehave worked hard to encourage ourstaff to report incidents and nearmisses so we can learn from them.
Incidents reported at WGHG
2006/07 1730
2007/08 1502
2008/09 1378
% of types of totalreported incidents
2006/07 Falls 42%
Medication andIV related 15%
Aggresivebehaviour 13%
2007/08 Falls 45%
Medication andIV related 13%
Aggresivebehaviour 11%
2008/09 Falls 37%
Medication andIV related 22%
Aggresivebehaviour 13%
Below, Heather Gillespie and Di Moredemonstrate the electronic risk managementsystem implemented this year.
TRIVIA QUESTION 9: How many paracetamol tablets are dispensed each year? ANSWER ON PAGE 12.
PAGE 11 QUALITY OF CARE NEWS
Care in the community
Black Saturday.. .our response
On Saturday February 7 our healthservice announced a Code Brown,external disaster alert. Baw BawShire was ringed with fire, and thePrinces Highway blocked in bothdirections. With the outstandingsupport of staff, emergencyprocedures swung into action.The day room at Cooinda LodgeNursing Home was cleared tomake way for residents evacuatedfrom Neerim South Nursing Home.The Emergency Departmentprepared for fire victims affectedby burns, smoke and minorinjuries. The hospital kitchenprovided meals to ambulance staff,and the Warragul Linen Servicemade linen available to emergencyrelief centres. The CommunityService counselling team arrivedat the relief centres by midafternoon to provide support.
The bushfires were devastatingfor our community. Even thoughseveral months have passed sincethose fateful days, the supportwe provide is ongoing. Countless
community members still needour help and we are assistingthem through our CommunityServices division. The Baw BawBush Fire case managementteam is located at our CommunityHealth Centre in Gladstone inWarragul and is working closelywith the other support serviceswe provide from that Centre.Above, Louise helps defend the Labertoucheproperty of Liz Winkel and Leigh Bedson.Liz and Leigh are receiving ongoing supportfrom the Bushfire Case Management teamlocated at our Warragul CommunityServices Division.
The best of both worlds
When the time comes that your lovedones moves into one of our residentialaged care facilities, Cooinda Lodgein Warragul or Andrews House atTrafalgar, you can rest assuredknowing they’ll continue to bepart of the wider community.
An ongoing highlight for residentsis the diversity of lifestyle enjoyedthrough programs organised“in-house” as well as those designedto involve them in the widercommunity.
An art program was commenced thisyear at Cooinda Lodge to provide theopportunity for residents to expresstheir thoughts, feelings and memoriesof days gone by through painting.The year culminated in the unveilingof a painted collage entitled ‘Momentsin Time’ that depicts a special memoryin time from each resident. Measuring4.5 x 1.5 m and with a central themeof the bubbling water fountain inthe Cooinda garden , the collageencapsulates memories of gardening,pets, children and family, horse riding,growing up in Europe, the beach,farming, working days, cooking andthe war years. Residents are lookingforward to hosting their own exhibitionat the West Gippsland Arts Centre inthe coming year.
Following the Black Saturdaybushfires residents had a great desireto be able to help so a “yellow day”was held. Residents and staff enjoyedmaking and eating yellow cup cakeswith the funds raised donated to theDrouin West Fire Brigade.
The “Random Act of Kindness”program at Andrews House providesresidents with the opportunity toconsider people and groups in thewider community who need a helpinghand. With the support of volunteers,staff and family members, residentsget together at the in-house “café”once a month where they enjoycappuccinos and cake. The money
Above, a highlight of the week for CooindaLodge residents is the art program. Working ontheir masterpieces are residents (L-R) Sophia,Margaret, Joahanna, Billie and Marie withLifestyle Coordinator Pauline Boorer and ArtTherapist Joan Bognuda.
raised is then used to buy supplies tomake items to donate or to make amonetary donation to a charity.Donations made this year included:� 50 calico dolls to the St John’s
Ambulance needles and threadprogram
� A slab of beer for local fire fighterswho helped on Black Saturday
� Groceries to fire victims� $95.00 to the Cancer Council
Biggest Morning Tea� West Gippsland Healthcare Group
Murray to Moyne Cycle Relay team� A box of groceries for the Salvation
Army to help a local family in need
Another special project is the‘Operation Christmas ChildSamaritan’s Purse’. To help childrenin overseas countries caught up inthe midst of war, famine, naturaldisasters and extreme poverty,residents fill shoe boxes with schoolsupplies, toys and personal itemsthat will be distributed to childrenat Christmas. These boxes becometreasured gifts to children who havenever received gifts before.
“Enjoyment and satisfaction inremaining an active member of thewider community is the best part ofthese programs”, said an AndrewsHouse resident.
Providing the essentials
Thanks to the ongoing generousdonations of local churches,service clubs and individuals, ourEmergency Relief program is ableto provide practical help to localfamilies in need.
Each week around 20 people areassisted in a practical way throughthe program which is another partof our community health serviceprovided at Gladstone Street inWarragul.
Food, petrol vouchers, assistancewith utility bills and generalhousehold expenses is availableto assist people in difficultcircumstances. The demand forthis service increased significantlythis year following the BlackSaturday bushfires with 898occasions of service, 192 morethan last year. We are grateful to
the Australian Government forfunding an additional $34,000 tomeet this demand. At Christmastime, the Emergency ReliefCoordinator works closely withthe Warragul Gazette, SalvationArmy and the Christian FamilyChurch food bank to prepareover 120 Christmas hampers tobrighten the Christmas of manyfamilies. For further informationabout the Emergency Reliefprogram telephone the WarragulCommunity Services Division on5623 4500.
Pictured above, the wonderful team ofvolunteers and staff preparing to packChristmas Hampers are back row (L-R)Alice Faragher, Margaret Lawrence,Rodney Dyson, Kate Palmer, TanayaMcKinnon, Lauren Gordon, Anita Hermans,Sam Stephens and Julie Ettery. Front row(L-R) Major Warren Elliott, Anne Pascoe,Lauren Roche and Stephanie Keeble.
TRIVIA QUESTION 10: How many units of blood (around 300ml) are used in one year? ANSWER ON PAGE 12.
Above, Andrews House resident Gwen Higginsstuffs a calico doll for the Random Act ofKindness program.
PAGE 12 QUALITY OF CARE NEWS
Community Health Services:Rawson CommunityHealth CentrePinnacle Drive Rawson 3825ph 03 5165 3236fax 03 5165 3268email [email protected]
Aged Care - Andrews HouseSchool Road Trafalgar 3824ph 03 5637 4100fax 03 5633 1018email [email protected]
Aged Care - Cooinda Lodge West Gippsland Hospital siteLandsborough Street Warragul 3820ph 03 5623 0769fax 03 5623 0896email [email protected]
Warragul Linen ServiceLey Street, Warragul 3820ph 03 5623 4056fax 03 5623 5074email [email protected]
Head office:West Gippsland Hospital41 Landsborough StreetWarragul 3820ph 03 5623 0611 fax 03 5623 0896email [email protected]
Community Health Services:Drouin - Baw Baw Healthand Community Care CentreYoung Street Drouin 3820ph 03 5625 0200fax 03 5625 0204email [email protected]
Community Health Services:Warragul Community Services31-35 Gladstone StreetWarragul 3820ph 03 5624 3500 fax 03 5624 3555email [email protected]
Community Health Services:Trafalgar Community Services(Old RSL building)Contingent Street Trafalgar 3824ph: 03 5624 3500email [email protected]
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West Gippsland HealthcareGroup 2009 Qualityof Care ReportConsumer Feedback FormThe Report is designed to inform our community about the services provided by 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: 15-35 36-50 50-65 Over 65 Gender: Male Female
How much of the report did you read? All Some A little None
Was the Report easy to understand?
Very easy Easy Not easy but not difficult Difficult Very difficult
Did you find the report informative? Yes No
Please tell us what you liked about the report. Any other comments:
Please return in person to main reception, West Gippsland Hospital, 41 Landsborough Street, Warragul, 3820or post to the address above. Alternatively, you may complete the form at:
www.wghg.com.au
Answers to Trivia Questions:
TRIVIA ANSWER 1: 14 millionTRIVIA ANSWER 2: 9,278TRIVIA ANSWER 3: 779TRIVIA ANSWER 4: JenniferTRIVIA ANSWER 5: 379,968TRIVIA ANSWER 6: 3,207TRIVIA ANSWER 7: 13,520TRIVIA ANSWER 8: 1,115TRIVIA ANSWER 9: 220,000TRIVIA ANSWER 10: 1,170
2008 Graduate Nurses with education staff are (L-R) back row Lisa Bethune, Crystal Braaksma,Marandah Schnabl, Bronwyn Edwards, Kara Piedmont, Jean Bramley, Louise Allen (Educator) andKatie Lawrence. Front row Jeanette Dyason (Educator), Jan Ashby (Educator), Kerrie Morello, LauraFlahavin, Debbie Williames (Educator) and Anne Curtin (DON).
Staff education, training andprofessional development iscoordinated by the Staff DevelopmentUnit. While the majority of oureducation programs are basedaround clinical areas, opportunityis given to all staff to participate infurther education.
The number of nursing studentsundertaking clinical placementincreased by 100% this year with213 nurses attending for a total of32,400 hours. In addition to this,89 medical students undertookclinical experience and a numberof paramedic and personal careattendant students were also hosted.This year also saw the introduction ofa clinical placement program in theMidwifery Unit to support students
undertaking the double degree innursing and midwifery at MonashUniversity.A graduate nurse program is offeredto equip Division 1 Registered Nurseswith skills and experience to assistin their transition from university toworking as competent practitionersin the hospital setting. The programincludes a comprehensive round ofrotations to provide a broad range ofclinical experience and enhance theircareer path. This year 10 nursescompleted the program.
The willingness of our nursing staff tosupport and encourage nurses new toWGHG is outstanding. Over 120 nursepreceptors mentor, supervise, coachand act as a point of reference fornew graduates and students.
Short course in-service educationis delivered in house by the staffeducators through shortpresentations or demonstrationswhile they also provide longer termcontinuing education andprofessional developmentprograms and links with externaleducation providers.
A new program was introducedthis year to support Division 2Nurses with medicationendorsement to practice in acuteareas. To date seven Division 2nurses are now working in thiscapacity.
To assist with maintaining skillsnurses undergo a range of annualcompetency tests with some ofthese involving online testing.
Mandatory online competenciesinclude:� basic life support� hand hygiene� manual handling� falls� fire safety� neonatal resuscitation.To provide a consistent methodto record continuous professionaldevelopment across the regionWGHG as part of the GippslandContinuing Nurse EducationProgram have developed a regionbased nurse education trainingrecord.
Staff education
Staff education program
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