2019-2020 report | 2020-21 future priorities

Safety & Quality Account 2020-20212019-2020 REPORT | 2020-21 FUTURE PRIORITIES

1

About WSLHD

WSLHD Safety & Quality Account

WE ACKNOWLEDGEWestern Sydney Local Health District acknowledges the first people of the land. The overarching Aboriginal nation in Western Sydney is the Darug nation.

We pay our respect to Elders past, present and emerging. We acknowledge the significance of land, water, spirit, kinship and culture, and the importance that these elements have to the health, well-being and future of the Aboriginal community.

Artwork by Leanne Tobin. Leanne’s artwork reflects the vibrancy and transitional motions of the dragon-flies as they move through their journey of life.

About WSLHD


2

WSLHD is committed to continuously improving the quality and safety of its services, whilst creating an environment in which there is transparent responsibility and accountability for safeguarding high standards of safety and quality in the delivery of care.

National Safety and Quality Health Care

Standards Version 2, as at January 2019,

requires the provision of a signed Attestation

Statement by the Board. The purpose of this

statement is to ensure Board approval of

the accuracy and strategic alignment of the

account. The statement should confirm a

clear commitment to improving the safety

and quality of care across the district

or network.

Western Sydney Local Health District (WSLHD)

is privileged and entrusted with the care of

people living in the Cumberland, Blacktown,

Hills Shire and Parramatta Local Government

Areas (LGAs). WSLHD also provides tertiary

care to residents of the Greater Western

Region. With this comes the requirement

for accountability, transparency and

commitment to continuous safety

and quality improvement.

WSLHD works in partnership with community

members, consumers and key organisations

to plan, deliver and evaluate healthcare,

leading to better quality, safety and patient

outcomes. Strong established partnerships

with organisations such as the University of

Sydney, Western Sydney University, Western

Sydney Primary Health Network, Family and

Community Services and Sydney Children’s

Hospitals Network provide opportunities

for new approaches to multi-agency

service delivery, funding and governance

to improve outcomes for the community

of Western Sydney.

The purpose of this Account is to illustrate

our achievements for the 2019/2020

financial year and the future projects

planned for the 2020/2021 financial year.

This is our retrospective reflection of

performance against specific focus areas,

key performance indicators and most

importantly, meeting the expectations

of our community.

GRAEME LOY CHIEF EXECUTIVE WESTERN SYDNEY LOCAL HEALTH DISTRICT

OUR VISION

Western Sydney

Local Health District’s

vision is to be a trusted

partner with our

community, delivering

modern, cutting edge

health care to make

Western Sydney the

healthiest place to

live in NSW.

OUR MISSION

Equitable access

to safe, high quality

care underpinned by

NSW Health CORE

Values: Collaboration,

Openness, Respect

and Empowerment.

FORWORD

“As a Board we are

responsible to ensure

our clinical governance

frameworks are

effective to maintain

and improve our

standards of

patient care.”

3

Contents


0102

0304

050607

08

Contents

SNAPSHOT OF ACHIEVEMENTS OVER THE PREVIOUS 12 MONTHS 10

Key Achievement 1: Responding to Emergencies 10

Bushfires 10

Mental health nurses shower support on NSW south coast: “the community is grieving” 10

Western Sydney medical heroes deployed to support bushfire crisis 10

Our response to the emerging COVID -19 Pandemic 11

Mental Health - Hotline for COVID 11

COVID-19 People & Culture Strategy: “Workplace Wellness Team” 11

Key Achievement 2: Community Engagement 12

Aboriginal partnerships Auburn/Mental Health Services 12

Key Achievement 3: Digital Program 12

Watchlist 12

FirstNet Launchpoint 12

Key Achievement 4: Responding to our growing communities 13

Auburn Baby Steps 13

Project Air 13

Blacktown Redevelopment 14

Westmead Redevelopment 14

Key Achievement 5: Exceptional People 15

WSLHD SAFETY AND QUALITY GOVERNANCE STRUCTURE 17

Hospital and Service Accreditation 19

Quality Awards Program 2019 19

WE SAID WE WOULD; THIS IS WHAT WE DID! REPORT CARD 2019/2020 22

Healthy People 24

Exceptional people 26

Integrated research, education and clinical care 27

Patient experience matters 30

Spending Wisely 31

Information underpins everything we do 33

ABOUT WESTERN SYDNEY LOCAL HEALTH DISTRICT 6

Demographics 6

Our Community 6

WSLHD Staff Composition 7

Our Health 7

Our Services 7

Children Fully Immunised 7

4

Contents


050607

08

PATIENT AND CARER EXPERIENCE 36

How we measure and what we do 36

Recognise, Engage, Act, Call, Help is on its Way (R.E.A.C.H) 38

Patient Safety Video 38

Carer Program- caring for our carers 39

Compliments 40

Our Patient Stories 41

WSLHD Partnering with Consumers Standard 2 committee 42

PEOPLE AND CULTURE 44

Safety Symposium 2020 44

Cultural Change Strategic Framework 44

Workplace Wellness Drop-In Centres 44

Wellness Warriors support almost 5,000 staff through COVID-19 44

Department Visits 44

Manager Connect 44

FORMAL RESULTS 46

Strategy 1: Keep People Healthy 46

Strategy 2: Provide World-Class Clinical Care Where Patient Safety is First 47

Pressure Injury 48

Fall Related Injuries 48

Healthcare Associated Infections (HAI) 48

Respiratory Complications 49

Blood Clots 49

Medication Complications 49

Cardiac Complications 50

Vaginal Tears in Childbirth 50

Neonatal Birth Trauma. 50

Strategy 3: Integrate Systems to Deliver Truly Connected Care 51

Mental Health Services 52

Seclusion and restraint data 52

Access Block (Mental Health Presentation in ED >24hours) 53

Inpatient Absconding 54

Strategy 4: Develop and Support Our People and Culture 54

FUTURE PRIORITIES 56

Leadership 56

Culture 57

Research 57

Harm Minimisation 58

Vulnerable People 59

Patient Experience Matters 61

REFERENCES 65

5

About WSLHD


182,240ED Presentations

164,645Admissions

35,257Surgeries

9,807Births

39,157Vaccines injections in High Schools

ABOUT WSLHD0101

Snapshot of Achievements over the previous 12 months


6Left: Westmead Hospital emergency department director Dr Matthew Vukasovic.

WSLHD is responsible for delivering and managing $1.7 billion in public healthcare across more than 120 suburbs

Demographics

Western Sydney Local Health District

(WSLHD) provides a vast and complex

range of healthcare to around 1 million

residents and many more across the state

and internationally. WSLHD is responsible for

delivering and managing $1.7 billion in public

healthcare across more than 120 suburbs

spanning 780 square kilometres in the

Blacktown, The Hills Shire, Cumberland and

Parramatta local government areas (LGAs).

WSLHD employs more than 10,000 dedicated

individuals across 70 sites including Westmead,

Auburn, Cumberland, Blacktown and Mount

Druitt hospitals as well as a network of

comprehensive integrated care and

community-based services.

WSLHD incorporates

780 km2

four Local Government

Areas and sits on

traditional lands

of the Darug

Aboriginal nations.

WSLHD has a

population of about

1 Millionwhich is predicted

to increase by 2021,

with a 59% increase of

those aged 70 years

and older by 2026.

13,400people are Aboriginal

9,500live in Blacktown LGA

50.3%residents speak

a language other

than English

QUICK STATS

77,955Children up to

4 years old in WSLHD

135,077Young people

15 to 24 years old in WSLHD

138,097Children 5 to 14

years old in WSLHD

13,390People in WSLHD

identify as an Aboriginal person

1 in 4Australians aged over

16 will experience mental ill health each year

79,181People

aged 70+ in WSLHD

50.3%Speak a language

other than English at

home in WSLHD

25%Of Australians

have two or more chronic conditions

Our Community

We have the second largest population

in our catchment area of any LHD in NSW.

About half (46.8 per cent) of residents

were born overseas. A total of 50.3 per cent

of our community speak a language other

than English at home with 71.1 per cent of the

50.3 percent living in the Cumberland LGA.

Western Sydney is home to the largest

Aboriginal and Torres Strait Islander

population outside rural areas, with

many living in socioeconomically

disadvantaged areas.

The 2016 Census indicates about 13,400,

or 1.5 per cent of the population self-identifies

as being Aboriginal, with the majority (9500)

living in the Blacktown LGA.

There has been an increase of 59% in people

aged 70 years or over and a 54% increase

in people aged 85 years and over is forecast

from 2016-2026.

7

About WSLHD


M2

M2

M5

See footnote*

3

4

67

8

11

12

10

9

21

5

CBD

r

M1

M7

M7M4

Rouse Hill

Maroota

Gosford >

Bondi >

Castle Hill

Macquarie Park

Liverpool

Parramatta

ProspectReservoir

The Hills Shire LGA

CumberlandLGA

ParramattaLGA

Blacktown LGA

Future WesternSydney Airport

SydneyOlympic Park

See footnote*

SydneyAirport

SydneyHarbour

Bridge

Penrith

Marsden Park

WESTERN SYDNEY

HOSPITALS

1. Mount Druitt Hospital

2. Blacktown Hospital

3. Westmead Hospital

4. Cumberland Hospital

5. Auburn Hospital

WESTERN SYDNEY

COMMUNITY

HEALTH CENTRES

6. Mount Druitt Community Health Centre

7. Doonside Community Health Centre

8. Blacktown Community Health Centre

9. The Hills Community Health Centre

10. Parramatta Community Health Centre

11. Merrylands Community Health Centre

12. Auburn Community Health Centre

N01 2 4km

* Hatched area of Parramatta LGA is outside


PHOTO: Westmead Hospital Emergency department deputy director Dr Kavita Varshney and Clinical Nurse Educator Emma Dixon.

Our Health

We face a growing burden of disease,

increasing complex chronic conditions

and a rising demand for health services.

Concerning community health trends include

childhood obesity, diabetes, rising mental

health issues and conditions associated

with aging.

Our Services

Our strategic priorities reflect our

commitment to delivering modern health

care in the areas that matter most to

Western Sydney.

We will influence better health and wellbeing

in our growing community. Achieving our

priorities requires a shift in our resource

investment and a redesign of our business.

Our collective work over the last five

years has stabilised our operations and

consolidated our services, positioning our

organisation to meet future health demands

with confidence. We will continue to grow

into a stronger, healthier business over

the next 5 – 10 years.

To meet future demand and to provide

excellence to the people of Sydney’s

west we have embarked on:

• Multimillion dollar capital redevelopments.

• Researching world’s best practice

and innovations.

• Partnering with key healthcare agencies

and organisations providing integrated and

seamless pathways across the system.

We are dedicated to meeting and exceeding

the performance expectations of our service

agreement with the New South Wales Ministry

of Health. We are investing in our business to

ensure alignment with consumer and provider

expectations and contemporary evidence for

a better healthcare experience.

Only by working together, connecting,

innovating and striving for excellence

can we continually deliver exceptional

patient experiences.

Children Fully Immunised

There has been 0.9% increase in the coverage

rate in the 1 year old and 1.5% in the 4 year old

categories for non-Aboriginal children.

The rate of fully immunised Aboriginal

children at age four (4) years was 96%, a

decrease from a previous 97.4% rate; whilst

in the corresponding 2019-2020 quarter,

full immunisation compliance for 1 year olds

dropped to 88.6% from 94.8%. A designated

nurse has been following up those children

who have delayed immunisation schedules,

with the GP.

WSLHD Staff Composition

4,711– 43.3%Nursing & Midwifery

1,577- 14.5%Medical (salaried)

1,059- 9.7%Allied Health

389- 3.6%Scientific and

Technical Clinical

Support

259- 2.4%Oral Health

Practitioners and

Support

1,859- 17.1%Corporate Services

475- 4.4%Hotel Services

52- 0.5%Maintenance and

Trades

463- 4.3%Other Professional &

Para Professionals &

Clinical Support Staff

43- 0.4%Other

TOTAL

10,891 - 100.00%

94.2%at 1 yr. old

Non-Aboriginal Children

95.5%at 4 yr. old

Non-Aboriginal Children

88.6%at 1 yr. old

Aboriginal Children

96%at 4 yr. old

Aboriginal Children

NSW Health Information Exchange and EDWARD NAP DataMart.

About WSLHD


8

M2

M2

M5

See footnote*

3

4

67

8

11

12

10

9

21

5

CBD

r

M1

M7

M7M4

Rouse Hill

Maroota

Gosford >

Bondi >

Castle Hill

Macquarie Park

Liverpool

Parramatta

ProspectReservoir

The Hills Shire LGA

CumberlandLGA

ParramattaLGA

Blacktown LGA

Future WesternSydney Airport

SydneyOlympic Park

See footnote*

SydneyAirport

SydneyHarbour

Bridge

Penrith

Marsden Park

WESTERN SYDNEY

HOSPITALS

1. Mount Druitt Hospital

2. Blacktown Hospital

3. Westmead Hospital

4. Cumberland Hospital

5. Auburn Hospital

WESTERN SYDNEY

COMMUNITY

HEALTH CENTRES

6. Mount Druitt Community Health Centre

7. Doonside Community Health Centre

8. Blacktown Community Health Centre

9. The Hills Community Health Centre

10. Parramatta Community Health Centre

11. Merrylands Community Health Centre

12. Auburn Community Health Centre

N01 2 4km

* Hatched area of Parramatta LGA is outside


9



SNAPSHOT OF ACHIEVEMENTS0202



10Left: Drive through COVID-19 Testing Clinic Western Sydney University.

Key themes for WSLHD in 2019 and 2020 included an extraordinary and incredible response to the Bushfires and, global COVID-19 pandemic, together with unprecedented infrastructure growth, impactful research and incomparable focus on staff wellbeing.

Bushfires

WSLHD was part of a state-wide response

coordinated by the National Critical Care

and Trauma Response Centre and the

NSW Health Emergency Management Unit.

WSLHD heroic clinicians deployed included

three WSLHD emergency department

clinicians and six mental health nurses to

provide medical assistance and mental

health support to those personally affected

by the devastating bushfires.

The team worked in evacuation, recovery

and distribution centres across the south

coast communities where the reality of the

bushfire devastation was indescribable.

WLSHD is extremely proud of the volunteer

team for the provision of professional

expertise and care provided during this

devastating and traumatic time.

Key Achievement 1: Responding to Emergencies

WSLHD mental health staff Eliza Zhao, Rizvan Patel, Kathy Audley, Nick Dunne and Neralee Jeffrey in Batemans Bay.

WSLHD emergency department clinicians Dr Tracey Brown, Dr Kavita Varshney and Dr Evan Ferdous at Batemans Bay.

Mental health nurses shower support on NSW south coast: “the community is grieving”

Western Sydney medical heroes deployed to support bushfire crisis

SNAPSHOT OF ACHIEVEMENTS

11



Our response to the emerging COVID-19 Pandemic

Westmead Hospital is the designated home of the

NSW Infectious Diseases Unit and the first hospital in NSW

to provide care for a COVID-19 patient in January 2020.

Numerous mobile WSLHD COVID-19 clinics were set up

with testing exceeding 180,000 as at August 2020. Home

care for COVID-19 patients and mobile screening were

provided for our vulnerable and high-risk populations.

WSLHD also provided an additional 10,000 interpreting

sessions to facilitate understanding for returned travellers

spending their 14-day quarantine in Sydney hotels.

Mental Health - Hotline for COVID

NSW Government provided additional funding for mental

health workers to boost mental health services during the

COVID-19 pandemic with the aim to support the mental

health and wellbeing of people across the state.

As part of this initiative Western Sydney Mental Health

Services provided additional mental health staff and new

digital resources to ensure anyone who required support

was able to access it when they needed it through the

Hotline or online service.

COVID-19 People & Culture Strategy: “Workplace Wellness Team”

The People and Culture (P&C) team established

the Workplace Wellness Team to keep staff informed,

supported, focused and valued during the COVID-19

response. Numerous additional services were

implemented, including the following:

• Workplace Wellness Drop-In Centres at

Westmead and Blacktown hospitals

• Department Visits and information sharing

at Huddles across all facilities

• “Manager Connect”: information, consulting

and/or coaching support for managers

• Executive, General Manager and

Human Resource staff support

• A COVID-19 intranet portal with staff and

manager resources and information

• Wellbeing, mindfulness and meditation sessions

More than 5,100 staff interactions were delivered through

drop-in centres, coaching and ward visits. The wellness

support sessions provided staff with a safe space to talk

about concerns and have access to practical and realistic

advice on managing their feelings.

PHOTOS: Patient Antoine Kazzi getting tested for COVID-19 (left). Westmead Microbiology team (right).



12

Aboriginal partnerships Auburn/ Mental Health Services

To facilitate identification of and improve engagement

with our local Aboriginal and/or Torres Strait Islander

patients, families and community, a hospital wide

program was initiated at Auburn Hospital. The program

included an audit to obtain relevant information

of components needed to promote a ‘welcoming

environment’. In addition, a staff survey was conducted

to determine what the obstacles were to

“Asking the Question”.

Improvements made in response to the staff survey

and audit results included the installation of flags,

Aboriginal land maps and a Welcome to Country video

on all patient screens. Furthermore an educational

session was developed to train frontline staff on “asking

the question” to better identify Aboriginal and/or Torres

Strait Islander patients. An Aboriginal community walk

around was held to engage with the community and

identify further culturally appropriate improvement

opportunities. This led to the initiation of the Auburn

Hospital Multicultural Garden project.

To date there has been an increase of 62% from 2017-18 to

2019-20 (YTD) in Emergency Department presentations

who now identify as an Aboriginal and/or Torres Strait

Islander person. The welcoming environment audit

showed a 54% increase in compliance. Self-reporting for

staff “asking the question” also showed improvement

with more staff asking all new patients and those who

were readmitted.

Within the Western Sydney Mental Health district,

a project group consisting of the Aboriginal Liaison

Officer, Quality Improvement Officer and Redevelopment

Program Manager for Mental Health engaged with

Aboriginal communities for guidance and advice.

The project group met with the Men’s shed, Women’s

groups, Parramatta Koori interagency members and

other groups in South West Sydney at their respective

local meeting rooms. Discussions evolved around cultural

items and needs for the campus. All of these groups

attended a meeting on the Mental Health campus and

completed a tour of the facility. This enabled them to

identify needs and provide suggestions of changes

that could be implemented.

Recommendations from the collaborative project group

and the Aboriginal community were submitted to the

Mental Health Executive for approval. To date, current

works approved include the new pavilion which will

provide a shaded outdoor meeting place.

Continued engagement and collaboration with local

Aboriginal groups is being maintained to address the

emerging needs of our community.

Watchlist

The introduction of “Watch list,” to facilitate electronic

prescriptions for discharge at Blacktown Hospital,

enabled automated instantaneous notification of

electronic discharge prescriptions to pharmacy. This is

another “first” nationally in a public hospital. The program

has driven patient improvement benefits by reducing

discharge waiting time by 28% during the implementation

period. During this phase patients’ average waiting time

of 105 minutes was reduced to 76 minutes. A subsequent

sustainability review (period February - June 2020)

demonstrates further improvement with waiting times

decreased by 33% on average. Patients are now waiting

on average 74 minutes as opposed to 111 minutes for

discharge medications.

FirstNet Launchpoint

Auburn Hospital Emergency Department (ED) nurses

were the first in NSW to successfully implement the new

Cerner FirstNet tracking system known as LaunchPoint,

and use Dynamic Documentation templates to record

nursing assessments. The implementation aimed to

standardise best clinical practice and documentation

across the four (4) Emergency Departments across the

LHD. The implementation process has been extremely

smooth, with a 93% training completion rate from ED

nurses. ED nurses have felt supported and prepared for

the change due to the comprehensive eMR training.

Key Achievement 2: Community Engagement

Key Achievement 3: Digital Program

PHOTO: Westmead Hospital Aboriginal liaison officer Narelle Holden and Cumberland liaison officer Shai Grigg.

13



Auburn Baby Steps

The Auburn Baby Steps project used

My Experience Matters (MEM) data to

understand patient experience. Issues with

access to appointments and waiting times

were identified in the MEM survey.

Partnering with WSLHD’s Innovation &

Redesign Team, the Baby Steps Project

commenced in August 2019 as part of the

Agency for Clinical Innovation’s Centre for

Healthcare Redesign Graduate Certificate

Program. The aims of the project were to

provide timely access to specialised antenatal

care and improve patient experience at

Auburn Hospital.

The three key objectives/solutions include:

• Improving access and reducing risk

by increasing the number of women

commencing antenatal care by 14 weeks

gestation (currently 4%)

• Improving capacity through appropriate

care transfer and proactive appointment

cancellation when a woman gives birth

• Improving referral, bookings management

and notification processes including

referral entry into the hospital’s

patient administration system (iPM)

and implementation of robust referral

acceptance, attendance management

and prioritisation procedures

Key Achievement 4: Responding to our growing communities

Project Air

WSLHD Mental Health Services (MHS)

successfully implemented three Gold

Card Clinics in late January 2019, across

Blacktown, Parramatta and Cumberland

Hospitals in response to the NSW Project Air

Strategy for Personality Disorders framework.

These clinics work closely with the Mental

Health Acute Care Teams (MHAC Teams) to

ensure consumers and families affected by

personality disorder, are offered timely and

accessible psychological support. Consumers

are offered an appointment within 3 days

of presenting to Emergency Departments,

Admissions Units, and Acute Care Teams

across the District or following discharge

from inpatient services. A structured brief

intervention model, inclusive of individual

and family/carer components, is utilised.

As at December 2019, 185 patients

accessed this service.

The Gold Card Clinics partnered with

universities to facilitate an integrated training

program designed to equip clinicians

with contemporary best practice skills to

manage patients with personality disorder.

The program is offered to early-career

psychologists, with nine (9) provisional

psychologists trained in 2019.

The preliminary outcomes to date reflect the following:

15% of women

commence care at

<14 weeks gestation

(47% commencing

14-18 weeks

gestation-

baseline 39%)

94%

of referrals

were accurately

entered into iPM

(baseline 4%)

An average of

16% incomplete referrals

received (baseline

60%)

Greater than

3%

increase in

appointments

in 5 months

The Baby Steps project involves ongoing evaluation to inform efficient solutions.

PHOTOS: WSLHD Population Health Auburn Children Immunisation Clinic. Left to right: Mafi Fahina (Mother), Moriah Fahina (Baby girl), Hayley Carra (Reg Nurse). Blacktown Hospital Acute Services Building. Westmead Hospital Central Acute Services Building.



14

Blacktown Redevelopment

In response to the growing needs of our communities

in the Blacktown local government area, the opening

of the Acute Services Building at Blacktown Hospital

now facilitates access to new services for emergency,

birthing suites, centre for newborn care, women’s health,

hybrid and digital operating theatres and intensive care.

The expansion was part of the $700 million Blacktown

& Mount Druitt Hospitals expansion project.

Westmead Redevelopment

Westmead Hospital’s new Central Acute Services

Building (CASB) is now in the commissioning phase and

will be opening in February 2021. The 14-level building

includes two emergency departments and more than

300 patient rooms. This building is the centre part of

the $1 billion-plus Westmead Redevelopment project,

bringing world class infrastructure to the Westmead

Health Precinct.

15



In 2019/2020 numerous WSLHD staff were recognised for their exceptional contribution to healthcare. WSLHD is extremely proud of these staff achievements.

The Ralph Reader Award is the most

prestigious prize in cardiovascular research

to be awarded to investigators in Australia

and New Zealand. Two Westmead Hospital

cardiologist scientists, won this young

investigator prize at the 2018 Cardiac

Society of Australia and New Zealand

(CSANZ) Annual Scientific meeting.

The Basic Science prize and the Clinical

Research prize, 2 components of the Ralph

Reader award, were awarded to candidates

from the same hospital. This has never

occurred in the history of these awards.

The Basic Science prize was awarded to

Dr Sujitha Thavapalachandran and the

Clinical Research prize was awarded to

Dr Pierre Qian. Both are clinical fellows

at Westmead Hospital.

Key Achievement 5: Exceptional People

Ljubica Simic may be Westmead Hospital’s

happiest cleaner. Her uplifting personality

and kind-heartedness touched a family

so much that they nominated her for an

Australia Day Award.

The patient’s family said that “Ljubica used

to visit the family’s sick relative to say hello

and have a chat.” “She’d encourage the

patient to think positive thoughts … she is just

so happy and cheerful … she made us laugh

and made things so light-hearted when we

were in a horrible place.” “Her job is a cleaner

but she definitely has a much higher purpose

… she has an unbelievably golden heart.”

PHOTOS: Ljubica Simic Westmead Hospital’s happiest cleaner. Associate Professor Saurabh Kumar.



16

Member (AM)

Emeritus Professor Peter Zelas (left), has been

named a Member of the Order of Australia in

the 2020 Queen’s Birthday honours. He was

among distinguished people linked to Western

Sydney Local Health District (WSLHD),

to receive pre-eminent recognition for

achievements and service to Australia.

Medal (OAM) in the General Division

Auburn Clinical School head A/Prof Hadia

Haikal-Mukhtar (centre) was awarded the

Medal of the Order of Australia, for service

to medicine and to the Lebanese community.

A/Prof Haikal-Mukhtar is head of the Auburn

Clinical School, which is a partnership between

Auburn Hospital and the University of Notre

Dame Australia.

Officer (AO) in the General Division

Emeritus Professor Kim Oates, received the AO

for distinguished service to paediatric medicine,

as an advocate for child health and welfare, to

medical education and to professional societies.

Renowned renal physician Professor Jeremy

Chapman AC (right) has been announced as

the fifth person in history to receive the Asian

Pacific Society of Nephrology (APSN) Kenzo

Oshima Award. Prof Chapman is a world leader

in kidney transplantation. He has worked

at Westmead Hospital since 1987 and was

nominated in recognition of his outstanding

clinical, scientific and academic leadership,

particularly in the field of kidney transplantation.

PHOTOS: Emeritus Professor Peter Zelas (left). Auburn Clinical School head A/Prof Hadia Haikal-Mukhtar (centre). Renowned renal physician Professor Jeremy Chapman AC (right). Blacktown Cath Lab first procedure in Australia without using radiation. Richard Krawiarz (Patient in bed) and medical team.

17

WSLHD Safety and Quality Governance Structure


The WSLHD Clinical Governance Framework and Western Sydney Local Health District Safety and Quality Improvement Strategy are keystone documents.

Providing a structure for the management

of safety and quality and the achievement

of strategic priorities in line with the

District’s goals and visions.

Clinical Governance plays a pivotal role in

ensuring the patient remains the key focus

in the delivery of care. A culture of safety,

quality and harm reduction is achieved through

building capacity, capability and enhancing

leadership across WSLHD. Patient and

Carer experience data is used to strengthen

organisational systems and inform

day-to-day service provision.

The Board has ultimate responsibility to

ensure corporate and clinical governance

processes are in place that guarantee safe,

reliable and high-quality health care provision

to our community. Clinical governance

assurance is provided to the Board via the

Health Care Quality Committee (HCQC),

a committee of the Board. HCQC ensures

that mechanisms, controls and monitoring

processes are in place to deliver safe care.

SAFETY AND QUALITY0303



18

SAFETY AND QUALITY


Various measures including but not limited

to incident management, measuring patient

experience, the quality awards programs

and accreditation are utilised across the

LHD to ensure quality and safety focused

care is provided to our local communities.

WSLHD was the first site in NSW to

implement the new incident management

system, ims+, in partnership with eHealth and

the Clinical Excellence Commission (CEC).

As the pilot site, WSLHD has been integral

in informing ongoing improvement to the

ims+ system thus benefitting our other LHD

colleagues who transitioned to the system.

Numerous strategies were employed to

ensure the successful implementation of

the ims+ program. Over 8700 WSLHD

staff received training and information on

ims+ prior to its implementation. 90% of

staff surveyed, reported the ims+ system

to be an improvement from the IIMS

incident management system. 93% of staff

indicated that they felt supported and that

WSLHD was committed to the successful

implementation of ims+. WSLHD was able

to provide feedback to improve the flexible

delivery of education and training for future

ims+ implementation sites across NSW.

Standard 8Recognising and responding

to acute deterioration

Standard 7Blood Management

Standard 6Communicating for Safety

Standard 5Comprehensive Care

Standard 4Medication Safety

Standard 3Infection Prevention

and Control

Standard 2Partnering with Consumers

Standard 1Quality & Accreditation

Facility National Standards Committees

Facility Safety & QualityCommittee

Audit & Risk*

Nominations*

Finance, Performance & Assets*

Research & Development*

Professional Education*

* Subcommittees of the WSLHD Board

Health Care Quality Committee*

WSLHD BOARD

Standard 8Deteriorating Patient

Strategy

Standard 7Blood Safety

Standard 6Clinical Documentation &

Electronic Workflow

Standard 5LHD Individual Committees

Standard 4Drug and Therapeutic

Committees

Standard 3Infection Prevention

and Control

Standard 2Partnering with Consumers

WSLHD National Standards Committees

AntimicrobialStewardship (AMS)

Falls

Skin integrity &Pressure Injuries

End of Life

LHD Committees

19



Hospital and Service Accreditation

All healthcare facilities in Australia are mandated to

undergo an accreditation review. Mental Health Services,

Drug Health Services and Auburn Hospital underwent

accreditation assessment against National Safety and

Quality Standards Version 2 and have retained their

accreditation status. Westmead, Blacktown and

Mount Druitt Hospitals are to be accredited against

National Standards Version 2 at the next phase of

their accreditation cycle.

Quality Awards Program 2019

Each year, WSLHD hosts the Quality Awards

as an opportunity to harness the creative and

innovative ideas of staff who are committed

to making a difference to patient care and

health outcomes.

Winners of 2019 WSLHD Quality Awards

The Physical Health Promotion Project

established a first time partnership between

Blacktown Hospital’s Women’s Health Clinics

and Riverstone Neighbourhood Centre, a

non-government organisation. Access to

antenatal services for women finding it

difficult to get to Blacktown Hospital due to a

lack of transport and/or personal or financial

difficulties, is now facilitated. Clinic attendance

has exceeded expectations.

Don’t Fall for It! A Falls Initiative sought to

reduce falls risk and hospital admissions for

falls-related injuries for all patients admitted

to Westmead Outpatient Physiotherapy.

Initiatives included implementation of the

first WSLHD outpatient falls risk screening

tool together with additional falls prevention

strategy meetings with staff, patients

and family. Outcomes for participants

During the COVID-19 pandemic, all accreditation

assessments were placed on hold by The Australian

Commission on Safety and Quality in Health Care,

with accreditation reviews rescheduled to commence

in the recovery phase of the pandemic in consultation

with stakeholders.

Integrated and Community Health have been accredited

under the Quality Standards - Aged Care.

included no falls-related hospitalisations,

a reduced average falls risk from moderate

to low, and 80% compliance with a home

exercise program.

The Emergency Care to the Sound of Music

program was developed in response to the

unexpected increase in drug-related deaths

and injuries at NSW music festivals. WSLHD

was the first local health district to apply

disaster management principles and deploy

a team to festivals using self-developed

equipment, resources and medication kits.

Early recognition and management of severe

drug toxicity at festivals led to reduced illness

and no further deaths after deployment.

Getting the basics right: Supplemental

oxygen is the first program implemented to

address supplemental oxygen compliance

in a non-respiratory service. The program

enabled staff to identify knowledge deficits

and generate and implement solutions based

on their own learning styles. Significant

improvements included increased prescribing

compliance from 0 to 100% and increased

target oxygen saturation range documentation

from 14% to 86%.

PHOTOS: Quality Awards 2019 set (left). Staff enjoy the 2019 Quality Awards (right).



20

Streamlining Bowel Cancer Screening is a nurse-led

rapid access faecal occult blood test (FOBT) clinic.

It is an original and effective approach to the growing

clinical problem of bowel cancer. The nurse specialist

provides rapid triage, initial consultation, education on

diet and bowel preparation and liaises with GPs regarding

outcomes. The FOBT clinic has significantly reduced

the burden on gastroenterology clinics, providing a

streamlined, accessible, patient focused service for

FOBT-positive patients.

The “Food for thought: didn’t think we do healthy in

the West” project aimed to improve food outlet staff

engagement to promote healthy food and drink choices.

The stakeholder engagement model worked successfully

with engaging both small and large scale businesses.

At Mount Druitt Kiosk, compliance with the Healthy

Food and Drink framework rose from below 20% to

100% in one year.

Saving lives: Priorities in Action mental health model

of care in Westmead Hospital ED was revolutionised by

the implementation of a Child and Youth Mental Health

ED Navigator project aimed at reducing non-urgent

presentations by 50%. The navigator saw 71% of young

people who presented to Westmead ED during the

week, leading to a reduction in re-presentation rates

from 20% to 3%. Sustained evaluation demonstrates

decreasing wait times, effective links with GPs and

service providers after discharge and the potential

to improve outcomes for the youth.

Chief Executive Award - Supply, Storage and Administration of Medications (SSAM) project

introduced a basket storage system in the medication

room for non-imprest medications in Blacktown

Hospital’s surgical unit, as opposed to using bedside

drawers for each patient. Nurses saved an average

of almost 60 minutes to complete the round, which

improved overall productivity and morale. There is

now extra space available on benchtops to prepare

medications and patients are less susceptible to risks

as the ability to self-administer medications has

been removed.

Chair of the Board Award –

It takes Two – A partnership approach between WSLHD and Blacktown City Council, the Munch &

Move NSW Health program is aimed to reduce childhood

obesity by 5% by 2025. By December 2018, 100% of

Blacktown City Council’s early learning childhood

services had adopted the program, an increase from

17% in July 2017. Outcomes of the program included

significant improvements to food menu compliance,

staff training, reduced food waste and colloquial

evidence that children were enjoying more vegetables.

Newslocal People’s Choice Joining the I and MI in IMI (Intramuscular Injection): Muscle Matters! Was a project

which addressed the need to choose correct sites for

injecting depots. Drug concentration is altered if depot

injections are administered at an unlicensed muscle

site. A baseline 12-month audit in June 2018 found only

83.6% of long-acting antipsychotic depot administrations

were being given correctly. After implementing all the

strategies, correct administration improved to 92.3%

by October 2018 and 100% by April 2019.

PHOTOS: The 2019 Quality Awards ceremony (left). The Quality Awards are WSLHD’s event of the year (below).

21

We said we would; this is what we did! Report Card 2019/2020


REPORT CARD 2019/20200404



22

Name of project Progress/outcome

Aboriginal Patient Dashboard

A component of the ED presentation dashboard for staff includes the discharge status of

patients identifying as Aboriginal, Aboriginal and Torres Strait Islander as well as Torres Strait

Islander communities. The dashboard is due for publishing in the near future. The intent of

the dashboard is to be able to facilitate the identification of needs.

Universal Delirium Precaution

The implementation has commenced with a rollout plan developed.

Health Literacy Hub in ICH – Implementation of Parenting Plus

Eight pilot programs were delivered to 86 culturally and linguistically diverse groups.

The new parents’ program content was modified using an intensive co-design process involving

frontline and managerial health staff and consumers. Version 2 of the Parenting Plus program

is now ready for wider roll-out.

Multicultural Health Committee

The first WSLHD Multicultural Health Committee meeting was held in May 2019. In 2019/2020

the Committee focused on identifying and collecting data to help establish the current level of

service delivery across the District that address the health needs of Culturally and Linguistically

Diverse (CALD) consumers and communities. Service self-assessment tools were used to map

how well the District is doing against NSW multicultural health policies.

A CALD Data Working Group was also established to identify and access data sources to

better understand the health of CALD populations in WSLHD. The group is working with

WSLHD Epidemiology and Health Analytics and Clinical Analytics and Performance Unit to

identify and access key patient data that can be used to identify priority groups and issues.

The collected data will be analysed to identify gaps, establish priority focus areas for

the District and will assist in the development of the WSLHD Multicultural Health

strategic framework.

Clozapine Peer group

The Clozapine Peer Group commenced April 2019 and continues to be held on a bi-monthly

basis with ongoing evaluation with its participants. It is a multidisciplinary group joining

consumers with pharmacy services, librarians, doctors, nurses, peer services, dieticians and

the carer and family liaison officer. Clients can share their lived experience with Clozapine,

as well as ask questions of staff and get support for any side effects endured.

So far the group has received positive feedback, clients have been relaxed and engaged in

different activities presented, and are keen to continue using the new initiative. The Clozapine

Peer Group scheduled presentations for 2020 include: pathways to community living; diet and

exercise; smoking cessation; oral health; sexual health; and mental health. Every event will also

have time for social activities, positive thinking, aspirational reflections and healthy snacks.

Patient Flow Collaborative

Mental Health Services and Westmead Hospital participated in the ‘Patient Flow Collaborative 2’

with the Ministry of Health. Key activities included the development of a comprehensive

‘Mental Health Patient Flow Demand Escalation Framework’ to effectively manage demand

and capacity across mental health services. This included the development of Short Term

Escalation Plans (STEP) to provide fast and efficient patient flow responses during periods

of unforeseen increased activity and demand.

STEP allows for accurate demand analysis, improved decision making, forward planning,

communication and collaboration with external partners. This collaborative has assisted in

streamlining mental health admission pathways from Westmead ED through to mental health

facilities across the District. The implementation of the NSW Health ‘Patient Flow Portal’ and

‘Electronic Patient Journey Boards’ in all mental health inpatient units has allowed for

improved patient flow processes and transparency of service capacity and flow.

We said we would; this is what we did!

Left: ENABLE graduate Hiro Kojo shows off one of her paintings to the Minister for Mental Health Bronnie Taylor.

23



Name of project Progress/outcome

NSW Health Primary School Mobile Dental Program

Following funding as part of a NSW Premier’s priority, the NSW Health Primary School Mobile

Dental Program (PSMDP) was implemented in July 2019, targeting schools with the highest

levels of socio-economic disadvantage. Oral Health teams visit these schools and deliver a

preventive care package including dental examinations, oral hygiene instruction, diet advice

and topical fluoride application.

Ongoing dental care is provided by Oral Health teams in our fixed clinics. A total of 3,771

students accessed the program. The capacity of the program and participation by schools

have increased with the recruitment of 21 dedicated staff members in early 2020. Initial

findings have demonstrated an increase in identification of more serious dental disease

through the school assessments, allowing earlier interventional treatment for children.

Chronic Pain and Building pathways

A standardised pain assessment tool was developed and resources identified for use by consumers. The Pain assessment tool contains very comprehensive questioning to reveal patient pain improvements and outcomes measured before and after interventions. COVID-19 changed the way information and care were delivered to improve health outcomes for patients. The focus has now turned towards developing a self-paced booklet to promote patient engagement and provide clinicians with staged interventions.

The Westmead pain service clinicians and the Integrated Chronic Care Program (ICCP) identified several ways pain services can work collaboratively with consumers and provide timely interventions. Future plans include replicating other LHD pain service ways of working.

New Eye treatment using guide

Initial studies were very positive, with glue sealing corneal perforations and inducing healing with minimal inflammation, scarring or vascularization. Results were published in the Science Advances journal and aired on the Channel 9 News Australian media on 3 July 2020. Further trials were planned for earlier this year however due to COVID-19 trials have been delayed. Recommencement of the trial is planned after winter 2021.

National Gynae-Oncology Registry Pilot

The National Gynae-Oncology Registry (NGOR) pilot was one of eight research projects to be awarded a MRFF Ovarian Cancer Research Grant in 2020. The NGOR was awarded $3.5 million over 5 years to expand on the existing ovarian cancer module. The grant will enable the extent of variation in quality of care, its impact on outcomes and patient reported outcomes to be monitored. Thus far, 575 patients have been recruited to the ovarian cancer module (47 from Westmead).

The first Ovarian, Tubal and Peritoneal Cancer Module Quality Indicator Report was circulated to the Steering Committee in March 2020. The working group has revised the existing quality indicator set, following feedback from the steering committee.

In the meantime, several other gynaecological cancer modules are progressing. The endometrial cancer working group, chaired by A/Prof Alison Brand (Westmead), has finalised the endometrial module. A literature review of relevant quality indicators was circulated for review. In March, a teleconference was held to discuss and finalise the identified quality indicators. The cervical cancer module working group (Member Dr Michael Burling, Westmead) has been finalised and a literature review of relevant quality indicators was undertaken. In May, a working group teleconference was held to discuss quality indicators.

Obesity Clinic Over the last 12 months, the Blacktown Hospital Obesity Clinic focused on research and patient support. A current research study is exploring the impact of intensive weight loss on cardiac health, bone and body composition, medication use and cost and pituitary hormones. Group based models of care for psychological and dietetic intervention are being trialled in 2020.

Weekly peer support groups were established for patients to attend after metabolic surgery which has resulted in increased post-operative follow up, maintained lifestyle changes and reduced social isolation.



24

Healthy PeopleWe are invested in keeping the people of Western Sydney healthy - now and in the future. Together with our partners, we are improving children’s health for current and future generations. We are addressing Western Sydney’s diabetes hotspot challenge. We are enhancing the understanding and management of mental health in our community.

WE WILL:

• Promote a good start for the

first five years of life

• Overcome diabetes together by

increasing prevention, screening and

enhancing community and hospital

management to slow the progression

of diabetes in our community

• Increase community awareness and

understanding of mental health issues

and breakdown stigmatism

Planned and Realised Actions 2019/2020

Saving Lives: Priorities in Action - Child and Youth, Mental Health, ED Navigation Service

Emergency Departments are the first point

of contact for many young people and their

families seeking mental health expertise in

times of crisis. WSLHD Perinatal, Child &

Youth Mental Health Services collaboratively

with Western Sydney Primary Health Network

(PHN), introduced a Child and Youth Mental

Health Emergency Department (ED) Navigation

pilot establishing a new Model of Care for young

people presenting to Westmead ED.

The risk lens was broadened to include

a comprehensive trauma-informed needs

assessment and short-term post-discharge

involvement, to reduce non-urgent

re-presentations.

The pilot exceeded expectations with the

Navigator service seeing 71% of young

people during the week. The re-presentation

rates reduced to 3% for young people

who attended the ED linked with the ED

Navigator, compared to 20% for those seen

only by pre-existing Consultation Liaison

Psychiatry services.

PHOTO: WSLHD Population Health Stepping On Program Greystanes Library. Left to right: Bharatkumar Joshi (Program participant), Yi Ming Wang (Program Participant), Lanying Rao (Program participant), Harsha Joshi (Client).

25



Only 5% of young people who arrived in

the ED between 11:30am – 8.00pm waited

longer than 60 minutes for a Child & Youth

Mental Health assessment.

Migrant students say hello to health help

The Multicultural Health team joined forces

with TAFE NSW Blacktown for the latest

Hello Doctor event, which saw hundreds

of English-language students gain access

to important healthcare messages.

These messages were delivered in key

languages including Arabic, Persian, Dari

and Tamil. Doctors, nurses, oral health

and mental health experts were joined by

representatives from SafeWork NSW,

Energy & Water Ombudsman NSW and

other government and community agencies.

Students appreciated learning more about

topics ranging from dental hygiene, diabetes

testing, cervical cancer screening, to your

rights at work. Feedback from staff and

students indicated the day was excellent.

The success of the day has been attributed

to the strength of partnerships between

Multicultural Health, WSLHD and TAFE

NSW Blacktown.

Venous Thromboembolism (VTE) Prevention Program

In January 2020, WSLHD implemented

an electronic alert to remind clinicians to

complete the VTE risk assessment for their

patients. Early data indicates that there has

been an improvement in the number of

risk assessments undertaken. An upgraded

risk assessment tool and alert are due for

release by eHealth later this year. In addition,

the maternity electronic VTE risk assessment

tool has been implemented at Westmead,

PHOTO: Ping has her blood pressure checked by WSLHD supportive care clinical nurse specialist Alex Rudnitsky.

Auburn and Blacktown. Data indicates

that there has been a good uptake, with

an average of 91% of women risk assessed

at Westmead.

Sepsis

WSLHD developed and implemented

an Emergency Department alert to aid

sepsis recognition on presentation. The

alert algorithm has now been adopted by

NSW eHealth and has been incorporated

into a suite of tools for the recognition and

management of sepsis. WSLHD is currently

working on an electronic dashboard to

present the clinical elements of patients

who are placed on the Sepsis Pathway, with

planned implementation for later this year.

Middle Years Project (MYP)

The Middle Years Project (MYP) a

partnership project with NSW Department

of Education, WSLHD, Sydney Children’s

Hospitals Network (SCHN), Family and

Community Services (FACS), Police, Juvenile

Justice and Western Sydney PHN was

implemented during 2019/2020. This group

provides multi-agency support for vulnerable

students in years 5 & 6 with behavioural

disorders, to help improve their transition

to high school. This program is supported

by a Service Level Agreement with NSW

Department of Education. During 2019/2020,

104 screens were conducted with 21 full

assessments; 79 group sessions and 53

individual sessions were held. MYP continues

to follow and support young people in the

transition from primary to high school. The

project has had a positive impact on the

engagement of young people in high school

during the transitionary time.



26

Exceptional PeopleOur people are the heart of our organisation. We want to support, nurture and recognise them. We are committed to supporting our people to work with confidence through robust education programs to ensure they maintain their ability to deliver world-class healthcare into the future.

WE WILL:

• Invest in our staff and support systems

to attract, retain and develop people of

the highest calibre; strengthen our

recruitment practices and invest in

optimising the performance of

our people

• Reinforce clinician leadership and invest

in leadership skill development, roles

and responsibilities to promote effective

decision making

• Cultivate collaborative and cohesive

behaviours for working together

‘The Knock on Effect’ – Pressure Injury Forum

‘The Knock on Effect’ Forum was

developed in response to an increase in

hospital acquired pressure injuries across

the district in 2019. The Clinical Practice

and Innovation team created an innovative and

thought provoking video depicting the true

story of a patient who developed a pressure

injury whilst receiving treatment in WSLHD.

It highlights the devastating “knock on”

effects on the lives of patients and families,

even years after the initial injury.

Clinicians were challenged at the forums,

hosted at all facilities across the LHD, to

reflect on current practice and develop

innovative solutions to prevent patients

developing pressure injuries. An evaluation

of the impact on practice is scheduled

to be undertaken.

Chronic & Complex (CAC) Allied Health Minimum Documentation Standards

Minimum documentation standards were

developed and endorsed for all allied health

disciplines across chronic and complex

(CAC) allied health outlining accreditation

requirements, compliance with policy

directives and clinical requirements.

Minimum documentations standards and

the introduction of templates aim to provide

equity and consistency in the service

provided to the clients receiving CAC Allied

Health services. Clinical documentation

compliance improved from 10% to 92% and

changed from being task to patient focused.

General assessments improved by 57% and

responsiveness to clinical concern improved

by 28%. Documented plans and handovers

also dramatically improved by 41%, enabling

continuity of care for clients.

Initiative of the Month

WSLHD Nursing & Midwifery Clinical Practice

and Innovation Team commenced a program

in March 2019 acknowledging and celebrating

nursing and midwifery practice development

and quality improvement activities across

WSLHD. This activity aims to support teams

to continue with the valuable work they are

undertaking and encourage other teams to

commence their own improvement activities.

Each month a nursing and midwifery team

engaged in a practice development or

quality improvement initiative is awarded

the title ‘WSLHD Nursing & Midwifery

Initiative of the Month’.

Westmead Hospital plastic surgeon develops new tool to fight deadly melanoma.

A team led by Dr Varey and Associate Professor Serigne Lo from the Melanoma Institute Australia developed an online calculator to predict the risk that a patient’s primary melanoma has spread to nearby lymph nodes. The tool calculates risk based on a range of factors entered by the treating doctor and has the potential to better identify melanoma patients who are most likely to benefit from a sentinel node biopsy, as well as those least likely to benefit.

The main benefit of the calculator is likely to be for those deemed to be at low risk of disease spread, who can safely forgo a sentinel node biopsy. Avoiding unnecessary procedures is good for patients, clinicians and health services.

27



In FY2019/20 seven teams were

acknowledged, with their work being

celebrated at a local level to recognise staff

effort. At a district level, achievements

were celebrated via the intranet and pulse

articles were published to share the quality

improvement initiatives.

Research grants awarded to Western Sydney Local Health District

Grants have been awarded to researchers

within Western Sydney Local Health District

(WSLHD) in the 2020 National Health

and Medical Research Council (NHMRC)

Investigator Grants scheme, covering a

diverse range of health projects including

kidney transplantation, liver disease, heart

health and tuberculosis.

The WSLHD recipients are as follows:

Dr Caleb Ferguson. A trial to assess the

effectiveness of a digital education program

to improve quality of life for people living

with the most common heart rhythm

disorder, atrial fibrillation.

Prof Clara Chow. Exploring low-cost,

innovative health service provision and

clinical management of heart disease, the

leading cause of illness and death worldwide.

Prof Jacob George. Using mathematical

modelling and genetics to improving

treatment of fatty liver disease, which

affects one in three Australians.

Dr Justin Beardsley. Determining the size of

the problem of lung infection problems due

to the mould Aspergillus in Vietnam, where

the issue is often wrongly labelled as failed

tuberculosis treatment, and how best to

address it.

A/Prof James Chong. Developing innovative

heart regenerative therapies that could be at

the clinical trials stage in the near future. This

would mean that new heart muscle, grown

from stem cells, could help repair damage

caused by a heart attack.

Prof David Harris. Using genetically-

engineered immune cells to prevent organ

damage in end-stage kidney disease.PHOTOS: Prof Clara Chow (left). Prof Jacob George (right).

Integrated research, education and clinical careIntegral to providing excellence in clinical care we will evaluate and act on the needs of our priorities to drive continuous improvement. Research will be translated into effective clinical service models that deliver positive health outcomes.

WE WILL:

• Take an integrated whole of hospital

approach to ensure care is delivered in

the best way, applying best practice,

for the best value

• Clearly delineate our services, coordinating

our surgical and interventional programs

to improve clinical and cost outcomes

• Reform our mental health services so that

people with mental illness are supported

to live well in the community and access

treatment as required



28

Prof Jonathan Iredell. Bringing together

modern genomics and the promise of novel

positive therapies to eradicate antibiotic-

resistant organisms and genes from people

at risk from severe infection.

A/Prof Germaine Wong. Using big data

science to predict complications in kidney

transplantation, and find new and better

ways to identify and treat at-risk individuals.

New outpatient clozapine handling procedure during COVID-19 pandemic

During the COVID-19 pandemic, Blacktown

Mental Health Services developed strategies

to keep both patients and staff safe. In order

to minimise close contact and practise social

distancing, most clozapine patients were

offered telehealth consultation with Medical

Officers. Clozapine outpatient prescriptions

are written, dispensed and delivered to

patients at home. Procedures have been

implemented to ensure medication delivery

is carried out in a safe and secure manner,

without any physical contact between

staff and patients. There is an escalation

process to prevent relapse should nursing

staff during delivery notice any change in

the patient’s mental state. This process has

enabled patients to continue to be reviewed,

monitored and receive their prescriptions

in a timely fashion.

Innovative Education Delivery - Cumberland Education Department and Yaralla

Yaralla Mental Health Unit created a

dedicated education space to facilitate

learning in a relevant and time efficient

manner. Relevant equipment was purchased

together with adaptation of presentations.

Nursing staff learning opportunities have

increased and less time is spent away

from the unit. Ongoing updated education

material is displayed via a slide show on

a large television screen located in the

nurse’s station. Mandatory in-service

education, traditionally held in the

Education Centre, has been successfully

adapted to fit into appropriate time slots

and presented on the ward. The response

from staff is positive – stating that

“we have been able to attend more in-service education than before.”

Evaluating the effectiveness of the Chronic Disease Management Program (CDMP)

In 2019, the Hub partnered with Integrated

and Community Health to supervise a group

of University of Sydney School of Public

Health Capstone students to analyse project

data to assess the impact of the CDMP on

different domains of health literacy.

The data analysis identified statistically

significant improvements and provided

the first evidence of the potential impact of

the CDMP on improving different domains

of health literacy amongst a diverse sample

of participants with chronic diseases using a

multi-dimensional instrument. A manuscript

reporting the results was published in the

International Journal of Environmental

Research and Public Health as part of

the special issue on Health Literacy and

Equity – Interdisciplinary Perspectives

and Recent Trends in Health Literacy

Research and Action around the World.

Co-authors included the University of

Sydney and WSLHD staff and students.

PHOTO: Technology

enhances working with colleagues

across the district.

29



Building WSLHD staff capacity through the Health Literacy Seminar Series

The Health Literacy Hub offers a bi-monthly

health literacy research seminar series for

healthcare professionals in Western Sydney.

The series covers best practices and research

innovations in the area of health literacy with

the aim to build capacity within WSLHD to

improve health literacy and outcomes for

our patients and consumers.

Eight seminars have been delivered since

2018, with an additional three scheduled for

2020. Up to 178 healthcare professionals

registered for individual seminars, with over

700 professionals registered across the series.

The seminars will continue to be conducted

bi-monthly across 2020/2021.

The Speech Pathology

The Speech Pathology (SP) team was

successful in the Paediatric Innovation

Funding Scheme (PIFS) grant application

for the “Growing Little Language Learners:

An Integrated and Community Health

(ICH) and Early Childhood Education and

Care (ECEC) partnership to improve health

and developmental outcomes for children

in Western Sydney” research project.

The project started as a partnership with

Cumberland council. Through a successful

grant application and partnership with

University of Sydney and council, the

acceptability of this program has now been

evaluated. Clinician researchers have been

invited to attend a writing for publication

workshop with two abstracts accepted for

presentation at national conferences.

The SP team’s learning has been shared

across other Allied Health services and

has informed new Child and Family

Health research project thinking.

Targeted Early intervention and place based care:

Seventy two percent (72%) of enrolled

children who had not previously accessed

child and family services were screened for

delays in language and communications.

Children with identified communication

delays are now provided clinical intervention

in the preschool era, using a whole of

preschool care model approach to support

the child’s development. The program has

been evaluated using environmental and

educator assessments. Where educator

participation in professional development and

mentoring was high, project outcomes show

significant improvement in all subscales.

These early results indicate the program

is effective in addressing social inequities

in children’s health and development.

PHOTO: Western Sydney speech pathologists to support little language learners.



30

Patient experience mattersWe will improve our communications, be transparent and accountable. We will deliver safe, quality care whilst promoting dignity and respect. We will strengthen our systems, our processes and our care interactions. We will ensure the voice of the people of Western Sydney is heard in all aspects of care - health care policy, planning, design, delivery and evaluation.

At Cumberland Hospital, peer workers,

carers and staff collaborated to maximise the

benefits associated with service relocations

in preparation for the Parramatta Light Rail.

In 2019, five cottages were refurbished.

A new Pavilion and new 20-bed subacute

mental health inpatient unit will become

available later in 2020 to replace Boronia.

Peer workers consulted with two large

consumer groups in July 2019 and small

consumer group consultations in 2020

to inform the overall design and layout.

WE WILL:

• Learn from the experiences of our

patients, carers and families, with a focus

on collaborating with people from our

community to improve our services

• Strengthen our care teams working

collaboratively with patients, carers

and families to provide holistic

coordinated care

• Help people to better understand

their health and manage their care

Mental Health Building works - consumers co-design

Elements of co-design have been

incorporated into a variety of major capital

works projects in Mental Health Services (MHS)

across WSLHD. At Blacktown Hospital, a

Project User Group (PUG) consisting of

peer workers, carer representatives and

staff collaborated with the project team to

work from schematic to detailed design for

a new acute mental health inpatient unit at

Blacktown Hospital. A transition room and a

Keith’s Closet have been incorporated into

the facility design and will be included in

the revised models of care based on PUG

member recommendations.

PHOTO: Westmead patient Melvern Beyers with Westmead Hospital interns Dr Hayden Andrerson (right), Dr James Grogin (left) and Dr Vlad Danaila (dark blue shirt), who helped Melvern when he fell from his wheelchair in Westmead Hospital’s busy food court.

31



Spending WiselyWe will achieve real results from our investment. We will ensure we are efficient, productive and innovative in business design and delivery. Building on our strong foundation in health economics to make Western Sydney healthier in the face of finite resources and growing demands.

WE WILL:

• Accurately evaluate and assign our

activities to attract appropriate funding

• Analyse high quality data and information

to maximise our use of resources, improve

our operational efficiencies and reduce

variations in care

• Pursue broader opportunities to attract

additional resources

Patient Reported Measures - Integrated & Community Health

WSLHD is working collaboratively with the Agency for Clinical

Innovation to improve the recording of the Ministry of Health’s

Patient Reported Measures (PRM) Program. The Health Outcomes

Patient Experience (HOPE) will be the IT solution, capturing both

experience and outcome measures. Patient Reported Experience

Matters (PREMs) Data is being collected from a range of various

services including:

WSLHD Health Care Interpreter Service Video Interpreting Project

In February 2019, eHealth together with

ACI started the development of a future

single state-wide Telehealth platform

myVirtualCare (mVC). WSLHD HCIS was

invited, as an early adopter of this platform,

to participate in the creation of a designated

Virtual Waiting Room for Interpreters.

Testing of the platform commenced in

Blacktown Women’s Health Clinic (WHC)

in November 2019 and moved to a trial

involving patients in February 2020. Since

3 April 2020, as a consequence of the

social distancing rules, phone interpreting

has become the HCIS’ predominant mode

of interpreting, while the interest in video

interpreting has grown exponentially.

90.3% of services are now delivered via

the phone, 8% onsite and 1.7% via video.

The uptake of video interpreting is a

significant achievement and something

HCIS will further develop. A total of 110

video sessions were provided over the last

2 months (17 in March and 93 in April 2020).

Out of those 110 sessions, 65 were done in

WSLHD and 45 were provided to other users.

The Leading Better Values Care (LBVC)

PREM has been translated into 9 languages

for use across WSLHD. In addition, the

following activities are underway:

• Translation of LBVC Telehealth PREM

into 9 languages- in progress

• Mapping of Referral Pathways for

PROMIS29 using WSLHD Health Pathways

• LBVC Dashboard build

An Integrated Care Clinical Reference

Group including representatives from

LHDs/SHNs has been established.

The group will facilitate the embedding

and sustaining of the PRM program and

to improve the culture of WSLHD, an

investment in change management

training has been developed.

• High Risk Foot Service

(HRFS)- Blacktown

• Telehealth and Osteo- refracture

Prevention- Blacktown

and Westmead

• Telehealth and Osteoarthritis

Chronic Care Program- Auburn

• Bronchiolitis PREMS 2019

season – Mount Druitt

Paediatric Team

• Direct Access Colonoscopy

Baseline PREMS across

Westmead and Auburn

• COVID-19 In-home

telephone support service

PREM using MEM

• Co-ordinated use of Redcap

to rollout PROMs in the LBVC

space while we await HOPE



32

The District’s savings in terms of travel

associated costs are shown below.

In summary, the initial results from the video

pilot project are positive. Future work entails

further development of video interpreting

capacity by:

• Training interpreters (both staff and

some Sessionals) on how to use the

Telehealth platforms in order to

provide video interpreting

• Redesigning the current workplace to

increase suitability for video interpreting.

Violence, Abuse & Neglect (VAN) Services Redesign Project

The District is on track in the implementation

of the VAN Framework. There are strong

levels of integration across current VAN

services including a newly refreshed VAN

Committee; consistent levels of supervision

and support for staff; effective interagency

relationships and robust capacity building

across the LHD. Areas for improvement

identified include involving consumers in

VAN service planning, ensuring VAN

information is reflected in LHD strategic

planning and refining data collection to

allow development of expansion strategies

for VAN services. The VAN service has been

enhanced by the addition of permanent

clinical positions including Domestic

Violence, Adult Survivor, Integration and

Community Development Counsellors.

6S Lean Thinking Storeroom Project

The aim of this project was to Minimise wastage (out

of date stock); maximise staff time (less time spent by

clinicians looking for stock) and maximise space. New

storage solutions were purchased making accessibility

and visibility to products easier; reduced time spent

collecting and ordering supplies and also reduced

cleaning. Re-location of stores to one specific area

made ordering of supplies seamless, reducing over

ordering, minimising wastage and therefore cost.

This has also facilitated keeping the area clean and

clutter free. The introduction of the communication

board in the store room improved communication

helping to reduce delays when ordering priority

products. This successful project has been rolled

out across the five Community Nursing teams.

PHOTOS: WSLHD Interpreter Services health care interpreter Yulita Luck in one of the WSLHD Interpreter Services new accoustic booths. Westmead Hospital staff threw on their pyjamas to encourage patients like Elias Mardini (left) to get up, get dressed and get moving.

Information underpins everything we doWe understand that health strategy and digital health are now one and the same. Fit-for purpose health service delivery depends on access to high quality information. Information management and digital technologies will transform the way we work, where and how we provide services, how patients interact with us and how we integrate clinical care with research and education.

WE WILL:

• In collaboration with our partners,

implement our eHealth strategies

and investment plans so we have the

information systems and services we need

• In collaboration with our University

partners, data sciences will be a core

component of healthcare planning,

design and delivery

• Build our health informatics capability

by establishing clinical information

leadership roles and embedding health

informatics in our management training

and leadership development

The e-Patient Communication Portal (ePCP)

The e-Patient Communication Portal

(ePCP) is an online system that guides

staff through a five-step process (refer

to below diagram) so they can download

pre-defined templates and tools and check

the readability, understandability and

actionability of content.

A range of accessible health literacy

resources are provided as part of the system

to assist in the development or revision of

patient communication material.

SUBMITyour resource to HLH

for approval to publish

5REVIEW

your resource withconsumers for feedback

4DEVELOP

your content usingsoftware on your PC

3DOWNLOADa template from our

template design library

2

ePCP 5 STEPdocument builder

REGISTERyour resource using

our online form

1

The automated process is linked to the

consumer review processes so that staff

can develop and modify resources based on

consumer co-design and feedback from a

range of end-users, prior to submission for

final approval. The e-PCP has the ability to

connect staff to the LHD STREAM printing

service. User acceptance testing (UAT) will

commence in late May/June 2020 and will be

modified according to testers' feedback. The

Hub is planning an evaluation of the system

across 2020/21 following its implementation.

Clinical Emergency Response System (CERS)

Following the implementation of the

standardised WSLHD CERS for all adult

inpatients in February 2019, significant

improvements have been demonstrated

in the notification of red zone breaches.

Visibility and accessibility of data continues

to be an ongoing challenge for the

monitoring of patient observations and

staff adherence to clinical practice

guidelines for deteriorating patients.

As part of the Digital Health Program, a

Watchlist for the Between the Flags (BTF)

program has been implemented for adult

inpatients on a standard observation chart.

The Watchlist is set at a ward level and is a

real time visualisation of all patients on that

ward and their observations. It is currently

only available to those clinicians that have

a digital health profile (DHP), however the

majority of nursing staff will be transitioning

to a DHP by the end of 2020.

Work is now underway to standardise

speciality services and specific population

groups, such as paediatrics and community

services. In addition eHealth has released

BTF version 4.1 which includes the electronic

medical record (eMR) version of the maternity

and neonatal standard observation charts.

Planned implementation is October/

November 2020.



34

Free tech talk

A forum facilitated by chief medical

information officer A/Professor Naren

Gunja to discuss the ways Western Sydney

Local Health District (WSLHD) is embracing

digital and technology advancements.

All WSLHD hospitals have now transferred

over to electronic medication management

(eMeds) which replaces paper records.

Integrated Chronic Care Program (ICCP)

Short Message Service (SMS) a new tool

for ICCP, is currently being trialled by

Health Coach Staff. The in-house SMS

system was successfully set up to send

appointment reminders from Health Coach

Staff to their clients. The rationale for this

tool is to remind clients of their telehealth

appointment, to encourage better client

preparation for the calls and to reinforce

the time-sensitivity of their goals/actions.

At this point, data and patient feedback

are currently being collected to determine

its uptake amongst Health Coach Clients.

The intention is to expand its use by the Care

Facilitators looking after the Aboriginal/

Torres Strait Islander cohort and then

to all care facilitators.

Got Ya Back Midiga

The “Got Ya Back Midiga” was a project

initially developed in 2011 by the WSLHD

Integrated Violence Prevention & Response

Service (IVPRS) in partnership with the

community and the Aboriginal Affairs

and Yarramundi Kids Company. The

program aimed to close the gap for the

Aboriginal community by raising awareness

and preventing child sexual assault. The

Aboriginal Affairs and Yarramundi Kids

puppet show was delivered to over 500

children across five schools in the Mount

Druitt area, along with education and

training to school staff, parents and carers.

The project led to many disclosures of

current and past child sexual assault by

school staff, parents, carers and children.

The project was structured to ensure

that there were immediate multi-agency

responses including reporting, investigations,

support and counselling. The Got Ya Back

Midiga project was evaluated successfully.

However to ensure long term project

sustainability, a culturally specific script has

been developed so that an alternative video

resource option could be created for use

across numerous community settings.

The script is ready for production, through an Indigenous Production

Company, who have proposed a flat animation story. In 2020, IVPRS

received funding from MoH and Education Centre Against Violence

(ECAV) to develop the animated video resource and associated

materials for implementation.

Device Integration – Recovery

The Device Integration project was introduced into a Recovery

Unit in March 2020 and involves the use of existing eAnaesthesia

GE Gateway infrastructure. The device retrieves specific vital sign

values from the GE Patient Bedside Monitor and transmits this into

the patient’s electronic medical record (eMR). Device Integration has

improved patient safety and quality of care provided by recovery

nursing staff through providing reliable, accurate and complete vital

sign data, and enabling real time access to vital sign information.

Transcription errors and data omissions have reduced, facilitating

more time on patient care and improving workload efficiency.

Staff are now able to dedicate more time to focus on interacting

with the patient to ensure patients have a better experience in the

postoperative care unit. Device Integration is easy to use and has

been readily taken up by the recovery team.

Ultrasonic Induced Sputum

As of March 2020, patients with respiratory conditions at Blacktown

and Mount Druitt Hospitals are now receiving validated evidence-

based practice testing for Tuberculosis and Pneumocystis jiroveci

fungus (PJP) pneumonia. This project required procurement of

2 ultrasonic nebuliser machines, training of staff using validated

competency checklists, infection control approval and CSD (Central

Sterilisation Department) processes. The likelihood of obtaining false

negative test results is reduced compared to the previous system

used to obtain induced sputum specimens.

PHOTO: Westmead Hospital emergency department staff specialist Dr Amith Shetty.

PATIENT AND CARER EXPERIENCE0505

Patient and Carer Experience


36Left: Westmead patient Mamoud El Massiny with registered nurse Aileen Dalay.

It is very important for us to understand our patient experience, celebrate what works well and identify where we can improve.

How we measure and what we do

We have various measurement tools

including the State level Bureau of Health

Information (BHI) patient experience surveys

measuring patient experience across all

NSW hospitals and our local real time

My Experience Matters (MEM) Survey.

To date, MEM has collected over 11,500

local survey responses since 2017 covering

inpatient, outpatient and community settings.

Our benchmark for patient experience is 85%

and we are currently above the benchmark.

Our data has shown us the following:

• Last year 2% of patients identified

as Aboriginal.

• Cost of parking and availability of

spaces has been an issue for patients.

Some changes made in response to

MEM data include:

• Updated information about how to

claim concessional parking available

on our WSLHD Internet site.

• As waiting times in clinics are an issue,

several clinics have undertaken reviews and

system improvements to their bookings.

One of the key positive themes identified

from the survey was staff compassion. Staff

compassion was iterated 271 times in the

comments and/or free text section within

the 2019 surveys.

Mapping My Experience Matters (MEM)

Experience and engagement data sets show

a slow consistent improvement trend from

January 2019 to the present time. The MEM

data is reported at a facility and unit level to

identify and inform improvement strategies.

The MEM survey tool is used to create

tailored patient experience surveys for

over 25 special projects. The recent MEM

COVID-19 community results informed us of

how much our patients valued the support

from clinicians calling them daily to provide

health or psychological support.

To date, MEM has

collected over

11,500local survey

responses since

2017

Our benchmark

for patient

experience is

85%and we are

currently above

the benchmark

Last Year

2%of patients

identified as

Aboriginal

JAN

-18

FE

B-1

8

MA

R-1

8

AP

R-1

8

MA

Y-1

8

JUN

-18

JULY

-18

AU

G-1

8

SE

P-1

8

OC

T-18

NO

V-1

8

DE

C-1

8

JAN

-19

FE

B-1

9

MA

R-1

9

AP

R-1

9

MA

Y-1

9

JUN

-19

JAN

-20

FE

B-2

0

MA

R-2

0

AP

R-2

0

MA

Y-2

0

JUN

-20

JULY

-19

AU

G-1

9

SE

P-1

9

OC

T-19

NO

V-1

9

DE

C-1

9

COMPARISON OF WSLHD MY EXPERIENCE MATTERS & BHI DATA FOR PATIENT EXPERIENCE 2018 - 2020

70

75

80

85

90

95

Under Performing

WSLHD Experience Score Linear (WSLHD Experience Score)BHI Experience Score

Performing

37



JULY

-18

AU

G-1

8

SE

P-1

8

OC

T-18

NO

V-1

8

DE

C-1

8

JAN

-19

FE

B-1

9

MA

R-1

9

AP

R-1

9

MA

Y-1

9

JUN

-19

JAN

-20

FE

B-2

0

MA

R-2

0

AP

R-2

0

MA

Y-2

0

JUN

-20

JULY

-19

AU

G-1

9

SE

P-1

9

OC

T-19

NO

V-1

9

DE

C-1

9

COMPARISON OF WSLHD MY EXPERIENCE MATTERS & BHI DATA FOR PATIENT ENGAGEMENT 2018 - 2020

60

70

80

85

90

95

75

65

Under Performing

WSLHD MEM Engagement Score Linear (WSLHD Engagement Score)BHI Engagement Score

Performing

JULY-19 AUG-19 SEP-19 OCT-19 NOV-19 DEC-19 JAN-20 FEB-20 MAR-20 APR-20 MAY-20 JUN-20

MENTAL HEALTH SERVICE - YOUR EXPERIENCE OF SERVICE (YES) RETURN RATES

100

200

300

400

0

285 274 265180

264325 323

188

352

163254

187

The MEM surveys facilitate early

identification and escalation of issues and

inform project or service improvements.

MEM surveys are translated into the

16 most commonly spoken languages,

including languages of our most vulnerable

newly arrived populations.

As health adapts and develops new

telehealth models of care delivery as a

result of COVID-19, MEM surveys will be

developed in collaboration with teams to

monitor and respond to patient experience.

WSLHD Mental Health Service YES (Your Experience of Service) return rates 2019-2020 for the Safety and Quality Account

In the 2019/20 financial year, there has

been 1791 Your Experience of Service (YES)

consumer satisfaction surveys returned from

Inpatient Services and 1269 returned from

Ambulatory (Community) Services.

“In the first 3 months of our trial we had a big win. Through identifying upcoming appointments for women who had already given birth, we were able to reschedule 109 appointments for other women needing an appointment”.

Julianne Harvey

Innovation and Redesign

Project Lead Western

Sydney health District.



38


INPATIENT - YOUR EXPERIENCE OF SERVICE (YES) RETURN RATES

50

100

150

200

250

0

190

140

158

95126

198209

101

172

101

181

120

The District’s return rate of YES surveys for inpatient services over the last 2 financial years is 36%, which is above the 33% state average.


AMBULATORY (COMMUNITY) - YOUR EXPERIENCE OF SERVICE (YES) RETURN RATES

50

100

150

200

0

95

134107

85

138 127114

87

180

62

73 67

The District’s return rate of YES surveys for Ambulatory (Community) services over the last 2 financial years is 5%, which is above the 2% state average.

Feedback Friday

Feedback Friday was initiated at Auburn

Hospital to better understand patient

and carer experience, and make informed

improvements as a result of the experience

feedback. Feedback Friday occurs on one

scheduled Friday each month, to obtain

patient and carer feedback from patients

and carers, within the hospital. Responses

are reviewed and distributed to wards and

departments, who are required to develop

improvements and solutions to address

feedback themes and issues.

To promote ward and unit participation, a

competition is being run which will reward

individuals and wards for promoting and

obtaining surveys and making improvements

in response to feedback.

Recognise, Engage, Act, Call, Help is on its Way (R.E.A.C.H)

R.E.A.C.H is a system developed by the

Clinical Excellence Commission (CEC) that

helps patients, their family and carer/s

escalate their concerns with staff about

changes in a patient’s clinical condition.

R.E.A.C.H has been implemented in

all WSLHD facilities including

Cumberland Hospital.

In 2019, we worked collaboratively with

the Clinical Excellence Commission and

our Aboriginal Community to develop

R.E.A.C.H information for Aboriginal Patients.

This brochure is now available across NSW

and all WSLHD facilities. Between January

2019 and April 2020 there have been

62 REACH calls across WSLHD.

Patient Safety Video

The patient safety video ‘What matters to

you matters to us– how to stay safe during

your hospital stay’ was created by WSLHD

to provide information to patients about

the hospital experience. The concept is the

same as airline flight safety videos. The aim

of the patient safety video is to encourage

patient involvement in their own care

and ensure safety during their stay. The

video is displayed on the bedside Patient

Entertainment Systems (PES).

Working collaboratively with the Health

Care Interpreter Services (HCIS), translated

videos in the eight most commonly spoken

languages in Western Sydney were created

and are available on the PES. A transcript of

the patient safety video is also available in

English and six languages including Persian,

Vietnamese, Turkish, Korean, simplified

Chinese and traditional Chinese. Translated

information on pressure injuries, falls and

blood clot prevention is also available

on the PES.

Overall

79%of mental health

consumers who

completed the

survey were reporting an

excellent or very

good overall

experience in

quarter 4 of the

Financial Year

2019-20

Similarly,

90%of the Ambulatory

(Community) service

consumers who

completed the

survey were reporting

an overall score

of excellent or

very good overall

experience.

MENTAL HEALTH

SERVICES YES SURVEY

Percentage

of consumers

reporting an

excellent

or very good

experience.

39



Carer Program- caring for our carers

Western Sydney Health understands and values the contribution carers make to the people they care for. Our staff recognise that a carer constantly provides support when patients are in or out of our care.

Key initiatives of the Carer Program include:

• Carer Zones have now been built into

Westmead’s new Central Acute Services

Building (CASB)

• Visiting Hours and Staying Overnight

Procedure has been amended to facilitate

carers staying overnight with patients.

This has resulted in better and safer

outcomes for our patients

• We are working collaboratively as part of a

research project to examine the effects of

having a carer stay overnight and how this

could decrease the falls risk for a patient

• The patient contact information

components of information patient

manager (iPM) has been upgraded to now

record a patient’s carer’s contact details

or to record if the patient themselves is

a carer. Administration staff have been

educated about the importance of

collecting this information. The upgrade

went live in April 2020 and by mid-May

we had nearly 1000 carers registered

on the iPM system

• The iPM upgrade has allowed us to identify

how many young carers are engaging

with our services which informs our

Young Carers Program information and

resources availability

The PES has been updated with specific

information for carers such as visiting hours

and information on how to organise an

overnight stay within our Carer Zones.

A district wide Carer Survey helps us monitor

issues that are important to our carers.

By the end of 2020 we aim to increase the

number of carer surveys by 25%, to improve

Carer Experience.

PHOTO: Westmead patient Paul Molly and his wife Betty Molly.

40



“Our little man arrived a few weeks early & I just wanted to say a HUGE thank you, to you and your amazing team of midwives and doctors. After a very long labour in the end, I can’t thank everyone enough for being so patient, informative, kind and just overall wonderful throughout the birth of baby. Special mention to both the staff, who were by my side most of the birth & an amazing calming presence to have with me. Thank you all again. Looking forward to the next time with you and your amazing team.”

“I would just like to say a big thank you for giving me such a wonderful experience

with my second pregnancy and birth of my son. My first experience of labour and

breastfeeding was extremely overwhelming and stressful due to several factors.

I was so worried that I would have the same experience with my second baby.

Not only did the midwife help me to remain calm throughout the pregnancy but

during labour she really supported and coached me mentally and physically to be

able to successfully deliver and breastfeed my son.

I am absolutely sure that I would not have been able to do it without her continued support throughout my pregnancy and post birth visits. Without those visits from her, I am sure that my anxiety would have produced a very different result. I could not have had such a positive experience without her. I am eternally thankful that the Midwifery Group Practice was available to me.”

“My mother arrived to Blacktown Hospital Emergency via Ambulance on 27 January 2020 after she collapsed at home. She was later admitted to Ward for a total of five nights. I could not be happier with the treatment she received and the attention we were given. I would phone in at 8am, 10am then the last call at 8pm, and every time I was greeted with compassion and empathy for what we, as a family were going through. At one point my father and I were so distraught that when I phoned in, our nurse could hear it in my voice and insisted that I speak to mum, so very thankful. I want to thank your dedicated nurses for the AMAZING job they did in looking after, caring and helping my mum throughout her stay.”

WSLHD values all compliments received about patient experience and the care provided by our staff.

Compliments

41



Thumb print celebrates cancer patients’ final day of treatment

Blacktown Hospital patient Maryam

Shahrestani leaves her mark as she

completed her cancer treatment.

It was a special moment when breast

cancer survivor Maryam Shahrestani

painted her thumb green and pressed

it to the wall in Blacktown Hospital.

Each thumb print forms a new leaf on

a beautiful, evolving artwork created

by patients on the day they complete

their treatment. The visual concept

was inspired by the hospital staff

and patients of the Cancer and

Haematology Centre at

Blacktown Hospital.

Maryam made the latest addition to the

wall when she completed her last day

of cancer treatment this week, having

been diagnosed with early-stage breast

cancer after a routine mammogram in

June last year. “It was a huge surprise

when they told me I had cancer – I just

cried,” Maryam said. “I lost my sister

a few years ago to breast cancer so it

brought back some sad memories.

Our Patient Stories

COVID-19 survivor encourages testing: “I’m glad I played it safe”

Mohammed Zelka was supposed to be enjoying life as a student

in Poland this year. But while COVID-19 interrupted his plans and

even hit him personally, the 25-year-old considers himself one

of the lucky ones. Mohammed self-isolated from the moment he

re-entered the country in March, was diagnosed early, and received

expert advice and care throughout his journey from the Western

Sydney Local Health District (WSLHD) Public Health Unit and

COVID-19 Community Monitoring Clinic.

“I only ever got mild symptoms of the disease. A dry cough,

discomfort in my chest and some difficulty breathing, that was

pretty much it,” he said. “If this was any other year then I probably

would’ve kept going about my life with something like that.”

“I encourage everyone including my friends, family and colleagues that it’s very important to have regular check-ups with your GP and mammograms.”

“I’m glad I played it safe and got tested straight away.”



42

Consumer Councils

WSLHD has a number of councils initiated

over the last six years to better understand

the needs of our consumers and community.

The WSLHD Consumer Council has a large

membership, with 20 to 60 members in

attendance at monthly meetings. The co-

chairs of the WSLHD Consumer Council meet

with the Chief Executive on a monthly basis.

More recently we set up two new councils to

better understand the needs and experiences

of our community and create a channel

for two way information flow. The Auburn

Hospital Community Council was set up

in mid-2019 and meets monthly, whilst

Westmead Hospital Community Council,

set up in February 2020, has met twice. The

council membership consists of cross-sector

community leaders from education, health,

local council, police and other community

organisations along with representatives

from the WSLHD Consumer Council.

The Councils have been particularly useful

during COVID-19 to enable us to understand

the communication challenges being

experienced in parts of our community.

These challenges are communicated internally

through our WSLHD communication channels

and escalated externally to organisations and

agencies, including the Ministry of Health.

WSLHD continue to collect and analyse data

to measure the impact of the Community

and Consumer Partnerships program

across Western Sydney. We have found that

over a three year period (2016-2018) the

program appears to have built a culture for

partnership across the LHD. We are currently

assessing a number of activities that involve

Consumer Representative engagement,

with outcomes to be published in 2020.

WSLHD Partnering with Consumers Standard 2 committee

A partnering with Consumers Standard 2

committee was formed in 2019 The objective

of the partnership committee is to support

the LHD to identify, develop and implement

systems that build partnership with patients,

carers and other consumers in order to

improve the safety and quality of care.

The committee membership is comprised

of 50% consumers and 50% WSLHD staff.

CONSUMER COUNCILS

The WSLHD Consumer

Council has a large

membership, with

20 to 60

members in

attendance at

monthly meetings.

CONSUMERS STANDARD 2 COMMITTEE

The committee

membership

is comprised of

50%

consumers and

50%

WSLHD staff.

PHOTO: Free training is provided to new consumer representatives and they are supported by other experienced peers.

PEOPLE AND CULTURE0606

OVERARCHING PRIORITIES

Wellbeing, Bullying & WHS

Improve staff wellbeing and

empowerment, strengthen

processes, training and support

to effectively deal with bullying,

harassment and discrimination

to keep our workplace safe.

Job Satisfaction

Focus on listening to our staff as

well as improving skills, satisfaction

and empowerment through

fostering mentoring, training, talent

growth and building capability

to enhance purpose, mastery

and autonomy.

Keeping People Informed & Celebrating Success

Improve all aspects of communication

and collaboration as well as

recognising, acknowledging and

celebrating the success of our staff.

SPECIFIC PRIORITIES

Strategic Planning

Improve strategic, tactical and operational

planning – all levels of the organisation.

Staffing Numbers, Workload & Overtime

Improve focus on staffing levels, workload

priorities, skill mix and supports available to

prevent burnout and frustration.

Recruitment Confidence

Improve local and district recruitment practice

and processes, supports and training, attraction

and retention, decision making and review the

current Recruitment Supportive Model.

High Performance

Focus on training, improving skills, performance,

talent strategies and understanding motivators

to performance.

Diversity & Inclusion

Enhance the cultural competency framework

and related diversity programs across

the district.

Cultural Priorities

People and Culture


44

People and Culture


Left: Organisational development consultant and Workplace Wellness team co-leader Shari Hendricks.

PHOTOS: Hundreds of staff share ideas at first Safety Symposium. People & Culture team, dressed in purple vests, are supporting staff through the COVID-19 pandemic.

Safety Symposium 2020

We hosted the WSLHD Safety Symposium

event this year, with nearly 400 staff and

guests in attendance. We received over

1000 ideas on how to improve our safety

culture, separated into four categories of

“continue”, “start”, “stop” and “change”.

All of the feedback related to:

• Safety Processes

• Safety & the People Who Use

Our Services

• Safety & Leadership

• Training, Education and Support

Cultural Change Strategic Framework

In recent years, WSLHD has reported

consistently less than desirable results in

People Matter Experience Surveys. These

results, as well as results gathered from

the World Cafés sessions have informed

the development of the cultural strategic

framework. Its purpose is to improve our

organisational culture. The framework

utilises an evidence based organisational

development methodology to strategically

develop teams and individuals across

the LHD to enhance a culture of

psychological safety.

Workplace Wellness Drop-In Centres

Established locations have been set up in

Westmead and Blacktown Hospitals for

staff to come visit, chat with one of our

Workplace Wellbeing Team and get the

latest information about COVID-19.

Numerous resources are available to our

staff ranging from Access EAP (Employee

Assistance Program) through to websites,

hotlines and community services. We are

checking in with all staff on what they

need to feel more informed, supported,

focused and valued.

Wellness Warriors support almost 5,000 staff through COVID-19

People and Culture team are visiting all areas of the LHD in

purple vests providing support to staff that may be feeling

overwhelmed by COVID-19 changes to the workplace.

Department Visits

Our team members are visiting departments (where safe to

do so and invited) to speak with managers and their teams,

providing the same support as in the Drop-In Centres.

Separate Manager Connect conversations can also be had

with managers in these areas. As we do not have wellbeing

centres at Auburn, Mount Druitt and Cumberland facilities,

days are arranged to visit to different areas.

Manager Connect

We have approximately 800 managers across the district.

This service is delivered in a number of ways, including via

email and phone calls to managers in specific areas as directed

by Human Resources (HR) and the Executive. Check-in topics

are based on ensuring our managers are informed, supported,

focused and valued. Coaching and consulting is provided in

addition to referrals to other resources and support.

FORMAL RESULTS0707

Formal Results


46Left: Surgeon cleaning hands before going into theatre.

7.2%of Non-Aboriginal

women who smoked

during pregnancy

892Number of

Get Healthy

in Pregnancy

Referrals

7902Number of

Hospital Drug

and Alcohol

Consultations

Strategy 1: Keeping People Healthy

The domains of effectiveness, efficiency and equity are focused on in Strategy 1.

Measure WSLHD target

WSLHD result

Have we improved since last report?

Data period

Equity

Percentage of Aboriginal women who smoked during pregnancy

49% 45% No Apr -Jun 2020

Percentage of Non-aboriginal women who smoked during pregnancy

7.0% 7.2% Yes Apr- Jun 2020

Effectiveness

Percentage of women quit smoking by the 2nd half of pregnancy > 27% 21.6% No 2020

Number of Get Healthy in Pregnancy Referrals > 772 829 Yes FYTD Mar-20

Percentage of children with height & weight recorded – childhood obesity > 70% 50.6% No FYTD Mar-20

Number of LHD residents who initiated Hepatitis C Antiviral Treatment > 350 134 No FYTD Dec-19

Efficiency

Number of Hospital Drug and Alcohol Consultations

> 7285 7902 Yes FYTD Mar-20

Data availability for these measures varies depending on the current programs reporting process.

Abbreviations

FY Financial year

FYTD Financial year to date

< Less than or equal to

< Less than

> Greater than

> Greater than or equal to

Key

Performing

Underperforming

Not Performing

Data extracted from NSW Health Monthly Performance Report June 2020.

It is well recognised that a healthy baby at

birth is really important for determining

future health and wellbeing. To help achieve

this outcome, it is important for mothers to

have a healthy lifestyle during pregnancy.

A key focus is helping women achieve a

healthy pregnancy with a strong emphasis

on quitting smoking. A project addressing

Women smoking in pregnancy, in Blacktown

hospital, demonstrated a 25% decrease

following an intervention. There has been an

increased percentage of Aboriginal women

who smoke during pregnancy since the

previous reporting period.

WSLHD developed and implemented

multiple strategies which includes opt-out

Quit line referrals, commencement of using

carbon monoxide monitors, introduction

of Safer Baby Bundle, development of

Aboriginal smoke-free home/no smoking

around children animations and delivery

of a social marketing campaign.

Childhood obesity is a growing issue. It is

important to recognise children who are

overweight or obese, as these children are at

greater risk for type 2 diabetes, cardiovascular

conditions and certain cancers in adulthood.

At WSLHD, staff training, an improved

communication strategy, identified champions

and a pathway to assist measurements have

been developed and implemented.

Hepatitis C is a blood borne virus that causes

damage to the liver which can have long-

term health consequences. Treatment with

direct-acting antivirals is now 95% effective

in curing patients with Hepatitis C. WSLHD

percentage of treatment initiations is 41.5%,

which is significantly below the target of

64.6%. Actions are being implemented to

improve treatment initiation.

Drug and alcohol misuse has both social

impacts through violence, crime and trauma,

and individual health impacts through

increased rates of morbidity and mortality.

Providing access to treatment is a key

component to improving outcomes

for patients.

47

Formal Results


The domains of safety, effectiveness, human centred culture and timeliness & accessibility are focused on in Strategy 2.

Strategy 2: Provide World-Class Clinical Care Where Patient Safety is First


WSLHD result


Data period

Safety

Hospital Acquired Renal Failure (Rate per 10,000 episodes of care)

< 2.3 0.5 Yes FY2019/20

Hospital Acquired Gastrointestinal Bleeding (Rate per 10,000 episodes of care

< 11 7.4 No FY2019/20

Hospital Acquired Delirium (Rate per 10,000 episodes of care)

< 39.4 27.8 Yes FY2019/20

Hospital Acquired Persistent Incontinence (Rate per 10,000 episodes of care)

< 5 1.9 Yes FY2019/20

Hospital Acquired Malnutrition (Rate per 10,000 episodes of care)

< 4.7 0.2 Yes FY2019/20

Discharged Against Medical Advice for Aboriginal Inpatients (%)

< 3.9% 2.9% NAFYTD

May-20

Effectiveness

Percentage of women quit smoking by the 2nd half of pregnancy

> 5.7% 4.7% YesFYTD

May-20

Percentage of children with height & weight recorded – childhood obesity

> 6.2% 6.3% YesFYTD

May-20

Human centred culture

Overall Patient Experience Index for adult admitted patients

≥ 8.5 8.16 NoOct-Dec

2019

Overall Patient Experience Index for emergency department patients

≥ 8.5 7.44 NoOct-Dec

2019

Patient Experience Index for admitted adult patients

≥ 8.5 8.09 NAOct-Dec

2019

Patient Experience Index for emergency department patients

≥ 8.5 7.44 NAOct-Dec

2019

Timeliness & accessibility

Percentage of patients who spent ≤ 4hours in Emergency Department

≥ 78% 59.0% NoFYTD

Jun-20

Percentage of patients transferred from ambulance to Emergency Department in ≤ 30 minutes

≥ 90% 85.5% NoFYTD

Jun-20


Data extracted from NSW Health Monthly Performance Report June 2020 and Quality Improvement Data System (QIDS) database July 2020

A hospital acquired complication

(HAC) is where a hospital risk

mitigation strategy may reduce

the likelihood of the complication

occurring. The national list of

16 HACS was developed by the

Australian Commission on Safety

and Quality in Health Care with

version 3 released early 2020.

Unplanned readmissions is used as

a measure for quality and safety.

Reducing avoidable hospital

readmissions can lead to better

health outcomes, improved patient

safety and increased health system

efficiency. While WSLHD is still not

performing unplanned readmissions

in the Aboriginal population, the

percentage has improved over

the last year.

Delays in patients being able to

access appropriate care through

the Emergency Department (ED)

can have a significant impact on

patient outcomes and on ambulance

resources. Two key performance

measures are the percentage of

patients who are still in the ED within

4 hours of presentation and the

percentage of patients who are not

transferred from the ambulance to

an ED cubicle within 30 minutes.

WSLHD is not performing or

underperforming in both these areas

with no improvement from last year.

PHOTO: Staff promoting “Stop Pressure Ulcers”.

Formal Results


48

Fall Related Injuries

Measure Fractures or intracranial injuries that occur as a result of a

fall in hospital.

More than one in three people over the age of 65 years will fall at least once per year. Patients in hospital can be more at risk of falling. Falls can result in fractures and brain damage.

Falls in hospital are one of the leading causes of injury and death in older Australians. A fall in hospital causing injury can increase the length of hospital stay and the likelihood of discharge to an aged care facility rather than home.

Prevention strategies include assessments for risk factors, equipment to aid safe mobilisation, medication management, education and communication.

WSLHD has a target rate of less than 4.6 fall related injuries per 10,000 episodes of care. Currently WSLHD is at 4.6 which equates to 72 fall related injuries for 57 patients.

Healthcare Associated Infections (HAI)

Measure Infections that occur

after admission to hospital.

One of the most common complications affecting patients in hospital are infections that develop after the patient has been admitted. Healthcare associated infections (HAI) significantly increase morbidity and mortality, as well as the risk of readmission within 12 months.

Prevention and control practices are essential to patient safety and to reduce HAIs. Patients, visitors and staff all play a role in HAI prevention, which includes, hand hygiene and following cough etiquette.

WSLHD has a target rate of less than 95.3 HAI per 10,000 episodes of care. Currently WSLHD has a rate of 102.6 which equates to 1674 infections for 1009 patients.

Data extracted from QIDS MMM DD 2020

Num

ber

of

Inci

den

ts p

er 1

0,0

00

bed

day

s

2018-19 2019-20

FALL RELATED INJURIES

0

1

2

3

4

5

6

NSW WSLHD WSLHD Target <4.6


Num

ber

of

Inci

den

ts p

er 1

0,0

00

bed

day

s

2018-19 2019-20

HEALTHCARE ASSOCIATED INFECTIONS

0

10

20

30

40

50

60

70

80

90

100

110

120

83.5

98.7


Num

ber

of

Inci

den

ts p

er 1

0,0

00

bed

day

s

2018-19 2019-20

PRESSURE INJURIES

0

1

2

3

4

5

6



IMPROVEMENT INITIATIVES

• Knock on Effect project- video

• Appointment of nominated champions

• Implementation of 5-Ps (Pain, pallor, pulse, paresthesia and paralysis) plus 6Th P – Power outlet

• Education and guidelines developed for managing prone patients in the ICS due to recent COVID-19 and increase in PI.


• A project collaborating with consumers on falls education is being scoped

• Initiative for toileting to be commenced

• Lessons learned forums held at each facility

• Building capacity in fall champions to promote appropriate falls risk mitigation.

• Leading Better Value Care initiatives.


• Reinforcement of Bare below elbows practice

• Increased vigilance regarding hand hygiene practices

• Large body of education on standard precautions donning/doffing PPE and transmission based precautions has been completed

• Business plan developed for a vascular access team, inclusive of district wide access to nurse practitioner.

Pressure InjuryMeasure Stage 3 or 4 deep tissue or unspecified hospital acquired

pressure injury.

A pressure injury is when the skin and tissue under the skin are damaged by constant pressure or friction. Pressure injuries can happen to a patient when they are unable to move due to illness, surgery or injury.

Pressure injuries can be painful and take a long time to heal. They can increase hospital length of stay and impact short and long term quality of life.

Prevention strategies include risk assessment, management plans, regular position changes, a healthy diet and keeping skin clean and dry.

WSLHD has a target rate of less than 5.8 pressure injuries for every 10,000 episodes of care. We have achieved a rate of 2.7 for 2019-20 which equates to 36 pressure injuries involving 34 patients.

49

Formal Results


Blood Clots

Measure Blood clots that occur

while admitted to hospital

A venous thromboembolism (VTE) or blood clot is when blood thickens inside a vein and blocks the flow of blood. Blood clots are one of the leading causes for preventable death in Australia, causing more deaths than road traffic accidents.

Blood clots can cause distressing symptoms including pain, swelling, limited mobility and respiratory distress.

Key prevention strategies include risk assessment on admission and every 7 days throughout the admission; medication that helps prevent blood clots from forming. Patients play a key role in prevention by staying as mobile as possible and asking about their risk assessment.

WSLHD has a target rate of less than 6.4 VTEs (Blood clots) per 10,000 episodes of care. Currently WSLHD has a rate of 6.2 and equates to 98 VTE (Blood clot) incidents for 77 patients.

Medication Complications

Measure Medications given in hospital that lead to respiratory complications, hypoglycaemic events or haemorrhagic disorders due to blood clot prevention medication.

Use of medication to treat a patient is one of the most common interventions that occurs in hospital. Because medications are used so frequently, it is more likely that an error may occur. It is estimated that 27% of clinical incidents that occur each year are a result of medication error.

Key prevention strategies include a comprehensive risk assessment on admission and ongoing monitoring of medication strategies implemented for care.

WSLHD has a target rate of less than 25.8 medication complications per 10,000 episodes of care. Currently WSLHD has a rate of 28.9 which is an increase from last year. This equates to 366 medication complications involving 341 patients. Of the 366 medication complications, 308 were for hypoglycaemic events.


• Designated areas in one of the smaller facilities for chest drain management initiated

• Chest tube insertion and management initiative developed to review complications arising from chest tube use. Educational strategies and training opportunities have been implemented for nursing and medical

• Initiative commenced to review oxygen use to minimise complications of CO2 retention. Oxygen prescription now occurring and greater vigilance with ceasing oxygen therapy when no longer required


• Individual patient assessment for risk of hypoglycaemia

• Appropriate management of patients who are fasting prior to surgery

• Review of guidelines where hypoglycaemia can occur as a result of treatment


• WSLHD has introduced an electronic reminder for doctors to complete the VTE risk assessment

• The GoShare platform is a platform used to provide information electronically to patients in the outpatient or community setting. Westmead Hospital is trialling the GoShare platform to provide patients with information on how to prevent blood clots from forming

Respiratory Complications

Measure Patients with respiratory failure and acute respiratory distress syndromes that require ventilation. Patients who acquire aspiration pneumonia.

Patients with respiratory complications can experience extremely distressing symptoms including shortness of breath, fatigue, fevers and anxiety. Respiratory complications increase the patient’s length of stay in hospital.

Prevention strategies include completing a risk assessment to identify risk factors, developing a prevention plan and ensuring that routine respiratory observations are taken.

WSLHD has a target rate of less than 17.3 respiratory complications per 10,000 episodes of care. Currently WSLHD has a rate of 19.8 which has increased from the previous year and sits outside the target range. WSLHD’s current rate equates to 269 respiratory complications for 246 patients.


Num

ber

of

Inci

den

ts p

er 1

0,0

00

bed

day

s

2018-19 2019-20

RESPIRATORY COMPLICATIONS

0

2

4

6

8

10

12

16

18

20

14

22


Note: Respiratory Complications were not previously reported in Service Level Agreements so 2018/19 data is reported against 2019/20 targets.


Num

ber

of

Inci

den

ts p

er 1

0,0

00

bed

day

s

2018-19 2019-20

VENOUS THROMBOEMBOLISM

0

1

2

3

4

5

7

6



Num

ber

of

Inci

den

ts p

er 1

0,0

00

bed

day

s

2018-19 2019-20

MEDICAL COMPLICATIONS

0

2

6

4

8

10

12

14

16

18

20

22

24

26

28

30

32


Formal Results


50

Cardiac Complications

Measure Cardiac complications that

occur after admission to hospital

Cardiac complications that occur after admission include heart failure, arrhythmias and cardiac arrest. These can be caused by too much intravenous fluid, medications that lead to complications, unstable angina or worsening condition. Cardiac complications can cause significant pain and discomfort as well as increasing the length of stay in hospital.

A key strategy is identifying those patients at risk of clinical deterioration.

WSLHD has a target rate of less than 43.7 cardiac complications per 10,000 episodes of care. While WSLHD current rate is within the target at 41.8, it has increased from last year when it was 33.2. This equates to 601 cardiac complications involving 515 patients.

Vaginal Tears in Childbirth

Measure 3rd & 4th degree perineal lacerations that occur while giving

birth vaginally

Perineal lacerations, also called vaginal tears, occur when the skin does not stretch enough as the baby’s head is being born or the baby’s head is too big. The severity of the tear is classified from 1-4, with 4 being the worst. First and second degree tears are relatively common and take a few weeks to heal. Third and fourth degree tears are more serious and can take longer for complete healing to occur. They can cause ongoing problems including urinary and faecal incontinence, sexual discomfort and psychological distress.

Key strategies include assessment of the perineum, slow controlled birthing of the baby, providing perineal protection during birth and episiotomy when required.

WSLHD has a target rate of less than 378.2 for 3rd or 4th degree lacerations per 10,000 vaginal births. The current rate for WSLHD is 336.4 which equates to 160 patients.

Neonatal Birth Trauma

Measure Trauma that occurs at the time of birth including cranial haemorrhage, nerve damage and injuries to the skeleton.

Babies that are larger than average, a difficult labour or when the mother’s pelvis is the wrong size or shape, are among the factors that increase the likelihood of trauma occurring at birth. Quite often these births require the use of hands or instruments to enable the safe delivery of the baby.

While most injuries that occur at birth heal with no complications, birth trauma can be significant and have lifelong consequences.

Key strategies include comprehensive antenatal risk assessments and following best practice guidelines for delivery.

WSLHD has a target rate of less than 63.9 for birth trauma per 10,000 births. WSLHD current rate is 47.5 which equates to 53 injuries involving 50 babies.


• Trilogy 202 ventilators have been procured exclusively for the Code Blue/Advanced Life Support (ALS) team to manage inpatient acute pulmonary oedema in a timely manner

• Chest pain pathway review for management in both Emergency and inpatient settings


• Both Blacktown and Westmead hospitals have introduced care bundles. These care bundles are made up of a number of evidence based interventions which when used together lead to better outcomes


• A comprehensive data analysis of the cases is being undertaken by a multidisciplinary team of experts to identify potential improvement initiatives

• Policy in development for use of foetal pillows to minimise injury related to manual manipulation


Num

ber

of

Inci

den

ts p

er 1

0,0

00

bed

day

s

2018-19 2019-20

CARDIAC COMPLICATIONS

0

5

10

15

20

25

30

40

35

45



Num

ber

of

Inci

den

ts p

er 1

0,0

00

bed

day

s

2018-19 2019-200

50

100

150

200

250

300

350

400

3rd and 4th DEGREE PERINEAL LACERATIONS

NSW WSLHD WSLHD Target <378.2 NSW WSLHD WSLHD Target <63.9


Num

ber

of

Inci

den

ts p

er 1

0,0

00

bed

day

s

2018-19 2019-20

NEONATAL BIRTH TRAUMA

0

5

10

15

20

25

30

35

40

45

50

55

65

60

51

Formal Results


The domains of safety, effectiveness, human centred culture, timeliness & accessibility and appropriateness are focused on in Strategy 3.

Strategy 3: Integrate Systems to Deliver Truly Connected Care


WSLHD result


Data period

Effectiveness

Percentage of Domestic Violence routine screening

≥ 70% 34.4% NAJan-Mar

2020

Percentage of referrals for victims of sexual assault receiving an initial psychosocial assessment

≥ 80% 88.7% NoFYTD

June-20

Timeliness & accessibility

Average time from Aged Care Assessment Timeliness referral to delegation

< 5 days

1.3 YesFYTD

Jun-20


Percentage of electronic discharge summaries completed and sent to the State Clinical Repository

> 48.7% 48.7% NAFYTD

Jun-20

Mental Health

Effectiveness

Acute Post-Discharge Community Care - Follow up within seven days (%)

≥ 70% 81.6% YesFYTD

Apr-20

Acute readmission - Within 28 days (%)

< 13% 17.6% YesFYTD

Apr-20

Appropriateness

Acute Seclusion Duration – Average

< 4 hours

11.9 No 19/20 FY


Percentage of Mental Health patients who scored their experience with the service as Very Good or Excellent.

≥ 80% 79% YesApr - Jun

2020


Data extracted from NSW Health Monthly Performance Report June 2020.

Discharge from a mental health inpatient admission and transition to

community-based care is a critical point for people receiving specialised

mental health care. People leaving hospital after an admission for an episode

of mental illness may be more vulnerable and are at increased risk of harm,

relapse or readmission without adequate follow up. In the FYTD Apr-20,

81.6% of inpatients being discharged from a mental health admission received

public mental health community follow-up within the first 7 days of their

discharge, which is above the NSW Health target of >70%.

Readmission to an acute mental

health inpatient unit within 28

days of discharge from mental

health inpatient care is often used

as an opportunity to monitor the

overarching performance of a

mental health system. High rates of

mental health readmission within

28 days point to opportunities for

improvement in hospital treatment

or community follow up care, or a

combination of the two. In the FYTD

Apr-20, 17.6% of inpatients being

discharged from a mental health

admission were readmitted within

28 days of discharge, which is above

the NSW Health target of <13%.

Consumer and care engagement in

comprehensive discharge planning

and timely community mental health

follow-up in the community often

support a reduction in acute mental

health readmissions within 28 days

of discharge.

According to the Bureau of Health

Information, the collection and

use of seclusion and restraint data

is a well-recognised strategy to

help reduce the use of restrictive

seclusion and restraint practices,

used in accordance with the NSW

Mental Health Act 2007. Information

on seclusion and restraint events

occurring in specialised mental

health units are collected by staff in

NSW public hospitals. In the 19/20

FY incidents of seclusion were on

average 11.9 hours in duration, which

is above the NSW Health target of

<4 hours. The program in WSLHD

Mental Health Services is based on

the Creating Positive Cultures of

Care Program and the Safe Wards

Program. The Program includes

the following strategies: leadership,

workforce development, trauma-

informed care, improving the

therapeutic environment, incident

review, consumer and carer

co-design and the use of data.

Formal Results


52

The recommendations from the

Review of seclusion, restraint and

observation of consumers with a

mental illness in NSW Health facilities

are being implemented.

The Mental Health Your Experience

of Service (YES) consumer survey

within WSLHD was completed by

3060 mental health consumers

in the FY19/20 in relation to both

their community and inpatient

mental health care. Of the surveys

completed, 79% of the consumers

reported an Excellent or Very Good

overall experience, in the Apr – Jun

2020 period, which was above

the NSW average of 76%.

Mental Health Services

Seclusion and restraint data Use of Seclusion and Restraint in

Mental Health inpatient units

WSLHD Mental Health Services has undergone extensive change in recent years, incorporating a multi-faceted approach in the Service’s aim to reduce the use of Seclusion and Restraint in Mental Health settings. Overall, since July 2014, fewer patients are going into seclusion, less frequently and for less time. The program in WSLHD Mental Health Services is based on the Creating Positive Cultures of Care Program and the Safe Wards Program. The Program includes the following key strategies: leadership, workforce development, trauma-informed care, improving the therapeutic environment, incident review, consumer and carer co-design and the use of data.

WSLHD has a target rate of less than 5.1 incidents of Seclusion per 1000 bed days. The number of incidents of seclusion has reduced from 6.1 per 1000 bed days (324 incidents) in the 18/19FY to 5.6 per 1000 bed days (295 incidents) in the 19/20FY. The use of Restraint has increased from 5.7 per 1000 bed days (303 incidents) in the 18/19FY to 6.2 per 1000 bed days (330 incidents) in the 19/20FY. While there has been an increase in restraint events there has been a concurrent decrease in seclusion events, in both frequency and duration.


• Monthly Seclusion and Restraint Reduction Forum

• The Seclusion and Restraint Database has enabled timely access to new and relevant data, which informs practice in a monthly forum with key stakeholders, as well as improving efficiency in mandatory data collection

• The use of trauma informed care

• Increased focus in the development, maintenance, use and collaboration with patients in planning their care

• Continued engagement in sensory modulation activities, including sensory gardens; art therapies such as mindfulness colouring; physical and rehabilitation activities; massage chairs; diversional therapies; and an activities program

WSLHD WSLHD Target <5.1 WSLHD No Target Rate Set

Data extracted from WSLHD Seclusion and Restraint database 1 July 2020

Does not include restraint events for mental healthpresentations in the Emergency Department.

Num

ber

of

Inci

den

ts p

er 1

,00

0 b

ed d

ays

Num

ber

of

Inci

den

ts p

er 1

,00

0 b

ed d

ays

2018-19 2019-20

SECLUSION - MENTAL HEALTH

MENTAL HEALTH SECLUSION RATE PER 1,000 BED DAYS

1.0

2.0

3.0

4.0

5.0

6.0

7.0

2018-19 2019-20

RESTRAINT - MENTAL HEALTH

1.0

1.5

2.0

2.5

3.0

3.5

4.0

4.5

5.0

5.5

6.5

6.0

6.1

5.6

5.7

6.2

PHOTO: ENABLE graduate Hiro Kojo shows Minister for Mental Health Bronnie Taylor (left) how she uses sensory toys as an outlet for her anxiety.

53

Formal Results


Access Block (Mental Health Presentation in ED >24hours)

Measure Mental health presentations to the Emergency Department (ED) that exceed 24 hours in duration prior to transfer or discharge

Chronic mental health conditions often coexist with other factors such as physical illness and alcohol and drug use that contribute to more frequent ED presentations and longer ED stays for these patients. Longer ED stays can be harmful to a patient’s mental state and increase the risk of adverse events for these patients. Therefore mental health presentations to the ED that exceed 4 hours, 12 hours and 24 hours are monitored with a target rate of 0 to exceed 24 hours.

Key strategies to reduce access block include effective patient flow; prompt, comprehensive mental health assessment; and acute mental health bed availability.

WSLHD has a target rate of 0 mental health presentations to the ED that exceed 24 hours. The number of mental health presentations to the ED that exceed 24 hours had increased from 16.7 per 1000 mental health ED presentations (92 incidents) in the 18/19FY to 45.7 per 1000 mental health ED presentations (270 incidents) in the 19/20 FY.

The number of mental health presentations to the ED that exceeded 24 hours in duration had steadily been declining, until late 2019 where a rise occurred in mental health presentations to the ED which resulted in a higher need for both mental health assessments in the ED and mental health acute inpatient beds.

At 49%, the primary driver during the 2019-20 financial year for breaching the 24 hours in the ED were due to mental health bed availability. This was followed by 11% of patients requiring acute medical care in the ED.


• Child and Youth Mental Health ED Navigator clinicians situated in Westmead and Blacktown ED to support mental health presentations of people under the age of 18

• Improved Patient Flow Short Term Escalation Plan (STEP) with improved communication and escalation of patient waiting times in the ED

• Improved discharge planning to reduced access block to acute mental health beds

• Ensure correct coding of mental health presentations and prompt assessment and referral to mental health

• Collaboration with NSW Ambulance in the Mental Health Acute Assessment Team (MHAAT) to support a reduction in mental health presentation

WSLHD No Target Rate Set

Data extracted from Aladdin 1 July 2020

Denominator is all Emergency Department presentations coded as Mental Health

Num

ber

of

Inci

den

ts p

er 1

,00

0 M

enta

l Hea

lth

ED

pre

sent

atio

ns

2018-19 2019-20

ED > 24 HOURS - MENTAL HEALTH

0.0

5.0

10.0

15.0

20.0

25.0

30.0

35.0

40.0

45.0

50.0

16.7

45.7

Formal Results


54

Inpatient Absconding

Measure Incidents of absconding from Declared Mental Health inpatient units by involuntary patients either directly from the inpatient unit or whilst on escorted leave from the unit

To support the safety of both the mental health inpatient and the broader community, the service has a responsibility to ensure that a rigorous process is in place to support the safe and appropriate multidisciplinary assessment of involuntary patients, prior to the approval of leave being granted and to reduce the risk of patients absconding.

Key strategies include an environmental measure to improve security, consumer observation and engagement, collaborative risk assessment and multidisciplinary care planning.

A continued decline has been noted in the number of inpatients absconding from Mental Health units, from 19.7 per 1000 episodes of care (for patients who were involuntary for all or part of their care) (38 incidents) in the 18/19FY to 17.7 per 1000 episodes of care (37 incidents) in the 19/20FY. Increased staff vigilance on consumer observation and engagement, risk assessments of courtyards and necessary minor capital works to replace courtyard furnishings with fixed furniture have all contributed to the continued decline.


• Effective capital works programs to improve security and reduce the opportunity to abscond with the installation of airlock doors and fixed outdoor furniture

• Consumer observation and engagement

• Appropriate risk assessment and care planning with the consumer and their carer/family

WSLHD No Target Rate Set

Data extracted from IMS+ and IIMS 1 July 2020

Denominator is all Patients who were involuntary for all or part of their care

Num

ber

of

Inci

den

ts p

er 1

,00

0

epis

od

es o

f ca

re

2018-19 2019-20

ADSCONDING - MENTAL HEALTH

0.0

5.0

10.0

15.0

20.0

25.0

19.7

17.7

Strategy 4 focuses on the domain of human centred culture

Strategy 4: Develop and Support Our People and Culture


WSLHD result


Data period

Equity

Percentage of staff engagement with the People Matter Survey

≥ 58.4% 61.1% Yes FY2018/19


The NSW People Matter Survey is run every year and provides an

opportunity for employees to provide feedback on their work place

experience. The percentage of completion is an important indicator

of staff wellbeing and a belief that change can occur.

PHOTOS: Bungarribee House registered nurse Joseph Toussaint looks after humans and aquatic creatures. Blacktown Hospital general services staff Binabahen Nizama and Rory Dunlop.

55



FUTURE PRIORITIES0808

Future Priorities


56Left: Dr Kanan Shah VMO Anaesthetist at Auburn Hospital.

Leadership

WSLHD Nursing & Midwifery Leadership Program

WSLHD is committed to providing our

nurses and midwives with opportunities to

grow professionally and supporting them

along their leadership journeys. Planning for

a WSLHD Nursing & Midwifery Leadership

Program is currently underway, with an aim

to develop and implement a standardised

leadership program that meets the needs

of emerging nursing and midwifery leaders

and maintains features of existing effective

leadership initiatives. This will involve a

mapping process of current strategies and

consultation with facility and service nurses

and midwives.

WSLHD Appreciative Inquiry and its application to clinical practice

WSLHD is facilitating two Appreciative

Inquiry five day workshops delivered

over three months. Team members are

encouraged to participate and focus on

an area for improvement within their unit.

Appreciative Inquiry is a collaborative

strength based approach to positive

change. It builds on positive experiences

to enhance day to day work and practice.

This methodology has been adapted for use

in health and is currently being used with

positive results. The use of Appreciative

Inquiry empowers and encourages inclusion

& participation, improves productivity

and reduces resistance to change. The

knowledge and skills learnt will assist in

coordinating local change initiatives.

Integrated & Community Health - HealthPathways

Thirty five percent (35%) of Australians have

a chronic condition and are high users of

health services. This population cohort often

receive treatment for their condition and

variable education to manage their condition

from multiple health service providers.

The aim of this project is to evaluate

the effectiveness of HealthPathways in

reducing unwarranted clinical variation

in chronic illness management education

to patients. The perceived non-compliance

with evidence based guidelines, may result

from a lack of formal training or available

guidelines for community clinicians.

Variable patient education in chronic illness

management results in patient confusion

with management plans, poorer patient

outcomes, an increase in avoidable hospital

admissions and additional stress on health

services. Health Pathways has the potential

to assist clinicians to adopt consistent best

practice and evidenced based guidelines,

and provide optimal health condition

management education to patients.

WSLHD is committed to providing our staff with opportunities to grow professionally and supporting them along their leadership journeys.

57

Future Priorities


Culture

The WSLHD People & Culture directorate continues to

lay the foundations for the evolution of WSLHD culture.

In 2019 and early 2020, WSLHD collected feedback

from staff through various World Café events and the

Safety Symposium. The Culture Steering Committee was

established, and the Organisational Development team

and external culture partner Bendelta were recruited.

The Organisational Development team launched and ran

our Workplace Wellness initiatives throughout the district

including the facility Wellness Centres and the Staff

COVID-19 Assist Call Centre to help all staff feel

informed, supported, focused and valued.

We are recommencing our primary culture work

which includes:

• Reconnecting with the Culture Steering Committee

and the Executive to guide and confirm priorities

moving forward

• Bringing Bendelta on board, establishing our

operational practices and beginning to map all the

various culture concepts, initiatives and major projects

• Key culture focus areas:

- Developing our “culture branding and messaging”,

along with strategies to keep all staff informed of

the culture work we are engaging with including

goals, progress and achievements. This will include

developing a shared vision for the culture we want

in WSLHD and what behaviours underpin that.

- Launching our Leadership Development Program

focusing on the Executive team, Heads of

Department, Facilities and Services Management.

This will support the growth and development of

these leaders, particularly with the unique challenges

and numerous changes happening at WSLHD.

Part of this work will focus on embedding the

desired behavioural competencies to support

the desired culture.

- Mapping and restructuring the 100+ previously

identified culture “projects” into a manageable

program of prioritised culture initiatives to be

delivered over a number of years.

The WSLHD People and Culture directorate is in the

process of taking the 2019 Culture Strategic Framework

and updating it to a multi-year strategy underpinned by

evidenced-based culture frameworks relating to our

CORE values and patient-focused services.

Research

Blacktown End-Of-Life Communication Project

The Blacktown End-Of-Life (EoL) Communication

research project seeks to develop an intervention and

implementation strategy to improve communication

and shared decision-making in end-of-life discussion

between consumers, their families and clinicians;

including Blacktown Hospital medical, nursing and allied

health staff. The collaborative Health Literacy Hub/

Palliative Care Project team developed an End of Life

proposal which was submitted at the end of 2019 for a

Research Education Network (REN) Grant. The team

was successful in receiving a REN grant of $50K. Grant

funding will be used to employ a Research Officer and

undertake data analysis, training and communication

material development across 2020/2021.

Mental Health Literacy Initiative

The Sydney Health Literacy Lab was concurrently

awarded competitive funding from the Mental Health

Commission of New South Wales to evaluate the Mental

Health Literacy Initiative. In 2019, Western Sydney

Primary Health Network (WentWest) was selected as one

of two pilot implementation sites for the project, working

with WSLHD Health Literacy Hub as an official partner.

Over the next 2 years, the Primary Health Network will

work collaboratively to implement and evaluate the

Initiative in Western Sydney, with a focus on process,

outcome and economic evaluation.

Health Literacy capacity training for WSLHD Allied Health Staff

In collaboration with the WSLHD Allied Health Research

Group, a Research Fellow in the Hub developed and

evaluated a health literacy training program for allied

health professionals in WSLHD, and explored the

feasibility of implementing the program and adopting a

train-the-trainer model to support wider dissemination.

The program combined didactic and experiential

teaching methods and behaviour change techniques,

with a focus on teach back and developing easy-to-

understand written materials. The Hub received a HETI

Grant of $4,000 over 1 year to develop and implement

the training.

SUCCESS App - A program supporting culturally and linguistically-diverse adults with CKD to engage in shared decision making

Collaboratively, researchers from the University of

Sydney, Western Sydney LHD, Nepean Blue Mountains LHD,

Sydney LHD and Northern Sydney LHD have developed

a model of care and a multi-component App-based

intervention to build health literacy capacity and enable

shared decision-making for Chronic Kidney Disease

patients including those with lower health literacy

and/or from CALD backgrounds.

PHOTO: Blacktown National Sorry Day Ceremony. Helen Emmerson (A/g Executive Director People & Culture) and general public.

Future Priorities


58

The SUCCESS App combines a standardised patient-

education system based on health literacy principles

with known effective behaviour change methodologies

and health literacy training skills. The feasibility of

implementing the App is currently being evaluated in

a multi-centre study and funding from the NSW Health

Translational Research Grant Scheme to conduct a larger

randomised controlled pilot trial over the next two years

has been received.

Chronic and Complex Nursing - Joint partnership project in Wound Care

The DEBED Study is a nested quasi-experimental study

which will examine the benefits of advanced practice

wound debridement education on nursing processes

and patient outcomes. The study will facilitate improved

service planning, provide better value and best practice

health care by establishing a representative cross-sectional

view of patients receiving wound debridement and their

management. Measurement of the service impact will

include determining whether:

• Wound healing times decreased

• Health costs associated with length of admission

to community health via reduction in nursing time

and wound product use, reduction in presentation

& representation to Emergency Departments &

admissions decreased

• Depression and anxiety decreased

• Pain reduced

• Social isolation reduced

• Quality of life increased and improved

The information will be used to support further funding

applications for implementation of advanced wound

debridement and wound management options including

the NSW Health, Leading Better Value Care and

Tranche 2 initiative.

Harm Minimisation

Towards Zero Suicides

Towards Zero Suicides is one of the NSW Premier’s

priorities to reduce suicides. WSLHD Mental Health

Services will be using elements of co-design with its

three priority initiatives: Zero Suicides in Care; Assertive

Suicide Prevention Outreach Team; and Alternatives to

ED Presentations. Recruitment will commence in 2020

and all three projects will have a strong focus on service

innovation through co-design between staff and those

with a lived experience, either as a consumer or a carer.

Parenting Plus

The WSLHD Health Literacy Hub has collaboratively

worked with Integrated Community Health (ICH)

Child and Family Health to implement Parenting Plus,

an innovative evidence-based health literacy training

program for new parents. The program was built on a

model of health literacy skill development shown to be

effective with disadvantaged and culturally-diverse adults

in Australia. This program is unique because it embeds

adult education based literacy, numeracy training and

shared decision making skill development into core

content relevant to new parenthood, co-designed

with consumers and service providers. During the past

financial year, the Hub pilot-tested the Parenting Plus

program using a pre-test post-test design.

The Program content and structure was modified

(see table below) using an intensive co-design process

involving frontline and managerial health staff and

consumers. Version 2 of the Parenting Plus program is

now ready for wider roll-out. The Parenting Plus Program

will be adapted across 2020/21 to include a focus on

addressing risk factors for stillbirth.

Parenting Plus topics (+ examples of functional health literacy course skills)

Cross-cutting communicative and critical health literacy skills embedded using Sufficient Exemplar Training

Topic 1: Development and

milestones (Discerning when to seek medical advice:

Reading nutrition labels)

Topic 2: Healthy

Relationships (Early help-seeking: Accessing services;

Communication skills)

Topic 3: First aid

for children (Reading a thermometer;

Interpreting medicine labels)

Topic 4: Physical activity

and nutrition (Reading and

understanding dietary guidelines; Applying

guidelines in everyday life)

3. Skills for Behavioural Implementation

2. Skills for shared decision making

1. Skills for accessing and critically appraising health resources

59

Future Priorities


Vulnerable People

Aboriginal Health

Whilst a large body of work was conducted at the onset

of the pandemic, WSLHD is committed to ensuring

we continue to support one of our most vulnerable

communities. The following activities are currently

underway and planned for 2020/2021.

• Launch of COVID-19 Competitions – We are currently

in the process of launching a video/art competition with

the local Aboriginal community on COVID 19 and what

they know, with various target groups and categories.

A prize package will be given to the top 3 most

innovative artwork pieces.

Integrated and Community Health - Child and Family

In response to the COVID-19 pandemic Community Family

Health Allied Health are in the process of implementing

new modalities of intervention via telehealth (telephone

and video-conferencing) with the aim to achieve:

• Telehealth capability across all services

• Meet consumer need and demand regarding how

services are provided in the COVID-19 context

• Keep families engaged in services including

therapy and interventions

• Support parenting capacity

• Improved health and development outcomes

for children and families

• New intervention modalities will undergo an evaluation

process to measure their impact.

The ‘Combining Health literacy skills And

Stillbirth Education’ (CHASE) intervention

embeds graded health literacy skills

(e.g. functional skills for reading nutrition

labels) across stillbirth awareness topics

(e.g. side sleeping). The program will be

iteratively revised with input from health

practitioners, health literacy and maternal

health experts, consumers and stakeholders

in WSLHD over the coming months and

evaluated in a multicentre feasibility study

across three Western Sydney sites.

Bilingual Community Educator Program (BCE) / Multicultural Health Service

The Bilingual Community Educator

Program (BCE) is the main health literacy

improvement strategy for CALD communities

in WSLHD. The program delivers culturally

sensitive health education on various priority

health topics using peer educators. The BCE

Program works regularly in collaboration

with many stakeholders including libraries

in Parramatta, Wentworthville, Greystanes,

Stanhope Gardens and Castle Hill, expanding

the reach of health education programs to

CALD communities.

A needs assessment was conducted

in 2019/2020 and a number of service

improvements have been initiated to

advance the program reach, effectiveness

and efficiency. In the same year, 40 BCE

programs across a range of topics including

but not limited to Cancer Screening (Bowel,

Breast, Cervical), Diabetes Awareness

in Your Community, Healthy Eating and

Physical Activity, Women and Children

Growing Together in New Country, New

Healthy Women and Changing Life Keep

your Balance were delivered. The programs

were delivered in various languages including

Tamil, Hindi, Punjabi, Urdu, Tagalog, Dari,

Mandarin, Cantonese, Arabic and Persian.

In 2020/2021, the BCE Program will focus

on advancing the implementation of

improvements identified and initiated

in 2019/20.

Future Priorities


60

• Provision of material masks to reduce the risk of

non-compliance – The intent of this activity is to

supply our local Aboriginal communities with masks.

Aboriginal designed mask materials have been ordered

in anticipation that mask use will become compulsory.

The masks will be distributed to our local Aboriginal

communities to reduce the risk of disease transmission

and fines associated with mask compliance. Infection

Prevention and Control will provide approval to ensure

appropriate material selection.

• The Aboriginal Health Hub is exploring options to

become a primary service for those who require

telehealth services and do not have access to data,

phone and internet services. This will ensure effective

follow up with patients

• The supply of pamphlets and face masks, as well as

essential packs for the vulnerable, sick and elderly

will continue

• Ongoing attendance at meetings across all relevant

parts of the local health district ensures that we are

kept informed and can provide the community with

ongoing information

• A 3 tiered approach on visiting patients in hospital

specifically for the Aboriginal community is being

developed. This visiting process is currently in draft.

• We are working with schools to develop a pamphlet

to ensure parents are kept informed if their school is

affected and closed for deep cleaning

• We continue to support unwell families with exceptional

circumstances during the pandemic response

Aboriginal Elder Olympics

The Aboriginal Elder Olympics 2020 event was

dedicated to Auburn Hospital, to provide education to

the community about the services available at Auburn

Hospital. Due to COVID-19, the event was postponed

and has been rescheduled for 2021.

The event will host up to three hundred people with

team representation from the Auburn – Liverpool

Aboriginal Men’s group, the Mount Druitt Men’s Shed,

plus representatives from Dubbo, Kempsey, Armidale,

Tamworth and Gunnedah.

The event is held to encourage people over the age

of fifty who have chronic health conditions to exercise.

This event gives health services an opportunity to

promote their available services to the community and

build strong relationships for future program partnership

in program development. This would have been the third

year in succession of the Elders Olympics. The team is

eager to prepare for the 2021 games.

Safer Baby Program

The Safer Baby Program, in line with care bundles

developed internationally, has been developed and

implemented with the aim to reduce the number of

stillbirths and serious adverse outcomes in newborns, as

well as improve maternal health outcomes and increase

satisfaction with care. The program is designed with

five key elements that are implemented in stages

with WSLHD plans to complete implementation

November 2020.

Foot Referral Pathway

The Foot Referral Pathway is currently in draft and for

consultation within Chronic and Complex Care (CAC).

The aim of the foot referral pathway is to obtain a

common understanding of referral to and from acute

and community services to enhance client care.

Cystic Fibrosis

The Federal Government announced $65 million for the

construction of a Cystic Fibrosis Specialist Service at

Westmead Hospital. The service will include a 16-bed

adult inpatient unit, 10 consulting rooms, four day-stay

beds, a diagnostic area and education, training and

research amenities. The Westmead Redevelopment team

is currently working with key stakeholders and consumers

through the design phase of the project.

Collaborative Commissioning

Collaborative Commissioning is a whole of system

approach designed to enable and support delivery of

value based care in the community. The aim is to deliver

value-driven, outcome-focused and patient-centred

healthcare by leveraging the principles of the quadruple

aim and developing pathways of care tailored to the

community’s needs.

PHOTO: Aboriginal mother with her newborn.

61

Future Priorities


In January 2020, the Collaborative Commissioning Joint

Development Phase commenced under a partnership

agreement with the Ministry of Health, WSLHD and

Western Sydney Primary Health Network to support

delivery of patient centred and value-based care in

the community.

In response to the COVID-19 pandemic, a supplementary

model of care has been proposed in addition to the two

approved work streams (Value Based Urgent Care and

Cardiology in Community). The additional model of care

will provide community based support for vulnerable

and identified high risk residents of WSLHD during the

current pandemic and will co-ordinate the comprehensive

care for confirmed COVID-19 positive patients in

the community.

Patient Experience Matters

Consumer information management: a consumer co-design project

The consumer information management project is part

of the overarching Redevelopment change program. The

project aims to create a consumer designed information

template on Westmead hospital services, access and

wayfinding details to improve information sharing and

care. The project will involve consumer representatives

interviewing clinical and non-clinical service leaders

to develop the information template and content.

The project is in partnership with the WSLHD

Community and Consumer Engagement Program.

WSLHD Youth Council

The WSLHD Youth Council identified future priorities with

a focus on health literacy, supporting patient reported

measures, development of Adolescent and Young

Adult space in Westmead Redevelopment and enabling

feedback from broader youth in Western Sydney.

The “Youth Hello Doctor” program was held at Arthur

Phillip High School in partnership with Youth Health and

Multicultural Health. This event bought together Year 10

students and youth services to celebrate young people

and raise awareness of the services available to them.

Future planned events including the recruitment of

new members with eligibility opened to 16 year olds+

(previously limited to 18-25 years old); Youth Week with

pop up stalls; Non-perishable food drive to donate to

Youth Health with collection bins situated in Westmead,

Blacktown and Mt Druitt reception areas and the

inaugural Youth Health Summit have all been

scheduled for the latter part of 2020.

Multicultural Health CALD Community and Consumer Engagement Program

Multicultural Health Services (MCHS) in partnership

with community stakeholders established a number of

working groups that involve CALD communities and

consumers to work with and support Multicultural

Health and the District. Establishment of groups

was essential to progress the development and

implementation of many MCHS projects including Hello

Doctor, African Communities Health Summit, health

needs assessments, health literacy initiatives and to

provide COVID-19 information to our CALD communities.

The groups assisted in identifying health issues and gaps

and planning culturally appropriate responses to address

the health needs of vulnerable migrant and refugee

populations in WSLHD.

In 2020/2021, MCHS will continue to work with

established groups and extend the service to Pacific

Communities and the African Australian Youth Suicide

Prevention Group. Work will focus on developing and

implementing new ways of delivering health information

and education, progressing cross cultural health

literacy projects, identifying priority health issues

for communities and working with them to develop

culturally respectful interventions.

The Chronic and Complex team

As an outcome of the research project, a catheter

Booklet: ‘How to care for your indwelling urinary

catheter at home’ will be developed.

The Research Project-IQ-IDC Study will evaluate the

effect of educational interventions for indwelling urinary

catheters to improve self-care and reduce catheter-

associated complications. In Australia, an estimated

380,600 additional annual public hospital bed days

are attributed to healthcare-associated urinary tract

infections primarily due to catheter-associated urinary

tract infections. Catheter-associated complications

such as recurrent urinary tract infections, catheter

blockages and urine leakage are common adverse events

experienced by patients with long-term catheters and

result in significant personal and healthcare system

related burden, adversely impacting the quality of life,

morbidity and mortality.

This study aims to improve the knowledge, self-care

practices and quality of life of patients living with

indwelling urinary catheters. This is achieved by providing

education and resources and preparing clients/carers to

self-manage the indwelling urinary catheter.

The project thus far has:

• Completed literature review and the paper has

been submitted for publication (under review with

Contemporary Nurse Journal)

• Received Ethics & Governance approval

• Successfully received ICH Research Launchpad grant

Future Priorities


62

Due to COVID-19, Ethics re-submission is being

planned to replace face to face interviews and focus

group sessions with telephone and/or Zoom interviews.

Integrated and Community Health - (Health Literacy Hub)

The Health Literacy Hub, one of 10 focus areas identified

by the Ministry of Health, is aimed at improving patient

experience. This has been established in a collaborative

partnership between WSLHD and the University of

Sydney. The concept of the Hub was identified as an

innovative approach to providing a valuable source,

focus and dedicated resource for experimentation

and adaptation of health literacy interventions.

The proposal and governance framework has

been developed and established with state-funded

infrastructure and resourcing, to deliver coordinated

defined actions to improve health literacy across all

NSW LHDs and communities. In the latter part of 2020,

a Patient Experience Strategy will be developed

with recommendations.

2020 vision for the future of health

Patients at the heart of healthcare was the focus

of planning for the future at the “2020 Vision for

the Future or Health” forum led by Western Sydney

health organisations. The forum was initiated and led

by WentWest’s clinical and consumer councils with

representatives from NSW Health, Western Sydney Local

Health District (WSLHD) and Western Sydney University.

The main focus of the forum was finding ways to improve

integrated care in Western Sydney and how to best take

forward the WSLHD-Western Sydney Primary Health

Network (WSPHN) integrated care program.

The integrated care program aim is to keep people out

of our emergency departments and hospitals where

possible and allow patients to remain with their families

in the community because we know that patients recover

much quicker at home. The partnership that WSLHD

has with WentWest is one of the strongest relationships

in the state. As a result, we have been able to lead the

way in developing a number of integrated care models

in Western Sydney, to achieve improvements in service

delivery, hospital efficiency and patient outcomes.

A Secure Electronic Referral System to improve referral processes from Primary Care to WSLHD Outpatient Clinics and Services - Integrated & Community Health

Eliminating paper-based referrals in healthcare is a

key priority of the National Digital Health Strategy-

Framework for Action 2018. This is underpinned by the

eHealth Strategy for NSW Health 2016–2026, to boost

collaboration between care providers around patient

care needs through shared care plans, collaboration tools

and referral solutions that will benefit the experiences of

healthcare consumers and clinicians.

In FY 2018/2019, just over 200,000 referrals were

received by WSLHD Outpatient Services from Private

Practice General Practitioners. Most referrals were

received by fax, phone or delivered in person by the

patient. A secure electronic referral system is a solution

to improve the referral process and experience for all

stakeholders. The draft secure electronic referral system

project has been submitted for review and approval

to engage with a vendor. The project will improve

ICH compliance with the NSW Outpatient Services

Framework 2019.

PHOTO: WSLHD staff in training.

63

WSLHD Board Attestation Statement


Health Western Sydney Local Health District

This attestation statement is made by Richard Alcock AO

Name of office holder/member of Governing Body

Holding the position/office on the Governing Body Chair

For and on behalf of the governing body titled

Title of office holder/member of Governing Body


Governing body's title (the Governing Body)

Western Sydney LHD -Auburn (110101) Western Sydney LHD - Blacktown and Mount Druitt (115100) Western Sydney LHD - Mental Health and Drug Health (115102) Western Sydney LHD - Westmead (150522)

Health service organisation name (the Organisation)

1. The Governing Body has fully complied with, and acquitted, any Actions in the NationalSafety and Quality Health Service (NSQHS) Standards, or parts thereof, relating to theresponsibilities of governing bodies generally for Governance, Leadership and Culture.In particular I attest that during the past 12 months the Governing Body:

a. has provided leadership to develop a culture of safety and quality improvement withinthe Organisation, and has satisfied itself that such a culture exists within theOrganisation

b. has provided leadership to ensure partnering by the Organisation with patients,carers and consumers

c. has set priorities and strategic directions for safe and high-quality clinical care, andensured that these are communicated effectively to the Organisation's workforce andthe community

d. has endorsed the Organisation's current clinical governance framework

e. has ensured that roles and responsibilities for safety and quality in health careprovided for and on behalf of the Organisation, or within its facilities and/or services,

64

WSLHD Board Attestation Statement


are clearly defined for the Governing Body and workforce, including management and clinicians

f. has monitored the action taken as a result of analyses of clinical incidents occurringwithin the Organisation's facilities and/or services

g. has routinely and regularly reviewed reports relating to, and monitored theOrganisation's progress on, safety and quality performance in health care.

2. The Governing Body has ensured that the Organisation's safety and quality prioritiesaddress the specific health needs of Aboriginal and Torres Strait Islander people.

3. I have the full authority of the Governing Body to make this statement.

4. All other members of the Governing Body support the making of this attestationstatement on its behalf ( delete if there is only one member/director of the governingbody).

I understand and acknowledge, for and on behalf of the Governing Body, that:

- submission of this attestation statement is a pre-requisite to accreditation of theOrganisation using NSQHS Standards under the Scheme

- specific Actions in the NSQHS Standards concerning Governance, Leadership andCulture will be further reviewed at any onsite accreditation visit/s.

Signed

Position Chair, Western Sydney Local Health District

Date

Schedule of health service organisations covered by this attestation statement

Name of health service organisation Address

Auburn Hospital 18 Hargrave Road, Auburn NSW 2144

Blacktown and Mount Druitt Hospitals Blacktown Road, Blacktown NSW 2148

Mental Health and Drug Health Services 1-11 Hainsworth Street, Westmead NSW2145

Westmead Hospital Cnr Hawkesbury & Darcy roads, Westmead NSW 2145

65

References


Australian Commission on Safety and Quality in Health Care (2020), Avoidable hospital readmissions, https://www.safetyandquality.gov.au/our-work/indicators/avoidable-hospital-readmissions viewed July 2020.

Australian Government Department of Health (2020), Smoking and tobacco and pregnancy, https://www.health.gov.au/health-topics/smoking-and-tobacco/smoking-and-tobacco-throughout-life/smoking-and-tobacco-and-pregnancy viewed July 2020.

Australian Institute of Health and Welfare (2020), Mothers & babies, https://www.aihw.gov.au/reports-data/population-groups/mothers-babies/about , viewed July 2020.

Australian Institute of Health and Welfare (2018), Children’s Headline Indicators, https://www.aihw.gov.au/reports/children-youth/childrens-headline-indicators/contents/6-overweight-obesity, viewed July 2020.

Australian Institute of Health and Welfare (2018), Alcohol risk and harm, https://www.aihw.gov.au/reports/australias-health/alcohol-risk-and-harm , viewed July 2020.

Australian Institute of Health and Welfare (2018), Illicit drug use, https://www.aihw.gov.au/reports/australias-health/illicit-drug-use , viewed July 2020.

C. Weber (2020), Engagement Survey isn’t working, gothamCulture, https://gothamculture.com/2017/03/30/8-reasons-your-employee-engagement-survey-isnt-working/ viewed July 2020

Hepatitis Australia (2020), What is hepatitis C?, https://www.hepatitisaustralia.com/what-is-hepatitis-c, viewed July 2020.

Hepatitis Australia (2020), A cure for hepatitis C?, https://www.hepatitisaustralia.com/hepatitis-c-cures, viewed July 2020.

Clinical Excellence Commission, Pressure Injury Prevention, http://www.cec.health.nsw.gov.au/keep-patients-safe/pressure-injury, viewed April 2020.

Australian Commission on Safety and Quality in Health Care (2018), Hospital Acquired Complication: Pressure Injury, https://www.safetyandquality.gov.au/sites/default/files/migrated/Pressure-injury-detailed-fact-sheet.pdf viewed April 2020.

Clinical Excellence Commission, Falls prevention, http://www.cec.health.nsw.gov.au/keep-patients-safe/Falls-prevention, viewed April 2020.

Australian Commission on Safety and Quality in Health Care (2018), Hospital Acquired Complications Fact Sheets, https://www.safetyandquality.gov.au/sites/default/files/migrated/Short-Hospital-Acquired-Complications-Factsheets-all-HACs.pdf viewed April 2020.

Clinical Excellence Commission, Healthcare Associated Infections, http://www.cec.health.nsw.gov.au/keep-patients-safe/infection-prevention-and-control/healthcare-associated-infections, viewed May 2020.

Australian Commission on Safety and Quality in Health Care (2018), Hospital Acquired Complications Fact Sheets, https://www.safetyandquality.gov.au/sites/default/files/migrated/Short-Hospital-Acquired-Complications-Factsheets-all-HACs.pdf viewed May 2020.


Clinical Excellence Commission, Venous Thromboembolism (VTE) prevention, http://www.cec.health.nsw.gov.au/keep-patients-safe/medication-safety-and-quality/vte-prevention, viewed May 2020.


Clinical Excellence Commission, Venous Thromboembolism (VTE) prevention, http://www.cec.health.nsw.gov.au/keep-patients-safe/medication-safety-and-quality/vte-prevention, viewed May 2020.


Australian Commission on Safety and Quality in Health Care (2018), Hospital Acquired Complications Information Kit, https://www.safetyandquality.gov.au/sites/default/files/2019-04/SAQ7730_HAC_InfomationKit_V2.pdf viewed May 2020.

Australian Commission on Safety and Quality in Health Care (2018), Severe (Third and Fourth Degree) Perineal Tears Clinical Care Standard, https://www.safetyandquality.gov.au/standards/clinical-care-standards/severe-third-and-fourth-degree-perineal-tears viewed May 2020.

The Leeds Teaching Hospital (2020), New approach to childbirth in Leeds will lead to better outcomes for mums, https://www.leedsth.nhs.uk/a-z-of-services/leeds-maternity-care/news/2018/02/12/new-approach-to-childbirth-in-leeds-will-lead-to-better-outcomes-for-mums viewed May 2020.

Royal College of Obstetricians and Gynaecologists (2020), OASI Care Bundle Project: FAQs, https://www.rcog.org.uk/en/guidelines-research-services/audit-quality-improvement/oasi-care-bundle/oasi-faqs/#whatcarebundle viewed May 2020.

Australian Commission on Safety and Quality in Health Care (2018), Neonatal Birth Trauma, https://www.safetyandquality.gov.au/sites/default/files/migrated/SAQ7730_HAC_NeonatalBirthTrauma_LongV2.pdf viewed May 2020.

Birth Injury Guide (2020), Birth Trauma, https://www.birthinjuryguide.org/birth-injury/types/birth-trauma/viewed May 2020.

References

References


66

INSTAGRAM

YOUTUBE

TWITTER

FACEBOOK

LINKEDIN

WESTERN SYDNEY LOCAL HEALTH DISTRICT

PO Box 574 Wentworthville NSW 2145 +61 2 8890 9902 [email protected]

www.wslhd.health.nsw.gov.au

2019-2020 report | 2020-21 future priorities

Documents