Quality of Care report for 2011-2012. - South West Alliance of Rural

QOC - food saftey [ ]1

QOC our community

What is Credentialing?

Moyne HealthyKids Project

Floyd - a man of his word

BEIMS - enhancing care

Moyne Health Services

quality of care Report 11/12

Introducing Moyne Health Services

3 MessagefromtheChiefExecutiveOfficer

4 WelcometotheQualityofCareReport

4 OurVision,MissionandValues

5 OurHighlightsandDisappointments

5 StrategicQualityGoals

6 Victoria’sOldestCountryHospital

OurLongevity-163YearsofServicetoThePortFairyCommunity

Our Governance

8 BoardofManagement

10 GovernanceinHealthcare

11 CredentialingforHealthProfessionals

11 CredentialingofClinicalStaffatMoyneHealthServices

11 DefiningtheScopeofClinicalPractice

Our People

12 Executive

13 KeepingourStaffKnowledgeandSkillsUptoDate

14 MaintenanceStafftraining

15 2011StaffServiceAwards

Involving Our Community

16 Wheredothepeoplewecaredforcomefrom?

17 MoyneShireCommunityProfile

17 DuringaTypicalWeek

17 CulturalDiversity

Ensuring Quality and Safety

20 Accreditation-ExternalReviewofQualityandSafeCare

21 MeasuringQualityandSafety-VictorianPatientSatisfactionMonitor

22 ResidentSatisfaction

23 PeopleMatterSurvey

24 EnsuringQualityandSafetythroughRiskManagement

25 SafeMedicationManagementAcrossMHS

25 MedicationManagement

26 SafetyInitiativesinResidentAgedcareMedicationManagement

27 PreventionandMinimisingFalls

27 ProgresswithFallsManagementinAgedcare

28 EnhancingPressureAreaPrevention

29 BloodManagement-thegiftoflife

30 PreventingandControllingHealthRelatedInfections

30 HandHygiene

31 InfectionSurveillanceandReporting

31 AntimicrobialStewardshipProgram

31 VaccinationProgram

32 EnvironmentalServicesCleaningProgram

33 FoodSafety-MealsonWheels(MOW)

34 ResidentialAgedCareIndicators

34 WoundManagement@MHS

35 YourSay-Comments,Suggestions,Feedback,Complaints,Compliments

36 LimitedAdverseOccurrenceScreening(LAOS)Program

36 BuildingEngineeringInformationManagementSystem(BEIMS)-enhancingsafecare

Continuity of Care

37 ServiceAccessCoordination

37 PuttingthePersonattheCentre

38 PromotingParticipation

40 Bed-sideHandover-aninitiativeinpartneringwithconsumers

41 MoyneHealthyKidsProject

41 AdvancesinClinicalPractice-KeepingusUptoDate

41 BedsideTroponinProject

42 SHEDProject

42 LifeStories

Floyd-amanofhisword!

Val’sStory

[ ] QOC - contents2

Contents

Message from the Chief Executive Officer

Iamdelightedtopresentthisyear’sQualityofCare(QOC)Reporttoourcommunity.TheQOCReportprovidesacomprehensiveandinformativecoverageofallaspectsofourhealthcareservices.Iamsureyouwillfindthetestimonials,illustrativematerialandthesubjectmatterinteresting.

IencourageyoutoreadtheQOCReportinconjunctionwiththe2012AnnualReport.ThiswillprovideyouwithanexcellentoverviewoftheperformanceofMoyneHealthServices.

CongratulationstotheQOCReportteamwhohaveworkedtirelesslyinpreparingthismaterial.TheTableofContentsandthecolourfulpresentationofthetopicsprovidethereaderwithaneasyguidetotopicsofinterestacrossarangeofmaterial.Thisyear,weareparticularlypleasedthatwereceivedthehighestscoreforGroupDandEHospitalsinthe2011VictorianPatientSatisfactionMonitor(VPSM)p[35].ThisfactalonedemonstratesthatourlocalcommunityandhospitalvisitorsholdMoyneHealthServicesinhighregard.

WewillcontinuetovalueyourfeedbackandIencourageyoutocontactMoyneHealthServicesshouldyouhaveanysuggestionsonhowwecanimproveourservices.

David Lee

Chief Executive Officer

Key Definitions

ACHSAustralianCouncilonHealthcareStandards.

ACSAAAgedCareStandardsandAccreditationAgency.

ACSQHC AustralianCommissiononSafetyandQualityinHealthCare.

BACeS BoardAssuranceonCompliancee-System.

BEIMS BuildingandEngineeringInformation ManagementSystem

BOMBoardofManagement.

CACPsCommunityAgedCarePackages.

CALD CulturalandLinguisticDiversity.

CEOChiefExecutiveOfficer.

DoH DepartmentofHealth.

DONDirectorofNursing.

DVADepartmentofVeteransAffairs.

EACHExtendedAgedCareintheHome.

ED EmergencyDepartment.

EEOEqualEmploymentOpportunity.

FOI FreedomofInformation.

HACC HomeandCommunityCare.

HRHumanResources.

ICT Information,CommunicationandTechnology.

KPIKeyPerformanceIndicator.

KRAKeyResultArea.

MHSMoyneHealthServices.

OH&S OccupationalHealthandSafety.

OPDOutpatientsDepartment.

QOC QualityofCareReport.

QPSQualityPerformanceSystem.

RNRegisteredNurse.

Separation Theprocessbywhichanepisodeofcareforanadmittedpatientceases.

SWARHSouthWestAllianceofRuralHospitalsisanITallianceofhospitalsandmultipurposeagencies.

VHAVictorianHealthcareAssociation.

VMIAVictorianManagedInsuranceAuthority.

VMOVisitingMedicalOfficer.

VPSMVictorianPatientSatisfactionMonitor.

WEISWeightedEquivalentInlierSeparations.AformulaappliedtotheresourceweighttodeterminetheWEISforrecoveryoffunding.

QOC - welcome [ ]3

[ ] QOC - welcome4

Welcome to our Quality of Care Report

ThisQualityofCareReportisouropportunitytosharewithyouhowweprovideaccessible,safe,highqualityhealthcare.IthasbeenpreparedinaccordancewithDepartmentofHealthguidelinestoprovideourcommunity-theconsumer,carer,patientandresidentofMoyneHealthServiceswithinformationaboutwhatwedo.Wehavechosentofocusonathemeof“Longevity”forthisyear’sreport.

AtMoyneHealthwetakequalityandsafetyseriously.OurStrategicPlan2012-2015placessafeandeffectivecareattheforefrontofallofouractivity.WehaveanumberofcommitteesresponsibleforourClinicalGovernancethatguidethisprocess.Thedataandotherinformationthecommitteesexaminerelatingtoqualityandsafecare,informsthecontentofthisReport.Weaimtoprovideyouwitha“lookinside”ourorganisationtoshowhowweensurethateverypersonreceivesthebestcareandservicespossible.

Adiversegroupofstaffhaveformedaworkingparty,andwithinputfromothershaveworkedtogethertogathertheinformationandwritethisyear’sQualityofCareReport.TheproductionofthereporthasbeenoverseenbyourGovernance,QualityandRiskCommittee.

Theplanningofthisreportinvolvedanumberofinformalmeetingstodiscusswhattoincludeandhowtopresenttheinformation.Toassistuswiththefinaldecisionwe:

• ReviewedtheguidelinesfromtheVictorianDepartmentofHealth,toensureweaddressedallthemandatoryareas.

• LookedatourpreviousQualityofCareReports.

• ReviewedQualityofCareReportsfromotherhealthservices.

• DiscussedwithmembersoftheCommunity‘whatshouldbeincluded’and‘How’?

Thereportincludesseveralsections.ThefirstsectionsdescribeMoyneHealthServices,ourgovernanceandourstaff.Thisisfollowedbysomedetailsofourhistorytakingintoaccountournominatedtheme“longevity”,detailsofourcommunityandwherethoseusingourservicescamefrom.Latersectionsdetailperformanceinformationandstatisticsincludingkeyareassuchasincidents,falls,medicationerrors.Howwemanagetheseareasandstrivetoprovidethebestpossiblequalityandsafecare.Wehavealsoincludedsomestoriesaboutpersonalexperiencesofsomeserviceusers.

CopiesofourQualityofCareReportwillbedistributedwiththeOrganisation’sAnnualReport.CopieswillalsobeavailableatlocalhealthclinicsandpubliclocationssuchastheVisitorInformationCentre.AcopywillbeavailableontheMoyneHealthServiceswebsite:www.moynehealth.vic.gov.au

Wewouldliketohearwhatyouthinkofourreport.Youcandothisbycompletingthefeedbackcardincludedinthereportandpostingittous,byputtingyourthoughtsintothefeedbacksectiononthewebsite(seeabove)orbycontactingmedirectlyon:(03)55680100.

Wethankallofthoseinvolvedintheproductionofthereport.Wethankyouforreadingthereportandhopethatyoufinditinterestingandinformativeandenjoyreadingit.

Belinda Westlake

Information, Quality & Risk Manager.

Our Vision, Mission and Values

Vision

OurVisioniswhatwewishtoseeinthefuture-Ourcommunitywillhaveaccesstoon-going,highestqualitycare.

Mission

OurMissionisourreasonforbeingandhelpsusimplementourVision-Toprovideanexcellent,sustainable,holistichealthcareservice.

Values

Weoperatethroughourcorevalues.

Wevalue:

• Competence,professionalismandintegrity

• Respectfortheindividual

• Activecommunityinvolvementandconsultation

• Accountability

• Equityinaccesstocare,impartiality

• Innovationandconstantlearning

• Kindness

QOC

5

Our highlights

CompletedtheMoyneHealthServicesMasterPlanforthecapitalredevelopmentofthesite.

AchievedthehighestVictorianPatientSatisfactionMonitor(VPSM)resultsinthestateforGroupDandEhospitalsp21.

Obtaineda$117,756HomeandCommunityCare(HACC)GranttoassistinestablishinghealthservicesattheKoroitsite.

PurchasedandimplementedtheBuildingandEngineeringInformationManagementSystem(BEIMS)resultinginasubstantialimprovementtomonitoringmaintenancerequestsandresponsetimes.

and disappointments

Receivedapoorhandhygieneresultof57%inourrecenthandhygieneauditp31.

Decommissionedthestaticrainwatertanksduetoincreasingcompliancecostsandinfrastructurechallenges.

QOC - welcome [ ]

Strategic Quality GoalsQuality of Care and Risk ManagementWe consistently provide high quality and safe care services to our consumers and our community (VHRP 1,2,5).

•Achieveandexceedaccreditationofourhealthcareservices.

•Monitor,reportandcontinuouslyimprovequalityandsafetyinourhealthcareservicestothecommunity.•Continuouslyexplorethefuturedirectionofeachofourhealthcareservices.•Providehealthcareservicesthatareresponsivetotheneedsofourlocalcommunity.•Collaborateanddeveloppartnershipswithotherhealthcareagenciesindevelopingourhealthcareservices.QOC

[ ] QOC - welcome6

Our Longevity - 163 years of service to Port Fairy CommunityMoyneHealthService(MHS)hasdevelopedfroman1849four-roomcottageat40JamesStreet,Belfast(PortFairy)toamulti-milliondollarhealthservice.

PortFairyHospital,Victoria’soldestcountryhospital,hasanimpressivehistoryofservicetothecommunity.

ThePortFairyHospitalhasenjoyedanalmostuniquelevelofcommunitysupport.Traditionally,manylocalfamilieshavegenerouslysupportedourhospital.

History ofOur Growth

1855

Thecentralportionofthepresentstructurewasbuiltwithaspecialgrantof£1000thatwasmatchedbythecommunity.

1875

Additionsweremadetothebuildingatacostof£1145/6/6andsupportedbyapublicappeal.Theseadditionsincludedthetwolargemulti-purposeroomsatthefrontoftheHospital.

1887

FatherMauriceStackbequeathed£1000thatwasusedtobuildtheStackFeverWard.TheFeverWardwasclosedin1939,however,aslateas1991itwasstillbeingutilisedtoaccommodatemaleresidents.

TheFeverWardwasthenaBoardRoomduringthe1950s.TheStackFeverWardwasinastateofdisrepairandwasdemolishedduring1992.Thesitewasthenusedtobuildanewdementiacentrein1998.

1891

Theupstairsportionofthe1855buildingwasconvertedtonursesquarters.Todaythispartofthebuildingisusedasaboardroom.

1934

LordandLadyHuntingfield,accompaniedbyMr.C.L.McVilly,SecretarytotheCharitiesBoard,openednewadditionstotheHospital.Theadditionsincludedasun-roomandaone-bedandatwo-bedroomontheNorthside,andanoperatingtheatre,birthroom,nursery,atwo-bedroomandtwoone-bedroomsontheSouthside.Thetotalcostwas£7,500.

1959

TheGovernorofVictoria,SirDallasBrookes,officiallyopenedanewmaternitywingoftheHospitalonthe4thFebruary.TodaythiswingformspartofthenewBelfastHouseNursingHome,establishedinMay1996.

1965

SirRohanDelacombe,GovernorofVictoria,openedtheNursesHomeadjacenttotheHospitalbuildingsonthe7thApril.ThisbuildingisnowthePrimaryCareBuilding.

1976

ThePrimeMinisterofAustralia,TheRightHonourableMalcolmFraser,M.P,opened,onthe22ndApril,anewoutpatientandcasualtydepartment,togetherwiththenewhospitalwardblocknowhousingtheAcuteServices.

1988

Atwenty-five-bedresidentialhostelcalledMoyneyanaHousewasopenedbytheGovernorGeneralofAustralia,SirNinianStephen,inJune.

1996

TheMinisterforHealthandAgedCare,TheHonourableRobKnowlesM.L.C.,openedBelfastHouse,a30-bedresidentialagedcarefacility,onthe19thMay.Thisbuildingwasconstructedatacostof$2million.

1998

MoyneHealthServicesestablishedPortFairyMedicalClinicnexttotheDaycareCentre,inpartnershipwithSackvilleClinicmedicalpractitioners,atacostof$325,000.

A$1.9millionredevelopmentofMoyneyanaHostelincludedthefollowing:

• 10-placedementiaunit

• dining/activitiesarea(TheWoodrupRoom)

2000

ThePortFairyHospital,BelfastHouseandMoyneyanaHouseandassociatedservicesbecameMoyneHealthServices.

2001

Thefollowingcapitalprojectsincluded:

• frontofthehospitalwasreturnedtoaheritagefacade,acoveredlinkwasputinplacetointegratetheservicesandtheacutewingadministrationareaswererenovated.

Victoria’s oldest country hospital

7

2004

MoyneHealthServicesundertookminorcapitalworkstorepairdamagetotheDayCentrebuildingandincreaseofficeandconsultingspace.Thebuildingwasre-launchedasthePrimaryCareBuilding.

2005

Constructionona17-bedextensiontoMoyneyanaHouse.Thenewwingprovidedanadditionalfiverespitebedsand12permanentresidentialplaces.

2006

SirNinianStephenopenedtheMoyneyanaHouseExtensionon28thApril.

2010

MoyneHealthServicesconducteditslastoperatingtheatrelistonthe24thSeptemberandextendedthePortFairyMedicalClinictoaccommodateadditionalGeneralPractitioners.MoyneHealthServicespurchased101RegentStreet.

2011

MoyneHealthServiceswasendorsedbytheDepartmentofHealthastheCommitteeofManagementoftheKoroitHealthServiceslandandbuildings.MoyneHealthServicesacquired98BankStreet,PortFairytofacilitatethefutureexpansionofthesite.

Present

TodayMoyneHealthServicesincorporatesthePortFairyHospital,MoyneyanaHouse(AgedCareHostel),BelfastHouse(AgedCareNursingHome),PrimaryCareServices,CommunityHealthServicesandHomeBasedServices.Itcontinuestobeanessentialandintegralpartofthecommunity.

QOC - welcome [ ]

QOC

[ ] QOC - governance8

Geoff YoulPresident

Geoff is President of the

Yambuk Recreational Reserve

Committee, Trustee Port Fairy

Public Cemetery Trust and

Vice President South West

District Rifle Association.

Geoff is a primary producer

based in Yambuk.

Terms of appointment

01.01.00-30.06.13

Board Committees

• Executive(Chair)

• AuditandRisk

• ExecutiveRemuneration

andGovernance

• MurraytoMoyne

(Amajorfundraisingevent)

Ralph LeuttonSeniorVicePresident

MSc(UQ)

Ralph is a self-employed

lobbyist, facilitator and trainer.

He sits on a number of

National Boards representing

vocational education and

training. President Port Fairy

Men’s Shed.

Ralph has vast experience in

management, research and

teaching.


01.07.10-30.6.13

Board Committees

• ExecutiveCommittee

• Environment(Chair)

• StrategicWorkingGroup

Charlie BlackwoodJuniorVicePresident

BachelorofVeterinaryScience

(SydneyUniversity),MACVSc,

BBsc.

Charlie is a Partner in the

Warrnambool Veterinary Clinic

located in Port Fairy. President

of Port Fairy Consolidated

School Council.


25.11.04-30.06.14

Board Committees

• Executive

• Audit&RiskCommittee

(Chair)

Susan Kewley

AdvancedDiplomaofBusiness

(HumanResources)

Susan is employed by

Moyne Shire as the Human

Resources Coordinator and

has experience in public sector

Governance, Strategic Planning

and Policy Development.

Member of the Moyne Shire

Arts & Culture Committee and

member of the Port Fairy

Book Club.


01.11.05-20.03.12

Board Committees


&GovernanceCommittee

(Chair)

• Marketingand

Communications

Peter O’Keeffe

Peter is the Director of

Global Power Design. Peter’s

interests include Folk Festival-

Construction Crew (30 years),

Red Cross-Disaster Relief Plan

(Water purification) and golf.


01.11.95-30.06.12

Board Committees

• Executive

• OccupationalHealthand

Safety(Chair)

• StrategicWorkingGroup

(Chair)

mhs board of management

QOCQOC - governance [ ]9

Kerrie Robertson

DipAppliedSocialSciences-

WelfareStudies,AssocDip

FamilyTherapy

Kerrie is a Social Worker and

Family Counsellor in private

practice.


24.10.02-30.06.14

Board Committees

• OccupationalHealthand

Safety

• Governance,Qualityand

Risk(Chair)

Eda Ritchie AM

AMusA,GradDipBusiness

Board member of Port

Fairy Spring Music Festival,

Melbourne University

Publishing, Ian Potter Museum

of Art, Hillview Quarries Pty

Ltd. Trustee of the RE Ross

Trust and Council Member

University of Melbourne.

Chair Victorian College of Arts

Foundation.


27.11.03-30.06.12

Board Committees

• Marketingand

Communications(Chair)

David Ryan

BA,LLB

David is a Solicitor. In addition to

his own legal practice, he works

for the Department of Human

Services as a Support Officer.

David is a committee member

of the local Multicultural

Development Unit.


01.11.95-30.06.13

Board Committees

• Governance,Quality

andRisk

• MurraytoMoyne

Richard Walter AM

BComm,MTRP(Melb),

MRP(Penn)

Richard is Independent Chair

of the Moyne Shire Audit

Committee.


01.07.08-30.06.14

Board Committees

• AuditandRisk


andGovernance

[ ] QOC - governance10

Governance in Healthcare

Goodgovernanceisvitaltoimprovingsafetyandqualityofhealthcareservices.

GovernancereferstothesetofrelationshipsandresponsibilitiesestablishedbyaHealthServicebetweenitsexecutive,workforceandstakeholders(includingconsumers).Governanceincorporatesthesetofprocesses,customs,policydirectives,lawsandconventionsaffectingthewayanorganisationisdirected,administeredorcontrolled.Itdetermineshowhealthservicesaredeliveredandhasadirectimpactonthesafetyandqualityofcare.

WhilemosthealthcareinAustraliaisassociatedwithgoodclinicaloutcomes,patientsdonotalwaysreceiveallthecarethatisrecommendedtothemandpreventableadverseeventscontinuetooccur.

Inrecentyears,Australianhealthserviceshaveincreasedtheirawarenessof,andinvestmentin,safetyandquality.Healthserviceshavedevelopedandimplementedpolicy,educationalmaterialsandprocessesforimprovement.Thesechangeshaveimprovedthesafetyandqualityofhealthcareforpatientsbutmorestillneedstobedonetoensureallpatientsareprotectedfromharmandreceivethehighestpossiblestandardofcare.

Projectionsfortotalhealthcarespendingindicatethatfinancialpressureonthehealthcaresystemwillcontinuetoincreaseinthefuture.

ACSQHC 2011

AtMoyneHealthServices(MHS)wearecontinuallystrivingforwaysofimprovingthequalityofcareweprovidetoourconsumers.ThisisreflectedinourMissionStatement:

“Toprovideanexcellent,sustainable,holistichealthcareservice”.

TheBoardofManagementembracetheconceptofQualityImprovementandacknowledgetheirresponsibilityundertheHealthServicesAct1988forensuringanappropriatestructure,systemsandprocessesareestablishedtosupporttheorganisationinprovidingqualityandsafecare.

TheBoardhasendorsedtheMHSQuality,RiskandGovernancepolicyasameansofensuringthesafetyandqualityofthecareweprovide.

Thedeliveryofhighqualityandsafecareisparamounttogoodgovernance.ArangeofmeasuresareinplacetoassistMHSinachievinghighqualityandsafetyincareandarebasedontheQualityFramework.

providing quality, safe care -

health service governance

QOC - governance [ ]11

Theobjectivebeingtomaintainaninformative,comprehensive,organisation-wideprogramthatdeliverstherightcaretoeverypatient,residentorclient,achievesthebestpossibleoutcomesoneveryoccasionandfocusesonthedomainsofqualityandsafety.

Credentialing for Health Professionals

Credentialingbyhealthserviceorganisationsisaprocessusedtoverifythequalificationsandexperienceprimarilyofmedicalpractitionerstodeterminetheirabilitytoprovidesafe,highqualityhealthcareserviceswithinaspecifichealthcaresetting.

Credentialinghasthepotentialtoimprovesafetyforpatientsbyensuringclinicianspracticewithintheboundsoftheirtrainingandcompetency,andwithinthecapacityoftheserviceinwhichtheyareworking.

Credentialingispartofawiderorganisationalqualityandrisk-managementsystemdesignedprimarilytoprotectpatients.

ThetermCredentialingisusedbyspecialistnursingassociationsandgroupsinadifferentwaytoaddressthelackofagreementaboutnursingspecialtycategories.

ACSQHC 2011

Credentialing of Clinical Staff at Moyne Health Services

Itisimportantthatallmedical,nursingandalliedhealthstaffhavetherightqualificationstopractice.MoyneHealthServicesensuresthattheacademicqualifications,skillsandprofessionalregistrationofallclinicalstaffiscurrentandappropriate.Thisallowsustobeconfidentoftheemploymentofqualifiedandcompetentmedical,nursingandalliedhealthstaff.

• Clinicalstaff,includingmedical,nursingandalliedhealthstaffmustprovideevidenceofregistration,qualificationsandongoingprofessionaldevelopmenthours

• Doctorsandalliedhealthstaffareappointedascontractworkers

• Doctorsareappointedforaperiodof3yearsandsubsequentre-appointmentsarefor3years

• TheBoardofManagementareresponsiblefortheappointmentandcredentialingofdoctors.

Duringthe2011-2012yearwehad1newMedicalStaffmembergothroughthecredentialingprocess.

MHShasaConsultantMedicalDirectorwhoprovidesongoingsupporttoensurerobustsystemsremaininplace.

Thereisaprocessofestablishingthequalificationsandensuringthatthepeoplewhoareemployedandworkinthehealthservicehavetheappropriatetrainingandcurrentprofessionalregistrationtopractice.Thisprocessisundertakenatcommencementofemployment(initialapplication)andannuallywhentheregistrationisdueforrenewal.ForNursingstaffthisoccursinApril-Mayeachyear.RegistrationwiththeAustralianHealthPractitioner’sRegulationAgency(AHPRA)isrequired.AHPRAwasformedbyanActofParliamentandisboundbytheHealthPractitionerRegulationNationalLaw(2009)TheNationalLawisinforceineachStateandTerritory.

Defining the scope of clinical practice

AlsoknownasPrivileging,followsonfromCredentialingandinvolvesdelineatingthescopeofanindividualmedicalpractitioner’sclinicalpracticewithinaparticularorganisation.

Department of Health, Victoria, Australia 2011

“To provide an excellent, sustainable, holistic health care service”

[ ] QOC - people12

Sandra Winnen

Food Services Manager

• AppointedNovember,2005.

• Responsibleforthesupervisionofcateringservices,mealsonwheels,foodsafetyplanandliaisonwiththeAuxiliaries.

• CoordinatescateringsupportforoutsideeventssuchasMurraytoMoyneandthePortFairyFolkFestival.

David Lee

BNurs(QUT),MComm(UQ)PGDipCSP,MAICD

Chief Executive Officer

• AppointedJuly,2007.

• ResponsiblefortheoveralloperationofMoyneHealthServices.

• Extensiveexperienceinthearmedforces,nursingandhealthmanagement.

• MemberofSWARHExecutiveCommittee,DepartmentofHealthQualityReferenceCommitteeandCharteredSecretariesNationalPublicSectorGovernanceCommittee.

Dr Bruce Warton RFD

MB,BS,Hons(Monash),BHA(UNSW),FRCSEd,FRCOG,FRANZCOG,FRACMA,AFACHSM,CHE,DTM&H(JCU),GradDipHealthandMedicalLaw(Melb).

Director of Medical Services

• AppointedJanuary,2011.

• Responsibleforassistingwiththedevelopmentofrobustcredentialingandprivilegesandmedicalappointmentsprocesses.

• BrucehasextensiveexperienceasaDirectorofMedicalServicesandinthearmedforces.

• FormerlyDirectorofMedicalServicesatWesternDistrictHealthServiceandGoulburnValleyHealth.

Leigh Parker

BBus(Acc),AFCHSE

Finance and Human Resources Manager

• AppointedMay,2008.

• Responsibleforthemanagementoffinance,informationtechnology,humanresourcesandoccupationalhealthandsafety.

• FormerlyDeputyCEOofTerangandMortlakeHealthService.

• MemberoftheSWARHFinanceCommitteeandtheFMISOracleWorkingGroup.

Fran Kinnersly

R.N.MRCNA

Director of Nursing

• AppointedFebruary,2005.

• Responsibleforthemanagementofclinicalcareservices.

• MemberoftheRoyalCollegeofNursingandanactivememberoftheVictorianSmallRuralHealthServicesDirectorofNursingExecutiveCommittee.

• Franhasextensiveexperienceinacuteandsurgicalnursingandmanagement.

• DeputyChairBarwonSouthWestNursingExecutiveGroup.

• CommitteeMemberofVictorianHealthcareQualityAssociationandPublicSectorResidentialAgedCareExecutiveLeadershipGroup.

mhs executive management

QOCQOC - people [ ]13

Belinda Westlake

BAppSC(HIM).MAE(Melb),FAAQHC

Health Information, Quality and Risk Manager

• AppointedOctober,2002.

• Responsibleforthemanagementofhealthinformation,qualityandriskprograms.

• BelindaholdsthepositionofChairoftheBarwonSouthWestQualityAdvisoryCommittee.

• PresidentoftheVictorianHealthcareQualityAssociation.

• MemberVictorianQualityCouncilPatientTransferGroup.

Glynis Dean

RNCertificateofPeri-operativeServices

Aged Care Services Manager

• AppointedMay,2011.

• Responsibleforthemanagementofresidentialandcommunityagedcareservices.

• Extensiveexperienceincriticalcarenursingandprojectmanagement.

Pauline McGee

RNRM

Primary and Community Care Manager

• AppointedMarch,2008.

• Responsibleforthecoordi-nationofthecommunityhealthcareservices.

• Paulinehasabackgroundinthecommunityhealthcaresectorincludingyouth,women’shealthandcommunityhealtheducation.

• MemberoftheSouthWestPrimaryCarePartnershipExecutiveCommitteeandmemberofRegionalAllianceofmentalHealthPromotion.

Tim Drew

Maintenance Services Manager

• AppointedJune,2011.

• Responsibleforthesupervisionandcoordinationofmaintenanceservices.

• Timisaqualifiedcarpenterandregisteredbuilderwithtwelveyears’experienceintheconstructionindustry.

[ ] QOC - people14

Maintenance Staff TrainingThroughouttheyear,theMaintenancedepartmenthascompletedvarioustrainingprogramsinanattempttoeducatestaffinbestpracticeandkeepskillsuptodateandrelevant.Thedepartmentismadeupoftradesmanandskilledhandymen.Thesecourseschallengestaffandmakethemawareofthepreciousenvironmentweworkin.

“a great deal of training has been given to staff”

AllmaintenancestaffhaveundertakenmandatorytrainingandattendedInfectionControlstudyseminars.Inadditiontothis,agreatdealoftraininghasbeengiventostaff,toensurethesmoothimplementationoftheBuildingandEngineeringInformationManagementSystem(BEIMS).

OneofthemajorimprovementswithintheDepartmentistheknowledgewehavegainedthroughattendingvariousoccupationalhealthandsafetycourses.Thesecoursesinclude:WorkingatHeights,WorkinginConfinedSpaces,HealthandSafetyRepresentativeandElectricalTestandTag.Inaddition,onestaffmemberhasbecomelicencedinhotwaterThermostaticMixingValveservicing.

Allofthetraininghasbeenembracedbystaffandprovidesthemwithsufficientknowledgetoperformmaintenancetasksinasafe,non-threateningmannertoresidents,patients,visitorsandstaff.

QOC - people [ ]15

2011 Staff Service AwardsThisyear’sstaffappreciationawardswereheldon14thOctober2011.Eachrecipientreceivedanindividualinvitationtotheawardsnight.PresidentoftheBoardofManagementofMHSGeoffYoulpresentedthestaffwiththeirawards.Thereweresevenstaff,frombothclinicalandsupportservices,whowererecognisedformorethan15yearsofservice.MHStakesprideinacknowledgingandrewardingit’sstaff,fortheloyaltyandpositiveoutlooktheybringtogethertomakeupthefaceofMHS.

BRONZE MEDALLIONS

LynLeddin 5YearsService

JohnKinnersly 5YearsService

PaulaLee 5YearsService

RobbieLee 5YearsService

JudithChaplin 5YearsService

RosemaryRees 5YearsService

TrudiBaxter 5YearsService

LillianSerong 5YearsService

MelindaPulham 5YearsService

FionaHellier 5YearsService

RebeccaKeane 5YearsService

LucyTaylor 5YearsService

ChristinePatterson 5YearsService

SandraSproal 5YearsService

SILVER MEDALLIONS

AnnVickery 10YearsService

DonnaKelly 10YearsService

JanetDrake 10YearsService

GiroPevitt 10YearsService

DonnaTodd 10YearsService

RachaelCoffey 10YearsService

MichelleArnold 10YearsService

CherylNeate 10YearsService

LaureenBeks 15YearsService

AngelaBrian 15YearsService

RobynHarrison 15YearsService

ShelleyCoffey 15YearsService

GOLD MEDALLIONS and a gift were awarded to

JennyRyan 20YearsService

SusanLane 20YearsService

FrancesKinnersly 25YearsService

[ ] QOC - community16

Where do the people we cared

for come from?MoyneHealthServicesislocatedinthecoastaltownofPortFairywithinMoyneShire,intheSouthWestofVictoria.PortFairyisnamedafteracuttercalled“Fairy”.ItwaspreviouslyknownasBelfast.Settlementoftheareadatesfromthe1830s,aidedbytheearlierconstructionofawhalingstation.

TheMoyneShirewascreatedin1994andcoversanareaofapproximately5,500squarekilometreswithapopulationofaround16,900.

TheareaservedbyMoyneHealthServicesconsistsofthetownsofPortFairy,Yambuk,Koroitandthesurroundingdistricts.Thisareahasapopulationofapproximately5000.

TheMoyneareaishometoawiderangeofservicesandindustry,includinghealthandcommunityservices,dairy,freshfishindustry,pharmaceuticals,manufacturedfoods,seafoodprocessing,quarrying(roadmaterialsandcutbluestone),transportandeducationcentres.PortFairyalsohasabusytouristindustrythatincludesweekend,summerholidaysandspecialeventssuchasthePortFairyFolkFestival.Attimesthisseesustreatingvisitorsfromawiderangeoflocations.

TheAdmissionsgraphshowsthepostcodesofpatientsadmittedtoouracuteservicesduringthefinancialyear2011-2012.

ItisalsointerestingtolookatwherethepeoplewhopresenttoourUrgentCareareacomefrom.Thepictureisalittledifferent.TheEmergencyAttendancesgraphshowsthetownorhomestateofthosewhopresentedtoUrgentCarebetweenJuly2011andJune2012.

TheEmergencyAttendancesgraphreflectstheholidaydestinationcharacteristicofPortFairywithanincreasedpercentageofpresentationsfrompeopleresidingoutsidethetownshipofPortFairy.ItwasinterestingtonotetheincreasedpercentagefromWarrnambool-aneighbouringRegionalcentrewithafullyfundedEmergencyDepartmentatthePublicHospital.

Port Fairy

Warrnambool

Macarthur

Yambuk

Killarney

Koroit

Broadwater

Hamilton

Other Victorian

Interstate

Port Fairy

Warrnambool

Macarthur

Yambuk

Killarney

Koroit

Broadwater

Hamilton

Other Victorian

Interstate

Overseas

Admissions

Emergency Attendances

QOC - community [ ]17

Moyne Shire Community Profile

The2011censusshowed15,955peoplelivingintheMoyneShire.Ofthese100(0.7%)werefromNonEnglishspeakingbackgroundsand143(0.9%)speakalanguageotherthanEnglishathome.Thetop4overseasbirthplacesrankedfromhighesttolowestwere:UnitedKingdom,NewZealand,NetherlandsandGermany-theNetherlandsbeingthedominantnon-Englishspeakingcountryofbirth.

TheIndigenouspopulationoftheShireis190(1.2%).

Peopleovertheageof65makeup16%ofthepopulation.

Source: Australian Bureau of Statistics, 2011 Census Quickstats

Cultural Diversity at Moyne Health

AsaruralproviderofhealthcareMoyneHealthServicesaimstomeetthechallengeofrespondingtoadiverserangeofissuesforserviceuserssuchastheirgeographicisolation,accesstosupportservices,and

lownumbersofCALDconsumers.CulturalresponsivenessisabouthavingaskilledworkforceabletorespondeffectivelytotheneedsofavarietyofconsumersinAustraliansociety.Itisrecognisedthatculturallydiverseconsumersinsmallercommunitiesmayhavehigherneedsduetoisolation.

Cultural Responsiveness FrameworkTheCulturalResponsivenessFrameworkaimstoconsolidatetheachievementsofculturaldiversityactionplansandtoimproveandextendculturalresponsivenessperformance.ItiscloselyalignedwithMHSStrategicPlanningprocessesandalsospecificallyalignedtothedomainsoftheVictorian Clinical Governance Policy Framework,2009.Itisbasedonfourkeydomainsofqualityandsafety:organisationaleffectiveness;riskmanagement;consumerparticipation;andeffectiveworkforce.Therearesixstandardsforculturallyresponsivepractice.

Domain: Organisational effectiveness

Standard 1: ‘A whole-of-organisation approach to cultural responsiveness is demonstrated

• AgencyandAustralianBureauofStatisticsdataisreviewedtoensureservicesareplannedtomeettheneedsofCALDconsumers

During a Typical Week,Moyne Health Services …• Providesover$230,000ofhealthandwell-beingservicestoourCommunity• Treats44EmergencyPatients• Discharges9patientsbacktotheirhome• Providesapproximately40patienttreatmentdaysinhospitalbeds(5-6patientseachday)• ProvidesResidentialAgedCareto520residents(75residentsperday)• Provides96DistrictNursingServicesvisits• Provides207CommunitybasedAgedCareclientvisits

[ ] QOC - community18

• Partnershipswithmulticulturalandethno-specificcommunityorganisationsaredevelopedandco-optedmembersprovideactiveparticipationinPlannedreviewandservicedevelopmentatMHS.

• TheInterpreterpolicyenablespeoplewithalowlevelofEnglishproficiency,orwhouseAuslanastheirfirstlanguage,accesstoprofessionalinterpretingandtranslatingserviceswhenmakingsignificantlifedecisions,orwhereessentialinformationisbeingcommunicated.

• InterpretersymbolsaredistributedtoserviceareasthroughoutMHSfordisplayinentrancesandwaitingareas.

Standard 2: Leadership for cultural responsiveness is demonstrated by the health service

• Trainingopportunitiesareprovidedtostaff

• Allstaffhaveaccesstotheculturaldiversitypoliciesandassociateddocumentationthroughtheonlinepolicysystem.

Domain: Risk management

Standard 3: Accredited interpreters are provided to patients who require one

• Overthepast12monthsinterpreterserviceswereaccessedforanItalianspeakingmaleinpatient.

• 98.9%ofpeopleinPortFairyspeakonlyEnglish.

Domain: Consumer participation

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

• Organisationalpolicyandproceduressupportconsumerchoicefortheprovisionofappropriatemeals.

• VPSMreportsindicatedexcellentresultsinthisareap21.

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

• TheCommunityDiversityCommitteeperformancewasreviewedtomonitorrelevanceandeffectiveness.

• AgaptoberesolvedatthemomentistoincreasemembershipandattendancetoCommunityDiversityCommitteemeetings.

Domain: Effective workforce

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

• StaffhaveattendedCulturalawarenesstrainingoverthelast12monthsOrganisationalpracticesandpoliciessupportculturalresponsiveness.

QOC - community [ ]19

Cultural Responsiveness In Action

Emergency Department

Overthepast12monthsMHSEmergencyDepartmentprovidedtreatmentto2312individuals.Thepie-chartbelowshowsthebreakdownofcountryofbirthforthesepeopleandshowsthecleardominanceofAustralianorigins.

Primary and Community Care Services

PrimaryandCommunityCareServicesincludeAlliedHealthandAmbulatoryServices.Overthepast12months(1July2011-30June2012)CommunityHealthServicesatMoyneHealthServiceswereaccessedby1208recipients.

Recipientsoftheseserviceswerefromfollowingcountries:Australia,England,NewZealand,Scotland,Wales,GermanyNetherlands,India,NorthernIreland,PhilippinesandSingapore.Interpreterserviceswerenotaccessedtodelivertheseservices.

IndividualsaccessingPlannedActivityGroupswereeitherAustralianorEnglishborn.CulturalCelebrationsheldbyPlannedActivityGroupsoverthepast12monthsincluded:

• StPatricksDay

• ShroveTuesday

• IndianLunchduringCulturalCelebrationweek

• AFLGrandFinalCelebrationie:FootyTippingresultsandpresentation

• HighTeafortheQueen’sDiamondJubilee

• “ArmchairridetoChina”-PhotosandstoriesandmemorabiliafromatriptoChina

• ChristmasBreakup,BigCookedBreakfastforclients,staffandvolunteers

• Buffetsupper,reminiscenceforsinglepeoplewithnosignificantothers

Improving care for Aboriginal and Torres Strait Islander Patients

2011ABSCensusDataindicatesthattotalpopulationandhousinginformationconfirmedthat3,094peoplepermanentlyresidedwithinPortFairy.

Ofthese,17residentsidentifiedthemselvesasbeingAboriginalorTorresStraitIslanders.TosupportAboriginalandTorresStraitislanderhealthoutcomes,MHSiscontinuingtoimproveserviceaccessforthisgroup.WorkingcollaborativelywithregionalAboriginalLiaisonOfficersand“ClosetheGapProject”CoordinatorsisfundamentaltoassiststafftoidentifyandaddressgapsandbarriersinreferralpathwaysforAboriginalandTorresStraitIslanderpeopleinourregion.Thesepartnershipssupportstafftodeveloptheskillsrequiredtoundertakeculturallyappropriateassessmentstosupportdeliveryofculturallyappropriate,timelyandcoordinatedservicestoAboriginalandTorresStraitIslanderfamilies.

Australia

England

New Zealand

Netherlands

USA & Canada

Ireland

Singapore

Other

What we know about our community

Country of Birth

Non-Indigenous (3094)

Indigenous (17)

[ ] QOC - quality & safety20

Accreditation - External review of quality, safe care

Accreditationisasystemtopromoteandsupportsafepatientcareandcontinuousqualityimprovementofhealthservicesthroughaprocessofregularassessmentandreview.Byitselfaccreditationdoesnotensurethesafetyandqualityofhealthcareprovidedtopatients.However,accreditationiseffectiveaspartofanimprovementsystembecauseitcanverifythatactionsarebeingtaken,thatsystemdataandinformationarebeingusedtoinformtheanalysisofissuesandprogramsolutions,andthatsafetyandqualityimprovementisbeingachieved.

ACSQHC 2011

Externalaccreditationprogramsprovidetheopportunityforustohaveanindependentreviewofhowwellweprovidequality,safecare.Itisanopportunitytomeasuresafetyandqualityofcareandservicesthroughtheeyesofexternalexperts.

AtMHSweparticipateinanumberofaccreditationprogramstocoverthewiderangeofservicesthatweoffer.Thereareseveralexternalbodiesdeliveringaccreditationprocessesdesignedtoassessthecareweprovideandensurethatitissafeandeffectivewhenmeasuredagainstnationallysetstandards.

Theaccreditationprogramsinvolvetrained,externalassessorsvisitingourHealthServicetomeasurethestandardsofcareandserviceprovided.Thestandardsassessedspanacrossclinicalareasincludingacute,agedcareandprimaryandcommunitycareandnon-clinicalareassuchasmaintenance,foodservices,cleaning,financeandadministration.

TheAustralianCouncilonHealthcareStandards(ACHS)istheaccreditingbodyresponsibleforaccessingMHSasawhole.ACHSsurveyorslookatservicesacrossthewholeorganisationincluding:AcuteCare,ResidentialAgedCareandPrimaryCare.TheyusetheEvaluationandQualityImprovementProgram(EQuIP)standardsandcriteria.WealsoparticipateintheAgedCareAccreditationProgram.

TheAccreditationprocessesforHealthServicesacrossAustraliaisabouttoundergosignificantchange.TheAustralianCommissionforSafetyandQualityinHealthCaredevelopednewaccreditationstandards-“theStandards”followingextensivepublicandstakeholderconsultation.TheStandardsareacriticalcomponentoftheAustralianHealthServicesSafetyandQualityAccreditationSchemeendorsedbytheAustralianHealthMinistersinNovember2010.

TheStandardsprovideanationallyconsistentanduniformsetofmeasuresofsafetyandqualityforapplicationacrossawidevarietyofhealthcareservices.Theyproposeevidence-basedimprovementstrategiestodealwithgapsbetweencurrentandbestpracticeoutcomesthataffectalargenumberofpatients.TheStandardsaredesignedtoassisthealthserviceorganisationstodeliversafeandhighqualitycare.

TheBoardofManagementofMoyneHealthServiceshavemadethedecisiontoproceedwiththeAustralianCouncilonHealthcareStandards(ACHS)forhospitalaccreditationsurveysandhaveelectedtoparticipateinthe“EQuIPNational”program.ThiswillseeMHSparticipatinginaPeriodicReviewsurveyinJune2013usingtheEQuIPNationalstandards.

ThepastyearhasbeenrelativelyquietinrelationtoAccreditationvisits.Thedetailedresultsandscheduledreviewsareoutlinedinthetableabove.

TYPE OF ACCREDITATION OUTCOME

AustralianCouncilonHealthcareStandards

OrganisationWideSurveyApril2011

ExcellentResultswithongoingaccreditationachieved

Periodic Review June 2013

HomeandCommunityCare(HACC) NofurthercontactsinceoursuccessfulreviewoftheDistrictNursingServiceswasconductedinconjunctionwiththePeriodicreviewinApril2009.

Likely review with Periodic Review June 2013

CACPsandEACHReview SuccessfulreviewlookingatCACPsandEACHstandardswasachievedinNovember2011

AgedCareAccreditation-

BelfastHouse

MoyneyanaHouse

Accreditationsuccessfullymaintained-nounannouncedvisitsinthepast12months

AgedCareSiteAuditscheduledfor18thand19thSeptember2012

QOC - quality & safety [ ]21

The Victorian Patient Satisfaction Monitor - Measuring Quality and Safety

TheVictorianPatientSatisfactionMonitor(VPSM)hasbeendevelopedbytheDepartmentofHealthtoassisthospitalstoimproveservicesandpatientsatisfaction.Itisasurveythataskspatientsabouthowtheyfeltabouttheirhospitalvisit.ResultsfromtheVPSMsurveyareusedbyhospitalstoidentifywaysthattheycanimprove.AstandardisedquestionnaireissenttoallMoyneHealthServicespatientsiftheyhaveagreedtoparticipate.TheinformationisthencompiledbyUltrafeedback,thecompanycontractedbytheDepartmentofHealthtocollect,analyseandreportthedata.

TheinformationthatwereceivebackfromVPSMresponsesisusefultoassistwithmonitoringthequalityofthecareandservicesthatweprovide.Thereportsreceivedprovidedetailsthatallowustoprioritiseareasforfurtherworkandalsotoacknowledgetheareasthatwearedoingwellandtopassthisinformationontostaff.Thegraphshowsthe

overallinformationthatwereceive.ThesearethemostrecentresultsthathavebeenreceivedfromUltrafeedbackandtheDepartmentofHealth.Thesummaryreportstates:

“Patients were very satisfied with most aspects of their stay at Moyne Health Services. The Hospital is typically performing above D Category average. Specifically, Moyne Health Services scored statistically significantly higher than the Category D average in the most recent survey for the Overall Care, General Patient Information, Treatment and Related Information, Complaints Management and Discharge and Follow-up Indices and the Consumer Participation Indicator”.

“…the majority of patients reported that they were helped a great deal by their

stay in hospital and felt that the length of time spent in hospital was about right.”

Whenwecomparetheseresultswithprevioussurveys,themostsignificantvariationisadramaticimprovementintheDischargeandFollow-upindicatorwherethesatisfactionratingraisedfromarateof86to89increasingthegapbetweenthelevelofsatisfactionatMHSandthatatothersimilarsizedfacilitiesandallfacilitiesaroundVictoria.

Thequestionnairehasthreequestionsthatareconsideredtomeasurethepatient’s“overallhospitalexperience”.Theseare:

• Thinkingaboutallaspectsofyourhospitalstay,howsatisfiedwereyou?

70

75

80

85

90

95

Moyne Health Similar Hospitals - average Average - ALL Victorian Hospitals

Access andAdmission

ComplaintsManagement Discharge &Follow-up

ConsumerParticipation

Overall CareGeneral Pt Info Treatment Info

Physical Enviro MoyneHealth

SimilarHospitals-Average Average-ALLVICHospitals

22

• Howmuchdoyouthinkyouwereactuallyhelpedbyyourstayinthehospital?

• Wasthelengthoftimeyouspentinhospital…?(toolong,tooshort,aboutright)

ThetablebelowshowsthecurrentandpreviouswavemeanscoresforoverallsatisfactionforMHS,aswellasthecurrentwavemeanscoresforoverallsatisfactionforsamecategoryhospitalsandforthestate-widesample.

Thecategoryorstate-widescoreiscolouredorangeandshaded,whichindicatesthatthecorrespondingscoreforMHSis(statistically)significantlyhigher.

Resultswereverygoodandweresupportedbythefollowingcomments:

“Friendly, approachable staff, excellent on call doctor. Wasn’t in my home town (arrived via ambulance) but still had excellent care, follow up phone call from doctor with blood test results.”

“My family and I were so pleased to see that there are still hospitals like this around. This is the way hospitals should be like!”

AtMHSwefindtheVPSMprovidesuswithveryusefulinformationandagreatdealofdetailabouthowourpatientsfeelaboutthecareandservicesthatweprovide.Wewillcontinuetousetheseresultstoidentifyourweakerareasandtoprogressivelyimproveacrossallareas.

0

20

40

60

80

100

MEAN SATISFACTION

MHS WAVE 21 MEAN 4.83

MHS WAVE 20 MEAN 4.63

CATEgORY D WAVE 21 MEAN 4.73

CATEgORY D WAVE 20 MEAN 4.52

Thinking about all aspects of your hospital stay, how satisfied were you?(where1=Verydissatisfiedand5=Verysatisfied)

QOC[ ] QOC - quality & safety

Satisfaction with Residential

Aged Care Services

ThelevelofsatisfactionwithourResidentialAgedCareServicesisconstantlybeingmonitored.BothAgedCareHomes-BelfastHouseandMoyneyanaHouseholdregularResidentmeetingstoensurethatthelinesofcommunicationarekeptopen.Thesemeetingsprovideanopportunitytotalkaboutwhat’shappeninginthehomesandtodiscussanyconcernsthatresidentsmayhave.ItisalsoquitecommonforhealthservicestafftoattendthemeetingstoprovideanupdateaboutspecificissuesforexampletheFoodServicesManagermightattendtotalkaboutmenuupdates.

BothHomesalsoparticipateinanannualsatisfactionsurveywhichtakesacomprehensivelookathowhappyresidentsarewithallaspectsofthe

careandservicesprovided.Thegraphbelowshowstheresultsfortherangeofquestionsanswered.Theresultswerepleasingwiththeoverallsatisfactionratingachievingascoreabove90%satisfied.

Theresultsthatwereceiveareusedinplanningandeffortsaretakentoimproveinourweakerareas.Wealsocompareourresultswiththeresultsachievedatsimilarorganisations.ThisisdonethroughourmembershipwithQualityPerformanceSystems(QPS)andwereceivereportsbackthatshowhowweareperformingcomparedtootherplaces.ThegraphbelowisforMoyneyanaHouseandshowsthatourresultscorrespondwiththoseofothersimilarfacilities.BelfastHouseachievedsimilarresults.

10.OverallV

iews

oftheHom

e

9.MaintainingC

omm

unityC

ontact

8.ResidentServices-Environm

ental

7.ResidentServices-Food

6.ResidentServices-Medical,

TherapyandPersonal

5.TheHom

e’sCom

fortandSurroundings

4.YourAccom

modation

andLivingArea

3.InvolvementandSocial

Environment

2.Activities&

PassingTim

e

1.ServicesReceivedfrom

CareStaff

Moyneyana: 87.33 Minimum Mean Maximum

100

80

60

40

20

0

Resident Satisfaction - Section Results - Total % ScoreBelfast House 2011 - Results (Average Percentage Score)

Resident Satisfaction Index


About the People Matter Survey

ThePeopleMatterSurveyisaclimateandopinionsurveythatcollectsdataonemployeeperceptionsofthevaluesandprinciplesappliedintheirworkplace.TheSurveyalsogathersinformationonabroadrangeofpeoplemanagementissuessuchasemployeecommitmentandjobsatisfaction.

ForVictorianpublicsectororganisations,thevaluesandprinciplesappliedwithintheorganisationmustreflectthepublicsectorvaluesandemploymentprinciplesoutlinedinthePublic Administration Act 2004 (PAA).ThesevaluesestablishthenatureoftherelationshipbetweenGovernment,thecommunityandworkcolleaguesandextendtoeverythingwedo.

SomeMoyneHealthServices(MHS)staffparticipatedinthisyear’ssurveyalthoughweonlymanagedalow19%responseratemakingitdifficulttodrawvalidconclusions.FromtheinformationgatheredMHSperformedstronglyinsomeareasandtherewereareasforimprovementidentified.

Our disappointments, where we scored in the lowest quartile of the result, were in the following areas:

• Values

• Responsiveness

• Integrity

• EqualEmploymentOpportunity

• Genderisnotabarrier(indicated that it was)

• Intentiontoleave

• JobSatisfaction

• Fairpay

• Jobsecurity

• Overalljobsatisfaction

Our pleasing results where we achieved scores in the highest quartile were in the following areas:

• AwarenessofOrganisationalPoliciesandProcesses

• YourExperiences

• JobSatisfaction

• RegularFeedback/recognition

• Abilitytoworkonowninitiative

• PatientSafety

• Workplacewellbeingandcommitment

• Principles

• Merit,FairandReasonableTreatment

• Values

• Impartiality

• Leadership

Therewasawiderangeofresultsandthereappeartobesomeinconsistencies.TheseresultswillbelookedatinconjunctionwithEmployeesatisfactiondatatodeterminewhatareasneedfurtherwork.

QOC

Staffsocialisingaftermuchhardwork,ataPost-accreditationcelebration

24

Ensuring Quality and Safety through Risk Management

MoyneHealthServices(MHS)recognisesthattherearerisksinherentacrossallareasofbusinessanditisourorganisation’spolicytoachieve‘bestpractice’inidentifyingandcontrollingalltheriskstowhichitmaybeexposed.

Riskisthechanceofsomethinghappeningthatwillhaveanimpactonourobjectives.TheMHSRiskManagementPolicydefinesRiskManagementas“coordinated activities to direct and control an organisation with regard to risk”.Wemanageorganisationalriskstominimiseanynegativeimpactontheachievementofourobjectivesandtomaximiseourabilitytorealisepotentialopportunities.

AlllevelsofstaffatMHShaveresponsibilitiesassociatedwiththemanagementofrisk.Thisprocessspecifiestheriskresponsibilitiesofdifferentgroupsandindividualsthroughouttheorganisation.TheBoardofManagementandExecutiverelyonhavingaccesstodetailedandcurrentriskinformationtoassistthemtomakemoreinformeddecisionsregardingstrategicdirectionandoperationalobjectives.

AtMHSRiskManagementisintegratedintoexistingbusinessprocessessuchasplanning,qualitymanagementandinternalaudits.Theobjectivesofariskmanagementframeworkareto:

• Provideasystematicapproachtotheearlyidentificationandmanagementofrisksallowingustomeetpublicinterestobligationsandbusinessobjectives;

• ProvideconsistentriskassessmentcriteriatakingintoaccountMHS’sriskappetite;

• Makeavailableaccurateandconciseriskinformationthatinformsdecisionmakingandbusinessdirection;

• Adoptrisktreatmentstrategiesandcontrolsthatarecosteffectiveandefficientinreducingrisktoanacceptablelevel;and

• Monitorandreviewrisklevelstoensurethatriskexposureremainswithinanacceptablelevel.

Benefits

Riskmanagementprocessesareinplacetosupportustomeetourvaluesanddeliveronourobjectives.Applicationofaconsistentandcomprehensiveriskmanagementprocesswill:

• Increasethelikelihoodofusachievingourstrategicandbusinessobjectives;

• Encourageahighstandardofaccountabilityatalllevelsoftheorganisation;

• Supportmoreeffectivedecisionmakingthroughbetterunderstandingofriskexposures;

• Createanenvironmentthatenablesustodelivertimelyservicesandmeetperformanceobjectivesinanefficientandcosteffectivemanner;

Safeguardourassets-human,propertyandreputation;and

• Meetcomplianceandgovernancerequirements.

ThelastyearhasseensomesignificantachievementsinRiskManagement.Theseinclude:

• EnhancingreportingandaccountabilityprocessesthroughtheAuditandRiskCommitteetotheBoardofManagement

• ImproveddocumentationfortheongoingmonitoringandreviewofRisksontheRiskRegister

• Achievingahighlevelofcomplianceinourannualself-assessmentoftheRiskManagementProgram

• Achievinga“VeryGood”(Highest)ratinginourVMIASiteRiskSurvey(SRS).

[ ] QOC - quality & safety

NEEDS IMPROVEMENT ADEQUATE gOOD VERY gOOD

Recommendationsmadewithrespecttocontrollingortreatinghighorextremerisks,orasignificantnumberoflowormediumlevelrisksand/oranumberofoutstandingtreatmentrecommendations

Thesitedemonstratesriskmanagementsystemswithasignificant,ornumberof,risksrequiringtreatmentoradditionalcontrols

Thesitedemonstrateseffectiveriskmanagementwithmostriskappropriatelycontrolledwithaminorrecommendationshavingbeenmade

Thesitedemonstrateseffectiveriskmanagementwithrisksappropriatelycontrolledandfewornorecommendationshavebeenmade

Summary of ObservationsPortFairyHospitalhasachievedanoverallSRSratingofverygood.

MoyneHealthServicesPortFairyHospitalFINALSRS.doc©VMIA2012

25

Safe Medication Management across MHS

AtMoyneHealthServicesweaimtoprovideconsistentsafemedicationmanagementacrossallareasofthehealthservice.Medicationmanagementhasbeenwidelyreportedasanarearesponsibleforahighnumberoferrorsandadverseeventsduringhealthserviceadmission.1.6percentofhospitaladmissionsarereportedtobeassociatedwiththeoccurrenceofanadversemedicinesevent,andmedicinesareconsideredtobethecausalagentof10percentofalladverseeventsexperiencedinHospitals.

Medicationadministrationisamultidisciplinaryprocess,beginningwhenthemedicalpractitionerdecidestoprescribemedication,continuingwiththewritingofthemedicationchartandthedispensingofthemedicationfromthepharmacy,andendingwiththepreparationandadministrationofthemedicationtothepatient.Errorsmayoccuratanystageintheprocess.

MostmedicationadministrationrelatederrorsatMHSare:

• Signatureomissions(28%ofallreportedmedicationincidents)-themedicationwasgivenbutnotsignedfor,or

• Omitteddose-medicationmissedornotadministeredattheduetime.

Therewerealsosomeincidentsreportedinvolving

• Medicationgivenatthewrongtime

• Wrongdosegiven(oftenfollowingachangeindose)and

• Documentationcalculationerror-incorrecttotalling(miscount)ofthedangerousdrugregister(remainingstock)andtranscribingerrorsfromonepagetothenext

ThePieChartbelowdemonstratestheareasthatmostoftheincidentsoccur.Itshouldbenotedthatsignatureomissions-wherethedrugwasgivencorrectlybutthedocumentationwasnotcompleted,isthemostcommonerrorinBelfastHouse.

WealsoreceivefeedbackfromhospitalpatientsaboutthecarearoundmedicationsthroughtheVictorianPatientSatisfactionMonitor(VPSM)-asurveysentouttopeopleaftertheyaredischargedhome.Therearetwoparticularquestionsrelatingtomedicationmanagement:“Explanationofpurposeofmedicines”and“Explanationofside-effectsofmedicines”thatareillustratedinthegraphbelow.

Medication Management

Policyandproceduresareimplementedacrossourservicestosupportanddirectsafedeliveryofmedicationstoourpatientsresidentsandserviceusers.Toensurethepoliciesandproceduresarereflectiveofcurrentandsafepractices,referencesfromsuchsitesastheAustralianCommissiononSafetyandQualityinHealthCare,BestPracticeModeldevelopedbytheAustralianPharmaceuticalAdvisoryCouncilandtheNursingandMidwiferyBoardofAustraliaareusedwhenreviewingandrevisingthecontentanddirectivescontainedwithinthepolicies.

Staffareprovidedwithtrainingeachyear.WehaveengagedtheservicesofRuthGreentoprovide“inhouse”professionaldevelopmentdaystodeliverevidencebasedfactsandchallengeourstafftoimprovetheirknowledgeandpracticeintheadministrationofmedications.Staffcompleteanannualon-linemedicationcompetencytorefreshtheirknowledge.TheSOLLEsystemallowsustoenrolourstaffintoonlinecompetenciesandallowsthemanagerstomonitortheprogressofstafftowardsthecompletionoftheircompulsorycourses.Therearealsoothercoursesofinterestavailable.StaffalsohaveaccesstoAgedCareChannelrecordedprogramsthatcoverpharmacologyandadministrationofmedicationsforallstafffromRNstoPCAs.Staffhaveaccesstocurrentdrugreferences/textse.g.TherapeuticGuidelines,AustralianMedicationHandbook,tonameacouple.Theseareavailablebothashardcopybooksandonline.Newlyqualifiedstaffhavesupervisedmedication“rounds”untiltheyhavebeenassessedascompetentbyourClinicalNurseEducator,tomanagedmedicationadministrationwithoutdirectsupervision.

Intheeventofanincidentoccurring,wehaveanonlinereportingsysteminplace,‘Riskman’.Staffeitherself-reportorwhenfoundtheincidentisreported.TheUnitManagerisalertedbyemailthatanincidentrequiresinvestigation.Theinvestigationprocessorreviewoftheincident,ispartofourcontinuousimprovementprocesswherethepersoninvolvedmayexplainthecircumstancesthatwereinvolvedandthatledtothe

Acute

Belfast House

Moyneyana House

Other areas

0

1

2

3

4

5

Latest Survey Previous Survey Similar Hospitals Average forVictoria

QOC - quality & safety [ ]

PurposesofMedicines SideEffectsofMedicines

TheresultsshowthatMoyneHealthServicesisconsistentlyperformingbetterthansimilarfacilitiesandbetterthantheaverageforVictorianHospitalintheopinionofthepatientswhocompletedthesurveys.

Location of Incidents

incidentoccurring.Thefocusoftheinvestigationistopreventtheincidentbeingrepeatedagain.Theresultoftheinvestigationprocessallowsustotightenourprocessesifagapisrecognised.Dependingontheoutcomesoftheinvestigation,areviewofthemedicationmanagementpoliciesandproceduresorstaffcounsellingandeducationmaybetheendresult.

Safety Initiatives in Age Care Medication Management

InResidentialAgeCareaRegisteredNurseisresponsibleforthemedicationmanagementportfolio.ThisensurescontinuityforstaffandprovidesaresourcepersonforstudentnursesandGraduateNursestoutilise.

InconjunctionwithourlocalPharmacist,fromMcLean’sPharmacy,whoperformsrandomMedicationChartaudits,theAgeCareNurseUnitManager(NUM)meetswiththePharmacisttoconductCollaborativeResidentialMedicationReviews.ThesearereviewsonrandomlyselectedResident’smedications.Medicationsthathavebeenprescribed

arereviewed,thecombinationsofmedicationsandanysideeffects,recommendationsarethenmade.TheprocessconsiderstheResident’scompleteportfolioofprescribedmedications.Thefindingsarethenpassedontotheirdoctorforreviewandcommentasrequired.

Medicationchartsareauditednightlyforsignatureomissions,residentinformationdetailsandprescribingdocumentation.TheseauditshaveassistedustoreduceourreportedMedicationincidentnumbers.

TheintroductionofMedicationexpiryauditsallowsus,eachmonthtocheckthatallmedicationsthatareopened(Eye-drops,Medicines,Creamsetc.)arelabelledwitha‘date’openedsticker,sothatstaffcanidentifyexpiredstockanddiscard.ThisensuresthatResidentsarenotreceivingexpiredmedications.

TheintroductionoftheResidentindividualmedicationordercharthassuccessfullyaidedinthepreventionofoverorderingofResident’smedications.Italsoensuresthatthereisacontinuoussupplyofmedicationsrequired.

Policyandprocedurespertainingtomedicationmanagementareregularlyreviewed.Theseandaccompanyingprotocolsareinplaceandareconsistentwithlegislativerequirements,nationaljurisdictionalandprofessionalguidelines.Wecontinuetoprovideeducationalopportunitiesforcaregiverstoupgradetheirmedicationqualificationsandthereisasysteminplacetoverifythattheclinicalworkforcehavemedicationcredentialsappropriatetotheirscopeofpractice.


Prevention and Minimising of FallsFalls are a common public health problem, becoming increasingly more frequent with increasing age. Although falls can occur at all ages, they become particularly problematic for older people or those from high falls risk populations when compounded by an acute health problem requiring hospitalisation, or for those requiring admission to residential care settings.

Victorian Quality Council, 2004.

PhysiotherapistshaveanimportantroleinminimisingtheoccurrenceoffallsatMHSbyidentifyingfactorsthatmaycontributetoafallandimplementingstrategiestopreventfalls.Strategiesmayincludeprescribingexercisestoimprovemusclestrengthandbalancereactions,prescribingagaitaid(walkingstickorwheeliewalker)tocompensateforanybalancedeficit,oralteringthehomeenvironmenttoremoveanyhazards.Manyfallsarealsobehaviourrelated,soitisimportantforindividualstobeawareoftheircapabilitiesandlimitations.

Fallsareaparticularchallengeinresidentialagedcarefacilitieswhereagerelatedriskfactorsareinevitable.AtMoyneHealthServices,thephysiotherapistvisitsallresidentsinMoyneyanaHouseandBelfastHouseshortlyaftertheiradmissiontoassesstheirbalanceandmobility.Acareplanisthenputinplaceoutlininghowmuchassistancetheseresidentsrequirewiththeirmobilitytasks.Residentsareencouragedtodoasmuchastheycanforthemselvesinordertomaximisetheirphysicalabilities,butstaffareavailabletoassistincaseswheresafetywouldotherwisebecompromised.Eachresidentisreviewedatleasteverysixmonthswherethisassessmentprocessisrepeatedsothattheplancanbeupdatedifanychangeisdetected.Thiscareplanalsoincludesanexerciseprogramthattheresidentmayperformtoimprovetheirbalancecapability.

InMoyneyanaHouse,alowerlimbstrengthandbalanceexerciseclassisconductedonaweeklybasis.Thistargetseachmusclegroupinthelowerlimbsandalsoaimstochallengetheresidents’

balance.Residentsarealsoencouragedtowalkforexercise,andhaverecentlybeenmotivatedbya‘WalkaroundVictoria’programwheretheircumulativedistancewasplottedonamap.Thisthemewasthentiedintotheirweekly‘FriendshipGroup’whereresidentsdiscussedthetownsandotherdestinationsthattheyhadtheoreticallyreachedalongtheway.

Forresidentsinthecommunity,anoutpatientphysiotherapyserviceisavailabletothoseeligibleforHACC(homeandcommunitycare)funding.Thisincludespeoplewhoareelderly,frail,haveadisabilityorcareforsomebodywithadisability.Thisservicealsoinvolvesanassessmenttoidentifyfactorsthatmayincreasetheriskofafallandstrategiestoaddressthesefactors.Ifappropriate,areferralmaybemadeforindividualstoattendthecommunitygymwheretheycanhaveaccesstoequipmenttohelpimprovetheirlimbstrengthandbalanceinagroupenvironment.

Progress with Falls Management in Residential Aged Care

Ourfallsmanagementprogramisfocussedonminimisingthenumbersoffallsandalsotheinjuriesthatresultfromfalls.Therearemanystrategiesinplacetoassistustoachievethisandwehavebeenabletomaintainalowlevelofinjuriesresultingfromfallsthemostcommonbeingskintears,orsmallcutsthatmayrequireabandaid.WecompareourperformanceinthisareawithotheragedcarefacilitiesacrossAustralia.Ourresultshaveconsistentlyshownthatwehavelessfallsthanaverageandlessinjuriesthanaverage.Wehavemaintainedtheseresultsforanumberofyears.

Thegraphbelowshowsourfallsincidentsforthepastthreeyears.Wemust

rememberthatfallsincludefoundsittingonthefloorandanymovementdownwardandsoattimeswillinclude“falsepositives”sosomeoccurrencesthatwerenotactuallyafall.

Someofthesefallsarerecordedwhenresidents“rolloutofbed”.Toassistinreducingtheseverityoftheseincidentsfloorlinebedsareprovidedforhighfallsriskresidents.TherecentacquisitionofthreenewfloorlinebedsinBelfastHousehasincreasedthenumberofatriskresidentsusingthesebedsandreducedthelikelihoodofharmfromafall.

Wecontinuetoreviewcareplansandconductfallsriskassessmentstoensureallappropriatepreventativemeasuresareinplace.WealsoworkwithourPhysiotoeducatestaffandresidentsregardingfallsmanagement.Residents’mobilityispromotedthroughvariousprogramssuchastheMoyneyanaMovers,walkinggroupandtheWalkaroundVictoria

“Falls are a common public health problem, becoming increasingly more frequent with increasing age”


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Falls Incidents


Enhancing Pressure Area Prevention

Pressureulcersarealargelypreventableadverseoutcomeofahealthcareadmission.ResearchindicatesthatPressureinjuriesarethefifthmostcostly,commonlyoccurring,preventablecondition.TheimportanceofpressureinjurypreventionandeffectivemanagementofpressureinjurieswhentheydooccurhaspromptedtheinclusionofStandard8:PreventingandManagingPressureInjuries,inthenewNationalSafetyandQualityHealthserviceStandards.

Bothstaffandpatientshavearoletoplayinpressureulcerprevention.Patientsareincreasinglyencouragedtobemoreinvolvedintheirowncare.Developingpatientawarenessoftherisksofpressureinjuriesanddevelopingcareplansinpartnershipwiththem,canimprovecompliancewiththecareplanandminimisepressureinjuries.

Apressureinjuryisasore,anareaofskinthathasbeendamagedduetounrelievedandprolongedpressure.TheterminologyvariesfromPressureUlcertoPressureInjury,PressureInjuryisinlinewithnationalandinternationalmovestorecognisethatulcersareonlyoneformofapressureinjury.Pressureinjuriesare

usuallyfoundonbonypartsofthebody,butcanoccuralmostanywherethatpressurehasbeenappliedforaperiodoftime.

TheVictorianQualityCouncildeveloped‘Move,Move,Move’and‘PreventingPressureUlcers-aninformationbookletforpatients’toimproveconsumerunderstandingofpressureulcerpreventionandmanagement.ThisinformationisprovidedintheadmissionpackgiventoeverypatientandresidentadmittedtoMoyneHealthServices.

MoyneHealthparticipatesinthePressureUlcerBasicsonlinetraining,conductedbytheVictorianQualityCouncil.StaffcompletetheonlinepressureulcertrainingpackagesthroughourSOLLEeducationprogram.

OnadmissiontoMHS,allpatientsandresidentsarethoroughlyassessedtodeterminetheirriskofdevelopingapressureulcerduringtheirhospitalstay.Wherethereisahigherrisk,morepreventativemeasurescanbetakenbythenursingstafftoimproveoutcomesandreducepressureulcers.

Nursingstaffusearangeofspecialequipmenttohelpreducethepressureulcerrisksuchas:airordynamichighdensitymattresses,pressurerelievingcushionsandheelwedges.Patients

andresidentsareencouragedtokeepasactiveastheirconditionallows,andareencouragedtohaveregularpositionchangesduringtheirstay.

MoyneHealthServices-BelfastHouserecordedonepressureulcer(December2011)inthelast12months.Nursinginitiativestotreatthisincludeduseofairmattressandregularpositionchangesinbedoftheresident.TherearecontinualeffortsincludinglookingatequipmentandinnovationstoalleviatepressureareastoourResidents.

AsamemberofQualityPerformanceSystemsbenchmarkingprogram,wecompareourperformanceinPressureUlcermanagementwithothersimilarfacilitiesacrossAustralia.Weareproudtohaveonceagainachievedexcellentresultsacrossallfacilitiesandhavemaintainedthisresultforseveralyears.

Preventing Pressure Ulcers

Whatcanyoudo?

MOVE, MOVE, MOVE

Thebestthingyoucandoisrelievethepressurebykeepingactive,andchangingyourpositionfrequently,whetheryouarelyinginbedorsittinginachair.Ifyouareunabletomoveyourself,thestaffwillhelptochangeyourpositionregularly.Specialequipmentsuchasairmattresses,cushionsandbootiesmaybeusedtoreducethepressureinparticularplaces.

LOOK AFTER YOUR SKIN

Keepyourskinandbeddingdry.Letstaffknowifyourclothesorbeddingaredamp.Tellstaffifyouhaveanytendernessorsorenessoverabonyareaorifyounoticeanyreddened,blisteredorbrokenskin.Avoidmassagingyourskinoverbonypartsofthebody.Useamildsoapandmoisturizedryskin.

EAT A BALANCED DIET

Wanttoknowmore?

Askyournurseorhealthcareprofessional.

Department of Human Services, Victoria Victorian Quality Council


Blood Management - the gift of lifePatientbloodmanagementencompassessafepracticefortheuseofbloodforapatient.Itisindividualisedcare,whichhasthepatientsafetyatthecentre,withcarefulattentiontocorrectdetailandprocedures,theaimbeingbettertreatmentoutcomes.

TheBloodMattersProgramisaVictorianStateGovernmentprogramforimprovingthequalityandsafetyofhospitaltransfusioncaretopatients.Qualitymanagementintheclinicaluseofbloodcomponentsinvolvesadministeringtherightquantityoftherightcomponentintherightwayattherighttimetotherightpatient,withadequatedocumentationofbothprocessandoutcomes.MoyneHealthServiceactivelyparticipatesintheBloodMattersProgramandmonitorscompliancewithprocesseswhenmanagingbloodproducts.Thisensureswehaveanddemonstratethesystemsinplacetopreventerrorsinbloodmanagement.InadditionMoyneHealthServicesparticipatesinmonitoringperformancewhenmanagingbloodbyreportingresultsasauditedviatheACHSClinicalIndicatorsprogram.

AllRegisteredNurses,priortoparticipatinginanypartofthebloodtransfusionprocessmustsuccessfullycompletethenationaleducationprogram‘BloodSafee-learning’developedbyclinicalexpertsintheareaoftransfusion.

MoyneHealthServicesprovided68bloodtransfusionsepisodesina12monthperiod(July2011-June2012).In2011-2012MoyneHealthServiceshashadanincreaseof59%moretransfusionepisodeswherebloodhasbeentransfusedtopatientsatMHSincomparisontothe2yearsprevious.

MHSdatacollectionandmonitoringofthetransfusionprocessusedconsistentclinicalindicatorsforaccreditationpurposesatStateandNationallevels.Someoftheclinicalindicatorsmonitoredinclude:

• Clinicalandlaboratoryindicationsfortransfusion

• Appropriatepatientidentificationpriorandduringtransfusion

• Pre-transfusiontesting;observationandidentitychecksandposttransfusionobservation

• Bloodwastage(unitsunabletobetransfused)

• Reportingofadverseevents

Auditresultswhenmeasuredagainstthe“Better,Safer,Transfusions”criteriaareillustratedbelow:

2011-2012resultsasdemonstratedinthegraph:

• PatientConsentsigned:100%

• BloodWastage:nounitsofbloodwerewastedorreturnedtobloodbank(100%usagecompliance-improvementarea)

• Clinicalandlaboratoryindicationsfortransfusion:metcriteria97%oftransfusionepisodes(x2didnothaveapre-transfusionrecordedhaemoglobinlevel)

• Nursingdocumentationpre-transfusion:100%compliance

• Correctprocessmaintainedforpatientidentification:100%compliance

• Nursingdocumentationduringtransfusion:100%compliance

• Nursingdocumentationposttransfusion(completed):98%compliance(improvementarea94%to98%)

OftheRegisteredNursesthatparticipatedinthebloodtransfusionmanagementprogram,100%haveattendedthemandatoryonlinebloodtraining(BloodSafeeLearning)requiredpriortomanaginganypartofthebloodtransfusionprocess.BloodSafeeLearningAustraliaisAustralia’smostrecognisedonlinecourserelatingtoclinicaltransfusionpracticeincludingbloodspecimencollection,transportation,useandpatientbloodmanagementandaimstoimproveclinicaltransfusionpracticeandpatientbloodmanagement.

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Preventing and Controlling Health care related Infections.

TheinfectioncontrolprogramatMHSisdevotedtomaintainingthesafetyofallpatients,residents,healthcareprofessionalsandthesurroundingcommunitybyprotectingthemagainstinfectiousdiseases.Toassistindeliveringasuccessfulprogram,itisvitalthattheprocessofidentifying,preventingandimplementingcontrolmeasuresisutilisedandmaintainedinordertoreducetheriskofinfectiontransmission.

hand hygieneHandhygienecompliancecontinuestobeoffocusatMHS.ItiswellresearchedandrecognisedbytheWorldHealthOrganisationgloballythathandhygieneplaysasignificantroleinpreventingthetransmissionofinfection.Itisasimplemeasurethatwhenperformedcorrectlycanreducetheriskofinfectionandillness.MHSHandHygieneauditoutcomesareallreportedtotheDepartmentofHealthwiththeexpectationthattheAcceptableQualityLevels(AQL)willbemet,whichis

currently65%withanexpectedincreaseto70%inthenearfuture.ForthesereasonsMHShasbeendevotedtoimprovingstaffhandhygienecompliancerates.Overthepast12monthsstaffhavecontinuallybeeninformedoftheexpectationforcorrectperformanceinrelationtohandhygiene.ThishasbeenimplementedandgovernedbyreviewingMHSHandHygienepolicy,monitoringforcomplianceofthe5momentsofhandhygieneandcompliancetoadheretoMHShandhygienepolicyinrelationtojewellery;byinternalandexternalaudits.Staffawarenessandeducationhasbeenthemainkeytocontinuallystrivingtoimprovecorrect

handhygienecompliance.HandhygieneeducationandpromotionwillcontinuetobeaprioritytoensuresafeoutcomestoallstaffandclientsatMHS.

ThepoorhandhygieneresultisreflectedinthemostrecentVictorianPatientSatisfactionmonitorresultwhichasks“how often did you observe hospital staff cleaning their hands between attending patients?”Resultsweredownfrom61%to51%ofthetime.Thisdeclinehasbeenaddressedthroughextratrainingwithdetailedexplanationsforstaff,directivesfromseniormanagementandtheintroductionofdisciplinaryprocessesfornon-compliance.

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Infection Surveillance & Reporting

Infectionratesurveillanceandreportinginrelationtohospitalandcommunityacquiredinfectionsassistsinimplementingprocessestominimisetheriskofinfectiontransmission.AtMHSacuteandoutpatientwardpresentationsarerequiredtobereviewedandreportedtotheVicNISScoordinatingcentre.InfectiontypesmonitoredandreportedincludeClostridiumdifficile,MRSAinfections,VancomycinResistantEnterococcusinfectionsandBloodstreaminfections.Influenzavaccineuptakebystaffmembers,occupationexposuresandhandhygienecomplianceoutcomesarealsoreportedtotheDepartmentofHealthviaVicniss.ThisprocessenablesMHStheabilitytomonitorforpotentialriskfactorsortrendsandassistinplanningandevaluatinginterventionstopreventtransmissionofinfection.

MHSrecognisesthatagedcareresidentsarevulnerabletoinfectionsduetolivinginalargecommunallivingenvironment,whichiscateredtobyalargeflowofhealthcareprofessionals,visitors&families.Atpresent,surveillanceandmonitoringofagedcareinfectionratesisnotarequirement,howeveratMHSpotentialorsuspectinfectionsarereportedviathe‘Riskman’system.ThisyearthisprocesshasenabledMHSinfectioncontrolprogramtoidentifyareaswhereinterventionsandeducationwererequired.Areasincludedincreasededucationandawarenessof

therelativelynew‘gastroenteritisbug’,Clostridiumdifficile.Educationinrelationtobladdermanagementandcathetercarewasdeliveredtostaff.Aneducationalopportunitywasalsoprovidedforresidentsandtheirfamiliestoattend.

Antimicrobial Stewardship Program

MHSInfectioncontrolprogramissupportingtheAntimicrobialStewardshipProgram.ThisprogramisaimedatassessingcurrentantibioticusageinAustraliaincludingtheappropriatenessandeffectivenessforassistinginthereductionofHealthcareAssociatedInfections(HAI)andlimitingtheincreaseofmulti-resistantorganisms.Thisinitiativewasimplementeddueto“recognition that as antimicrobial resistance increases and development of new antimicrobial agents’ declines, it is critical that antimicrobials are used wisely and judiciously”.ThisprocessrequiresreportingtoTheAustralianCommissiononSafetyandQualityinHealthCare(ACSQHC)forreviewofcurrentusageandprescribingwithinourhealthcarefacilities.MHSinfectioncontrolisaimedatprotectingtheirclientsfromunnecessaryillnessesanddevotedtoassistinreducingHealthcareAssociatedInfections(HAI)andlimitingtheincreaseintheprevalenceofmulti-resistantorganisms.

Vaccination ProgramMHShasexpandeditsstaffvaccinationprogramtoassistinreducingtheriskofpreventableillnessessuchasPertussis(whoopingcough).OverrecenttimesithasbeenevidentthroughoutAustraliatherehasbeenanincreaseinpresentationsforwhoopingcoughplacingnewbornsatrisk.PertussishasalsobeenpresentwithintheMoyneregiondisplayingtheneedtopromotevaccinationuptake.ThisyearMHShasincludedthepertussisvaccinealongwiththeInfluenzaandHepatitisBvaccinefreetoallstaffmembers.

WiththecurrentinfluenzaseasonuponusMHScontinuestoofferinfluenzavaccinationforprotectiontoourstaff,residentsandpatients.Thisyeartherehasbeenanoticeableincreaseintheuptakeofthevaccinebystaffandvolunteers.Upuntilthe30thJune2012,andwithstaffcontinuingtoaccessthevaccine,therehavebeen115influenzavaccinesadministeredtostaff&volunteers,6Pertussisvaccines&3coursesofHepatitisBadministeredsincelateMarch.Agedcareresidentshavemaintained“herd”immunitywithinthefacility’swith85%ofresidentschoosingtohavetheinfluenzavaccinethisyear.InfluenzacontinuestobeveryprevalentwithinourcommunityandongoingpromotionfortheuptakeoftheinfluenzavaccinewillcontinueandbesupportedbyMHS.

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MHS Aged Care Influenza Vaccine Uptake 2012


Environmental Services Cleaning Outcomes ThisyearMHSEnvironmentalServicehavesuccessfullyimplemented‘microfiber’cleaningacrossthewholefacilitywhilstmaintaininghighcleaningstandards.Lastyearstaffundertookaninitialcleaningtrialwithintheacuteward.Thistrialwasimplementedinonedepartmenttodeterminetheeffectivenessofthe‘microfiber’productsandthefeasibilityofintroducingthisnewproductMHSwide.DuringthistimeregularswabbingofsurfaceswasperformedtoensurethecleaningprocesseswereeffectiveandthesafetyofMHSclientswasbeingmaintained.

Environmentalservicesstaffhavedemonstratedthewillingnessanddedicationtoimproveandmaintainsaferpracticeswithintheirdepartment.Theyhavesuccessfullyprovidedstaff,residents

andpatientswithanimprovedcleaningpracticethatwillcontinuetoprovidegoodcleaningoutcomesacrossthewholefacility.Thissystemhasproventobe;userfriendly,environmentallysafer,andmoretimeefficient.Theintroductionof‘microfibre’cleaningatMHShasprovidedacleanandsaferenvironmentforstaff,patients,residentsandvisitors.

Toensureeffectivecleaningstandardsaremaintainedenvironmentalserviceshasalsoincludedworkingmatrixes.MatrixeshavebeenimplementedtoensureamorefluentworkflowcanbemaintainedandcleaningjobsareconsistentlyperformedasrecommendedbythecleaningstandardsofVictoria.TheintroductionofthematrixeshasprovidedstaffwithasenseofownershipinregardtotheirworkpracticeoutcomesatMHS.

Infectioncontrolauditsareperformedonaregularbasistoidentifytheneed

forimprovement.Thisyeartheseauditshaveledtotheimplementationofnursescleaningschedules,upgradingofclinicalwastebinsandstorage,improvingcurrentpractices,maintainingcompliance,andimplementingandpurchasingequipmentsuchasmoreeffectivealginatebagsandsafetyneedledevices.

MHSisawareandstronglyappreciatesthatinfectioncontrolmeasures,basedonbestpractice,currentstandardsandguidelineswillprovidethebestprotectionforpatients,residentsandhealthcarepersonnel.MHSwillcontinuetostrivetowardspromotingsafety,qualityandavaluedhealthcareservicetoitscommunity.

QOC

Acceptablequalitylevel(AQL)forVeryHighRisk90%,AQLforallotherareas85%,Overallhospitalscore(OHS)is90%

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VHR=VeryHighRisk,HR=HighRisk,MR=ModerateRisk,LR =LowRisk


Food Safety - Meals on Wheels (MOW)Afoodsafetyprogramisadocumentedsystemformanagingparameterslinkedtofoodsafety.MoyneHealthServicesprogramssystematicallyidentifythefoodsafetyhazardsthatarereasonablylikelytooccurinfoodhandlingoperations.Eachhazardidentifiedcanbecontrolledandwherenecessaryacorrectiveactionisputinplaceandregularreviewprovidedoftheprogramtoensureitisappropriate.FoodSafetyisakeyaspectoftheFoodServicesprovidedbyMoyneHealthServices.

Eatingwellisimportanttoassistpeopletostayhealthyandindependent.MoyneHealthServicesMealsonWheelsprogramdelivershealthymealstotheclient’shometonotonlyensuretheirnutritionalrequirementsarebeingmet,buttoprovideregularsocialcontactandafriendlychecktoseealliswell.Thisassistspeopletocontinuetoliveintheirownhomes,wheremostarehappiest.Ouraimistoimprovequalityoflifebyhelpingpeoplemaintaintheirsafetyandindependenceathomeandinthecommunity.

MealsonWheelsprovidemealstosuitaclient’spersonalrequirementsandcanaccommodatespecialdietaryneedsandtastepreferences.

StandardMealsonWheelsconsistofsoup,mainmeal,dessertandjuiceandmaybedeliveredhot,coldorfrozen.MoyneHealthServicesofferasevendayserviceoffreshlycookedmealsandvolunteerstodelivermealstoclients’homes.MealsonWheelsdeliveredmealsarepreparedaccordingtonutritionalguidelinesthatrequirethemealstoprovideonethirdofnutritionalneedsfortheday.

QOC

“Eating well is important to assist people to stay healthy and independent”


DistrictNurseKatieHowellloadingthecarfortheday.

Residential Aged Care Indicators In2003theGeronticNursingClinicalSchoolofLaTrobeUniversitydevelopedasetofqualityofcareperformanceindicatorsfortheDepartmentofHumanServicesforuseinResidentialAgedCarefacilities.Theindicatorswereintendedtoassistinmonitoringandimprovingthequalityofcarebeingprovided.

MoyneHealthServiceshasreportedtheirresultsinrelationtotheindicatorssincetheinceptionoftheprogram.Theinformationthatiscollectedincludes:

Indicator 1: PrevalenceofPressureUlcers

Indicator 2:PrevalenceofFallsandFall-relatedfractures

Indicator 3:IncidenceofPhysicalRestraint

Indicator 4:IncidenceofResidentsPrescribed9ormoreMedicines

Indicator 5: IncidenceofUnplannedWeightLoss

Theseindicatorsarecollected,reportedandthenthefeedbackandcomparisondatareceivedfromtheDepartmentisreviewed.BothBelfastHouseandMoyneyanaHouseconsistentlyachieveexcellentresultsfortheindicators.Therehavebeenafewexceptionaloccasionswhenourratesarehigherthanexpectedbutthiscanbeexplainedbyisolatedsituations.Theoverallinformationindicatesthatweareperformingatahighlevelandachievingsomeofthebestresultsbeingreported.

WeusethisinformationinconjunctionwiththeinformationthatwegetfromQualityPerformanceSystems(QPS)toprovideapictureofhowweareperformingincomparisontoourpeersandtoidentifyopportunitiesforimprovement.

Wound Management @ MHS

AllNursingstaffatMHShavetheopportunitytoaccessawiderangeofeducationalandprofessionaldevelopmentsessionswithregardswoundcareandmanagementofthehealingprocess.TheeventshavebeencoordinatedbyourregionalWoundCareConsultantLeslieStewart.Acombinationoffacetofacestudydaysandtheuseof“webex”softwaretoprovidethesesessionshasincreasedtheaccesswithintheworkenvironmentforstaff.Thishasallowedustomakethemostoftheopportunitiestogaintheinformation.

Thequalityofthepresentershasbeenexceptional,withseveralsessionsbeingprovidedbySandyDeanawell-knownguruofthewoundcareassociation.Topicsincluded:Assessment, measurements, debriding, dressings and compression strategiestobeabletomanageawidevarietyofacuteandchronicwounds.

TheDistrictNursingstaffareabletomanageawiderangeofwounds,withintheperson’shome,ratherthanhospitalisation.TheuseofVistrak - (which traces wound, calculates viable & non-viable tissue, takes circumference measurements) dopla (circulation) recordings and sequential photos of the wound progress are some of the techniques that are utilised.Liaisingwithotherhealthprofessionalsaspartoftheteammanagementapproachtowoundhealing,theprocesswillpossiblyincludereferralstodietitian,podiatrist,diabeticeducators,GP’s,OT’sandphysiotherapist.“HealthCareGuides”producedbyConnectedWoundCare(aDHSsupportedinitiative)havebeenproducedtoeducateandprovidesupporttotheclienttobepartofthepartnershipinthehealingofchronicwounds.


Your Say - Comments, Suggestions, Feedback, Complaints, Compliments

Commentsandcomplaintsfromconsumersprovideuniqueinformationabouttheirneedsandthequalityofcareandservicesthattheyreceive.Thereareanumberofwaystomakeasuggestion,shareanideaormakeacomplaintregardingthecareandservicesthathavebeenreceivedatMoyneHealthServices.

“Comments,Suggestions,FeedbackForms”and“ComplaintsForms”,areavailablethroughoutthefacility.TheycanbefoundintheAcuteHospitalattheNurse’sStation,attheFrontReceptionandintheStaffDiningRoom,CommunityHealth,inBelfastHouseandinMoyneyanaHouse.

Staffarehappytodiscussanyconcernsorlistentoideasforimprovement.Inmostcasestheywillrecorddetailsononeoftheaboveformsandensureitispassedtotheappropriatemanager.Consumersandtheircarersareencouragedtodiscussanyconcernsaboutclinicalcarewiththeirtreatingdoctor.

InVictoriaindividualshavearightofaccesstotheirhealthinformationandtomakecomplaintsabouthealthserviceproviders.TheOfficeoftheHealthServicesCommissioner(HSC)isanindependentstatutoryauthorityestablishedtoreceiveandresolvecomplaintsabouthealthservices.TheHSCalsohandlescomplaintsaboutdisclosureofhealthinformationandaccesstohealthinformation.

The2012annualreviewofourcomplaintsmanagementprocesseswasdoneusinganewtoolthatwasdevelopedbyNSWHealth.Itwasverycomprehensiveandidentifiedafewareasthatwecoulddevelopfurther.Weachievedaverygoodscoreof80%compliant.Themajorareaforfurtherdevelopmentisinthetrainingoffrontlinestaff.WehaverecentlygainedaccesstoausefulDVDfromtheAgedCareChannelthatwillmeetourneedsinthisarea.StaffwillbeencouragedtowatchtheDVDtoimprovetheirunderstandingofthemanagementofcomplaints.

OurresultsintheVictorianPatientSatisfactionMonitor,asurveyofAcutepatientsshowongoingsteadyimprovement.Thegraphbelowshowsourperformanceoverthelast5yearsinthe“ComplaintsManagementIndex”.ItshowsconsistenthighlevelperformancethatisratedaboveothersimilarorganisationsandsignificantlyabovetheaverageforallVictorianHospitals.

“Staff are happy to discuss any concerns”

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Limited Adverse Occurrence Screening (LAOS) Program

What is LAOS?LAOSpromotesthedetection,monitoring,preventionandearlymanagementofadverseeventsinVictoria’ssmallruralhospitals.InsmallruralhospitalsGPsworkingasVisitingMedicalOfficers(VMOs)admitpatients,provideacuteservices,andparticipateinafter-hourscare.LAOSprovidessmallruralhospitalsandVMOswiththeresourcestoparticipateinconfidentialpeerreview,whichpromotesdiscussionofadverseeventsandoffersrecommendationsforimprovedclinicalcare.

MoyneHealthServices(MHS)hasparticipatedintheOtwayDivisionofGeneralPracticeLAOSprogramforthepastnineyears.TheLAOSprogramprovidesanimportantaspectofourclinicalandmorespecifically,medicalqualityprogram.RecommendationsreceivedthroughLAOSarediscussedatourVisitingMedicalOfficers(VMOs)meetingwheredoctors,nursingstaffandmanagementcanconsidereachrecommendationandmakedecisionsabouttherelevancetoMoyneHealthServices.TheyarealsoconsideredatourClinicalGovernancemeetings.

EffectivefromJuly1,2009theLAOSselectioncriterionforselectionofrecordshasincluded:

1. Patientdeath

2. Unplannedreturntotheatrewithinsevendays

3. Unplannedreadmissionwithin35daysofdischarge

4. Transfertoanotherhealthservice

5. Patientlengthsofstaygreaterthan35days,and

6. Anyrecordwhichhasbeenrecommendedbyadoctororotherhealthprofessionalforreview.

Asaresultofthe“EvaluationofLAOS2012”theLAOSProgramaswehaveknownitwillnolongercontinuebeyondDecember2012.ItisanticipatedthatthepeerreviewprocessprovidedthroughtheprogramwillbeincorporatedintoMHS’sClinicalGovernanceProgram.

36

MaintenanceManagerTimDrewintroducesBEIMStostaff.

[ ] QOC - quality & safety

BEIMS - enhancing safe care:

TheBuildingandEngineeringInformationManagementSystem(BEIMS)waslaunchedliveinMarchofthisyear.BEIMSisanelectronicandautomatedsystemformaintenancerequisitions,contractandcontractormanagementandpreventativemaintenance.

PreviouslyMHSusedapaperbasedsystemformaintenancerequisitions,servicecontractsandpreventativemaintenance.Thesesystemswerebasedonaseriesoftriplicaterequisitionslips,handwrittennotesandcalendarentries.Thesepaperbasedsystemswereinefficient,labouriousandcreatedthepotentialforitemstobemissedoroverlookedduetohumanerror.

TheintroductionofBEIMShasimprovedthefollowingatMHS:

• linesofcommunicationbetweenmaintenancerequestorsandthemaintenancedepartment

• OH&Soutcomesthroughadocumentedandauditablepapertrail

• contractmanagement

• contractormanagement

• staffsatisfaction

• thenumberofhoursspentonunplannedwork

• reportingonmaintenancecostsandperformances

• compliancewithaccreditationstandardsandstatutoryobligations

BEIMShashadapositiveinfluenceonsomanypartsoftheorganisationandwillcontinuetodosoasfurtherBEIMSmodulesareintroduced.TheaboveimprovementsarecertainlyenhancingsafecareatMHS.

QOC - care [ ]37

Service AccessServiceaccessisanintegratedsystemsupportedbysystematicprocessesandconsistentpracticewhichcansignificantlycontributetopositiveconsumer,organisationalandwiderservicesystemimpacts.Serviceaccess/intakeisaboutmakingitsimplerandeasierforpeopleandtheircarerstoaccessservices.

Olderpeople,peoplewithadisability,carersorpeoplewithconcernedfamilyorfriendscanphonetheCommunityCareCoordinator(CCC)andreceiveone-to-oneadviceaboutappropriateagedcare,alliedhealthandcommunitybasedservices.Theymayalsomeetface-to-faceifpreferred.

Thiscreatesopportunitiestoinfluencetheservicesystemasawholebypartneringwiththeconsumertoenhanceservicecoordinationandintegrationwiththegoalofimprovingconsumeroutcomes.

ServiceCoordinationplacesconsumersatthecentreofservicedeliverytoensurethattheyhaveaccesstotheservicestheyneed,opportunitiesforearlyinterventionandhealthpromotion,andimprovedhealthandcareoutcomes.

TheCCC,canassistreferraltoservices,suchas:

• districtnursing

• podiatry

• homesafetyreview

• organisedgroupswithsocialsupportactivities

• physiotherapy

• occupationaltherapy

• AgedCareAssessmentServices(ACAS)

Putting the Person at the Centre

AtMoyneHealthServicesweareworkingtowardsenhancingthepersoncentredapproachtoprovidingcare.

Patientorconsumercentredcareishealthcarethatisrespectfulof,andresponsiveto,thepreferences,needsandvaluesofpatientsandconsumers.Differentdefinitionsandterminologyhavebeenusedtodescribetheconceptsinthisareabutkeyprinciplesofpatientcentredapproachesinclude:

• treatingpatients,consumers,carersandfamilieswithdignityandrespect

• encouragingandsupportingparticipationindecisionmakingbypatients,consumers,carersandfamilies

• communicatingandsharinginformationwithpatients,consumers,carersandfamilies

• fosteringcollaborationwithpatients,consumers,carers,familiesandhealthprofessionalsinprogramandpolicydevelopment,andinhealthservicedesign,deliveryandevaluation.

Patient-centred care is ‘an approach to the planning, delivery, and evaluation of healthcare that is grounded in mutually beneficial partnerships among healthcare providers, patients and families’.

Institute for patient and family centred care.

Thereisincreasingevidencesupportingthisapproachtoachieveimprovementsinthecareexperienceforcarerecipients.Someoftheimprovementsidentifiedinclude:decreasesinmortality,reductioninratesofhospitalacquiredinfection,reducednumbersofsurgicalcomplications,improvementsinpatientfunctionalstatusandhigherqualityclinicalcare.

WearefocusingonmanyoftheseareasthroughouttheHealthServiceandmonitorourperformancethroughtheQualityProgram.TheVictorianPatientSatisfactionMonitor(VPSM)assessessatisfactionwiththeseaspectsforourHospitalinpatients.Ourmostrecentresultsindicatethatweareperformingquitewellinthisarea.Thegraphbelowillustratesourachievementswhencomparedwithourpreviousresults,theaverageforsimilarsizedhospitalandtheaverageforallhospitals.

Policy Context

ServiceSystem:

AgencySystems

ConsumerCare

SocialSupport

GP’s

HPopportunities

CH

Acute

Sub-Acute

Rehabilitation

4.3

4.4

4.5

4.6

4.7

4.8

Current Results Previous survey

Moyne Similar Hospitals All Hospitals

Access to Services

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Promoting ParticipationMoyneHealthServicesencouragestheparticipationofCommunitymembersandConsumersindecisionmakingabouthealthpolicyandplanning,careandtreatment,andthewellbeingofourcommunity.WefollowtheguidelinesestablishedbytheDepartmentofHealthintheir“Doingitwithusnotforus”,StrategicDirection2010-13.ThisistheVictorianGovernment’spolicyandhasthefollowingaim:

Forconsumers,carersandcommunitymemberstoparticipatewiththeirhealthservicesandtheDepartmentofHealthinimprovinghealthpolicyandplanning,careandtreatment,andthewellbeingofallVictorians.

Advantagestoincreasedparticipationinclude:

• Anaidtoimprovehealthoutcomesandthequalityofhealthcare

• Animportantdemocraticright

• Amechanismtoensureaccountability.

How Moyne Health Services meets the standards:

Standard 1:

Theorganisationdemonstratesacommitmenttoconsumer,carerandcommunityparticipationappropriatetoitsdiversecommunities.

• TheConsumerConsultationandParticipationPolicyhasbeenadoptedbytheBoardofManagementandisavailabletoallstaffthroughthePromptonlinepolicysystem

• TheCommunityHealthandWell-beingGroupincludesrepresentationfromkeyareasoftheCommunityandCommunityGroups.

• TheVictorianPatientSatisfactionMonitor(VPSM)resultsspecificallyrelatingtotheConsumerParticipationIndexprovideuswithusefuldataaboutourperformanceintheHospitalarea.Thesatisfactioninthisareahasbeenconsistentlyhighandabovethesatisfactionreportedforsimilarhealthservices.TheVPSMsurveyasksthreekeyquestionsaboutparticipation:

•Theopportunitytoaskquestions(1)

•Thewaystaffinvolvedyouindecisions(2)

•Arestaffwillingtolistentohealthcareproblems(3)

See results in the graph below

Standard 2

Consumers,and,whereappropriate,carersareinvolvedininformeddecision-makingabouttheirtreatment,careandwellbeingatallstagesandwithappropriatesupport.

WeperformedverywellintheVPSMConsumerParticipationIndicatorasindicatedbythegraphbelow.

WeassesstheinvolvementofagedcareresidentsintheirannualsatisfactionsurveythroughtheQualityPerformanceSystem(QPS).TherearetwoquestionsthatspecificallyaddressResidentinvolvementinthecareprovided.Weachievedveryhighscoresforboth(shownintheorangetables):

Standard 3

Consumers,and,whereappropriate,carersareprovidedwithevidence-based,accessibleinformationtosupportkeydecision-makingalongthecontinuumofcare.

• TheVPSMprovidesuswithusefulinformationinthe“writteninformationrating”.Thisisanareathatwehaveconsistentlyreviewedinrecentyears.ThegraphbelowdemonstratesourperformanceinthisareathelastVPSMsurveyperiod.Itispleasingtoseethatwhencomparedtootherhospitalswerateverywell.

WealsocollectthisinformationfromouragedcareresidentsthroughtheQPSsatisfactionsurvey.Theyratehowwellwekeeptheminformedaboutthingsthatmayaffectthem.Themostrecentsurveywasrated:

3.6

3.8

4

4.2

4.4

4.6

1 2 3

Opportunities to have a say in things that may affect you

4.40/5 88.00%

How well are you informed of the things that may affect you

4.31/5 86.25%

Consumer Participation Rating - Specific Questions

Being kept informed about things that may affect you

4.31/5 86.25%

Moyne VIC Average D Hospital Average

3.6

3.7

3.8

3.9

4

4.1

4.2

4.3

4.4

Written Info aboutCondition

Moyne

VIC Average

D Hospital Average

QOC - care [ ]39

Standard 4

Consumers,carersandcommunitymembersareactiveparticipantsintheplanning,improvement,andevaluationofservicesandprogramsonanongoingbasis.

ACommunityConsultationprojecttogatherinformationforserviceplanninghasbeencompletedandtheinformationusedinplanning.

ThereisaServicePlanningCommitteewithrepresentationfromstaff,doctorsandcommunityrepresentatives.

Suggestions,complaints,feedbackprocessesarewellestablishedandaplainlanguageflierhasbeendevelopedtoassistthecommunity,staff,patients,residentsandtheirfamiliestounderstandtheprocess.

OurAuditandRiskCommitteehasseveralCommunityRepresentativeswhoareactive,productivecommitteemembers.

Standard 5

Theorganisationactivelycontributestobuildingthecapacityofconsumers,carersandcommunitymemberstoparticipatefullyandeffectively.

Weareprogressivelyworkingondevelopingthisarea.Wehaveinplace:

• Communitymembershiponsomeoperationalandstrategiccommittees

• Processestoensureparticipationincareacrosstheorganisation

• Processestoencouragesuggestionsandfeedback.

“Doing it with us not for us”

[ ] QOC - care40

Bed-side handover - an initiative in partnering with consumers.

Thereisplentyofevidencesupportingthenotionthateffectiveclinicalhandovercanreducecommunicationerrorsbetweenhealthprofessionalsandimprovethesafetyofpatientcaredelivery.CommunicationproblemshavebeendemonstratedtobeamajorcontributingfactorinhospitalsentineloradverseeventsthathavebeenreportedtotheVictorianDepartmentofHealth.Theriskofadverseeventsoccurringactuallyincreaseseachtimeapatientisdischargedortransferredbetweenunits,medicalofficersandcareteams.

Consumercentredcareinvolvestheactiveparticipationofpatients,consumersandcarersintheplanning,deliveryandevaluationofcare.Theeffectivenessofhandovercommunicationmaybeenhancedbytheparticipationofpatients,carersandfamilymembers.MHSAcuteServicescommencedtriallinghandoveratthepatientbedsideattheafternoonshiftchangeoverasofJune2012,theaimbeingtoreducepotentialmisunderstandingsandcommunicationerrorswhenattendingtotheclinicalhandoverofpatientinformation

Thepatient/consumerisintroducedtotheincomingteamandparticipatesinthehandoveratthepatientbedside.Thisincomingteamreviewsthemedicationchartsandadministrationrequirementsformedications,andincludesthepatientinreviewingtheirownmedicationmanagement.Thepatientandcarerareincludedindiscussionandencouragedtoparticipateinmanagingfortheirplanofcareduringtheadmission,andindiscussionsandplanningforexpecteddischargefromhospital.Thepatientisabletoparticipateactivelyinthecareprogression,expectationsandpreparationforexpecteddischargefromhospital.

Recentfeedbackhassupportedthetrialofclinicalhandoveratthepatientbedside.Patientsreporttheyfeelmoreincludedintheplanningandactioningoftheircareandhaveclearerexpectationsforwhentheyarepreparingfordischarge.Thisreducesthepotentialfordependencyuponthesystem,resultsin

reductioninthelengthofhospitalstayandlikelihoodoffrequentreadmissionbyensuringclearcommunicationandgoalsettingbetweenthepatientandtheircaregivers,carers,alliedhealthandmedicalprofessionals.

Moyne healthy Kids Project SouthWestHealthyKids(SWHK)Moyneisacommunitybased,healthdevelopmentinitiativepromotingphysicalactivityandhealthyeatinginchildrenandtheirfamilies.Itisacollaborativepartnershipoflocalgovernment,communityandhealthagenciesincluding:MoyneHealthServices,TerangandMortlakeHealthServices,MoyneShireCouncil,SouthWestHealthcare-MacarthurCommunityHealthandSouthWestSport.

MoyneHealthServicesCommunityHealthisprimarilyinvolvedwiththecommunitiesofPortFairyandKoroit.

Our concerns

Weareconcernedaboutthecurrentupwardtrendinoverweightandobesity,particularlyinchildren.Thenumbersofourchildreneatinganutritiousdietarelow.Levelsofphysicalactivityaredropping,whilsttimespentusingelectronicmediasuchastelevision,theinternetandcomputergamesareincreasing.Studiesfirmlyestablishthelinkbetweenpoornutritionandeatinghabits,combinedwithadeclineinahealthylifestyle,andresultingoverweightandobesity.InAustraliamorethantwothirdsofmenandmorethanhalfthewomenareoverweightorobeseandstudieshaveprojecteda50%increase

inobesityandasustainedprevalenceofoverweightfortheAustralianpopulation.“Tomorrow’soverweightandobeseadultsaretoday’schildren”.

“Healthyeatingandexerciseincreaseenergy,moodandconcentration.Theseallenhancelearningcapacityandphysicaldevelopment.”Feedbackaboutobesityandtheimportanceofnutritionandphysicalactivitytochildren’sdevelopmentandlearning:

• Morethanthreequarters(78.4%)ofstakeholdersinterviewedreportedthattheyhadaroletoplayinaddressingchildhoodobesity.

• Thirtysevenpercent(37%)ofstakeholdersinterviewedthinkthecommunityhasanissuewithobesityandbeingoverweight,while12%didnotthinkitanissueinthecommunity.Afurther34%ofresponseswereeitherunclearordidnotdirectlyanswerthequestion.

About lunchbox contents

Onaverage12.4%oflunchboxesacrossall‘communitiesofinterest’didnotcontainamainmeal(Definedasasandwich/wrap,left-overorfastfood-proteinorspreadwithbiscuitsalsocountedasamainmeal).InMoyne10.6%oflunchboxesweremissingmainmeals.

Other key findings from the lunchbox audit include:

• Fewlunchboxes(average5.1%)acrossallcommunitiesofinterestcontainedatleastoneserveofvegetables.

• Onaverage28%oflunchboxesacrossallcommunitiesofinterestdidnotcontainfruit.

• Onaverage72%oflunchboxescontainedoneormoreservesoffruit.

QOC - care [ ]41

• Anaverageof60.8%ofalllunchboxescontainedatleastoneserveofbiscuits

• Anaverageof21.9%containedtwoormoreservesofbiscuits.Unfortunately this category does not distinguish between sweet biscuits and dry biscuits, or between home-made and commercial biscuits.

• Anaverageof26%ofalllunchboxescontainedatleastoneserveofcakeorslice (Unable to distinguish between home-made and commercially made cakes/slices or serving size)

• Anaverageof15.6%containedatleastonemueslibar.

• Justoverhalf(50.4%)ofalllunchboxescontainedpackagedsnackswithanaverageof21%oflunchboxesacrossall‘communitiesofinterest’containingtwoormorepackagedsnacks.

• Nineteenpercent(19%)oflunchboxescontainedconfectionary.

• Eightpercent(8.1%)oflunchboxescontainedsweeteneddrinks.

Advances in Clinical Practice - Keeping us Up to Date

The Point of Care (POCT) Troponin ProjectBACKGROUND:Troponin is a complex of three proteins found in blood integral to muscular contraction in skeletal and cardiac muscle.

• TheVictorianCardiacClinicalNetwork(VCCN)commencedinFebruary2009andaimstoimprovequality,access,equity,costeffectivenessandsustainabilityofcardiacservicesinVictoriathrough:

• Facilitatingacoordinatedapproach,basedonevidencebasedguidelinesforthecareandmanagementofbothadultsandchildrenwithcardiacconditions.

• Workingacrossorganisationalboundariestodevelopeffectivehealthsystemresponsestoenhancecardiacserviceprovisionandimprovecardiachealthoutcomesacrossthestate.

In2010theVCCNorganisedacardiacservicessurveytobeconductedacrossallservicesinregional/ruralVictoria.Someoftheconsistentrecommendationsfromthesurveyswere:

• Thataframeworkforthemanagementofacutecoronarysyndromeinruralstate-widehealthservicesbedevelopedwhichtakesintoaccountthelimitedaccesstosupportservicessuchasradiologyandpathology.

• Accesstoacardiologist(couldbephoneonly)bemadeaccessibletoallruralhealthservices24/7.

• Thedevelopmentofaconsistentpolicyforpointofcaretestingdevelopedforallruralhealthservicesandthatthispolicyincludesacompetencytool.

Aspartofarangeofactivitiesfor2011-12theVCCNdecidedtoundertakeapilotofpoint-of-caretroponin(POCT)assaystoassistinthetriageofpatientspresentingwithchestpainintheEmergencyDepartment/UrgentCareServicecentresinsmallruralhealthservices.ItwasdecidedtoundertakethispilotinthesevenhealthservicesintheSouthWestRegion.

PURPOSE Theoverallaimistointroduceanacutecoronarysyndromepathway,toSouthWestVictoria,andevaluateitsimpactbyimprovingaccesstoevidence-basedacuteandfollow-upcardiaccare,throughtheprovisionofthefollowingresourcesandimplementationstrategies.

OBJECTIVES• Introduceapilotprojectonbedside

POCTbloodtestingforcardiactroponinincentresthatcannototherwiseensureaturnaroundtimefortroponinassaysof<60minutes(24/7)tosupporttimelyriskstratificationanddecision-makingregardlessofgeographiclocation.

• ImprovedaccessibilitytospecialistcardiologyadviceregardingECGinterpretation,otherdiagnostictestinterpretation,triageandtreatmentdecisions.Thisservicewouldaimtoprovidepromptadvice24hours/7daysaweekutilisinganescalatingpagingservice,withanaverage

responsetimeof<10minutes.

• Provisionofcomprehensivecardiaccontinuingmedicaleducationforthemedicalandnursingworkforceservicingtheseareas.

• Adherencetocardiacclinicalguidelines.

• DevelopagreedClinicalPathwaysforChestPain/AcuteCoronarySyndrome.

TheprojectinvolvedPointofCareTroponin(POCT)testinginsevenhealthservicesintheBarwonSouthWesternRegionofVictoriaforpatientspresentingwithasuspectedacutecoronarysyndrome.Sevenhospitalsiteswereidentifiedforinclusion:Warrnambool,Portland,Timboon,Camperdown,PortFairy,Heywood,andTerang.

Dr.TimBaker,DirectorofSWHCWarrnamboolEmergencyDepartment,wastheoverallleadclinician.TechnicalsupportwasprovidedbyRosyTirimacco,iCCnet(IntegratedCardiovascularClinicalNetworkCHSA)SouthAustralia.MargaretBullwastheCardiacClinicalFacilitatorfortheproject.Herroleinvolvedmedicalandnursingstaffeducation,supportandfeedbackthroughouttheprojecttimeframeoftenmonthsandco-ordinatingasteeringcommitteetodelivertheprojectoutcomes.RocheprovidedtrainersforPOCTmachine12thDecember2011andMHSwentlive19thDecemberwiththeiCCnetproviding24hoursupport.

OUTCOME• ReviewoftheASSESSMENT&

MANAGEMENTclinicalpathwayforCHESTPAINMANAGEMENT@MHS

• OngoingPOCTbloodtestingusingtheRoachcobash232machine,withtechnicalsupportandqualitymonitoringby,iCCnetSouthAustralia.

• Ongoingaccesstoadvicelinetoon-callcardiologistinGeelong(BarwonHealth).

• Reliable,qualitativetestsformyocardialdamagemarkerstoassistclinicianstorapidlyriskstratifypatientsandensureearliermanagementmeasuresintotheroutinecareofthesepatients.

• ImprovedaccuracyandspeedwithwhichchestpainpatientspresentingtoMHSarediagnosedandtreated.

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ShED - Small Hospital Emergency Department, Project

TheSmallHospitalEmergencyDepartmentproject(SHED)wasaregionalprogramruncollaborativelybetweenDeakinUniversityandanumberofsmallruralhealthserviceswithemergencydepartmentsthatarenotfundedbytheDepartmentofHealth.Theprojectwasestablishedtogatherinformationaboutthenumbersandtypesofattendancesattheseemergencydepartmentsanddetailsabouttheoutcomeoftheattendance-howmanypeoplewereadmittedortransferredorhowmanyreceivedtreatmentandwenthome?

TheSHEDprojectgatheredasubstantialamountofveryinterestinginformation.IthasnotyetbeenfinalisedbutMHShasseensomepositiveoutcomesfromourparticipation.TheprojecthasencouragedandallowedforsomesignificantchangesinthewayinformationaboutEmergencyDepartmentattendancesisgatheredandmaintained.Wenowhavegooddataaboutthepeoplewhoattendandthisinformationisusedforfutureplanning.Thequalityoftheclinicalinformationhasalsobeenimprovedandprovidesahigherqualityofdocumentationforongoingpatientcare.

Insummarythisprojectprovidedtheimpetustomovetoelectronicrecordsintheemergencyareaandhasledtosignificantimprovementintheinformationthatisavailable.Wecannoweasilyprovidestatisticalinformationandveryquicklyaccessinformationneededforpatientcare.

Life Stories

Floyd - a man of his word!

“Floydisamanofhisword”statedEffieGriffen.FloydwasborninBankSt,PortFairy,grewupinYambukinalargefamilyofthreebrothersandasister.HisfatherwasNormanWattsandmotherIdaHumphryswhocamefromStHelens.HeattendedschoolatConsolidatedSchoolinPortFairy.Whenheleftschoolhestayedonthefarmtowork.FloydMarried

LynnGraysonin1970andtheyhavefourchildren,Tim,Justin,LisaandNaomi.

AneighbourofFloyd’squoted“IhavebeenaneighbourofFloyd’sandLyn’sforoverfortyyearsandgottoknowFloydverywellandasweallknowFloydhadavegiepatchatYambukorshouldhavesaidpaddocksofvegies,egpeas,carrots,beans,potatoes,pumpkins,younameitFloydgrewitandIforgotthesaladonions,”“Floydwasahardworkingpersonandwouldhaveagoatanythingespeciallyworkingwithsteel”.

FloydisstillamemberoftheYambukFireBrigadeandhasjustreceivedhis50yearsofservicemedal.FloydwasalsoamemberoftheBoardofManagementhereatMHS.HewasontheBoardfromAugust1972untilNovember2003.Hehasseenawealthofchangestothehospitalanditssurroundings.Floydislookingforwardtoallthefuturechangesinthenext15yearsatMoyneHealthServices.HesometimeswisheshewasstillontheBoardwhenhecanseewherechangesneedtobemade.

FloydmovedintoBelfastHousein2005afterhehadastroke.Heisnow66andtakingaveryactivepartinBelfastHouse.

Floydsharehistimebetweenbeingthejokeking,growingalltypesofvegetablesinthegarden,attendingallresidentsmeetings,bowls,runsthehoionaWednesdaymorningandattendspubluncheseachfortnight.FloydgrewtomatoplantsfortheresidentsofMoyneyanaHouseoneyear.NancySmyrksaid“TheywerekeptverybusydowninMoyneyanamakinggreentomatopickleswithallthetomatoesthatyear”.Floydstilllovesajokeandachatandlikestokeephiseyeonallthechangesaroundhim.Floydsaid“IfyouareunabletoliveathomeBelfastHouseisthebestplacetobe”.

QOC - care [ ]43

Val’s StoryUponenteringtheCollegestreetentranceatMoyneyanaHouse,youmayfindthe‘urge’toindulgeinabitofretailtherapy.Thereismuchhereto‘tempt’thehappyshopperandresident.ValHardingismorethanhappytoassistwithyourpurchases.

ValistheRetailManageroftheFriendsofMoyneyanaHouse‘Craft’table.

ValcametoMoyneyanaHousefouryearsagofromGeelongandhashadalonghistoryofCharityandVolunteerinvolvement.Val’smothervolunteeredregularlybeforeandafterretirementandVal’sdaughtercurrentlyworksforacharityoutletinGeelong.Togethertheyarenowabletoshareacommongoaltowardshelpingothers.

ValhasstrongtiesinPortFairywithhersister,SylviaAllenandextendedfamilylivingherealso.

SincecomingtoMoyneyana,Valhasinvolvedherselfinboththe‘home’andthesurroundingPortFairycommunity.

SheisalongtermmemberoftheThursdayCraftGroupheldatFayLemke’shomeandthroughthisassociation;theMoyneyanaHouseCrafttablewas‘born’…………nowaveryprofitablelittlefundraiserforthe‘FriendsofMoyneyanaHouse’.

Valisinvolvedinthestockingofitemsonthetable;generalupkeep;takingorders;collectingmoneyaswellasmakingcraftsforthetableherself…….....…averybusyladyindeed.

Whennot‘keepingshop’,Valcanbefoundbusywithchoresaroundthe‘home’………collectingandfoldingofthelinenserviettesforthediningroom;stockingthefruitbowlsonthetables;generalhousekeepingwiththe‘resident/family’kitchenette;givingexpertattentiontotheindoorplantswithhervery‘greenthumbs’;attendingtotheneedsofthebudgieshereinthehomeandassistingresidentsandvolunteerswiththeMondayafternoonBingo.Valisvery‘techsavvy’andutilisesthecomputertoemail,playgames,accessonlineshoppingsitesaswellaskeepinguptodatewithalltheGeelongnewsthroughdailyaccessoftheGeelongObserveronline.

ValisveryhumbleinregardstohersuccessesinlifehereinPortFairyandstatesthat,“Havingthecrafttableaswellasmyotherjobsaroundthe‘home’givesmeagreatsenseofpurpose……toalwaysknowwhatIwillbedoingwhenIwakeupeachday”.

ShetalksaboutthegreatpersonalpleasurethatshereceivesthroughhelpingothersandthatherinvolvementwithboththecommunityinMoyneyanaandthroughoutPortFairy,hasledtomanynewmeaningfulfriendshipsaswellasastrongsenseofbelonging.

Wethinksheisjust………wonderful.

LeisureandLifestyleStaffRobbie&OrielbelievethatresidentslikeValdemonstratehowaperson,livinginresidentialcarecanstillleadafullandactivelife,withopportunitiesfordecisionmaking,maintainpersonalidentityandindependence,achievement,communityinvolvement,helpingothersandsuccess.

MOYNEYANA HOUSE31 College Street,

Port Fairy Vic 3284

PORT FAIRY HOSPITAL30 - 36 Villiers Street,Port Fairy Vic 3284

BELFAST HOUSE 97 Regent Street,

Port Fairy Vic 3284

SPRINg PARK 33 Mill Street,

Koroit Vic 3282

PhotograPhy Francis & Francis © 2012

QOCMOYNE HEALTH SERVICES

P.O. Box 93 Port Fairy VIC 3280Phone: (03) 5568 0100

www.moynehealth.vic.gov.au

Quality of Care report for 2011-2012. - South West Alliance of Rural

Documents

Transcript of Quality of Care report for 2011-2012. - South West Alliance of Rural