quality of care report 2010/2011 - awh.org.au to the community as possible. we encourage ... urana...

Qual i ty of Care Report 2010/2011Albury Wodonga Health

AlburyWodonga

Health

2 | Albury Wodonga Health Quality of Care Report 2010/2011

Our VisionAlbury Wodonga Health – the best of health.

Our PurposeTo deliver quality healthcare services in unique models of partnership to improve our regions’ health.

Our ValuesThe application of our values to Albury Wodonga Health are essential in achieving our wider goals and objectives. They describe the ethos of the organisation which underpins our ability to deliver improvements in service. They reflect a commitment by the organisation to create an environment that is inclusive, professional, rewarding and fair. Our values are:

• Ethical: Both in our clinical endeavour and our business practices we will be just in all our dealings.

• Teamwork: Esprit de corp, harmony, partnership and unity are valued.

• Respect: Appreciation of the worth of others and regard for their contribution is inherent.

• Trust: Confidence that all are doing their best, honestly and positively.

• Accountability: Understanding that all bear a personal responsibility to our community.

• Compassion: Consideration, empathy and humanity are given freely to our patients and staff alike.

• Equity: Fairness, integrity and justice are apparent in our actions.

• Patient and Client Focussed: Our purpose is to serve our patients and clients in order to achieve the Vision and Purpose of Albury Wodonga Health.

Why do we produce the Quality of Care Report?

Each year, Albury Wodonga Health produces the Quality of Care Report to inform the community about the measures we take to ensure the services we provide are of a high standard. This year’s report was produced with the assistance of a Working Group consisting of staff and community members.

The report offers an overview of the work we have undertaken in 2010/11 and includes various stories from patients, staff and consumers about their experiences with Albury Wodonga Health. The report also details how we have performed on a number of key performance indicators and outlines the safety and governance systems we have in place to ensure we continue to improve.

While producing an annual Quality of Care Report is a requirement of the Victorian Department of Health we are committed to making it as valuable a reporting tool to the community as possible. We encourage you to take the time fill in the feedback form on page 41 to assist us to reach this goal.

Albury Hospital Main Corridor

Albury Wodonga Health Quality of Care Report 2010/2011 | 3

Contents

Why do we produce the Quality of Care Report?

Contents

Message from the Chair of the Board and CEO

Introducing Albury Wodonga Health

Exciting Developments Underway

Our Partners

Accreditation

Consumer ParticipationAlbury Wodonga Health Improving Participation

Mental Health Services Working Collaboratively

A Fresh Start to Infant Mental Health

Volunteers...You Are Worth Your Weight in Gold!

An Early Christmas Present - Meredith’s Story

Mandatory Reporting Requirements

Continuity of CareEnsuring Safe, Effective and Efficient Patient Centred Care

Palliative Care and District Nursing

Assisting People to Take Control and Live a Healthy and Active Life

The Road to Recovery - Lindsay’s Story

Albury Wodonga Health Responding to Demand

Quality and SafetyWe are Continuously Monitoring Clinical Care

Dental Service Performance

Credentialing and Scope of Practice

Staying Upright - Falls Prevention

A Combined Program for Preventing and Controlling Infections

Safe Use of Blood and Blood Products

Appendix 1 - Albury Wodonga Health Services

Appendix 2 - Glossary

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3

4

5

7

8

8

10

12

14

15

16

18

24

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25

26

29

32

33

34

35

36

38

39

40


On behalf of our Board, staff and community we are delighted to present the 2010/2011 Albury Wodonga Health Quality of Care Report.

This report has been developed by our staff and community members and is written for you, our community, our patients and your carers.

Our Quality of Care report aims to inform you of our achievements over the past year as we strive to meet our vision ‘Albury Wodonga Health – the best of health’. Quality remains central to the provision of health care and all aspects of our service are subject to scrutiny and review where necessary. We aspire to ‘do it right the first time’ but when we fall short, we aim to learn from those occasions.

The second year of the life of Albury Wodonga Health has been the year of consolidation and review, but we have also experienced considerable activity on many fronts. The clinical activity at both the Albury and Wodonga Hospitals has been significant with 62,544 patients treated in the Emergency Departments, 31,398 patients admitted to hospital, 12,235 procedures performed and 1,625 babies born.

This year has also seen a significant focus on greater involvement and consultation with the staff and community. Our Community Advisory Committee in cooperation with staff and the Board has developed our first Community Participation Plan which will see us working together to involve the community in our plans and on operational issues.

Staff Engagement Forums have also provided staff with opportunities to be informed and comment on issues of concern. During the year over 500 staff members have attended these sessions and have provided feedback.

Again this year, our report describes a range of the services and programs found in the rich tapestry that is Albury Wodonga Health.

Many people have had input to our Quality of Care Report and we thank them for their contribution. Members of our Community Advisory Committee have provided valuable suggestions about the presentation and areas of specific interest. For example, this year we have provided more stories from patients that have used our services following feedback that this is an area of interest.

We hope you will find our report interesting and informative. Feedback is important to us and we would like to hear your thoughts on this year’s report. Details about how to provide your comments can be found elsewhere in this report (see page 41).

Ulf Ericson Stuart Spring(Chair) (Chief Executive Officer)

Message from the Chair of the Board and the CEO


COLEAMBALLY

JERILLDERIE

LOCKHART

URANA

BERRIGAN

OAKLANDS

COBRAM

MULWALA

YARRAWONGA

TOCUMWAL

DENILIQUIN

FINLEY

NUMURKAHNATHALIA

SHEPPARTONKYABRAM

WANGARATTA BEECHWORTH

YACKANDANDAH

CHILTERN

COROWARUTHERGLEN

ALBURYWODONGA

TALLANGATTA

CUDGEWA

THURGOONA

CULCAIRN

HOLBROOK

HENTY

THE ROCK

TUMBARUMBA

TOWONG

WALWA

ADELONG

LEETON

COOLAMON

NARRANDERA

TEMORA

COOTAMUNDRA

JUNEE

WAGGA WAGGA

0 10 20 30 40 50 60 KilometresSCALE 1:1,000,000N

Primary Catchment supporting approximately 125,000 people- Acute, sub-acute and ambulatory services

Secondary Catchment supporting approximately 165,000 people- Acute/specialist treatment

Outer Catchment supporting approximately 320,000 people- Specialist referral (eg. Urology/Facio-maxillary)

CORRYONG

Introducing Albury Wodonga Health

Albury Wodonga Health is unique. Established on 1 July 2009 it is the first cross border public health service to exist in Australia, and operates under an agreement between New South Wales and Victorian governments to provide one of the largest regional health care services between the two capital cities. It supports an outer catchment population of 320,000 and covers the North-East of Victoria and Southern New South Wales.

Albury Wodonga Health Catchment

The population of Albury Wodonga is around 90,000 with approximately 7,300 of its residents born outside of Australia. The main migrant groups within our region have been identified as coming from Germany, New Zealand, the Netherlands, Croatia, Scotland, the Philippines, India, Sri Lanka, Indonesia and Africa. Population statistics also reveal that approximately 1,500 Aboriginal and Torres Strait Islander people live within the region. To meet the needs of our diverse community Albury Wodonga Health has established a Cultural Diversity Plan (see page 22).

Our Community


Our servicesAlbury Wodonga Health provides a comprehensive and growing range of health services spanning the primary, non-critical and critical needs of regional residents. The Albury and Wodonga Hospitals offer unique specialised services such as; orthopaedics, paediatrics, oncology, critical and intensive care at Albury Hospital, and maternity, special care nursery, ophthalmology and dialysis at Wodonga Hospital. Some services, such as emergency, are offered at both the Wodonga and Albury Hospitals.

We also offer a range of services that are provided outside of the hospital setting these include Allied Health, Community Rehabilitation, Mental Health, and Dental.

In 2010/11 A lbur y Wodonga Hea l th:

• Utilised 260 beds across its two sites.

• Admitted 31,398 inpatients.

• Treated more than 62,500 patients in the Emergency Departments.

• Performed 12,235 medical procedures.

• Delivered 1,625 babies.

• Had a full time equivalent workforce exceeding 1,000.

• Operated with annual operating revenue $162.4 million.

A comprehensive list of the services provided by Albury Wodonga Health is provided in Appendix 1 (see page 39).

Some of our achievements of 2010/2011

• The successful bid to the Commonwealth for the development of the Regional Integrated Cancer Centre (see page 7).

• The establishment of a common pathology provider, Dorevitch Pathology, and development of pathology laboratories, both at Albury and Wodonga Hospitals (see page 29).

• Development of Albury Wodonga Non-Emergency Transport Service which includes a partnership with the Royal Flying Doctor Service (see page 30).

• Development of the stroke service and initiation of the thrombolysis service – already proving to be of benefit in selected patients.

• Reorganisation of the structure for the maternity services, both medical and nursing.

• Combining the two hospitals’ waiting lists and cross checking of that list (see page 29).

• Acquiring and commissioning over $4 million worth of new equipment.

• Transfer of the catering services, environmental services and engineering services from NSW Health to Albury Wodonga Health.

• Increased consumer and community participation across our services (see page 10).

• Implementation of the Community Participation Plan (see page 10).

Albury Hospital Reception Wodonga Hospital Reception


Service planA very significant project that will define our future is the development of the Service Plan. This plan, being prepared under the auspice of the Victorian and NSW Departments of Health is well underway, examining the clinical and organisational strengths, the pressures we face and the gaps in clinical services, as we grow as a single organisation.

As part of our Service Plan development we will also need to prepare a Master Development Plan that will identify actions required to meet future demands.

Wodonga Hospital refurbishmentWodonga Hospital will receive $5.5 million in capital investment throughout 2011/12 for the following key projects:

• Expansion of the renal dialysis service from six to nine chairs.

• Upgrade of the emergency department to create additional space for those people using the service.

• Establishment of an endoscopy surgicentre to meet the community’s needs.

Exciting Developments Underway

Thanks to the fantastic work of the Albury Wodonga Cancer Consortium and the community, funding has now been secured for the development of a Regional Integrated Cancer Centre. Work has now begun on making the project a reality with the first task being the creation of a master development plan that will confirm the site for the Centre.

The $75 million project is scheduled for completion in 2014.

Regional Integrated Cancer Centre

People rally for the Regional Integrated Cancer Centre. (Photo courtesy of Albury Wodonga News Weekly)


Albury and Wodonga Hospitals are accredited by the Australian Council on Healthcare Standards (ACHS). The ACHS EQuIP accreditation program provides health care organisations with a framework to deliver a consumer-centred service while focusing on continuous improvement. The program incorporates a systematic external peer review and guides organisations through a four year cycle of Self-Assessment, Organisation-Wide Survey and Periodic Review to meet ACHS standards.

During October 2011, we will undertake our first organisation wide survey as Albury Wodonga Health. We look forward to reporting on the results of this first review in next year’s Quality of Care Report.

Our Partners

Accreditation

Our partners include:

• Consumers

• Communities

• Our workforce and their families

• Our volunteer workforce

• Suppliers

• Other health services

• Community health services

• Local health interest and support groups

• Local, state and federal governments

• The media

We operate in an extensive and diverse region across the north east of Victoria and southern New South Wales. Our partnerships with other organisations are vital to the effective delivery of services in this environment. The stories and reports detailed throughout this report highlight the various partnerships we enjoy.

Wodonga Hospital accreditation plaque

Albury Hospital accreditation plaque


consumer participation


Meredith, Murray and Hamish Wallace



During the year we have increased community participation activities. The focus has been on readying the organisation to embrace consumer participation and on gathering information about the community’s expectations.

These areas are central to our first Community Participation Plan (CPP) which was developed by staff, the Community Advisory Committee, and the Board. The CPP provides a strategic framework to strengthen, guide and support consumer, carer and community participation. It aims to ensure the delivery of quality services for the benefit of our communities and to improve the experience of patients and staff.

The CPP has provided a plan to actively enhance community participation throughout the year. Key initiatives achieved during the year include:

• Community Advisory Committee member attendance at conferences and training sessions.

• Consumer involvement in the preparation of the Quality of Care Report, Cultural Diversity Plan, and Strategic Plan.

• Consumer involvement on a number of working groups and committees.

• Establishment of a Participation Team charged with ensuring the organisation is ready to embrace participation principles.

Albury Wodonga Health Improving Participation

This is the vision of a group of enthusiastic consumers and staff who have come together to bring about change within our health service. The Participation Team is a newly established group of individuals who are passionate about making participation a part of all our daily activities.

The Team has come up with an aspirational set of objectives to keep the organisation motivated and passionate about involving consumers. These objectives focus on culture change, increasing awareness, education, getting consumers involved, and making things happen!

We look forward to reporting all of the wonderful achievements of this team in next year’s Quality of Care Report.

If you would like to be more involved in your health service please contact our Community Advisory Committee Resource Officer on telephone 02 6051 7649 or email [email protected].

A culture of participation is evident and integral to the operation of Albury Wodonga Health


I applied to join Albury Wodonga Health’s Community Advisory Committee (CAC) in 2009 after reading a newspaper advertisement inviting active community members to help develop our new cross-border health service. I had been living in Albury for 26 years, had enjoyed my work with community groups across the region during my time as a food industry trainer at Wodonga TAFE and wanted to continue working usefully in some way in our community.

Having had type 1 diabetes for 20 years, I saw joining the CAC as a great opportunity to highlight the need for improved diabetes services in this region, badly needed given the growing numbers of people being diagnosed with diabetes. And, although I had no idea what being a member of the CAC would entail, I saw it as an effective way to contribute to the development of our health services for all in this region, not just those who live with diabetes.

Our CAC first met in January 2010. Being in the CAC from the beginning has not been without its challenges - we have been on a very steep learning curve together. Three of us went to Melbourne for a seminar where we met up with CAC members from across Victoria and that reassured us that we were on the right track and that we could do it! I also attended a national conference on Quality in Health Care in Canberra that strongly promoted consumer involvement and heard about many inspiring consumer participation activities.

In our first year the CAC contributed to Albury Wodonga Health’s very first Strategic Plan then began developing the Community Participation Plan that will guide our activities through till 2014. We couldn’t have done our work without the very positive support we’ve received from the senior executive team at AWH and the help of our Resource Officer.

We are now working to raise our profile across AWH, as well as out in the community, highlighting the importance of consumer participation in health care. Several of our members sit on AWH committees and working groups as consumer representatives and requests for our participation are increasing so we now need to recruit more community members interested in contributing to the improvement of our health care.

Creating a new image for Albury Wodonga Health

Making it easy to identify staff specialties and promoting a professional image were the key aims of introducing a new uniform. We worked together with local businesses and everyone had the opportunity to vote for their preferred colour and pattern. Those receiving the top votes were then presented at fashion parades, followed by a final round of voting. The fashion parades were unique, fun-filled events that proved hugely popular.

With our new uniforms now on show we see a team of distinguished, smart, professionally clad employees proudly representing their organisation and individual departments.

The success of the uniform project was described by Susan Campiciano, a patient of both Wodonga

and Albury Hospitals, who commented that “The staff look very smart and professional and it’s great to be able to pick out each person’s role.”

Registered Nurse Rebecca Livermore added “The new uniforms are very functional, professional looking and are great for knowing who is who.”

Community Advisory Committee Meeting

AWH Staff displaying our new uniforms

Liz Hare shares her experience on the Albury Wodonga Health Community Advisory Committee


Client Satisfaction Survey

We have made a Client Satisfaction Survey. The survey was made after talking with staff and people who use our service. It is based on what they said was important.

The first survey covered 6 months of time. These first results show people were pleased with our services. Answers on the survey have given us important

Recovery orientated practice to mental health and the recovery starWe introduced Recovery Orientated Practice in December 2010. Recovery Orientated Practice is a way of looking at the whole of a person and their wellbeing.

• It builds on a person’s strengths. • It is based on people deciding their own future. • It is based on different care for each person’s needs. Recovery Orientated Practice sees these things as being very important;

• Hope• Being included within the community• Setting goals for yourself• Supporting you in managing things yourself We know that people are experts on their own lives and experiences. Mental Health workers can offer information and skills on treatment services available. We can work together to bring the best result.



January-June 2011 Percentage of Clients who either Agree or Strongly Agree with the Questions asked

1. The service is supporting me to reach my recovery goals 83%

2. I would recommend a friend or family member to this service 86%

3. I am greeted by receptionist in a warm and friendly manner 89%

4. The staff focused on my strengths and inspired hope for my recovery 83%

5. I find the building and the décor promotes a sense of warmth and makes me feel... 84%

6. Overall I was satisfied with the service I received 87%

Helping the Recovery Orientated Practice is the way we use ‘advanced statements’. These statements talk about what might happen in the future. They are the wishes of what the person who experiences mental illness wants to have happen if they become unwell. They talk about the type of care and the type of treatment they might want.

It has been great to see more people using advanced statements this year. We will continue to encourage more people to do this.

information. This is now being used to help us make our service better.

The next step is to ask people five new questions in a survey. These questions will ask about different issues that are important and ‘real’.

We plan to do this survey again in 12 months. This will let us compare the results with the first survey. It will also let us work out how helpful the Recovery Oriented Practices have been.



‘Having used the service before, I know I am in

good hands. In my eyes the Adult Mental Health

Service is getting better. Thank you.’

The Recovery StarThe Recovery Star is a tool that helps people to talk about the important things that they are facing in their recovery. Each person rates where they are at for each area of life.

• It lets people have full control of their future. • It lets people be in charge of their own decisions. Not everyone has been able to use the Recovery Star so far. We plan to use it more in the future. People keep a copy of their Recovery Star after each review.

People who are not using the Recovery Star have Individual Service Plans. These Individual Service Plans have been planned out, put into action and reviewed by everyone working together. They have strategies to meet people’s mental health and social needs. The plans also include ways to meet the needs of the person’s family and / or support people.

Starting use of Recovery Oriented Practice has allowed us to do more work together with people in the community, people with mental illness and special interest groups. Recovery Oriented Practice has also helped in:

• Running education sessions.• Planning the Recovery Star pilot project. • Making resources to help with recovery.• Talk ing about mental health issues with people

in the community.

We also run an education session each week for staff. These sessions include talks from people with mental illness and carers.

We are clear about encouraging people with mental illnesses to take part and show leadership. This is led by: • State and Australia wide mental health policies. • National Practice Standards for staff.• Policies for people who use our service.

Encouraging ParticipationWe know that the feedback and ideas of people who use our service are necessary if any improvements in services are to be made.

We are working towards making more ways for people who use our service to be involved. We are aiming for these ways to be similar right across our area.

We have several ways that show how important people’s input is:

• The work of the Consumer Consultant.• an interview with each person.• support and advocacy.• ways to give feedback.• surveys which ask about your experience of our service.

We hope to support people in helping us to plan, develop and review our services. This way we can change and improve our service to meet the needs of the community.

‘I thank all the wonderful staff who have helped me recover from my illness, they continually give me strength and support to get me through.’

‘I really thank everyone here. Outstanding people and kindness,

none better.’

‘I like the new building.’

Albury Wodonga Health - Adult Mental Health Service



A new Mental Health Coordinator star ted th is year. They wil l work with the Infant Mental Health Program. The Coordinator’s job was star ted af ter many years of research about emotional dif f iculties when childrenare young. The research looked at what ef fect emotional dif f iculties when children are young has on mental health when the children are older. The research included psychotherapy reading groupsand looking at how the children and parents played together.

The Kids Early Action Program in Schools (KEAPS) was star ted from the research.

The Kids Early Action Program in Schools (KEAPS) showed there are many children in our area with behaviour difficulties in their first years of school.

The Mental Health Coordinator gives support to childrenwho are babies up to four years old. This new service also works together with other groups in the community. The Mental Health Coordinator can give education and other help to people working with children with emotional and behavioural dif f iculties.

At the moment the Mental Health Service is:

• Running a psychotherapy group for mothers and babies who are involved with the Child Protection Unit.

• Offering Infant Mental Health Assessments in a clinic with the Maternal and Child Health Services.

• Giving out Information Sheets to help people in the community learn about the mental health of babies and toddlers.


A Fresh Start to Infant Mental Health

North East Child and Adolescent Mental Health Service reception



Volunteers.... You Are Worth Your Weight in Gold!

We are proud of our long history of volunteering and the community spirit that is so important to the functioning and support of our local hospitals. This year, to recognise the amazing achievements of our volunteers we held an appreciation breakfast during National Volunteer Week.

We have over 14 different volunteer programs, with approximately 250 volunteers giving their valuable time and energy every week. Some volunteer groups have been serving for many years, such as the Pink Ladies Volunteer Program, which commenced over 40 years ago. Others such as the Ronald McDonald Family Room, which recently celebrated its one year anniversary, are recent additions. What they all share is a great compassion and generosity of spirit for their local health service.

Program Activity Offered at

Pink Ladies Freshen flowers for in-patients Albury and Wodonga

Ward Volunteer Program Provide emotional and social support for Patients in Medical and Surgical Units

Wodonga

Newspaper Trolley Program

Provide a newspaper and magazine trolley service for Medical, Surgical, Obstetrics and Dialysis units at Wodonga Hospital

Wodonga

Palliative Care Volunteer Program

Provide social support, transport, respite and other assistance for palliative care patients and their carers

Wodonga

Chaplaincy Volunteer Program

Provide pastoral care for in-patients at both hospitals Albury and Wodonga

Fundraising Volunteers Fundraising for purchase of equipment Wodonga

Fundraising Auxiliary Fundraising for purchase of equipment Albury

Opportunity Shop Volunteers (Auxiliary)

Fundraising for purchase of equipment and other items Wodonga

Dog Therapy Program Provide social support and diversion for patients in Medical and Childrens Units at Albury Hospital

Albury

Heart Foundation Walker Program

Provide coordination and support to group of walkers, improving their exercise capacity

Wodonga

Ronald McDonald Family Room Volunteers

Provide social support and light duties to support families staying in the Ronald McDonald Family Room who have a sick child as an inpatient at Wodonga Hospital

Wodonga

Some of the volunteer activities that have been conducted throughout the year include:

John and Phyllis Bower with the photo of Paddywack that is now displayed in the Children’s Ward

Enid Antone and Helen Martin, two of our lovely Pink Ladies


Murray and I were excited to be expecting our first baby. My pregnancy had been very normal; I was feeling well and full of energy. I still had a little over 12 weeks left before we were due to welcome Hamish into the world when things took an unexpected and frightening turn.

I woke up on Monday morning and knew that something wasn’t quite right so came into Wodonga Hospital straight away. After having things checked out and the baby monitored I was given the all clear and headed off to work. That afternoon as I was leaving work I didn’t feel that well, I had stomach cramps and more blood loss. This was the last night of our antenatal classes, but rather than going to our classes we found ourselves back in the examination room.

I went from being told that I would need to be admitted to Wodonga Hospital for a few nights to having to be flown by Air Ambulance to Melbourne. This all happened very quickly when it was confirmed that my “cramps” were contractions and they were getting closer together!

I really felt like everyone was over reacting, but I can’t thank the staff who were on duty that night enough as they did everything right by me, and by Hamish. As I was waiting for the plane to arrive Murray went home to pack the hospital bag and Kerrie who had been running our antenatal classes came and sat with me. Having someone that I knew sit with me when I was scared and unsure what to expect really helped. I felt like she really cared about what we were going through and her support was invaluable.

My flight left Albury airport at about 11.30 that night and thankfully my contractions had started to slow. Early Tuesday morning I was admitted to the Mercy Hospital for Women in Melbourne and was later joined by Murray who spent what was left of the night sleeping in a chair beside my bed. By lunch time Tuesday things were looking up with Doctor’s believing I would be home by the weekend. Later that day however, an ultrasound revealed that I was 6 centimetres dilated and Hamish was ready to make his entrance into the world.

I was rushed to the birthing suite where I was closely monitored and given medication that would give both Hamish and I the best chance of a safe delivery. We stayed there until lunchtime Wednesday when it was clear that Hamish needed to be delivered.

Hamish was born at 4.20pm, on 27th October 2010. He was 12 weeks early, weighed just 1,433 grams and was 42.5 centimetres long. Thankfully he was a big baby for only 28 weeks – he must have liked those peanut butter sandwiches I craved!

An Early Christmas Present – Meredith’s Story


Hamish’s first photo with Santa


Hamish just 30 minutes old


Hamish spent four weeks in intensive care in Melbourne before being transferred to the Wodonga Hospital. It took us a while to settle into a new routine in Wodonga and to get used to Hamish not being in intensive care. During this time the Special Care Nursery staff were very supportive, there with tissues when required and words of encouragement on those days when it all felt too much.

We thought it was going to be easier once we were back at home, but the long hours at the Hospital were tough on Murray and I. We were fortunate enough to be able to use Ronald McDonald house during Hamish’s 8 week stay at the Wodonga Hospital. Being able to have a place to just hang out, rest, catch up on some emails and do all the washing a new mum has was a huge relief. Ronald McDonald house is an amazing facility which really helped our family get through this difficult time in our lives.

The staff at Ronald McDonald House went out of their way to make our time at the hospital pleasant. I was really sad when I realised that Hamish would not be able to have a photo with Santa for his first Christmas. I was so surprised and extremely happy when two days later Santa appeared in the nursery!

After 80 days and three days before his due date we were able to take Hamish home.

Murray and Hamish (9months) at home

Meredith and Hamish having a cuddle in the Wodonga Special Care Nursery

Inside Ronald McDonald House


Studying midwifery while working and caring for a family - Joann Crosby’s experience

The midwifery course has been more challenging to me than previous post graduate study, as there isn’t a chance to experience the area before committing to the course. The registered nurse has to agree to the study commitment, work hours and complete change in nursing focus, before stepping foot onto the maternity ward. The intense study requirements, the hours spent on writing worksheets after the shift was over, and the ongoing continuity of care component has meant little time for family when not at work. Whilst at work, I as a student midwife was constantly looking for opportunities to have cares signed off in the workbook and diary and at the same time had to learn to nurse in a completely different way. Support from the staff on the ward was very important to my (and my fellow student midwives) success, and I think their understanding of the challenges we were experiencing helped more than they realise.

The demands of both the work and study has led me to believe that to succeed in the course, one must remain focussed on the many rewards of being a midwife – being a part of that special time in a woman’s life.

Being employed by the hospital, rather than attending a placement has enriched the experience far and beyond what solely attending a university could have.

I am glad I have completed the course, the sense of accomplishment when finishing such a demanding course made the hard year worthwhile.


Mandatory Reporting Requirements

Standard Albury Wodonga Health Achievements

1. AWH demonstrates a commitment to consumers, carer and community participation appropriate to its diverse communities

We have implemented seven of the eight strategies identified in ‘Doing it with us not for us’ to encourage and facilitate participation, these include:• Community Participation Policy.• Community Participation Plan (see page 10).• Recording and reporting on consumer, carer and community participation to the wider community. This

has been achieved throughout the year via various news articles, our two year anniversary newspaper feature, and our Quality of Care Report.

• Cultural Responsiveness Plan (see page 22).• Improving Care for Aboriginal and Torres Strait Islander Patients (ICAP) Program (see page 20).• Ensuring systems, processes and structures are in place to consult and involve consumers, carers and

community members. This has been achieved primarily through our CAC and consumer representation on various Committees and Working Groups. Further enhancement to our participation systems, processes and structures are planned for 2011/12. Building the capacity of staff to support consumer, carer and community participation. This is the primary objective of our newly developed Participation Team (see page 10).

The remaining strategy that we are currently in the process of developing is our Disability Action Plan which is due to be rolled out in late 2011.

2. Consumers, and, where appropriate, carers are involved in informed decision-making about their treatment, care and wellbeing at all stages and with appropriate support

Consumer Participation IndicatorThe Consumer Participation Indicator score on the VPSM offers us an indication of whether patients have felt they have been given the opportunity to participate in their own health care. We are currently exceeding the 75% target with our consumer participation indicator score tracking steadily at around 80.8%1. This score indicates that our patients feel that they are given the opportunity to participate in their own health care.

Maternity Services IndicatorQuestion 2 of the VPSM Maternity Module provides us with an indication of whether women thought they were given an active say in making decisions about what happened during their labour and / or birth. We are currently meeting the 90%1 target for this indicator. This would suggest that the majority of women using our maternity services feel that they are actively involved in the decisions about their child’s birth and labour.

Community Health ServicesWe are currently investigating various methods for determining how satisfied clients / carers are with their involvement in decisions about their community health care and treatment. We are hoping to be able to report our progress on this indicator in future reports.

Mental HealthWe have implemented all of the engagement activities identified in ‘Doing it with us not for us’ to encourage and facilitate participation, these include:• Use of ‘advance statements’ (see page 12-13).• Completion of the consumer self-rated measure (see page 12-13).• Consumers’ co-signatory on individual service plans, treatment and care plans or recovery plans (see page

12-13).• Evidence of consumer held records (see page 12-13).


Participation Indicators – Doing it with us not for us: strategic direction 2010-13This section of our Quality of Care Report details our progress towards achieving the five new standards for consumer, carer and community participation as required by the Department of Health. These indicators were developed to monitor the implementation of the Victorian Government’s Doing it with us not for us Strategic directions 2010-13.

This is the first year we have been required to report on these indicators and we look forward to monitoring our progress towards achieving them over the coming years. It should be noted that due to not previously reporting on these items, in some instances we were unable to collect hard data on our performance. Measures are currently being put in place to improve our ability to report on all participation indicators in the future.



3. Consumers, and where appropriate, carers are provided with evidence-based, accessible information to support key decision-making along the continuum of care

Consumer Information ResourcesProcesses currently exist within our Quality Unit to ensure that all consumer information is evidence based and accessible. We are in the process of developing a process to enable us to utilise the Department of Health’s Checklist for Assessing Written Consumer Health Information. This will assist us in ensuring that the information we provide is evidence based and easy to understand.

VPSM IndicatorQuestion 20 (item 2) of the VPSM offers us an insight as to whether our patients think that the written information on how to manage their condition and recovery at home is good to excellent. We are currently exceeding the 75% target with a result of 85%1. This indicates that our patients are relatively happy with the quality of information they receive for taking care of themselves after leaving the hospital.

4. Consumers, carers and community members are active participants in the planning, improvement, and evaluation of services and programs on an ongoing basis

Consumer participation across Albury Wodonga HealthWe are committed to actively involving consumers, carers and community members in the planning, improvement processes and evaluation of our services. To this end, we have implemented all of the participation dimensions identified in ‘Doing it with us not for us’ to encourage and facilitate participation, these include:• Strategic planning. The CAC was involved in the review of our Strategic Plan and will have the opportunity

to be involved in our Service Plan development during 2011/12.• Service, program and community development. This is primarily achieved via the implementation of our

CPP (see page 10).• Quality improvement activities. Our Quality and Clinical Governance Committee includes consumer

members (see page 32).• Developing and monitoring feedback, complaints and appeals systems and in the review of complaints.

Both the Quality and Clinical Governance Committee and CAC regularly review the complaints, compliments and feedback received.

• Ethics, quality, clinical and corporate governance committees. Consumer representatives sit on the Albury Wodonga Human Research Ethics Committee and others previously mentioned (above).

• Consumers, carers and community members are involved in the development of consumer health information. Our CAC has reviewed various consumer health information material throughout the year.

5. AWH actively contributes to building the capacity of consumers, carers and community members to participate fully and effectively

Supporting consumers, carers and community membersDuring the year we have developed an orientation and training program for our CAC. Our CPP also outlines the following initiatives to support consumers that will be implemented during 2011/12:• Development of a consumer orientation and training kit for consumers on AWH committees.• Development and trial of evaluation process of the consumer experience on AWH Committees.• Utilise training resources offered through the Health Issues Centre.• Attend AWH staff training events.Members of our CAC have also attended various information sessions and conferences throughout the year.

Mental HealthOur mental health unit has involved consumers and carers in the delivery of in-service training throughout the year (see page 12-13). Further improvements to our ability to report on this indicator are planned for the coming year.

Note:1 Results were taken from the VPSM Wave 19 which covers the period July to December 2010 and does not include the Albury Hospital


Improving Care for Aboriginal and Torres Strait Islander Patients (ICAP) program


1. Establish and maintain relationships with Aboriginal communities and services

We have continued to strive towards improved care for Aboriginal and Torres Strait Islander Patients. Partnerships continue to strengthen through the Albury Wodonga Aboriginal Health Reference group who are actively working as a collective on the Albury Wodonga Aboriginal Strategic Plan.

2. Provide or coordinate cross-cultural training for hospital staff

Cross cultural training continues to be provided to staff and we are in the final stages of completing our cross cultural package; this is being presented to our local Aboriginal services for evaluation.

3. Set up and maintain service planning and evaluation processes that ensure the cultural needs of Aboriginal people are addressed when referrals and service needs are being considered, particularly in regard to discharge planning

We have two representatives at the Closing the Health Gap Hume Region steering committee and the Client Journey working group. We will also continue involvement to implement the recommendations that will improve the client journey back to primary health.

4. Establish referral arrangements to support all hospital staff to make effective primary care referrals and seek the involvement of Aboriginal workers and agencies

The Aboriginal Services Directory located on the intranet is promoted at cross cultural training and during our in service sessions to staff. We employ an Aboriginal Hospital Liaison Officer who provides support across the organisation. This role enables the ongoing sharing of cultural expertise to treating staff, reassurance to Aboriginal and Torres Strait Islander patients and a vital link with referrals back to primary health.

Making Two Worlds Work - General Health artwork


Making two worlds work; changing hearts, minds and practiceMaking Two Worlds Work’ is a local project about starting change. It is about changing:

• Hearts.• Minds.• The way things are done.

It is about changing the way health services and Community services work with people in the Aboriginal Community. It is about helping services act in ways appropriate to the Aboriginal culture.

This project is run by both the Mungabareena Aboriginal Corporation and Women’s Health Goulburn North East (WHGNE). It is also supported by Albury Wodonga Health and the Upper Hume Primary Care Partnership (UHPCP).

People from the community and staff from these services have worked together to make a resource kit. The resource kit includes:

• art work.• easy to get information on the web.• resources to help improve how they provide

services.

Albury Wodonga Health has welcomed the ideas in the project. For three years we have been using the resources in ways such as:

• Using the symbols of welcome everywhere in the hospital.

• Two paintings hang in the entrances to the Maternity Ward and Allied Health Unit.

• Posters showing important parts of Aboriginal Health and Wellbeing are put on view in busy areas.

• Many of our information pamphlets and books use the art work from the resource kit.

The resources have helped us to change the culture of the hospital. For example the audit tool was used to evaluate the hospital’s cultural awareness training.

Staff who have finished the cultural awareness training are given badges showing the art work. They can pin these badges to their name tags.

Working together with people from the Aboriginal community on this project has added:

• more respect.• more trust.• more confidence. • stronger partnerships.• authentic partnerships.• long –term partnerships. between people in this area.

Maternity Ward, Wodonga Hospital - Making Two Worlds Work, Kinship Square artwork



Cultural Responsiveness Plan – Cultural responsiveness framework: guidelines for Victorian health services


1. Whole of organisation approach to cultural responsiveness is demonstrated

The Cultural Diversity Plan is in place. We are currently reviewing existing policies and procedures to ensure they link in with the plan and are relevant to the organisation.

2. Leadership for cultural responsiveness is demonstrated by the health service

We are currently identifying opportunities for new and improved initiatives and resources through the CPP and public feedback process.

Staff have attended Cultural training days.

3. Accredited interpreters are provided to patients who require one

A working group has been established to identify the key languages and number of people in our community requiring interpreter services. New posters with relevant languages will be placed around both hospitals.

4. Inclusive practice in care planning is demonstrated, including but not limited to dietary, spiritual, family, attitudinal, and other cultural practices

Both Albury and Wodonga Hospitals will be participating in the Victorian Patient Satisfaction Survey during 2011/12. The feedback we receive from the VPSM will be used to improve our current service. We have also established a Food Services Committee which will review culturally diverse dietary options.

5. CALD Consumer, carer and community members are involved in the planning, improvement and review of programs and services on an ongoing basis

Prior to submitting our Cultural Diversity Plan, feedback and opinion was sought from the CAC who continued to have input and updates on the progress of the Plan.

There are strong relationships with local indigenous groups (see page 20-21).

6. Staff at all levels are provided with professional development opportunities to enhance their cultural responsiveness

Regular Cultural responsiveness workshops are run through Wodonga TAFE which staff are supported to attend. Cultural responsiveness is to be incorporated into the orientation process for all staff with resources available via the intranet for ongoing professional development.

We developed and submitted our first Cultural Responsiveness Plan in December 2010. This plan aims to address the six minimum reporting standards set down by the Department of Health. Our performance against these standards is provided below:

Taste of Harmony lunches were hosted at both hospitals to celebrate our workplace diversity in the most delicious way! The delicious smells wafting through the corridors enticed staff and visitors to take a tasting trip around the world and the chatter around the tables included people’s experiences whilst travelling to other countries as well as stories from their cultural backgrounds, including some secret family recipes.

A huge thank you to the catering staff from both hospitals. Your enthusiasm and hard work made this day a success to be remembered by all of us.

A taste of harmony


Wendy Small at work in the Wodonga Hospital Kitchen


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Ann and Lidsay Jarvis at home in the Kiewa Valley


We aim to ensure that all patients who enter our facilities are provided with safe, effective and efficient patient centred care.

All patients undergo a comprehensive assessment when they arrive at our hospitals. These assessments help us identify people who may have difficulty in looking after themselves at home, or in their current care facility. Once identified these patients and their carers work with our Multidisciplinary Team to maximise their functional ability so they can leave our hospitals appropriately and safely.

Our approach values communication and we ensure that patients and their carers are part of the care plan, treatment and arrangements necessary for them to leave our hospitals.

We have implemented the following strategies to improve patient centred care within our hospitals:

• Development of Patient Information Brochure.

• Nurse bedside handover.

• Provision of information regarding resources available in the community and at local hospitals to ensure safe and appropr iate suppor t.

• Monitoring of those patients who are readmitted to hospital to identify whether we could do things better.

Ensuring Safe, Effective and Efficient Patient Centred Care

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After being diagnosed and undergoing treatment for cancer Rhonda Plumb has been using our palliative care and district nursing services. During an interview at her home Rhonda shared her experience of these services.

“The district nurses have been coming to my home for almost eleven months now. They are good; they work in with my doctor’s visits and blood tests. And, I can change their time if I can’t make it. I have got to know them all and they are all lovely”.

What do you like about the district nursing visits?“The questions I can get answered. Sometimes I don’t take in everything at the oncologists and I get home and I’m not sure. So I ask them (district nurses) and they sort all that out for me. I can ask them about anything and they take my blood pressure. They deal with my issues here at home and I don’t have to go out.”

How does palliative care help you?“Well, it was the equipment at first. I could not turn over in bed without my bed pole. And the chair in the lounge is great and so is my wheelie walker. I can only walk so far and if I can sit down for a couple of minutes, then I’m right.

I find palliative care reassuring and then of course there is Jean (palliative care volunteer). It’s just nice to have someone different to talk to, because there are things you don’t tell family, things they won’t discuss. With Jean I can talk about anything I like.

I find the care has been wonderful. I had never been sick in my life and now this and I didn’t realise there was anything out there until I was in Albury Hospital and a nurse asked if I minded if she got in touch with district nursing and palliative care and I said okay. Until then we were just muddling along by ourselves and my husband had to go back to work, because the bills keep coming.

They organised for a lady to come from the council to help me with showering and the things I can’t do. And they organised for my tests be taken at home too.”

Palliative Care and District Nursing

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Rhonda Plum and Jean Wirges (volunteer) enjoy a cuppa


During 2010 our Community Health team worked with Mungabareena Aboriginal Corporation, the Local Aboriginal Education Consultative Group and Melrose, Wodonga and Wodonga West Primary Schools, children and parents on the Healthy Lunchboxes project.

The project was developed through consultation with indigenous community members. The aim was to promote healthy eating habits in children, improve knowledge about healthy lunchbox choices and expose the children to a range of healthy lunchbox choices that include traditional ingredients.

We held two sessions in each primary school, catering for Koorie students from prep to six. The sessions included activities about food groups and healthy lunch box choices. Students then decorated lunch box posters with pictures of foods they would include in a healthy lunch box. Each poster was laminated and children were able to take it home to put on their fridge.

The project also introduced children to basic cooking skills. The cooking session saw groups of four or five students given a healthy lunch box snack to cook using a traditional indigenous ingredient. Children were keen to take the food home to share with their families. Children were also provided with a lunch box containing toothpaste, a toothbrush, a small snack container, a healthy lunch box snacks recipe booklet and a balloon.

A total of 61 indigenous students participated in this successful project.

Many patients receive health care without being admitted to hospital. Care is delivered by our nursing and allied health staff either in the person’s home or in the community health centre in consultation with the person’s doctor. People who receive help may have diabetes, heart or lung problems, foot problems, eating problems, or need help adapting to the changes in life that ageing brings.

Our service aims to keep people healthy by encouraging healthy lifestyle choices such as healthy eating, exercise, giving up smoking and encouraging immunisation. We focus on assisting people to take control and live a healthy and active life.

Assisting People to Take Control and Live a Healthy and Active Life

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Healthy lunchboxes an early intervention initiative


Lindsay and Ann Jarvis are energetic and vibrant members of the Kiewa Valley community whose lives were turned upside down during their involvement at the United Dairy Farmers of Victoria conference in May 2010. Lindsay suffered a severe haemorrhagic stroke leaving this normally active and articulate man without speech and use of the right side of his body. After spending two nights at Echuca Regional Health, Lindsay was flown to Cabrini Hospital (Malvern) where he experienced a life threatening crisis. The next three and half weeks required total nursing care which was essential to ensure Lindsay’s survival and future rehabilitation.

After a road ambulance trip he arrived at the Wodonga rehabilitation unit still unable to speak or move his right side. During his nine week stay Ann describes the care and attention of the rehabilitation team as exemplary. “It is testament to their hard work, skill and commitment, that at the end of this time, he was walking and talking” Ann said.

Following Lindsay’s return home he had two further setbacks to his recovery with unexpected returns to the Wodonga emergency department and medical ward. Ann commented “that under extreme duress the emergency staff performed heroically”.

The Road to Recovery - Lindsay’s Story

Ann and Lindsay Jarvis at home in the Kiewa Valley Lindsay playing Wii Tennis as part of his rehabilitation

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When Lindsay was finally given the all clear to come home again, he and Ann were faced with a difficult decision. Lindsay was given the opportunity to participate in the Transition Care Program either in the home, or as a patient at Yackandandah Bush Nursing Hospital. Lindsay chose to enter the hospital despite his already long stay and became the first patient in the Indigo Shire to experience these services. “It was the turning point in my recovery. I had intensive speech, occupational and physiotherapy plus diversional therapy in the form of interactive social activities with Yamaroo Hostel residents.” Ann explained the service as simply “magic”.

During his stay at Yackandandah Lindsay describes the process the speech pathologists used to help recover his written and oral communication “They encouraged me to begin writing a diary even though I couldn’t recognise the letters of the alphabet or single numbers. Thoughts from my brain did not translate to the pen but after a period of weeks there was a dramatic improvement. I was so happy to be able to write a ‘Happy Birthday’ message to my grandson, even though it took me all morning!”

Six months after his return home, and twelve months after his initial stroke, Lindsay was able to return to where it all began. Lindsay was inspired by his therapists to set a goal to attend the 2011 United Dairy Farmers of Victoria

conference. Lindsay explained that he has attended every one of the past 30 conferences and did not want to miss this one. As part of his therapy he planned, wrote and finally presented a speech to the conference.

Albury Wodonga Allied Health staff say that Lindsay’s determination, positive optimistic attitude and edifying work ethic, along with the support of his family and community has been the key to his recovery.

Lindsay still has a long way to go, filling in the gaps, but we all believe he will get there!

Lindsay receiving treatment from Kate Dahl (Physiotherapist) at the lymphodema clinic

Lindsay and Lara Castles (Speech Pathologist) reviewing the diary as part of his speech therapy


Supporting the recovery process - transition care

When an older person is admitted to hospital they often experience changes in their physical ability and function as a result of being unwell. Making a full recovery can be a slow process. Transition Care is a program that assists older people by supporting the recovery process either in the person’s own home or at one of the hospital’s partner facilities. An example of this is a 96 year old lady on the program recovering after an operation for a hip fracture. She is slowly building strength in her legs so she will be able to walk as confidently as before and return home with the support of her family.

Wodonga Hospital provides the Transition Care program in 16 locations across the region. The main aim is to assist older people in their recovery after a hospital admission through offering a combination of therapies, such as example physiotherapy and occupational therapy, service support and coordinated care. It also provides an opportunity for clients and their carers to consider long term care arrangements which may include living independently at home or looking at permanent care options.

People can access Transition Care in their own homes and also at a number of partner facilities including Westmont Homestead, Yackandandah Bush Nursing Hospital, Beechworth Health Service and Tallangatta Health Service. The strong relationship Wodonga Hospital has with its partner facilities means people have the option to continue their recovery close to family and home which is important to regional communities.

Leonie Bell, Diversional Therapist (Yackandandah Bush Nursing Hospital)


My Health, My Life; enhancing health literacy and self management of chronic illnessMY HEALTH, MY LIFE! is a four week chronic disease self management group program, followed by individual health coaching sessions over a period of six months. An initial health coaching session is conducted face to face, with follow up sessions conducted over the telephone. The program aims to encourage and support people with chronic conditions and their carers to independently lead a lifestyle that optimises their health potential.

MY HEALTH, MY LIFE! was developed at the Wodonga Hospital and has been successfully trialled at Tallangatta Health Service, Upper Murray Health and Community Service, Beechworth Health Service, Indigo North Health Service, Numurkah District Health and Yarrawonga District Health Service. It has also recently been trialled with the local Aboriginal community.

What participants have said about MY HEALTH, MY LIFE!

“I used to say ‘unwell’, now I explain better”

“I ask questions at the doctors, I never used to ask questions before the program. I am more confident to ask and get more details”

“I can talk to my wife and children about how I am feeling. I wasn’t able to do this before group”

“I have more positive thinking, more self belief”

“Cutting down beer was a bit stressful. I don’t have any on Mondays or Tuesdays. I use positive self talk.”

“I learnt to accept my condition, in a personal sense, not a medical sense. I look in the mirror, its a par t of me and I accept it ”

“I’m more healthy on the inside. Definitely not the same person who went to that group... Positive comes up a lot, but I am. I feel dif ferent”

“I don’t have too much stress these days... Perhaps I’ve changed the way I’m looking at things”

“I went and bought a car, it (the course) built confidence and self esteem”


AWH Elective Surgery Access UnitOur elective surgery access unit has been changing the way we do business to improve the quality of pre-operative care for patients who are having elective surgery, and to meet Department of Health access targets.

During the year we combined the Albury and Wodonga elective surgery waitlists which involved undertaking a comprehensive audit of the new combined waitlist. This process gave us the opportunity to identify areas of improvement the first of which was to centralise the elective surgery access unit into new offices at the Albury Hospital. This will have huge benefits in the form of improved communication and access to patient information.

A further improvement has been to implement an enhanced model of care which ensures that a patient is managed by the same administrative and clinical staff members from the time they submit their paper work until they have their surgery. The improvements we have made in this area will offer many benefits to patients and their families, including:

• Improved access and care in the lead up to their elective surgery.

• Enhanced communication with surgeons and staff.

• Improved flow of elective patients through the hospital theatres.

Pathology services at the Albury and Wodonga Hospitals have traditionally relied on courier services with samples tested offsite. During the year we reviewed the provision of these services which resulted in the contracting of Dorevitch Pathology to provide the service across both hospitals.

We now have a laboratory operating onsite at both hospitals. This has improved our turnaround times and greatly enhanced our ability to respond to emergencies.

A further enhancement in the form of a ‘chute system’ to enable the delivery of samples directly from other units within the hospital to the laboratory will be implemented over the coming months.

Dorevitch Pathology - Enhancing turnaround times and response to emergencies

continuityofcare Albury Wodonga Health

Responding to Demand

Theresa Richards at work in the Dorevitch Pathology laboratory, Wodonga Hospital

AWH Elective Surgery Access Unit


Transporting our patients safely

Our patient transport department has been slowly establishing itself over the past few months with its launch held on the 1 July 2011. This new initiative offers our patients transport to other facilities, hospitals, appointments or home. These transfers can take us as far as Corryong to Deniliquin to Wagga Wagga to Wangaratta - wherever our patients need us to take them.

Our dispatch officer, two drivers and a nurse escort all work together to ensure a smooth and safe operation for our patients. Keep an eye out for us in our green and black shirts.

The patient transport department has also just become partners with the Royal Flying Doctor Service and is very excited by the opportunity to have non-emergency patient transport flights anywhere in Victoria and New South Wales. We are thrilled to have the Royal Flying Doctors on board and our partnership so far has proven to be effective and very safe.

Not only is our department designed to give our patients that warm personal touch to patient transport, it is also a major cost saver for the organisation and will allow NSW and Vic ambulances to attend to higher priority cases.

In June 2010 our Dental Clinic relocated to a new state-of-the-art ten chair facility at 155 High Street Wodonga occupying the basement of the Gateway Community Health Centre. This clinic has five chairs dedicated to the Community Dental Clinic Program. The other five chairs support the Student Training Program which is a partner initiative with Latrobe University Bendigo.

Dental students began their first clinical rotation at the new clinic in July 2010. These students are supervised mostly by experienced dentists currently working locally in private practice and who have chosen to give back to the community through supporting the Latrobe program.

The Student Training Program has allowed us the opportunity to shift our focus to Oral Health Promotion within the community. Throughout the coming year we will be looking at developing linkages with S4M (a program developed to educate preschool children and their parents), Aboriginal Health, Child and Adolescent Mental Health, Drug and Alcohol, and Aged Care to further this activity.

The expansion of our facility and the dental student program has increased the number of patients we were able to see by 1,000 in 2010/11 compared to 2009/10. This is having a significant impact on reducing our waiting lists.

Wodonga Dental Clinic

Soroush Adel, Maree Kelly and Sam Navidi at the Wodonga Dental Clinic

AWH Patient Transport Vehicle


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AWH Patient Transport Vehicle


We are all responsible for reducing risks and improving the quality of clinical care within our hospitals. To help us meet this responsibility we have a clinical governance program which is based on the Victorian Clinical Governance Policy Framework. This framework includes four key areas of:

• Consumer participation• Clinical effectiveness• Effective workforce • Risk management

As part of this program we work together to identify clinical risks, monitor performance and improve outcomes in key areas such as medication safety, patient falls and uplanned readmissions. This system of reporting, monitoring and cross-checking by people with a range of skills and across the health service allows us to identify any emerging trends and act on them accordingly.

For significant incidents a formal Root Cause Analysis is undertaken by an independent team. These teams are established as needed and consist of staff with relevant expertise and experience. Following their analysis the teams make recommendations for change that will prevent or significantly reduce the risk of a similar incident occurring again.

The Clinical Governance program is overseen by the Board Quality Committee.

We are Continuously Monitoring Clinical Care

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Risk managementWe all share the responsibility to identify and manage risks. This process is a part of the way we go about our daily business within the health service. Activities ranging from strategic planning to individual work functions all address risk management.

Our commitment to risk management has been further strengthened throughout the year with the development and adoption of a new Risk Management Policy and Framework. This “cascading” model allows every department to identify risks relevant to their area and those risks then feed into our risk register. Improvement activities are targeted to address identified risks. The purchase of new software which allows links between incidents, the risk register and quality improvement activities will assist us in ensuring coordination of all risk management and improvement activities.


We provide emergency and general dental care to eligible Victorian residents via the following five main programs:

• Early Childhood Oral Healthy Program• Child Dental Program• Youth Dental Program• Community Dental Program• Dental Student Program

Tracking our performance against other dental services and the state average offers us an important tool for identifying areas of improvement. Our 2010/11 dental services performance is detailed below.

Dental Services Performance

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Notes:Restorative dentistry aims to preserve tooth structure, protect the dental pulp, eliminate decay and replace missing tooth structure. Correct diagnosis, treatment planning, case selection and material selection are required for a successful restoration. State average return rate has remained the same as 2009/10 figure of 5.1% however our restorative return rate has shown an improvement from 2009/10 figure of 5.9%.

The aim of providing treatment to patients presenting for emergency care is to address the immediate emergency problem (e.g. pain). An appropriate measure of quality in this area would be to identify patients where care has failed to resolve the initial emergency problem. State average repeat emergency care rate has increased from 2009/10 figure of 5.3%. Similarly our repeat return rate has also increased from 2009/10 figure of 4.7%.

Complications following tooth extraction generally occur within 7 days of the extraction. Such complications can be minimised by actions taken by the dental team. Such measures include the checking of the medical history, minimising operative trauma, providing the patient with post operative instructions and where required, the prescribing of antibiotic and/or analgesics. State average unplanned return rate has remained the same as 2009/10 figure of 1.0% however our unplanned return rate has shown a significant improvement from 2009/10 figure of 2.6%.

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What does this mean for Albury Wodonga Health Doctors?Our credentialing system ensures that all doctor’s qualifications are verified on appointment and that they provide proof of ongoing registration annually.

In addition to credentialing of medical staff on appointment, processes have been implemented for annual and triennial review. This system is based on the Victorian Department of Health’s Credentialing and defining the scope of clinical practice for medical practitioners in Victorian health services guidelines. Further refinements to medical credentialing and scope of practice are planned based on the Victorian Department of Health’s Partnering for performance policy and guide.

Scope of practice for non-medical staff is defined in position descriptions and reviewed annually through the performance planning and review process. We now have access to the Australian Health Practitioner Regulation Authority (AHPRA) facility of Multiple Registration Checks. This will allow us to engage AHPRA to undertake the checking of registrations for all professional groups that require registration with AHPRA.

Complaints Management

We are committed to improving our service by working with consumers and responding to consumer feedback. Both formal and informal feedback assists us to learn what we are doing well and where we need to improve.

As our organisation has evolved, we have refined the way we manage complaints, with an emphasis on responding quickly, in person, and directly to the person providing the feedback. We monitor all compliments and complaints, and trend and summary data is reported in a range of forums including internal management meetings, Community Advisory Committee meetings and Board Quality meetings.

Areas in which we commonly receive positive feedback include quality of care and cleanliness of rooms. The areas in which we are striving to improve are the provision of adequate explanations of plans of care, and waiting times.

We have implemented the following improvements as a result of consumer feedback:

• Improved communication with patients and between departments when referrals are made to the fracture clinic.

• Frosting added to windows in the Emergency Department.

• Increased car parking spaces.

We also participate in the Victorian Patient Satisfaction Monitor program, which is administered by an independent organisation. Our results from this survey are consistent with or slightly higher than comparable hospitals across Victoria and have remained at consistent levels throughout the year.

Credentialing and Scope of Practice

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Credentialing is a formal process of checking qualifications, experience and professional standing of clinicians. Scope of practice follows on from credentialing and outlines what is appropriate clinical practice for a clinician within a particular setting, based on the qualifications of the clinician and the capability of the organisation.

AWH international Medical Graduates - Dr Sajee Fernando, Dr Kathy Ebert and Dr Anuradha Tillekeratne


Falls are a common problem for older people and are often the reason people are admitted to hospital. Falls within hospital can cause additional complications and increased lengths of stay.

Preventing falls and minimising harm from falls continues to be a major focus for Albury Wodonga Health.

The Falls Committee provides an interactive forum for monitoring and evaluating falls incidents, applying strategies for falls prevention and improving management of falls within the health care setting. The Committee has been instrumental in standardising the clinical tools and processes used across both Wodonga and Albury Hospitals.

Some positive outcomes of the Committee so far include: a revised Clinical Screening tool, which directs staff to the more comprehensive Falls Assessment tool. This allows further assessment of high risk patients, as identified from the screen.

Once the patient’s risk has been rated, a Multidisciplinary Care Pathway will be completed which ensures that particular patient needs are met. These include items such as history of previous falls, mobility constraints, types of medications, eyesight issues, mental status, environmental influences and elimination problems.

It is important that the hospital staff work together with the patient and their families to reduce the risk of falling.

Staying Upright – Falls Prevention

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April falls day - we all love a good dress up!

Staff at Albury Hospital dressed in orange on the first day of April to increase falls awareness. The day included quizzing staff on falls prevention. The answers were later shared over a tasty lunch. Falls prevention is a high priority for everyone at Albury Wodonga Health. April Falls Day was successful in making everyone think and talk about falls and what we can do to reduce these incidents in our Hospitals.

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Inpatient Falls July 2010 to June 2011


Maintaining a safe environment for our patients, staff and visitors is the main aim of the Albury Wodonga Health Infection Prevention and Control program. We are extremely vigilant in our aim to keep our patients safe by preventing the spread of the organisms that cause hospital associated infections.

Hand hygiene is a simple, low-cost and extremely effective approach that we use to prevent infections. We actively participate in the World Health Organisation’s “SAVE LIVES: Clean Your Hands” campaign and use the “Aussie 5 moments for hand hygiene” as a reminder to everyone about the importance of cleaning your hands. We check on how well our staff are performing by auditing hand hygiene performance. Results of these audits show that we have exceeded the Victorian Department of Health target of 60% and the Australian average of 68%

compliance. Visitors to the hospital are encouraged to use our alcohol based hand rubs called DeBug™ in Wodonga and Avaguard ™ in Albury.

Watching for infection risks is another major part of our infection prevention and control program. We do this by participating in the Victorian Hospital Acquired Infection Surveillance System (VICNISS) and review all caesarean sections, total hip and knee replacements and gall bladder surgery as well as blood stream infections, especially in our high risk patients in the intensive care and haemodialysis units. While we strive for and frequently achieve zero infections, reports show that our infection rates continue to remain very low and compare favourably with other Victorian hospitals.

A Combined Program for Preventing and Controlling Infections

qualityandsafety


Assessing our performance by reviewing our compliance with the Australian Infection Control Guidelines and the Standards that govern the cleaning and sterilization of instruments is an important measure to ensure the safety of our patients. We regularly achieve above average results in these audits and reviewing our performance and the recommendations from these audits allows us to identify risks and implement changes where needed.

Environmental cleaning plays an important role in ensuring the safety of our patients. To make sure we continue to achieve a high standard of cleanliness, we audit cleaning processes against the Victorian Cleaning Standards. Our cleaning rates are consistently improving and we are

exceeding the Victorian standard targets of 90% in very high risk areas and 85% in high and moderate risk areas. Feedback from our patients reported in the latest Victorian Patient Satisfaction Monitor showed that we obtained especially high performance scores for the cleanliness of the patients’ room. Our latest external audit report shows a significant improvement from an average of 91.8% to 99% overall.

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SAFE USE OF BLOOD AND BLOOD

PRODUCTS

Pre-transfusion sampling

Consent / patient Information

Reaction / Incident Reporting

Storage and Handling

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ordering

Credentialing /educationprogram

Blood productadministration

Laboratory / Blood bankprocesses

What are blood products?All blood products transfused at our hospitals come from the Red Cross Australia. The Red Cross blood bank has multiple collection centres around Australia where people from the community voluntarily donate blood for use in our hospitals and emergency services.

The blood is screened for bacterial and viral contamination and processed into differing components. After testing and processing the blood is then made available to pathology laboratories and hospitals. The products produced include concentrated red cells, plasma, platelets, and various clotting factors.

Prior to a patient receiving a blood product a sample of their blood is taken and sent to the pathology lab for testing. The tests determine your blood group and match you to the product reducing the risk of a transfusion reaction.

Blood and blood products are used at both hospitals to treat people having surgery and those who have suffered an injury.

Using blood products safelyTo assist us improve the safety of delivery of blood products our nursing staff receive specialised training in pre transfusion sample collection and administration of blood products with a focus on early recognition of a transfusion reaction.

All staff involved with blood and blood product prescription and administration complete a two hour internet based training program yearly. This program is called Bloodsafe and is a program provided by the South Australian Department of Health, Australian Red Cross Blood Service and Transfusion Medicine Service.

Bloodsafe encourages standardisation of transfusion practice, reporting of adverse events and increased patient information and choice around transfusion. All adverse events are reported through a central reporting tool that collects data throughout all Victorian Hospitals.

We scrutinise and investigate all adverse events via the Blood Transfusion Committee which meets monthly to discuss blood and blood product issues.

Safe Use of Blood and Blood Products

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Blood Transfusions 2010/2011


• Acute Geriatrics• Anaesthetics• Breast Surgery• Cardiology• Chemotherapy• Colorectal Surgery• Critical Care• Day Procedure Unit• Dialysis Unit • Dental• Dermatology• Diagnostic GI Endoscopy• Drug and Alcohol• Ear, Nose & Throat• High Dependency Unit• Emergency Department• Endocrinology• Facio-maxilliary Surgery• Gastroenterology• Gynaecology• Haematology• Head & Neck Surgery• Immunology and Infections• Interventional Cardiology• Medical Diagnostic Clinics• Medical Imaging Services• Medical Oncology• Mental Health• Neurology• Obstetrics• Ophthalmology• Orthopaedics• Paediatric Medicine and Surgery• Pain Management• Palliative Care• Pathology • Plastic & Reconstructive Surgery• Neonatology• Rehabilitation Medicine• Renal Medicine• Respiratory Medicine• Rheumatology• Upper GIT Surgery• Urology• Vascular Surgery

• Aboriginal Health• Antenatal Classes• Cardiac Rehabilitation• Chronic Disease Management• Community Midwife Program• Community Health & Health Promotion• Community Rehabilitation Centre• Continence Clinic• Diabetes Education • Dietetics• District Nursing• Drug and Alcohol • Fracture Clinic• Health Information Management• Hospital Admission Risk Program• Hospital in the Home• Hydrotherapy• Immunisation• Inpatient Allied Health Services• Lymphoedema Clinic• Meals on Wheels• Occupational Therapy• Pacemaker Clinic• Pain Management Program• Palliative Care• Perioperative Service• Pharmacy• Physiotherapy• Podiatry• Post Acute Care Program• Pre-Admission Services• Public Dental Service• Public Health Clinic• Rehabilitation Clinic• Rural Allied Health Team• Social Workers• Speech Pathology• Sexual Health / Family Planning Clinic• Stomal Therapy• Transition Care Program

qualityandsafety

Appendix 1 – Albury Wodonga Health Services

Outpatient and Allied HealthSpecialties


Appendix 2 – Glossary

Term Definition

Allied Health A group of medically prescribed health-care services, such as occupational therapy, speech pathology, and physical therapy, provided by licensed professionals

AWH Albury Wodonga Health

Carers Families and friends providing unpaid care to consumers

Clinician A practicioner who works directly with a patient.

Community Advisory Committee (CAC)

An advisory committee to the Board and one way in which we actively involve community members in improving the services we provide

Consumer People who are current or potential users of our services

Continuity of Care Uninterrupted health care for a condition from the time of first contact to the point of resolution or long-term maintenance

CPP Community Participation Plan (see page 10)

Dialysis A process of filtering and removing waste products from the bloodstream

Endoscopy Visual examination of interior structures of the body with an endoscope

GI Gastro Intestinal

GIT Gastro Intestinal Tract

Inpatient Someone who requires an overnight stay at the hospital

Maternity The care of women at childbirth and their newborn babies

Midwifery The practice of assisting at childbirth

Oncology Medical care of people with cancer

Ophthalmology Medical care of the eyes

Orthopaedics A medical specialty concerned with the skeletal system, especially the extremities and the spine, and associated structures, as muscles and ligaments

Paediatrics Medical care of children

Palliative Care An approach to health care that is concerned primarily with attending to physical and emotional comfort rather than effecting a cure

Participation Occurs when consumers, carers and community members are meaningfully involved in decision-marking about health policy and planning, care and treatment, and the wellbeing of themselves and the community

Pathology The study of disease by the use of laboratory tests and methods

Peri Operative The care given before, during and after surgery

Renal The kidneys

Surgicentre A place where minor or ‘same day’ surgical procedures are performed

Thrombolysis Disolving a blood clot / thrombus

VPSM (Victorian Patient Satisfaction Monitor)

A survey that asks patients about how they felt about their stay in hospital. Results from the survey are used by hospitals to identify ways that they can improve

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How did you obtain this report?

Sent Directly AWH Waiting Room

Via Staff Member Via Internet

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Information Provided:

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Presentation:


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If you have ticked “Poor” or “Fair” please let us know how we may improve.

What other information would you like to see included in the report?

We need your feedbackWe rely on your feedback to ensure the Quality of Care Report continues to provide the information you want about the safety and quality of your health services.

Please complete the feedback form to the right and either:• Return via reply paid mail (details on the reverse side

of this page)• Return in person to the main reception at either Albury

or Wodonga Hopsital• Simply send us an email at [email protected]

AlburyWodonga

Health

Albury Wodonga Heath Annual Quality of Care Report

2010/2011 What do you think of our Report?

We value your feedback so we can ensure our futurereports meet your needs.

Our financial reports are located in a separate report which can be viewed on our website at www.awh.org.au

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ContributionsThis report was written by many people, our thanks go to everyone for their willing participation. Special thanks go to the AWH Quality of Care Working Group and the following community members who contributed stories:

• Lindsay and Ann Jarvis• Rhonda Plum• Jean Wirges• Joann Crosby• Meredith Wallace• Liz Hare

Photography CreditsWe give our thanks to everyone who willingly acted as a model for these photographs; patients, staff and community members.

The majority of images used in this report were captured by Ellen Maclaine with other contributions by staff and community members.

A special thank you to Albury Wodonga News Weekly for providing the photograph on page 17.

EnquiresAny enquiries regarding the information presented in our Quality of Care Report can be directed to AWH via email at [email protected] or telephone 02 6051 7546.

Albury Wodonga HealthPO Box 326

Albury NSW 2640ABN: 31 569 743 618

Albury HospitalBorella Road

Albury NSW 2640Ph: 02 6058 4444

Fax: 02 6058 4528

Wodonga HospitalVermont Street

Wodonga VIC 3690Ph: 02 6051 7111

Fax: 02 6051 7477

quality of care report 2010/2011 - awh.org.au to the community as possible. we encourage ... urana...

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