image© private hospitals ... · pdf file• as i see it • on the ground •...

June 2009 • Policy Patter

PLUS... • Roxon Finds Religion• Proposed National Safety and Quality Framework• Patients saved from Choking in Silence

• Pharmacy Focus• As I see it • On the ground

Sustainability in Private HospitalsIm

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Australian Private Hospitals

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Chief Executive Officer: Michael Roff Director Policy and Research: Barbara Carney

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APHA NATIONAL COUNCILJohn Amery ................. Mater Health Services N.QldSteve Atkins ............................. Healthe Care AustraliaDr Leon Clark .................. Sydney Adventist HospitalPhilip Currie .................... Sydney Adventist HospitalPeter Freeleagus ... Cura Day Hospitals Group Pty LtdChristine Gee ................... Toowong Private HospitalLeanne Kemp .. Manningham Day Procedure CentreAlan Kinkade ............................... Epworth HealthCareMoira Munro .................................................. Perth ClinicCraig McNally .............................. Ramsay Health Care

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4

Private Hospital - June 2009

46 Michael Ryan - Pharmacy FocusA Pharmacist’s Role in Mental Health Care

5

Regulars

12 Michael Roff - As I see itRoxon Finds Religion

32 Christine Gee - Quality in Focus

38 Barbara Carney - Policy Patter Private Health in the Spotlight in Federal Budget

68 On the groundwith Geoff Adams

Features

16 Health of the Environment Affects Individual Health

18 Sustainable Healthcare in Action

14 Green Hospitals and Our Ailing Economy

64 Alison Choy Flannigan - Legal Matters

40 APHA Private Mental Health Facilities

60 54

28 Standardised Clinical Technology for E-Health

Contents

36 Patients saved from Choking in Silence

08 Chris Rex - Presidents Report

A proposed National Safety & Quality Framework

63 Angela Hook - Member Benefits

27 Electronic and Paperless PBS Prescribing

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Sustainability in Private Hospitals

Environmental concerns are front-of-mind with more media reports coming out daily about the effects of climate change, environmental degradation, water conservation and droughts. Every sector of society is affected by these issues and private hospitals are no different. APHA, on behalf of its’ members, recognises the serious nature of the difficulties facing the Australian and global communities as a result of climate change. What is different is that hospitals –whether private or public – have a core duty to care for their patients first.

This issue of Private Hospital looks at some environmental initiatives in place at a few of our member hospitals and it also looks at examples of best practice of environmental design for hospitals in North America. Private hospitals, like our public counterparts, are unavoidably large users of energy but hospitals around the world are looking at how to reduce their energy consumption and their costs.

Unfortunately there is another environmental issue that faces hospitals, but that no one seems to acknowledge. There is an increasing practice among medical device manufacturers to label such products as single use only. In many cases this re-labelling is not as a result of any particular safety and quality requirements but runs rather to reliability and life of the product (not to mention the increased sales of each device).

An example of such a product is a calf-stimulator which is used extensively in acute private hospitals. APHA has been advised that there is no reason, other than perhaps the manufacturer’s preference, for the product to be labelled single use. In addition to the considerable financial burden on hospitals, this practice of labelling medical devices as single use only is grossly irresponsible from an environmental standpoint. The increased energy and resource usage by the companies concerned as a result of the manufacture of a greater number of such devices and in unnecessarily

higher disposal costs of these devices after a single use are contributing to the environmental problem.

In our own bid to be environmentally friendly, information on this year’s APHA/Baxter Awards for Quality & Excellence can only be found online. Nominations are now open in three categories: Clinical Excellence, Ambulatory Care and Community Involvement. See www.apha.org.au or page 20 in this magazine for more information. Nominations close 30 July 2009 and the award winners will be announced at the Gala Dinner at the 29th Annual APHA National Congress at the Grand Hyatt in Melbourne on the 12th of October. Registrations for the Congress are also open and this year you can register and pay online at www.apha.consec.com.au.

Lisa Ramshaw Editor, Private Hospital

Editor’s Letter

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president’s report... with Chris Rex8

Means Testing the Rebate is Shortsighted

However, we can take heart from the fact that private health insurance is obviously still considered a valuable product by the Australian public as can be determined by the little impact on membership from the MLS changes announced in last year’s budget to date. The telling period however, will be the September quarter when most members will be doing their tax return.

It was interesting to note the tide of opinion pieces in the press, post budget announcement, from those who believe that the public health system is the answer to all our healthcare needs. The reality is, that across the world public health care systems are struggling to cope with the increase in demand for healthcare today - let alone what is ahead. Over the next few decades, we are going to experience an ageing population, the like of which we have not seen before and the impact on our healthcare system will be dramatic. In respect of the ageing baby boomers, there are significantly more of them; they are living longer than ever before, and, as they age, they will require more years of health care services than any other generation. Not only do they have different needs and expectations than past generations, but they’ll be managing more chronic conditions and therefore utilising more health care services. At the same time changing clinical trends mean that more medical services and technologies are available to them. In addition, some population projections undertaken by the ABS on behalf of the Department of Health late last year, show that the Australian population is growing much faster than was predicted just two years earlier. Over the next two decades, the population will increase by 6.9 million, an additional 3.2 million on previous assumptions, thanks to changing birth and migration rates. The bottomline is that healthcare is going to have to be delivered efficiently and effectively. We are just at the beginning of a sustained trend

toward greater hospital utilization. In response, Australia is going to need a viable public and private sector that work together as well as a government that is mindful of the value of the private healthcare sector in reducing the load on the public system.

Selling the benefits of nursing For healthcare institutions the one upside of an economic downturn and rising unemployment is that it may encourage more people to choose nursing as a career option and less to leave nursing for other career paths, given the stability of nursing as a profession. The shortage of nursing is not going to go away and with an ageing population which is estimated to double over the next 20 years, the situation is only going to get worse. All hospitals and governments should be using this opportunity to promote nursing to the wider population as a secure and stable profession which also offers flexibility and the opportunity to work across the globe.

Positive Outcome on Award Modernisation In my last report I wrote about the award modernisation process being undertaken by the ALP and the potential for these changes to negatively impact the private hospital industry to the tune of around $400 million per annum. I am pleased to report a reasonably positive outcome - thanks to representations from the APHA - many of the issues of concern have not been included in the final published awards.

The new awards which will apply to the private hospital industry in Australia from 1 January 2010: • Nurses Occupational Industry Award 2010 • Health Professionals & Support Service

Industry and Occupational Award 2010

There is to be a five year transitional period during which the changes are to be reviewed and in some cases adopted. The Transitional Clause that explains how this process is to work will not be released until mid-year but we

understand it is to address the intent that employees are not to be disadvantaged overall and there are to be no cost increases for employers.

I would like to thank Lucy Fisher and Lynda Hepworth for their hard work in this on behalf of the APHA and its members, in achieving this positive outcome.

Blood Tax This issue remains unresolved however the APHA is continuing to liaise with NSW Health to secure a positive resolution.

Going green This edition of the Private Hospitals magazine focuses on environmental initiatives being undertaken across private hospitals. It is good to see healthcare organizations taking a proactive approach to reducing their environmental footprint and investing in resource efficiency. However, it is important to note that hospitals generally will encounter a degree of conflict in their endeavours to achieve significant energy reduction targets with the obligation of hospitals to meet a raft of existing standards and to ensure we provide safe and quality care for patients. Hospitals have some novel constraints in achieving energy reductions such as tightly regulated acceptable temperatures in operating theatres, the 24/7 nature of our operations and special equipment and lighting requirements for clinical observation. To this end, the APHA made a submission last year to the draft CPRS legislation regarding these constraints.

The government’s decision to means test private health insurance for high income earners from 1 July 2010 is obviously disappointing given the previous assurances given by the Prime Minister and Health Minister that, following the MLS changes of last year, no further changes would be made and that they fully supported the balanced health care system.

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Private Hospital - October 2008

Nurses encouraged to protect themselvesAustralian nurses suffer high rates of injuries that can prevent them from working, and few can afford to take time off work to recuperate. Yet the cost of income protection insurance, which provides a monthly payment if you can’t work, needn’t hit the household budget.

Nurses are encouraged to review the income protection cover offered with their super fund memberships. Insurance premiums come out of HESTA members’ super accounts, rather than their wallets, putting income protection well within reach.

Growing evidence reveals that work-related health problems are an ongoing issue for the nursing community.

Back, neck and foot pain are among nurses’ most common health complaints. Limb and joint pain, repetitive strain injuries, and mental health issues can also prevent nurses from working.

Despite the high instance of injury and illness among healthcare professionals, few nurses have a financial safety net in place. And the default income protection insurance provided through super fund memberships may be insufficient for many people’s needs.

Changing individual commitments, including rent, mortgages, and family responsibilities, mean that nurses may need to review their income protection cover regularly.

HESTA’s online insurance calculator makes reviewing your cover easy. Visit www.hesta.com.au/calculate and enter your details to get an idea of what sort of income you’d want if you couldn’t work, and how much that level of insurance will cost.

For more information and forms to update your cover, download Your HESTA insurance guide from www.hesta.com.au/insure, or free call 1800 813 327.

This information is issued by H.E.S.T. Australia Limited ABN 66 006 818 695 AFSL No. 235249 regarding HESTA Super Fund ABN 64 971 749 321. It is of a general nature. It does not take into account your objectives, financial situation or specific needs so you should look at your own financial position and requirements before making a decision. You may wish to consult an adviser when doing this. Consider our Product Disclosure Statement before making a decision about HESTA – free call 1800 813 327 or visit www.hesta.com.au for a copy.

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as I see it... with Michael Roff

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Roxon Finds Religion

Those of you who attended the APHA National Congress in October last year, would recall the following statement by the Minister for Health and Ageing, the Hon. Nicola Roxon MP, in her presentation to delegates.

“I’ve made quite clear, on the question of public and

private, I am agnostic. If it works, I like it. That has

been my approach to date, and it will remain my

approach.”

Following the changes to the private health

insurance rebate arrangements announced in

the Budget on 12 May, it appears that rather

than remaining “agnostic”, the Minister has found

religion. The bad news for the health system, is

this religion entails a declining role for private

health care into the future.

The new system of rebates, comprising 10

different levels of rebate or surcharge (depending

on income and age), has been forecast to save

the Government $1.9 billion over four years (I will

come back to the Treasury modelling).

In her address to the APHA Congress, the Minister

went on to say;

“In practice, that means that I recognise the necessity

of both a strong public and a strong private sector.

Taking this holistic approach requires a deep

commitment to both public and private health.”

So perhaps using the “holistic approach”

argument, the Government could have justified

the rebate changes on the basis that the savings

would be diverted to the public health system.

The truth is, not one dollar of the $1.9 billion will

get anywhere near a public hospital.

Treasurer Wayne Swan let the cat out of the bag

on 20 May when responding to a question about

whether the Government would put the savings

from the health insurance measure into public

hospitals. He said;

“What we're doing is putting in place an essential

saving to make sure that we can fund sustainably the

age pension over time.”

So the savings are going to fund pension

increases, not to public hospitals.

One argument that has been put forward by the

Government to support the rebate changes is

that people earning $50,000 per annum should

not be forced to subsidise the health insurance of

millionaires. There are two logical inconsistencies

in this argument.

Firstly, this proposition could equally be applied

to public health services. That is, people earning

$50,000 should not be forced to subsidise public

hospitals services for millionaires. Of course, that

is exactly what happens. All taxpayers contribute

to funding public hospital services. And access to

these services is available to all Australians on the

basis of clinical need, regardless of income.

Secondly, the policy principle underpinning

support for private health insurance is the same

as that underpinning government support for

independent schools. That is, the Government

knows that it could not possibly afford to provide

schools and teachers for the entire population.

Therefore, it provides funding to independent

schools to make their services more accessible

(by reducing fees for all students) in recognition

of the fact they take pressure of government

expenditure. The same principle applies to private

health care, only the delivery mechanism for the

support funding is different (although in the days

of the commonwealth bed-day subsidy to private

hospitals, the parallels were more obvious).

Taken to its logical conclusion, the Government

should now be saying that fee reductions in

independent schools should only be available to

those below a particular income threshold (maybe

that will be in the 2010 Budget!).

Of course, we are not supposed to worry about

the rebate changes because Treasury has forecast

that only 22,000 people will drop their health

cover as a result of the changes. This is the same

Treasury modelling that predicted 492,000 would

leave health insurance in the 12 months following

the Government’s changes to the Medicare Levy

Surcharge introduced in October last year.

In fact, since that time, health fund membership

has increased by 110,000. For the Treasury figures

to prove correct, 600,000 people would have to

drop their cover between April and June. Sure,

the inability of Treasury to model health insurance

membership changes meant their predicted

disaster did not happen. But the point is they

were wrong. They were grossly wrong.

And the MLS changes were simple compared to

the complexity of the rebate proposals, which

will introduce 10 different levels of entitlement or

surcharge depending on income level and age.

Does anyone trust the Government to be able

to model this correctly? With the Medicare Levy

Surcharge changes, they got one figure wrong.

With the proposed private health insurance rebate

changes those errors could potentially be 10

times as big.

Another interesting detail buried deep in the

Budget papers is that the Department of Health

and Ageing expects health fund membership to

remain at the current level of 9.7 million into the

foreseeable future. So not only will there be a

slight decline in numbers, but that’s it – no further

growth in health fund membership, not even to

keep pace with population growth.

This means that by 2016, the proportion of

Australians with health insurance will have fallen

from the current level of 44.6% to 39.8%. By

2026, the level will have declined further to

33.7% (assuming of course that Treasury actually

got it right!).

How’s that for “a deep commitment to both public

and private health.”

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Green Hospitals and Our Ailing Economy

There is now mounting evidence that buildings are significant causes of human illness and environmental degradation says Robin Mellon, Green Star Executive Director, Green Building Council of Australia.

The Organisation for Economic Cooperation and Development (OECD) suggests that illnesses – such as asthma and respiratory problems, headaches and allergies - from indoor air pollution are now one of the most acute problems related to building activities around the world.

This is not surprising when we consider that most people spend 90 per cent of their time indoors. Many common materials emit dangerous compounds and harbor infectious moulds, fungi and bacteria, and for those people confined to the indoors due to illness the consequences can be life threatening.

How buildings are designed, and the materials and methods used to construct and operate them, also have significant consequences to the natural environment and health outcomes of people outside of the building envelope. Buildings are responsible for 40 per cent of the world’s greenhouse gas emissions, consume 32 per cent of the world’s resources in construction and generate 40 per cent of the waste sent to landfill.

But now, in the same way that healthcare professionals diagnose a patient’s illness and prescribe treatment, a growing number of building professionals are diagnosing the causes of sick buildings and prescribing strategies to build healthy alternatives.

This move towards green and healthy buildings is consistent with the core value of health care professionals – first, do no harm.

A growing body of research suggests that green health care facilities improve patient outcomes and reduce health risks to staff. Examples include a case study at the Mackenzie Health Sciences Centre in Canada, which found that depressed patients in sunny rooms recovered faster than those in darker rooms. Another study at Bronson Methodist Hospital in Michigan found that applying green design principles such as improved ventilation, private rooms, music, light and nature in its redevelopment project led to a

reduction in secondary infections and lower nurse turnover rates.

Additional benefits to green hospital construction, reported in a study by Robin Guenther, Principal at Perkins + Will in New York and author of Sustainable Healthcare Architecture, included a “consistent, positive correlation between green building, staff recruitment, retention and performance.”

Hospitals are among Australia’s most complex and most energy-intensive facilities – using around 2.5 times the amount of energy, per square metre, as commercial offices. Hospitals spend around 1-3 per cent of a typical operating budget on energy, or an estimated 15 per cent of profits.

With an emphasis on energy and water efficiency, green building practices also reduce operating costs and can have a significant impact on a hospital’s tight bottom line. Green buildings routinely save 20-30 per cent on energy costs, have a superior waste management capability and lower maintenance costs over their lifetime. What’s more, green buildings are flexible and durable spaces that are ‘future proofed’ against changes to government regulation or building standards.

Unsurprisingly, the United States is already leading the green charge into the healthcare space. The US has already rolled out more than 40 million square feet of green healthcare facilities, which represents about 180 healthcare projects so far.

The Boulder Community Foothills Hospital (BCFH) was the first healthcare facility to achieve Leadership in Energy and Environment Design (LEED) certification from the US Green Building Council. LEED is the equivalent of Australia’s Green Star.

BCFH is a 20,624-m², comprehensive 60-bed hospital that includes 24-hour emergency care services, an intensive care unit, as well as surgery, radiology and laboratory

services. Maternity care and paediatrics also are major components of the new facility, and two medical office buildings adjoin the hospital. The hospital opened to the public in September 2003.

The decision to pursue a high standard of green building for the new hospital was in line with a long-term commitment to environmental sustainability. The hospital has an active reduce, recycle, reuse program that has saved more than 17 million litres of water and 2,848,400 kilowatt hours of electricity since 1990. The hospital also provides free bus passes to all its 3,000 employees, has purchased wind power for its facilities and has a full-time environmental coordinator on staff. During May 2001, the BCFH board of directors recommitted itself to a set of environmental principles that include actions to “protect and preserve the environment.”

The new BCFH facility certainly reflects the Board’s commitment. The hospital’s energy efficiency features alone have reduced energy consumption by 30 per cent when

Robin Mellon of the Green Building Council

15


compared with traditional buildings, saving around US$95,000 year. Waste was minimised during the building phase with 62 per cent of construction waste diverted from landfill, and recycled content materials were chosen where possible.

Indoor environment quality (IEQ) was a priority, including formaldehyde-free MDF casework and insulation, low-VOC wood stains, paints and adhesives and a two-week building ‘flush-out’ to ensure the hospital had high IEQ before occupation.

The overall project cost, excluding land costs, was $45.6 million (or $452 per square metre), and the outlay for achieving LEED certification was estimated at 2 per cent of construction costs. With an expected life of 50 to 75 years, the hospital’s 12-year payback for green

features is well and truly worthwhile.

So, greening our hospitals can deliver environmental benefits, improve patient outcomes and boost staff morale. But can greening Australia’s hospitals cure our ailing economy?

A report released last year using the latest CSIRO modelling predicts that more than 251,500 ‘green collar’ jobs will be created in Australia’s property and construction industry by 2025 – that’s 45 per cent of the total number of new jobs, providing new opportunities and employment for many Australians. In fact, by 2025 we can expect most jobs will be varying shades of green.

What’s more, the Australian Conservation Foundation’s Green Gold Rush report has found that, with the right policy settings,

six market sectors – including property and construction - currently valued at $US15.5 billion and employing 112,000 people could grow by 2030 to a value of $243 billion and 847,000 jobs – simply by going green.

As the Chief Executive Officer and Founding Chair of the US Green Building Council of Australia, Rick Fedrizzi, said recently, “smart use of federal economic stimulus funding, by improving the efficiency of our existing building stock as well as our new buildings and communities, will create green jobs that save energy, water and taxpayer money.”

In Australia, our $42 billion economic stimulus package provides a golden opportunity to invest in green infrastructure in our schools, our homes, our offices and, of course, our hospitals.

Boulder Community Foothills Hospital, Boulder, CO, USA © Ed LaCasse, courtesy of Boulder Associates

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Health of the Environment Affects Individual Health

Recognising that the health of the environment directly affects individual health is the theory behind Kaiser Permanente’s most environmentally friendly hospital which was opened to patients and staff in October last year in Modesto, California. The opening of the hospital expanded Kaiser Permanente's health care offerings and features sustainable building design.

Kaiser Permanente's Modesto Medical Center has earned recognition as one of the "greenest" health care facilities in North America. The 670,000-square-foot hospital features energy-reducing materials and advanced green hospital furnishings and fixtures that use fewer toxic chemicals. Other design features, notably liberal use of natural light, promote health. And the hospital opened fully equipped with the electronic health record, KP HealthConnect™, eliminating the need for paper records.

"Modesto Medical Center exemplifies Kaiser Permanente's commitment to environmental stewardship," says Gregory A. Adams, president of Kaiser Foundation Health Plan/Hospitals, Inc., in Northern California. "Building greener hospitals is the right thing to do for our communities, just as it's the right thing for our patients and our employees."

Modesto Medical Center is one of several new hospitals for Kaiser Permanente. The organization is investing close to $24 billion in construction projects through 2014, with 26 major hospital projects planned to be completed across the United States by that date.

"Kaiser Permanente is committed to building health care facilities that are safe for patients, workers and the environment," says Christine Malcolm, Kaiser Permanente's senior vice president, National Facilities Services. "We also are pleased that the choice of green materials and building techniques has helped us to save money."

Top: Modesto Medical Campus, Modesto, California Bottom: Solar panels at Modesto Medical Campus

Opp Page: Farmers market at a Kaiser Permanente facility

Photos: Kaiser Permanente

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Industry-leading green features at Modesto Medical Center include:

• Permeable pavement that covers much of the parking area allows rain to filter into the ground, recharging groundwater levels and filtering chemicals from runoff. This is the largest installation of permeable pavement in the western half of the United States.

• Solar panels on top of the attached medical clinic that shield the rooftop mechanical equipment from view and generate 50 kilowatts of electricity – enough to power up to 20 homes. Parking lot lighting also is solar powered.

• Reflective or "cool" roofing that saves energy and money because the light color deflects heat from the sun.

• Air supply that is kept fresher because it is drawn solely from outside air, and because the facility uses materials that don't give off harmful fumes.

• Paint and upholstery that is low in volatile organic compounds, which have been connected to numerous health problems including cancer.

• Natural light, incorporated into the hospital design, which reduces the need for artificial light, thus saving energy.

• Rubber flooring that replaces vinyl in much of the building. Rubber is preferable to vinyl because it does not leach toxins, nor does it need to be waxed or stripped with harsh chemicals. Rubber flooring also

provides better traction (fewer slips and falls), generates less noise, and offers more cushioning underfoot for patients and staff.

• Carpeting throughout the hospital that is free of potentially harmful PVC (polyvinyl chloride) and is backed with recycled safety film from car windshields. Kaiser Permanente worked with the carpet's manufacturer, C & A Carpet (Tandus), to create the product, the first of its kind in the industry. Tandus now markets the carpet to other hospitals.

Kaiser Permanente is a leader in the environmental health care provider stakes. They recently won a System for Change Award, for their leadership in improving environmental performance in the health care sector. The award was announced at CleanMed 2009, a global conference for environmental leaders in health care. The award, which recognises health systems that have worked to gather environmental data, set goals and encourage eco-friendly practices, reflects their long-standing commitment to protecting the environment.

"Kaiser Permanente recognizes the health of the environment directly affects individual health”, commented Raymond Baxter, senior Vice President, Community Benefit, Research and Health Policy. “We are constantly working to reduce our collective impact on the environment and improve the health of the communities we serve."

As a global leader in sustainability, they build greener facilities, buy non-toxic materials when

feasible, and support sustainable agriculture. For example, the organization is working with suppliers to minimize the use of polyvinyl chloride in its operations and services. Recently, they made the decision to purchase patient controlled analgesic pump sets and patient identification bracelets that are completely free of PVC, which is a major source of dioxin, a known human carcinogen.

Their Community Health Initiatives also support the communities in which they work. Their approach emphasises public health interventions, policy change, organisational practices and the community conditions that influence health. Through programs like the ‘Healthy Eating Active Living’ program which is a strategy to address the obesity epidemic to their farmers markets at their facilities and working directly with local farmers to bring fresh, healthy food from nearby farms to hospital kitchens. Patients not only get excellent medical care, they also get fresh, healthy food that helps them get better.

PHAQ Hosts Two Important Conferences in June The Private Hospitals Association of Queensland will host two conferences on 25 and 26 June at the Australian Catholic University – Brisbane Campus in Banyo.

The first, Quality and Safety in Action will be held on 25 June and will cover a broad cross section of topical Quality and Safety issues and initiatives. The Quality and Safety in Action conference will look at effective management of lower level adverse events, national initiatives in quality and safety, the VTE-NICS project in the private sector, infection control resources, clinical handover framework and a chance for participants to get their medico-legal questions addressed. Presenters will include Prof. Chris Baggoley, CEO of the Australian Commission on Safety and Quality in Health Care, Shane Evans, Partner, Minter Ellison Lawyers and a number of practitioners from private hospitals.

On the 26th of June the 6th Innovative Practice in the Private Sector Conference will showcase innovations in the private hospital sector

which have demonstrated outcomes in the areas of Clinical and Non-Clinical Operations and initiatives in Education and HR management. Innovative practice though evident throughout the private hospital sector is often not publicly recognised or rewarded. With this in mind, PHAQ and HESTA Super Fund have established an annual award for private hospitals and day hospital facilities – The Innovative Practice in the Private Sector Award which is now in its 6th year. Case studies will be presented by a number of practitioners from around Australia. To enable the industry to participate in the selection process for this prestigious award, at the close of the final session, all registered delegates will select their top two candidates in order of preference and the winners will be announced prior to the conclusion of proceedings.

Both days will run from 8.00am to 5.00pm. For more information or to register, see www.phaq.org.

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Sustainable Healthcare in Action

St Andrews Hospital, an independent not for profit private hospital in Adelaide, is an outstanding example of a sustainable healthcare facility. St Andrew’s hospital has been providing medical care and facilities of the highest calibre since 1936. In keeping with its reputation as a centre of excellence, St Andrew’s has the latest medical facilities including seven Operating Theatres, Critical Care Unit and Emergency Service. These services are supported by a comprehensive range of Facilities such as Medical Imaging, Radiotherapy and Pathology on site.

St Andrew’s is accredited by The Australian Council on Healthcare Standards for demonstrating a sustainable commitment to quality and safety. This accreditation is a formal recognition of the hospital’s high level of care and desire to continually improve quality, safety and service for its patients.

One of the hospital’s key objectives is to demonstrate a commitment to environmental sustainability. It has taken steps to encourage the adoption of resource conservation and pollution prevention principles and effective environmental management systems, without compromising patient safety and care.

The “Natural” Choice The journey of implementing sustainable practices in the hospital began with the choice of the generator set. Concerns about air quality and about the cost associated with burning fossil fuels were major considerations in the decision process to favour cleaner burning gas engines. The Caterpillar Gas Generator Set was the “Natural” choice because of its dependability, efficiency and versatility.

Advanced combustion technologies allow Cat Gas Engines to deliver consistently lower emissions. Instead of just relying on exhaust after-treatments, Caterpillar engineers have tailored combustion chamber design, combined with electronic controls and managed ignition timing, to control emissions at their source, during combustion, where they can be controlled

most effectively and reliably. Through precise control of ignition timing as well as fuel-to-air mixtures, Cat Gas Engines not only meet but beat most air quality standards anywhere in the world. And they do it with significantly improved fuel economy.

Co-generation Improving energy efficiency is the best way to meet energy demands without adding to air and water pollution. The next sustainability element that St Andrew’s Hospital has adopted was to implement a co-generation system to work in conjunction with the Caterpillar Gas Generator Set.

Co-generation has obvious environmental and economic benefits, delivering higher resource efficiency and fewer air pollutants per unit of fuel than separate power generation and heating systems.

The Caterpillar 3500 Gas Generator Set rated at 505 kW supplies 80% of the hospital’s electrical power while the other 20% comes from the utility grid. The co-generation plant supplies 95% of the hospital’s hot water and steam that is used for heating and sterilization. Hot water is produced using the engine jacket water and a recovery boiler to generate steam. Through co-generation, the facility’s energy needs are effectively met with an overall thermal efficiency of about 80%.

A Cost Effective Option The co-generation plant in St Andrew’s Hospital operates 24 hours per day, 365 days per year and is utilized 95% of the time. This is the most optimal operating condition for a co-generation plant to be cost effective.

On average, about 2-3% of a health care facility’s overall operating budget is attributed to energy costs. Addressing the costs of energy may represent the largest potential for direct and indirect environment-related savings for the Hospital. Direct savings are related to savings in fuel purchases and can be expected to increase as fuel prices increase. The indirect savings result from reduced air pollution and global warming – and thus reductions in their associated health impacts.

Partners In Energy Efficiency In order to make co-generation a cost effective option, the power plant has to be well maintained. To this end, St Andrew’s Hospital has the assistance of a long-time partner, (APA), previously Origin Energy Asset Management (OEAM). The partnership started in1994 when OEAM, then the South Australian Gas Company built, operated and maintained the co-generation plant. APA still maintains the entire plant and performs all of the scheduled maintenance. St Andrew’s Hospital, APA and Caterpillar are indeed partners in energy efficiency.

Energy Watch At the end of 2008 a night time energy expenditure survey was conducted throughout all departments in the Hospital. It uncovered a number of key

Environmental Sustainability

19


areas where energy saving could be addressed. An action plan has since been developed, supported by after hours security personnel to oversee all areas of the hospital after dark and at weekends so that unnecessary appliances may be turned off when not in use.

Waste Management Apart from the specific strategy of incorporating the engineering specific co- generation system into the hospital’s energy consumption management, St Andrew’s has an active program in the area of Waste Management.

In conjunction with our waste management contractor St Andrew’s has embarked on a waste management program that actively pursues recycling waste streams such as: • Paper

• Card board

• Glass

• Plastic (including kimguard)

• Metal

Plastic recycling has been running for three years - very successfully until the beginning of 2009 when a directive was received to restrict the recycling products to outer coverings only.

The reasons being that of the high PVC content within some of our recycling products - used syringes, intravenous burettes, IV giving sets and plastic bottles to name but a few. These products when melted down caused the recycling mix to become brittle and the products fractured easily in the manufacturing process - when the PVC was removed the problems were resolved. This has caused some considerable disappointment to the hospitals many passionate recyclers.

A significant recycling culture within the organisation has been discovered since the program commenced – we have indeed recognised the need to nurture this resource by converting it into environmental and financial gain.

Long term recycling planning in the Operating Theatre Suite is also making headway for a recycling program later in 2009. When the capital building program has been completed - it is estimated that this department alone will produce 60% of the entire hospital’s plastic recycling outlay.

A very successful Printer Cartridge recycling project was initiated in 2007. The cartridges are re-used thus minimising both landfill and re-manufacturing energy use and costs. The funds raised from the proceeds of the cartridges are used to provide individual learning programs for deaf children who through losing their sense of hearing have been helped to overcome the negative impacts of their ability to learn.

Paper and cardboard is also being recycled successfully.

Food recycling has been investigated and planning is underway to generate a food recycling stream as soon as current operations are finalised.

The statistics of the volume per stream of waste are collated against the occupied bed days and used to benchmark with other hospitals in the nation.

St Andrew’s Hospital CEO Stephen Walker said the take up from staff to support our environmental commitment has been fantastic.

Parts of this article have been reprinted with permission from Electric Power News 2004


Association

Recognising outstanding achievements in Australian Private Hospitals

Download the Application Brochure fromwww.apha.org.au

Clinical Excellence – quality of care & patient outcomes

Ambulatory Care – acute, day surgery, psychiatric or rehabilitation

Community Award – recognising work with and in your local community

> ENTER NOW! Submissions close 30 July 2008.

> Winners announced at the Gala Dinner on the night of 12 October 2009 at the 29th Annual APHA National Congress at the Grand Hyatt in Melbourne.

> For Submission Criteria contact APHA Member Services Manager, Angela Hook, on 02 6273 9000 or [email protected].

> Visit www.apha.org.au.

Celebrate your achievements!Identify your hospital as a leader!Boost team spirit!

SPONSORED BY BAXTER HEALTHCARE

2009APHA / Baxter Awards for Quality & ExcellenceThe Baxters

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St George Private Hospital Has Gone Green

With the ever increasing concerns of global warming, St George Private Hospital continues to embrace their “Going Green” commitment to help reduce the Hospital’s carbon footprint.

After establishing its water savings plan in 2006, in conjunction with Sydney Water’s own “Every Drop Count’s” program, the Hospital continues to strive for further improvements to be water wise, energy efficient and consumer conscious.

One such exciting project has been the Hospital’s decision to replace its aging sterilising system, which will result in a staggering saving of water equivalent to approximately 30 swimming pools every month! Other initiatives, to help maximise “green” efficiencies have included the removal of inpatient room fridges, rationalising waste and improving recycling opportunities.

A collaborative approach has been adopted by the Hospital working with “Blue Sky Green”, specialist consultants appointed by the Department of Environment & Climate Change (DECC). This partnership has ensured the systematic review of all “green” opportunities and prioritising those with the greatest and most cost effective impact for St George Private.

An enthusiastic “Going Green” Team launched a comprehensive staff engagement program on Friday 5th June which coincided with World Environment Day. Many activities aimed at highlighting to the Hospital’s staff how they can make a difference to the environment were undertaken. In addition, the Hospital will be

donating to an African village’s water program as part of Oxfam’s “Unwrapped” gift initiative. The Program will provide training and education opportunities for all the Hospital’s staff encouraging them to encompass the green message in both their work life and their home lives too, helping St George Private Hospital to continue its role as a conscientious leader of environmental change in the health care industry.

For further information on the Hospital’s “Going Green” initiatives, contact Steve Brindley on 9598 5439. For further information on DECC’s Sustainability Efficiency Program, visit the website www.decc.nsw.gov.au

Environmental Initiatives

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Recycling Kimguard is the Way to Go

Ramsay Health Care is committed to “Going Green” as part of their annual plan. At North Shore Private the Environmental Focus Group is responsible for waste management and this group identified the need for recycling Kimguard used in the Operating Theatres. North Shore Private Hospital Operating Theatre commenced Kimguard recycling in August 2008.

The theatre complex includes eight operating theatres specializing in Cardiothoracic, Orthopaedic, Neurosurgery, Urology, Obstetrics & Gynaecology, Vascular, Plastics and General Surgery. The instrument trays, bowls, prep sets, and jugs are wrapped in double layer Kimguard and all this wrapping material was disposed into the general waste.

The North Shore Private staff was provided an overview on Kimguard recycling by their waste company representative. They were shown a number of products made from recycled Kimguard, examples included bowls, and children’s play tables and chairs. Education was also provided by the waste management representative on how to segregate Kimguard

from other waste effectively and efficiently.

Initially only four theatres commenced the trial in order to gauge compliance of staff recycling of Kimguard. However, within a couple of days it became evident everyone was very enthusiastic and wanted to recycle Kimguard from all 8 theatres.

Red 240 litre bins were placed in scrub bays outside each theatre participating in the trial and the Nursing Staff were trained to place all the Kimguard in the bins before the first count, and any trays opened after that initial count to store the Kimguard in the theatre until after the Final Count.

Theatre orderlies collected these bins which

are transported to the waste collection area for bailing. The bailing machine compacts the Kimguard into easily stacked bails ready to be collected by the contractor for weighing off site.

Outcome Currently 95% of Kimguard used is recycled in the operating theatre which is 850kg per month. The hospital receives credit from the contractor for the Kimguard recycled. Recycling has now commenced in the CSSD and Delivery Suite.

The key to our success is the enthusiasm from all the staff having a keen sense of responsibility for the environment.

By Linda Brown CNS Theatres (Operating Theatre Environmental Focus Group Representative)


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Environmental Stewardship in Action at St John of God Health Care

The organisation’s Our Vision document reinforces its environmental focus in the statement: “St John of God Health Care will demonstrate ecological concern and respect for the earth”. Across the group, there is a strong commitment to environmental stewardship, a philosophy summed up by the recently launched environmental logo.

St John of God Health Care’s environmental management network was established in 2005 – although initiatives had been progressing across the group since 1999 – to develop a master plan for programs to reduce waste, water, energy and greenhouse emissions, and to ensure compliance with the raft of emerging environmental legislation.

In 2007, the organisation’s highly innovative Environmental Capital Expenditure Fund was born. The delayed “returns” of this nature of capital expenditure do not lend themselves well to the usual capital expenditure criteria, hence the need for a dedicated fund.

This financial year alone, St John of God Health Care projects annual savings from the funded projects of 15 million litres of water and a reduction in greenhouse gas emissions associated with electricity and gas of almost 2,800 tonnes - the equivalent of taking 500 cars off the road, and according to Group Manager Safety, Health and Environment, Melody Stanton, across the organisation everything possible is being done – big and small, from worm farms to water saving – to protect the environment.

Current funded projects and projected annual savings include: • Upgrade of chillers at St John of God

Hospital Murdoch saving 500,000 kilowatts of electricity.

• Installation of energy efficient lighting and sensor lights at several sites saving 160,700 kilowatts of electricity.

• Hydrotherapy pool UV system at St John of God Hospital Bendigo saving almost

1 million litres of water.

• Water recycling system at St John of God Hospital Ballarat saving 5 million litres of water.

• Installation of a water recovery system to capture backwash from sand filters for use irrigating gardens and grounds saving 8 million litres of water at St John of God Hospital Subiaco.

• Purchase of hybrid vehicles for St John of God Pathology reducing carbon emissions by 8 tonnes.

The Environmental Capital Expenditure Fund has its sights set on introducing organisation-wide initiatives including flow regulators for taps and showers with projected water savings in the order of 53 million litres annually – enough to fill 53 Olympic size swimming pools.

Group Environmental Advisor, Kylee Carpenter, said: “Hospitals are 24/7 operations and need clean and even sterile environments and so are traditionally energy and water intensive. Given the energy and water issues we are facing in Australia, we need to do all we can to reduce our use.”

St John of God Health Care is reducing exposure to the risk of the increasing cost of utilities by planning now for the future. In an increasingly strategic approach to reducing its environmental footprint, St John of God Health Care’s future funding will be allocated based on water and energy audits of each facility.

The organisation will be required to report under the new National Greenhouse and Energy Reporting Act and is investigating systems to monitor and manage energy and water use.

The development of an Environmental Management System modelled on the ISO 14001 standard sees the organisation instituting policies, procedures, programs and training to ensure environmental risks are well managed.

“We may aim for ISO accreditation in the future, which will see us setting yet another benchmark as very few health care organisations worldwide have gone down this road,” added Ms Carpenter.

Commenting on the perceptible shift in attitudes towards environmental stewardship in the health care industry – of which St John of God Health Care is at the forefront – Ms Stanton said: “We saw it happen with safety and health a number of years ago where there was a fundamental shift towards a safety culture; now we are seeing the same transition towards environmental management in health care.”

To nurture a culture of sustainability St John of God Health Care has adopted ongoing reporting of environmental key performance indicators, benchmarking and training. It has formed many community partnerships and takes part in external programs such as Travel Smart. Developing direction around sustainable design in redevelopment and environmentally preferable purchasing are on the radar.

Group Chief Executive Officer Dr Michael Stanford said: “St John of God Health Care has vigorously and enthusiastically taken on the task of ensuring that as well as striving for excellence in providing quality health care, we also strive for excellence in protecting our environment. Both result in beneficial health outcomes.”

St John of God Health Care’s journey towards an environmentally sustainable future has been both timely and innovative within the health care industry. Its Environmental Capital Expenditure Fund has already committed $1.5 million to fund 37 capital projects to reduce energy, water and waste and which all have a long-term sustainability benefit, with more funding and initiatives on the way.


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Subiaco Wins Awards

In 2002, St John of God Hospital Subiaco launched a now highly commended environmental action strategy and appointed a dedicated environmental officer. The success of Subiaco’s environmental program is evident in the environmental awards and finalist places it has garnered, including winning the WA Environment Awards, twice being a finalist in the prestigious Banksia Awards, and winning the Greenhouse Challenge Plus Business Leadership Award.

The business leadership award also recognised the influence the hospital has had on environmental stewardship in the health industry. Having hosted and organised two Environmental Management in Health Care’ conferences in 2003 and 2005, the hospital has been a driving force in providing information on how to operate a sound environmental management system in the health care industry

Nepean’s waterwise garden

When the Rotary Club of Frankston Sunrise offered to build a Therapeutic Garden for the patients at St John of God Nepean Rehabilitation Hospital a water-wise theme was adopted.

Rain water tanks were installed to feed the drought-resistant plants via an efficient drip irrigation system. The garden is thriving, the patients love it – and similar environmentally sustainable systems are being considered for other garden areas.

Other initiatives the hospital has adopted in the past year include the installation of sensor lights and water-saving shower head, and “greener” cleaning procedures and products, including a low water floor mop. It joined Green Fleet to reduce emissions from its cars; uses recycled paper wherever possible; and recycles printer cartridges.

Nepean’s waterwise garden carefully tended by Greg Jenkinson

Murdoch leads the way

St John of God’s environmental journey began in 1999, when St John of God Hospital Murdoch established its environmental action committee. The hospital has since created a comprehensive environmental action plan and created a managerial level environmental position in recognition of the expanded scope and complexity of the hospital's environmental program, and testament to 100% leadership commitment.

Murdoch has over 1200 staff actively involved in identifying ways to further reduce emissions, who are also putting some initiatives into practice in their everyday lives; thus, multiplying the environmental benefits. Extensive recycling, and many other smaller initiatives, keep the environment very much top of mind at Murdoch.

In the past 12 months, thanks to the group-wide Environmental Capital Expenditure Fund, the hospital has completed three significant upgrades:

• Digital controls in the air handling system automatically and precisely adjusts energy use in response to actual air handling needs rather than preset parameters – likely to reduce greenhouse gas emissions by 2.93%, equivalent to 344 tonnes per year

• Energy Manager software monitors and reports actual energy usage at departmental level, and initiates control measures in times of peak electricity demand – expected to reduce greenhouse gas emissions by 166 tonnes per year.

• Flow restricting devices to showers and hand basin taps limit water usage – likely to save 1573.8 kilolitres of water each year.

Murdoch’s extensive recycling pays off – pictured are Manager Environmental sustainability Nerolie Nikolic (front), with Patient Care Assistant Maureen Raats

Mae Dominguez, St John of God Hospital Subiaco Environmental Officer, receives Greenhouse Challenge Plus Business Leadership Award award from then Environment Minister, Malcom Turnbull


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Victoria’s Epworth Eastern – First to Trial Electronic and Paperless PBS Prescribing

Epworth Eastern, in Box Hill, Melbourne, and part of the Epworth HealthCare group, was the first hospital in Australia to introduce electronic prescribing when the hospital opened in 2005. From that time, nurses could administer previously-prepared medications after referring to the electronic medication chart via laptops that were wheeled to patients’ bedsides. But until this trial began, doctors still needed to print and sign the medication chart before the pharmacist could prepare the medication.

Medication charts (which act as PBS prescriptions at Epworth Eastern) are generated electronically on the hospital ward or in the doctor’s consulting room using MedChart software. Once prescribed, the medication orders become immediately available on a screen in the hospital’s pharmacy, which is managed by Slade Pharmacy.

Epworth Eastern’s Executive Director Vincent Borg said the trial is based on normal prescribing workflow, but it is simpler and much quicker.

“Every day at Epworth Eastern, we have a more than 230 patients who potentially need prescription medications dispensed to them in a timely manner,” he said.

“Because doctors are able to access MedChart remotely, they can now safely prescribe at any time, not just when they are at the hospital.”

"The benefits are three-fold. A complete and legible order is available to the pharmacy as soon as it is

created; the pharmacists have access to accurate and up-to-date patient medication profiles; and nurses can administer medications from an easy to follow medication chart.

DoHA and Medicare Australia are continuing to refine and develop business rules for the broader implementation of paperless PBS prescribing. For the purposes of this trial, which is taking place at a Northern Territory Aged Care facility at the same time as Epworth Eastern, a computer record is

deemed sufficient copy for Medicare Australia's audit purposes.

The MedChart program for signatureless prescriptions was originally developed by HATRIX, a privately-owned Australian software company based in Canberra which has recently been acquired by Australian, publicly-listed, health software company iSOFT Gp Ltd.

By Colleen Coghlan, Media Manager Epworth HealthCare

In June last year, Epworth Eastern became the first hospital in Australia to trial paperless PBS prescribing following approval from the Federal Department Health and Ageing (DoHA) and Medicare Australia. The decision means the requirement to hand sign a printout of the electronic medication chart before that medication could be prepared by the pharmacy was removed. Instead the doctor’s ‘electronic signature’ is accepted as authorisation to supply the medication.


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Standardised Clinical Terminology: a Key Foundation for Recalling and Making Sense of Clinical Data for Better Health Outcomes

Currently there is no large-scale electronic health record (EHR) system in Australia, despite a number of trials and considerable research and development in building such systems. However there is recognition, in Australia and around the world, that electronic health and medical records will become an essential part of the delivery of high quality, safe, and efficient health services to the community. A vital aspect of this is ensuring that the record contains good, accurate information and that this information be understood when shared amongst healthcare providers.

To address this issue, many countries including Australia, Canada, Singapore, the United Kingdom, the U.S.A., Denmark, Sweden, and New Zealand have turned to SNOMED CT (Systematized Nomenclature of Medicine-Clinical Terms) to fill the role of a standard set of codes and terms to be used in the health record. To quote the National E-Health Transition Authority’s (NEHTA) website:

“One prerequisite to the safe exchange of clinical information between healthcare providers is establishing a common, coded clinical language or clinical terminology. The concepts and descriptions (or terms) used in clinical communications that describe diagnoses, procedures, therapies, medications, and so on must be accurately and consistently interpreted by all health IT systems and the clinicians that use

them.

SNOMED Clinical Terms® (SNOMED CT), the internationally pre-eminent clinical terminology, has been identified as the preferred national terminology for Australia.”

Benefits of adoption The recent Journal of the American Medical Informatics Association (JAMIA) paper Structured

Register online now!www.apha.consec.com.au

Early Bird Registration – Available until 21 July 2009Keynote Speakers – Include Bernard SaltHot Topics – E-health & Technology Session, Safety & Quality Session, Political Sessions, Customer Service & Stakeholder SessionTrade Expo – See the industry’s latest advances

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Product Labeling Improves Detection of Drug-intolerance Issues by G. Schadow provides a concrete example of the benefits of capturing clinical data using terminologies containing detailed structural information. The results of the study of involving records for more than 50,000 patients from the Indiana Network for Patient Care indicate that use of structured product labeling (roughly equivalent to the content in the Australian Medicines Terminology) resulted in detection of four times as many drug-intolerance issues on twice as many patients.

Another concrete example comes from work at the AEHRC on automated generation of an accurate cancer stage from histo-pathology reports, and to use this information to help improve cancer management, both for individual patients and at a population-level. The initial work was based on machine learning algorithms and gave very good results. However it was specific to lung cancers and difficult to generalise to other cancers, which have different staging guidelines. Preliminary results based on an alternative rules-based approach that exploits the clinical knowledge embedded in SNOMED suggest that more accurate results can be achieved and the approach is much more easily generalised to other cancers. This work indicates that processing of free-text or unstructured data can also benefit from the investment in SNOMED CT.

Barriers to adoption Naturally there is a large gap between identifying a standard and subsequently having that standard adopted. For SNOMED this is a particularly difficult problem because there is a great deal of technical depth and complexity associated with its use and a dearth of expertise and tools to support its use.

SNOMED is vast: it contains more than 311,000 active concepts organized into eighteen hierarchies, with unique meanings captured in over 1,360,000 links or semantic relationships, and a formal logic-based semantics. This breadth and detail provides a terrific foundation for assisting semantic interoperability when health records are exchanged and for providing computer assisted decision support. However, it presents a problem for the initial capture of information for the health record; nobody wants to select from a pick-list of 300,000 items or to have to perform a search and wade through the results list, filtering out, for example, elements of animal anatomy or non-human disorders.

There is also a problem with coverage; the content of SNOMED is patchy and of varying degrees of accuracy and completeness. One example of this is in the area of medicines, where, to fill the gap, NEHTA has invested greatly in producing the Australian Medicines Terminology containing over 70,000 new concepts for representing drugs, their constituent compounds and related packaging and dose forms. However, medicines is just one domain and there are many smaller specialist domains that are also not well served by the current SNOMED content. An example of this is the specialist area Skeletal Dysplasia, where there are both many missing concepts and out-of-date relationships for some of those concepts that are present.

New technology In an effort to address various barriers to adoption, researchers at the Australian E-Health Research Centre (AEHRC), a joint venture between CSIRO and the Queensland State Government, have been working on advanced software tools to both aid in the ongoing development of SNOMED CT and to foster its adoption and use in the Australian Healthcare sector.

The first outcome of this work is a software component, Snorocket™, which has been acquired by the IHTSDO for use in its Workbench tools to develop, maintain, and facilitate the use of SNOMED CT in health systems around the world. Snorocket’s key feature is speed – it is able to compute all the relationships in SNOMED in around one minute, ten to thirty times faster than the previously used software. Additionally, it can compute the consequences of changes to SNOMED in seconds. These features completely change the way maintainers of the terminology work since they can see the consequences of changes almost immediately, impacting both productivity and quality.

Following this, the Snapper Platform is a suite of tools being developed at the AEHRC to address these issues of SNOMED adoption. The Reverse Mapping component is used to create an extension of SNOMED based on set of terms from an existing terminology. It allows the creation of new concepts along with the definition of relationships between these concepts and core SNOMED concepts. The goal of the tool is to provide a simple and accessible path to getting started while providing information and functionality that enables gradual learning of the necessary elements of how SNOMED works. It does this by employing a direct-manipulation style user interface, full-text incremental searching of SNOMED terms, interactive graphical

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browsing of the SNOMED concept hierarchy, and a constraint checker for assessing conformance to the SNOMED content and editorial guidelines. Naturally, the Snorocket™ technology is used to underpin some of this functionality.

Using the technology It is unrealistic to expect that gaps in SNOMED content will or can be fixed in the short or medium term by the core bodies like NEHTA or the IHTSDO; there are just too many sub-areas, too much clinical expertise required, and not enough resources. There are, however, many existing clinical terminologies, either those associated with a particular specialty, or bespoke and ad-hoc terminologies created for a specific use or system. Hence a way forward is for specialists or specialist communities to build their own extension of SNOMED and then submit this content for inclusion in the core standard. While the development of such extensions currently requires sophisticated understanding of the conceptual details and inner workings of SNOMED itself, this is exactly the problem that the Snapper Platform is designed to mitigate.

While enhancing SNOMED is a useful goal in its own right, there is an additional more immediate benefit to building these extensions; they enable existing data sets that were collected using the existing terminology to be enhanced with SNOMED content enabling it to be queried and processed almost as if it were originally collected using SNOMED concepts. An immediate benefit of this is a simplification of the data integration problem when combining datasets from different sources.

Deploying SNOMED CT

Earlier we mentioned some problems associated with capturing the initial SNOMED-based content. The concept of an interface terminology is designed to address this issue; an interface terminology identifies a subset of a reference terminology, in this case, SNOMED CT, suitable for use in a specific context. When constructing an interface terminology, alternate navigation structures based on, for example, frequency of use or partonomy (i.e., a part-of relationship or anatomical structure) may be specified as well as

alternate preferred terms for concepts. In SNOMED parlance, these are known as Reference Sets or RefSets and it is vital for any software intended to be used for capture of clinical information to be able to support Reference Sets in order to ensure the quality and usefulness of the information captured. Unfortunately, there is a lack of widely available tooling for creation of these Reference Sets and building alternative navigation structures may require creation of new navigation concepts which in turn requires allocation of an extension namespace (a range of specific codes) from NEHTA even though such codes are never intended for use in the clinical record.

The Snapper RefSet Generator component uses the same search and navigation functionality to enable the construction of interface terminologies as described above. The Reference Set can be based on just the core SNOMED concepts, or on those from a SNOMED extension.

By Michael Lawley, Principal Research Scientist, Australian E-Health Research Centre, CSIRO

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quality in focus... with Christine Gee

A Proposed National Safety and Quality Framework

This highly commendable document will form the basis of a broad consultation aptly titled the Quality Health Care Conversation that was launched by the Commission on 1 June. Whilst the proposed framework was developed in consultation with consumers, clinicians, and health service managers, the Quality Health Care Conversation aims to engage with a wide audience encompassing patients, consumers, carers and support people, clinicians and health professionals, heath care providers and funders, health service managers, policy makers and researchers and seek feedback on the directions established in the proposed

National Safety and Quality Framework. The Commission will then use this feedback to prioritise the strategies listed in the discussion paper and to make recommendations for future action to improve the safety and quality of health care in Australia. .

The framework is designed to guide action to improve the safety and quality of the care provided in all health care settings over the next decade.

I believe this proposed framework provides a robust foundation on which to base a truly sustainable culture of safety and quality

within our healthcare system and to that end encourage you all to accept the Commission’s invitation to take part and have your say in this important conversation.

The Commission is keen to hear views from all health care stakeholders on the proposed framework and the possible strategies listed in the Discussion Paper on achieving the directions established in the proposed National and Safety Quality Framework.

Joining the Quality Health Care Conversation is easy, simply log on to the dedicated website at www.qualityhealthcareconversation.org.au.

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In keeping with the “sustainability” theme and flavour of this issue of Private Hospital, I am excited to present the Australian Commission on Safety and Quality in Health Care’s (ACSQHC) ‘Proposed National Safety and Quality Framework’.


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New Indicators Will Help Drive Quality Improvement in the NHS

The Indicators for Quality Improvement will help measure the quality of care clinicians deliver, highlight areas for improvement and track the changes they implement. They span the three dimensions of high quality care: patient safety, effectiveness of care and patient experience.

Clinicians can choose from the list the indicators that are most relevant to their work. The indicators are a key outcome from Lord Darzi's report 'High Quality Care for All in which he noted that high performing teams already measure the quality of care they deliver and benchmark their work against their peers.

Health Minister, Lord Darzi said: "These quality indicators have been developed in partnership with frontline staff. This initial list is just the start of a NHS wide resource that will challenge and stimulate NHS staff to drive up the quality of care they deliver to patients."

At this stage, the aim is to enable clinicians to fully understand the indicators, their methodology and source. Within the next few months, we will publish data that will enable local clinical teams to compare themselves with others as the basis for local quality improvement.

Over the next three to five years the list will be further developed to improve depth of coverage across all care pathways and quality dimensions.

The Indicators for Quality Improvement are on The NHS Information Centre Website http://www.ic.nhs.uk/mqi . Each of the 232 indicators has gone through an initial selection process to make sure it is suitable. This process was sponsored by five Royal Colleges and the British Cardiovascular Society, and canvassed the views of frontline staff from across the NHS.

The process used to develop this initial list of clinical indicators included: • An online survey to gather feedback on more

than 400 acute care indicators already in use in parts of the NHS

• NHS-led work to develop regional indicators for the ten year plans for improving the quality of care described in each SHA's local vision document

• Engagement with royal colleges and other professional bodies

The Royal Colleges that sponsored the survey of acute care indicators and continue to play a role in the development of Indicators for Quality Improvement are: • Royal College of Surgeons • Royal College of Physicians • Royal College of Anaesthetists • Royal College of Obstetricians and

Gynaecologists • Royal College Psychiatrists

A list of more than 200 indicators of high quality care in the NHS is being published for the first time to help clinicians drive up the quality of care they deliver to patients, the UK Department of Health and The NHS Information Centre announced in May.

Antiviral Guidelines and Rapid Tests for Diagnosing Influenza - Available on NPS WebsiteHealth professionals are urged to follow guidelines issued by the Department of Health and Ageing when prescribing antivirals for the treatment of swine influenza (H1N1).

The National Prescribing Service Ltd (NPS) have made these guidelines available on its website, along with links to information from the US Center for Disease Control, World Health Organisation and other industry organisations.

Current recommendations for the treatment of swine influenza using oseltamivir (Tamiflu®) or zanamivir (Relenza®) are only in the event of: • Close contacts of confirmed or probable cases, in consultation with the local

Public Health Unit, within 48 hours of contact

• Suspected cases, in consultation with the local Public Health Unit, if started within 48 hours of onset of symptoms, until influenza A is excluded or an alternative diagnosis is made.

There is no current recommendation for oseltamivir to be used as prevention by travellers visiting affected countries.

These recommendations are in line with those issued by the US Centers for Disease Control (CDC), which can be accessed at www.cdc.gov/swineflu/

recommendations.htm.

An article ‘Rapid tests for the diagnosis of influenza’ from the June edition of Australian Prescriber can also be accessed via the NPS website.

The article, written by Microbiology Registrar Hong Foo and Clinical Professor of Medicine, Dominic Dwyer, from the Centre for Infectious Diseases and Microbiology, Westmead Hospital, Sydney, outlines rapid influenza tests based on viral antigen detection with point-of-care tests and immunofluorescence, how they work and their limitations.

It is not expected that the Australian seasonal influenza vaccine will provide protection against this new strain of influenza virus. However, people over 65 and other vulnerable groups should still be encouraged to be vaccinated as this will provide protection against seasonal influenza.

Community pharmacists can access more detailed information through The Pharmacy Guild of Australia (http://www.guild.org.au/) and Pharmaceutical Society of Australia (http://www.psa.org.au) websites.

Doctors and other prescribers can access further information through the AMA (www.ama.com.au) and RACGP (www.racgp.org.au) websites.

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Patients Saved from Choking in Silence

Thousands of Australians suffer from swallowing disorders – and the most concerning effect “silent aspiration” – when food or liquid slips unnoticed past the vocal folds into the lungs. Elderly people who are admitted to hospital have a heightened risk of developing aspiration pneumonia.

Several patients at St Andrew's War Memorial

Hospital in Brisbane have been diagnosed

with the swallowing disorder dysphagia

and aspiration – thanks to a new screening

procedure introduced at the hospital in 2008.

Bundaberg pensioner Betty Peterson suffered

many years of poor health because of chest

infections that were unsuccessfully treated with

antibiotics. She was admitted to hospitals for

weeks at a time for suspected asthma. In 2009

Mrs Peterson was admitted to St Andrew’s for

a heart condition - and it was then that she

was also diagnosed with dysphagia and

suspected aspiration.

Speech pathologist at St Andrew’s Jasmine Jones said Mrs Peterson was helped thanks to a five-minute checklist designed to guide nursing staff in the identification and management of patients at risk of dysphagia and aspiration. At St Andrew's, speech pathologists assessed her swallowing using modified barium swallow – this confirmed her diagnosis and that aspiration was occurring. Because of problems with her voice she was referred to an ear, nose and throat surgeon who was able to perform bedside transoral injection of Restylene to assist in airway protection during swallowing and to improve

her voice.

“The treatment, along with several rehabilitation exercises, improved the effectiveness and safety of her swallowing and she is now able to enjoy normal food and soft foods,” said speech pathologist Kylie Perkins.

Mrs Peterson said that after her condition was diagnosed at St Andrew’s she was placed on a modified diet, such as thickened fluids and soft foods. She was given exercises to improve her ability to swallow and says she is feeling much better. She is looking forward to enjoying normal foods for the first time in years.

The Dysphagia Screening Tool, first developed at the Royal Brisbane and Women’s Hospital,

St Andrew’s speech pathologist Jasmine Jones conducts an examination on patient Mrs Betty Peterson. Mrs Peterson, who was admitted to the hospital for the treatment of a heart condition, was diagnosed as suffering from dysphagia and silent aspiration thanks to the introduction of the Dysphagia Screening Tool.

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was introduced at St Andrew’s after speech

pathologist Kylie Perkins and her colleagues

raised their concerns with St Andrew’s Director

of Medical Services, Dr Ian Brandon.

The hospital’s doctors, educators and speech

pathologists implemented a simple checklist,

and all nursing staff were trained to carry out

the screening when patients are admitted to

the hospital.

St Andrew’s conducted a survey of staff after

introducing the dysphagia and aspiration

training, and found a 26% increase in staff

saying they could identify patients who could

be at risk of dysphagia. It is now a standard

check that is done when all patients are

admitted, and as a result St Andrew’s has

identified a number of patients with dysphagia

and possible aspiration.

St Andrew’s has been ranked as one of Australia’s top-performing hospitals in a survey conducted by the Australian Council on Healthcare Standards (ACHS). Research carried out at the hospital that is used to improve patient care received an Outstanding Achievement (OA) and 25 Excellent Achievement (EA) ratings – placing St Andrew’s among the top few percent of hospitals countrywide. The organisation-wide survey praised St Andrew’s for its exceptional clinical care, commitment to quality improvement, and excellent strategic management. It said the introduction of the Dysphagia Screening Tool was an example of assessment systems that ensure current and ongoing needs of patients

are identified.

"The Dysphagia Screening Tool is an example

of a process introduced at St Andrew's that has

contributed to our ability to improve patient

care," said Liz Rossmuller, Director of Risk and

Quality at St Andrew’s. “ACHS standards are

designed to ensure optimal levels of patient,

staff and visitor safety and satisfaction. To

progress in four years ACHS rating of from

one Excellent Achievement in 2004 to 25 and

one OA in 2008, demonstrates the hospital's

success in achieving significant culture change

in both quality and risk management,” Ms

Rossmuller said.

policy patter... with Barbara Carney

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In this issue I look at the headline issues for health in the 2009 Federal Budget. In the weeks before it was handed down on 12 May, the Budget was widely predicted to be one of the toughest ever, one that would “inflict pain” on the whole community as the Government tackled the twin tasks of maintaining economic growth and containing the size of the budget deficit, already at record levels.

Health was tipped to be among the areas that would feel the sharp edge of the fiscal knife.

But were these predictions right? Going through the Budget papers, it is clear that savings have been made, but they do not impact evenly across the whole sector.

The single biggest savings measure in the health portfolio announced on 12 May is the proposal to means test the 30% rebate of private health insurance premiums. Introduced in 1998, the rebate has been the driver of the increase in health fund membership from around only 30% of the population to the current level of 44%. The proposed changes are estimated to save $1.9 billion in the four years commencing on 1 July 2009. The proposal is structured in this way:

The Commonwealth Treasury estimates the impact of these measures on PHI membership will be minimal, with only 22,000 people dropping out of health insurance. However, some scepticism is in order here, as this is the same Commonwealth Treasury that estimated that 485, 000 people would drop out as a result of the 2008 changes to the MLS. PHI membership actually increased in the December quarter of 2008.

Private health insurance has traditionally been

as much about politics as it is about health or

fiscal policy. The 2009 Budget continues this.

Health Minister Nicola Roxon said in her Budget

night media release:

“The Government is rebalancing the suite of

policies supporting private health insurance –

so that those with a greater capacity to pay for

their own private health insurance do so.

Consistent with the Government’s commitment

to maintaining the balance between public

and private health systems, high income

earners will receive less Government payments

for their private health insurance, but will face

an increase in costs should they opt out of their

health cover.

From 1 July 2010, the Government will introduce three new ‘Private Health Insurance Tiers’ – so that higher income earners receive less ‘carrot’ and more ‘stick’ to be insured.”

Leader of the Opposition Malcolm Turnbull said in his speech in reply to the Budget:

“There is one savings measure in this Budget which we will oppose. The changes to the private health insurance rebate are just the latest phase

in Labor’s unrelenting war against private health insurance. Labor hates private health insurance. Labor hates it because it encourages self-reliance and because it offers choice. Australians know that and that is why in the lead up to the last election the Prime Minister was asked time and time again whether he would change the private health insurance rebate. Again and again he and his shadow health minister said they would not.”

The biggest spending measure in the Health Budget was $60 billion over five years to the States for public hospitals. These funds will be delivered under the National Health Care Agreement between the Commonwealth and the States. No legislation is required to implement this agreement.

It is clear that the PHI rebate will be at the centre of the debate on the 2009 Budget that will unfold in the Parliament and the media over the coming months. At the time of writing, it is not known when the legislation to give effect to the PHI changes will be introduced. The APHA will be an active participant in any parliamentary inquiry on the legislation.

In the 700 pages of Health Budget information, there are several other measures which potentially impact on private hospitals. The APHA is in discussions with the Department of Health and Ageing about the detail of these and how they will be implemented. Some of them, such as the announcement of up to ten cancer treatment centres in regional areas, for which both the public and private sectors will be able to tender, are positive for private hospitals. Others, such as changes to the Medicare rebate for certain procedures, appear negative, but the detail is still unclear.

Over the next few months in particular, APHA will be advocating strongly for a sustainable private health sector and for private hospitals to be included in consultations on policy implementation. As the 2009 Budget shows, there is still a long way to go in finding a balance.

Private Health in the Spotlight in Federal Budget


Income Level Rebate

Singles earning up to $74k Couples earning up to $150k

Singles earning $74k-$90k Couples earning $150k-$180k

Singles earning $90k-$120k Couples earning $180-$240k

Singles earning over $120k Couples earning over $240k

Existing 30%/35%/40% (depending on age) rebates remain No change to Medicare Levy Surcharge (1%)

Rebate levels drop to 20%/25%/30% No change to MLS (1%)

Rebate levels drop to 10%/15%/20% MLS increase to 1.25%

No rebate MLS increases to 1.5%

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40


APHA Private Mental Health Facilities:Helping Patients Across Australia

Editor’s note: The April 2009 edition of Private Hospital magazine featured articles from a number of APHA Member Mental Health Facilities. Due to a production error, three facilities were not featured in that edition. Perth Clinic, Albert Road Clinic and Toowong Private Hospital were omitted in error. Below we look at each of these mental health facilities in detail.

Perth ClinicPerth Clinic is a 98 bed independent psychiatric hospital, centrally located in West Perth, Western Australia. The hospital has a strong commitment to safety and quality in patient care with the objectives of

1. Providing accessible, high quality treatment and care for patients

2. Maximising patient outcomes

3. Minimising /eliminating potential risks

4. Maintaining high levels of satisfaction amongst patients, visitors, referrers and staff

Treatment is provided for people with various types of mental health difficulties including depression, anxiety, bipolar disorder, psychotic disorders, post natal depression, alcohol and drug dependence and mental

health problems in adolescence and old age. The hospital provides inpatient services, an extensive day patient program and a hospital in the home program. Treatment is offered primarily in groups that are based on the Cognitive Behaviour Therapy and Interpersonal Therapy models of treatment. Individual treatment is also offered. Where possible patients are offered day patient treatment; minimising the disruption to their daily lives. To facilitate access for acutely unwell patients, the clinic maintains a 24 hour referral system that is available to general practitioners. In addition, the clinic is recognised as a leader in the field of Electroconvulsive Therapy and provides training to public and private sector psychiatrists and nurses.

Research is considered an important part

of promoting good patient outcomes and evaluating the effectiveness of our programs. The clinic maintains a strong relationship with the University of Western Australia and employs a Research Associate, ensuring that research activities are appropriately managed within the organisation. These research activities are clearly focused on the evaluation and ongoing improvement of patient outcomes. In total the clinic has contributed 15 publications in peer review journals, 2 articles in press and 28 presentations at national and international conferences since 2000.

Training of staff and students is also considered essential to promoting high quality services. The clinic has an extensive staff training program and offers placements to students of all disciplines (medical, psychology, occupational therapy, social work, nursing and counselling psychology)

The Clinic has maintained the highest level of accreditation with the Australian Council on Health Care Standards and has been recognised at the OA and EA level in many areas. This achievement is important in recognising staff contribution as well as raising the profile of the hospital.

The clinic has long been concerned with looking at evidence based practice and encouraging staff to participate in detailed evaluation of their programs. The following example shows some of the great work our staff are doing to improve patient outcomes and to promote continuous staff review of treatment.

Use of Outcomes Measures DOES Improve Patient Care We all know that evidence based practice relies on cycle of accountability in which data are collected and evaluated. Then, based on those

APHA Private Mental Health Facilities

Perth Clinic

41


evaluations changes to clinical services are made and re-evaluated, outcomes are reported to staff and other relevant stakeholders in a continuous quality improvement cycle. We also know that managing this complete cycle is not easy. However, in so doing we avoid some common pitfalls of data collection – namely that as far as frontline clinical staff are concerned, data disappear into a black hole and because outcomes are not assessed until discharge, day-to-day practice proceeds without reference to relevant feedback.

At Perth Clinic we have worked hard to design our systems and engage our staff in this process so that it has become part of our culture. One example of a data-driven clinical improvement process concerns the ongoing development of a “wellbeing thermometer” in which we are assessing mental health symptoms and wellbeing on a daily basis to inform treatment in much the same way a thermometer is used in physical medicine. This is in addition to the use of standardised measures such as HoNOS and MH-14 that are currently used in all Australian private psychiatric hospitals to capture admission and discharge outcome data.

By way of summary, the need for such a “thermometer” was highlighted by Perth Clinic’s staff. They saw that Perth Clinic had

an excellent system of measuring patient change from admission to discharge, but now needed to monitor changes during treatment. Therefore, the next step was to apply monitoring systems to inpatient psychiatric services. With initial funding from Medibank Private, we were able to trial the use of the World Health Organisation’s 5-item Well-Being Index (WHO-5) in an inpatient setting. This is a scale in which patients rated current function across the broad domain of “well-being”. During this trial, patients are asked to complete the WHO-5 on a daily basis so that their progress can be monitored throughout the course of their treatment. Our initial pilot work shows that the brief instrument is well-tolerated, improves during treatment (patient scores move from the abnormal to the normal range), and can identify those who are not responding to treatment.

By collecting the data on the wards and scoring it immediately, it is possible to provide feedback to staff so that each patient’s expected trajectory of improvement can be seen. Patients who are not improving as expected are identified, feedback is provided to them and treatment plans can be modified. We have already implemented a process whereby each patient’s response to the question about suicide rapidly becomes available to the nurses. Patients who indicate they have been

considering suicide are highlighted and this can be compared against other indicators to allow staff to readily identify patients at risk of self-harm who may not have been identified by other means.

At this time we are also able to show clearly that this style of intervention is effective with our patients, particularly those who are falling behind the expected trajectory of improvement. Feedback from our patients is that this process is very helpful to them – they value having some concrete evidence of their improvements and value feedback on what would be expected in terms of the course of their treatment.

In summary, the information being collected on each patient is rapidly available to staff in a form that clearly indicates the degree to which the person is progressing according to expectations. Treatment can be modified on an individual basis for patients who are not on track, and when a superior program is instituted, the improved outcomes will be evident. Happily the clinic has been awarded a second grant to continue this work and staff are excited about the prospect of continuing this project which we believe to be an “international first”.

Schizophrenia Still Misunderstood, Research Finds A new study conducted by SANE Australia finds almost half of all Australians still have a very limited understanding of schizophrenia and the everyday reality of living with the illness.

The study (conducted in conjunction with Virtual Medical Centre), surveyed nearly 900 people with 49 per cent admitting to having a poor understanding of schizophrenia and its impact.

The findings are disappointing but not surprising,’ says SANE Australia’s Executive Director Barbara Hocking. ‘A lot of education is still needed about the realities of schizophrenia – the fact is, with treatment, the majority of those affected lead full lives and participate in the community.

‘Unfortunately there is still a lot of stigma and discrimination towards those with schizophrenia, which is not helped by persistent myths about the illness. The

most common myth confuses schizophrenia with so-called ‘split personality’, which is not the case.

Another myth is that people affected by schizophrenia are violent, when in fact research shows that they are more likely to be victims of violence than to commit violent acts themselves.’

One in a hundred people will develop schizophrenia during their lives. More males than females are affected and 75% develop the illness between 16 and 25 years.

Schizophrenia is an illness which influences the normal functioning of the brain, affecting its ability to interpret information and make sense of the world. Symptoms can include

confused thinking, delusions, hallucinations, difficulty expressing emotions and withdrawal from others. There is no cure for schizophrenia but treatment, which includes medication, psychological therapy and community support and accommodation programs, can do much to reduce and even eliminate the symptoms.

SANE produces a number of education resources about schizophrenia to help people understand and make sense of the illness, as a first step to coping with its effects. SANE also operates a StigmaWatch program, which works with the community to monitor media portrayals of mental illness and suicide, advocating for an end to misrepresentations of schizophrenia. See www.sane.org for more information.


Youthbeyondblue Mental Health Website Launchedbeyondblue: the national depression initiative

has launched a new Youthbeyondblue website

aimed at raising awareness of the signs

and symptoms of depression, anxiety, and

associated drug and alcohol problems among

young people – and where to get help.

The website includes a wide range of new

fact sheets on depression and anxiety-related

topics, including how to help a friend, effective

treatments, alcohol and depression, cannabis

use, bullying, and eating disorders. All fact

sheets can be downloaded or ordered via the

website or by calling the beyondblue info line

1300 22 4636 / 1300 bb info.

The campaign aims to encourage family,

friends, workmates etc. of the person who may

be experiencing depression/anxiety to:

> look for the signs of depression

> listen to friends’ experiences

> talk about what’s going on

> seek help together.

According to beyondblue an estimated one

in five adolescents experience a diagnosable

depressive disorder by age 18. Around 6 per

cent of 16 to 24-year-olds (one in 16) have

depression and 15 per cent (one in six) have

anxiety.

The website is www.youthbeyondblue.com

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Albert Road Clinic

Albert Road Clinic is an 80 bed psychiatric facility that is recognised throughout Melbourne as a major specialist referral centre and accommodates 40 psychiatrists in private practice with skills covering the whole life cycle from Parent Infant Psychiatry through to Psychogeriatric Psychiatry.

The Clinic is a unique private psychiatric facility, specialising in in-patient, day patient and community services. Our hallmark is our commitment to quality psychiatric care across the life-cycle’s developmental stages. Albert Road Clinic is an affiliated teaching hospital with the University of Melbourne and has worked closely with the University of Melbourne to establish the Ramsay Health Care Chair of Psychiatry of the University of Melbourne.

Albert Road Clinic provides a number of accredited inpatient and outpatient services including:

INPATIENT PROGRAMS:

• Acute Adult Unit – a dedicated facility designed to accommodate adult patients requiring acute psychiatric intervention.

• Intensive Care Unit - a high dependency unit which provides a short term intensive therapeutic environment to meet patient needs. There is one staff member for every two patients with intensive individual one to one therapy provided.

• Parent-Infant Unit - provides expert assessment and treatment of the psychological and behaviour problems which may be experienced by parents and their babies.

• Adolescent Unit - provides specialist inpatient, outpatient and outreach programs for young people who are experiencing difficulties which prevent them from achieving their potential.

• Psycho-geriatric Unit - a comfortable, secure facility designed to accommodate elderly patients requiring acute psychiatric intervention.

• Electroconvulsive Therapy (ECT ) Suite - provides electroconvulsive therapy (ECT) for the Clinic. Patients are referred to this service by the patient’s treating psychiatrist when ECT is considered appropriate therapy.

OUTPATIENT PROGRAMS INCLUDE:

• Acute Adult program - provides day hospital treatment primarily in the form of skills training sessions, group therapy and individual review sessions.

• Aged Psychiatry - provides ongoing treatment for those not requiring inpatient care. It assists a smoother transition from acute hospital care to home and community based care.

• Adolescent Program

• Parent Infant Service

• Addictions Program

• Transitional Program

• General Day Program

• Outreach Program - facilitates maximum recovery, via ongoing treatment, support and individual rehabilitation, which is provided in a home environment. The program operates Monday to Friday 9am to 5pm.

OTHER SUPPORT SERVICES INCLUDE:

• The Professorial Psychiatry Unit (University of Melbourne Chair of Psychiatry) at Albert Road Clinic developed in 1996. The unit is active in teaching and research for undergraduate, graduate and post graduate trainees and supports a Registrar service. It also adds to clinical services within the hospital, with consultants providing assessment, treatment and second opinion services.

General Practice Assessment Service - this Albert Road Clinic initiative by the Professorial Psychiatry Unit is to assist general practitioners in their management of patients with psychiatric problems in the community. Patients are assessed by the Senior Registrar at the Clinic. Patients can usually be seen within one week with prompt feedback to the General Practitioner to assist in the patient’s treatment.

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Toowong Private Hospital

Toowong Private Hospital (TPH) is a 54 bed private mental health service situated in the western suburbs of Brisbane that is owned and operated by N.A. Kratzmann & Sons Pty Ltd. TPH provides an extensive range of treatment programs across inpatient, day patient and community settings.

The Hospital is an Authorised Mental Health Service under the provisions of the Mental Health Act (2005) Queensland. It operates an Emergency Admission Service, has over 80 credentialled private psychiatrists and provides sessional consulting rooms allowing for on-site specialist, general practitioner and allied health professional consultations.

The Hospital is both accredited and recognised as incorporating the National Standards for Mental Health Services by the Australian Council on Healthcare Standards and is a teaching hospital of The University of Queensland. TPH is a member of the

Private Mental Health Alliance (PMHA) and proudly contributes to its Centralised Data Management Service (CDMS).

N.A. Kratzmann & Sons Pty Ltd is a private family owned company that was incorporated in Queensland in 1959 and undertook construction of the hospital which opened in May 1976 under a lease arrangement until the Company assumed operation of it in December 1982. Wayne Kratzmann, Managing Director of N.A. Kratzmann & Sons Pty Ltd is Chairman of the TPH Board and maintains an active involvement in the operation and management of the Hospital.

Christine Gee was appointed as the Chief Executive Officer in 1997. Christine is the Immediate Past President of APHA. In April 2003 she was awarded a Centenary Medal for distinguished service to the health industry. In recognition of her contribution to the viability, growth, quality and achievements of the private hospital sector, she received the 2005 APHA Individual Achievement Award. Christine was the recipient of a special award created for 2007 in honour of the 20 year association of Baxter Healthcare and the Australian Council on Healthcare Standards that acknowledged an individual for longstanding service to quality in Australian Healthcare.


Toowong Private Hospital

44


Under Wayne and Christine’s vision and leadership TPH has developed to become a nationally respected and recognised psychiatric facility. Illustrating a commitment extending beyond clinical service delivery and into mental health research more broadly TPH established, jointly with The University of Queensland, a Professorial Chair, the first Chair in Psychiatry funded by a private psychiatric hospital in Australia. The Kratzmann Chair of Psychiatry and Population Health was realised in February 2000 with the inaugural appointment of Professor Harvey Whiteford. Professor Whiteford continues in that Chair today and was awarded with a Member of the Order of Australia (AM), for service to medicine as a leader in mental health reform, the development of national standards of clinical care, professional competence and economic policy” on Australia Day 2009.

The treatment and services provided are individually focused, reflecting the Hospitals core value that ‘People Come First’. The programs are delivered using one-to-one and group treatment approaches. As well as the specialised inpatient programs, TPH offers a range of day treatment programs including;

• CBT Anxiety/Panic Disorders Day Treatment Program

• CBT Mood Disorders Day Treatment Program

• Comprehensive Lifestyle Day Treatment Program

• PTSD (Work related) Day Treatment Program

• PTSD (Combated related) Day Treatment Program

• Tailored Therapy Day Treatment Program

• Tailored Therapy (Chill Out–Young Persons Group) Day Treatment Program

• Veterans Alcohol & Drug Day Treatment Program

Taking its role in health promotion and overall mental health wellbeing seriously, TPH provides a General Practitioner led Metabolic Syndrome Assessment Clinic (MSAC). The MSAC is a service developed as an educational and monitoring tool for Psychiatrists and their patients and provides a comprehensive medical, exercise and diet history and physical examination including measurement parameters for assessment of metabolic syndrome risk.

On 15 February 2008, TPH commenced as a pilot site for the Australian Government’s Mental Health Nurse Incentive Program (MHNIP). The MHNIP allows TPH to ‘auspice’ the

provision of specialist mental health nurses to its credentialed private psychiatrist practices and therefore allowing a model of coordinated care and case management not previously available to the private sector.

TPH undertakes workforce training and education across medical, nursing and the allied health professional disciplines of psychology, occupational therapy and social work. The hospital provides three RANZCP Psychiatry Registrar training positions (including one under the Australian Government’s Expanded Settings for Specialist Training Program). TPH has also recently participated as the ‘private hospital’ pilot site in the implementation phase of the National Practice Standards for the Mental Health Workforce project.

In 2001 The Queensland Government through its Centenary of Federation Committee approached TPH to manage a Legacy Initiative around young people at risk of suicidal behaviour. This initiative proved to be extremely successful and is a fine example of how a private facility can lead a project that combines private, public and non-government organisations to deliver an initiative with wide community benefits. In 2002, TPH partnered with beyondblue: the national depression initiative to support the Youthbeyondblue campaign and take it nationwide. Since then, beyondblue has worked to expand the focus of the campaign from suicide to youth depression awareness and prevention as a whole and to involve young people in all it does.

Toowong Private Hospital - continued


Staff at Toowong Private Hospital

45


Safety and Qualitypharmacy focus.... with Michael Ryan

46

The Intravenous Chemotherapy Supply Program – Good Theory, but Too Many Unknowns When the Government announced the Program in the 2008 Federal Budget it was described as a means ‘to reduce wastage of expensive chemotherapy medicines by funding only the amount of active ingredient (on a per mg basis) that a patient needs in an infusion or injection, and…to replace existing arrangements which remunerate entire vials of chemotherapy medicines even when some of the vial is not provided to the patient’.

The reason given by the Minister for Health and Ageing for the postponement of the 1 July 2009 start by 2 months was to ‘work with key stakeholders on resolving outstanding issues and to negotiate with industry stakeholders on modified arrangements’.

These stakeholders which include pharmacy, hospitals, medical, industry and patient groups, have voiced concerns about the potential impact of the new remuneration arrangements. The many unanswered questions as to exactly how the ICSP will operate has done little to alleviate these concerns.

Under the ICSP, pharmacy providers preparing chemotherapy in-house, will be faced with a choice between:

a) discarding the unused contents of ‘opened’ vials and incurring the cost of the unused portion; or

b) minimising waste (and financial loss) through multiple use of vials, which, depending on procedures used, may increase a number of inherent risks; or

c) using an outsourced provider and meeting the cost of that service from reduced PBS revenue.

Since unused drug remaining in a vial will not be reimbursed under the PBS (despite the pharmacist having paid for the full vial), there will be a strong incentive for pharmacists to minimise ‘waste’ and cost, by saving any unused portion of a vial to prepare subsequent doses. This may seem reasonable, except that there is no universally accepted shelf life for open vials. TGA-approved product information for almost all chemotherapy drugs recommends that vials be used either once only, or for no more than 24 hours. Nevertheless with the losses pharmacists face, many may opt to use ‘opened’ vials more than 24 hours after first opened, despite there being little evidence supporting the safety of this practice outside of TGA-approved facilities.

Alternatively, many of the ICSP-affected products are available from outsourced chemotherapy providers at a ‘per mg’ price. This provides the pharmacist / hospital with the choice of buying the ready-prepared product at a ‘per mg’ price and in turn receiving a ‘per mg’ reimbursement from the PBS. However, the PBS reimbursement may not always cover the cost of the outsourced provider’s ‘per mg’ charge.

It is difficult to predict with any accuracy, the cost to an individual pharmacy of the ICSP since much of the detail of the program is unknown. For example, as yet, no list of the ‘price per mg’ for each drug is available, making an accurate comparison of current and future payments for ICSP products impossible.

Preliminary calculations, using a per mg price based on the current list price per vial, suggest the difference between current and future reimbursement is significant. For example, for a pharmacist / hospital preparing chemotherapy in an on-site facility, a 136mg dose of oxaliplatin (prepared using one 100mg and one 50mg vial), currently attracts a PBS reimbursement of $1071. Under the ICSP arrangements, payment is likely to be $966. In terms of lost revenue, the cost to the pharmacist/hospital of this unavoidable ‘wastage’ of 24mg will be in the order of $105.

Other unanswered questions present an obstacle to providers seeking to manage the impact and plan for implementation. Will chemotherapy prepared for non-cancer indications (such as rituximab for arthritis) be funded in the same way? How will the preparation fee be paid on multiple doses of the same drug? Will a patient contribution be applicable for each dose? How will existing prescriptions written prior to the start date be managed?

These questions may form part of the ‘outstanding issues’ which contributed to

the postponement of the Program. The 2009 Federal Budget revealed that the two month delay in the implementation of the ICSP will cost the Government $5.9m - a strong indication that the Government is still committed to introducing the Program.

Regardless of whose perspective of the proposed Program you take, unless significantly more is known about the operation of the program, there are numerous risks for many people involved in chemotherapy if it proceeds without these issues being adequately and fairly addressed.

Michael Ryan1 and Rosina Guastella2

1 Director, PharmConsult and 2. Analyst / Consultant, PharmConsult

PharmConsult is Australia’s pre-eminent hospital pharmacy consultancy advising hospitals on the operational, financial, professional, service, and legislative issues associated with hospital pharmacy services.

Telephone: 03 9813 0580 Email: [email protected]


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49


How Small Can You Go?Measuring Molecules to Improve Drug Design

Scientists have developed an improved microscopy method for measuring the shape and size of proteins which could help them create new pharmaceuticals that are a better match for the proteins they target.

Major advances in our understanding of life depend on the development of new techniques to observe it, such as X-ray, electron or phase contrast microscopy.

It is for this reason that a new and more effective method for measuring molecular distances using fluorescence microscopy and image processing developed by the CSIRO (Commonwealth Scientific and Industrial Research organisation) has spurred enthusiasm among scientists and medical professionals alike.

The method, called Differential Aberration Correction (DAC) microscopy, measures distances at the molecular level in two and three dimensions using conventional fluorescence microscopy.

DAC microscopy is capable of measuring distances a million times smaller than a tape measure can – in nanometres rather than millimetres. Essentially measurements can be as small as one billionth of a metre.

Just as a tailor measures up a person for a suit, the CSIRO team say they want to use their technique to measure accurate dimensions of proteins called membrane receptors. These proteins sit on cell boundaries, acting as gate-keepers, and they represent a class of biomolecules targeted by over 50 per cent of medications.

Figure 1A) Fluorophores absorb and emit light with wavelength-dependant efficiency, as reflected by their absorption and emission spectrum, respectively (blue and green curves).

Figure 1B) Fuorescence filters are able to selectively let light of a selected color through while blocking other wavelengths.

Figure C) By selecting the filter such that it blocks the scattered light and passes the fluorescence light, it is possible to obtain great image contrasts, very much like a starry sky in the outback.

50


Therefore, understanding the complex structures of these molecules and how new drugs affect their structure will help drug companies design more effective pharmaceuticals.

A special feature of the new method, written up recently in the Journal of Microscopy, is that it has the distinctive advantage that it is suitable for studies at room temperature and in solution. This allows scientists to measure proteins as they exist in nature (in solution) instead of using coated or crystallised proteins as other techniques do. In effect, the new technology makes live cell imaging possible. This is particularly important for rational drug design but also has broader life sciences applications.

Cells are often viewed using conventional fluorescence microscopy. However, images obtained in this manner are inaccurate because light is bent differently for different wavelengths through the microscope.

Several universities have attempted complex and onerous hardware-based solutions to try to fix this problem. CSIRO researchers instead used a software-based approach that precisely

corrects the distortion at every point in the image.

For all its advantages, the optical resolution of fluorescence microscopy is limited by the Abbe diffraction limit—it is not possible in principle to distinguish between two point sources situated within 250 nanometres of each other. This is because their images (so-called point-spread functions or PSF’s) start to overlap too much (see Figure 2). The size of a large macromolecule is normally below 100 nanometres and so it would seem that fluorescence microscopy is not useful for addressing questions about the structure of bio-molecules.

But using multicolour fluorescence imaging (Figure 2), it was recently demonstrated that this view was too pessimistic—a resolution of 20 nanometres was obtained with the new DAC microscopy.

The technique depends on the ability of special molecules—the fluorophores—to absorb light at a certain wavelength, and reemit it at a longer wavelength (Figure 1A). Provided that suitable fluorescence filters are used, the light emitted by the fluorophore can be observed

with virtually zero contribution from the rest of the sample (Figure 1B and C). This allows seeing even the very weak signals of single fluorophores.

To be fair, DAC is only one of the many techniques that are actively being developed to solve such questions; a reflection of their importance. For example, in Fluorescence Resonance Energy Transfer (FRET), the proximity of the two probes causes one of the probes to emit less fluorescence with an efficiency that depends sensitively on the actual distance. However, this technique only operates to distances from one to 10 nanometers - a limitation that does not apply to DAC, which can measure from one to 250 nanometres, giving a more complete picture of drug-membrane receptor interactions. It will complement other techniques such as X-ray crystallography.

The DAC software was tested using fluorescent polystyrene microspheres only 100 nm across – about one thousandth the width of a hair.

The CSIRO Biotech Imaging team are currently looking at more samples that require the ability to see single molecules with very high contrast. Results have been extremely encouraging and they are starting to explore commercial possibilities.

The method has been shown to work both in 2D and 3D with a resolution of 20 nanometres. The demonstration was performed on a model system consisting of multi-color fluorescent microspheres, 100 nanometres in diameter. An Andor iXon EMCCD camera mounted on a BX61 Olympus microscope was used.

The scientists who developed the method at the CSIRO are now working towards improving the resolution and sensitivity of the method. Then, it should be possible to use the method to learn for example how pharmaceutical compounds bind to their targets – what type of conformational changes may be triggered – and how subunits are arranged in large membrane protein complexes, all questions that are difficult to address with current techniques.

By Dr Pascal Vallotton, Group leader of CSIRO Mathematical and Information Sciences.

Figure 2A) A point source imaged through a lense produces a Point Spread Function (PSF).

Figure 2B) Two point sources closer than 250 nm cannot be distinguished because their PSF’s overlap too much.

Figure 2C) If the two point sources have a different color, spatial overlap is avoided because the PSF’s lie in fact in different images.


Association

Members Survey 2009Coming Soon

What: Comprehensive Membership Survey

When: 19 June - 10 July

Where: To your Email - Survey Online

Why: Continued feedback & communication with membership is necessary for the APHA to progress towards the goal of understanding and delivering value to members. Please participate! Your feedback is important to us.

www.apha.org.au

© 2009 JupiterImages Corporation

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NHHRC Backs Person-Controlled Electronic Health Records

The National Health and Hospitals Reform Commission (NHHRC) recently released a supplementary paper to its Interim Report, which outlines the Commission's support for person-controlled electronic health records for every Australian.

NHHRC Chair, Dr Christine Bennett, said that the supplementary paper spells out the Commission's position that an electronic health record is arguably the single most important enabler of truly person-centred care.

"The timely and accurate communication of pertinent, up-to-date health details of an individual can enhance the quality, safety and continuity of health care," Dr Bennett said. "A person-controlled electronic health record would enable people to take a more active role in managing their health and making informed health care decisions."

According to recent research commissioned by the National Electronic Health Transition Authority (NEHTA), 82 per cent of consumers in Australia support the establishment of an electronic health record.

The Commission has made seven recommendations to make person-controlled electronic health records a reality. These include: • By 2012, every Australian should be able to

have a personal electronic health record that will at all times be owned and controlled by that person;

• The Commonwealth Government must legislate to ensure the privacy of a person's electronic health data, while enabling secure access to the data by the person's authorised health providers;

• The Commonwealth Government must introduce unique personal identifiers for health care by 1 July 2010;

• The Commonwealth Government must develop and implement an appropriate

national social marketing strategy to inform consumers and health professionals about the significant benefits and safeguards of the proposed e-health approach; and

• The Commonwealth Government must mandate that the payment of public and private benefits for all health and aged care services be dependent upon the provision of data to patients, their authorised carers, and their authorised health providers, in a format that can be integrated into a personal electronic health record.

The NHHRC supplementary paper, Person-controlled Electronic Health Records, is available on the NHHRC website at www.nhhrc.org.au under Interim Report of the NHHRC.

A Gala Affair for St Vincent’s Private HospitalCelebrating 100 Years of Serving the Nation, St Vincent’s Private Hospital’s Centenary Dinner held at the Art Gallery of NSW, was a who’s who affair with Former Prime Minister John Howard, Federal Opposition Leader Malcolm Turnbull, Shadow Treasurer Joe Hockey, Centenary Patron Roslyn Packer, Lady Sonia McMahon, Cardinal Pell and many more in attendance.

The black tie event included a viewing of the Archibald, art auction, entertainment from the Royal Australian Navy Band, fine wine, food and dancing. Master of ceremonies Julian Morrow led the night with Sr Annette Cunliffe, Congregational Leader, Sisters of Charity; Robert Cusack, Executive Director, St Vincent’s Hospital; Mrs Rosyln Packer and Nicholas Curtis, Chairman SV&MHS, and keynote speaker Mrs Terry Underwood, addressing the group.

Governor of New South Wales, Professor Marie Bashir wrote “so many of the medical, nursing and allied health staff, together with administrative and general staff, have contributed each in their

special way to patients with serious illness… St Vincent’s Private Hospital, together with the historic St Vincent’s Hospital alongside, are each part of the great history of Sydney and New South Wales. I have no doubt that there will be further celebrations of gratitude and acclaim in one hundred years hence.”

The centenary of St Vincent’s Private Hospital marks 100 years of excellence in compassionate care. Highlighting the extraordinary journey which began with a small number of beds in St Vincent’s Hospital, the humble beginning laid the foundation for what would become one of Australia’s leading healthcare facilities.

Julian Morrow, Master of Ceremonies

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Julian Morrow, Master of Ceremonies

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Moving Photography Exhibition brings to light every parent’s Taboo Fear

No one likes to see or hear of very sick children – it’s a universally-common horror that most people try not to contemplate in everyday life, yet Heartfelt, a photography exhibition by The Australian Community of Child Photographers (ACOCP) is about to shed new light on the subject.

ACOCP is an entirely-volunteer service that

provides family portraits of children that

have been stillborn; died neo-natally; are

terminally ill; or have been born very early.

Members of ACOCP’s nationwide network

of photographers go on location at any

time of the day and night to various

hospitals to do the shoots. They also supply

prints and albums to the families free of

charge.

On Monday 22 June 2009, ACOCP will

open its Heartfelt Exhibition which will run

for two weeks at MLC Gallery in Ultimo in

Sydney. Free to the public, the showing

features 20-30 images of the best of 153

pictures submitted by proud ACOCP

photographers with the blessings of the

children’s families.

Dawn and Shane Johnson’s twin girls

were born early at 27 weeks in April 2008.

Sadly, their daughter, Ava was stillborn

and daughter, Briana passed away at seven

days old. ACOCP president, Jessie Broome

photographed both girls at Monash

Medical NICU. Since then, Dawn and Shane

have been strong supporters of ACOCP and

will also attend the exhibition, where Dawn

will speak about their experience with the

ACOCP.

“It means so much to me to have those

pictures and the memories of both girls

and it’s wonderful to have the pictures of

Ava as we didn't get to spend as much

time with her as Briana.” Dawn said. “It was

hard to look at them the first time as it was

almost like reliving the last few hours of

the day we had to say goodbye, but I am so

glad that we were able to get them done

and I cannot thank ACOCP enough.”

This exhibition draws together family

portraits, which display the emotional

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sensitivity and awareness of these highly skilled and proficient photographers. The images, often taken under difficult circumstances, both technical and personal are warm, beautifully detailed accounts of family love. Photographers are careful to balance the importance of representing the events these families are enduring, whilst minimising the many interventions and difficulties these children are facing.

Cristina Garduño Freeman, curator of the exhibition, urged people to support the exhibition by taking the time to visit. “These photographs are more than just images, each one tells the story of a young life, at times tragically short, at times endured, but always loved. These photographs are not documentaries, but rather tangible memories that help families both grieve and delight in their children. These photographs show the significant role that photography plays in creating a sense of

family for all of us.”

For more information on the ACOCP’s

service and the exhibition see www.

heartfelt.org.au or www.acocp.org.au

All Photos courtesy of ACOCP

“It means so much to me to have those pictures and the memories of both girls and it’s wonderful to have the pictures of Ava as we didn't get to spend as much time with her as Briana.” Dawn said. “It was hard to look at them the first time as it was almost like reliving the last few hours of the day we had to say goodbye, but I am so glad that we were able to get them done and I cannot thank ACOCP enough.”

You’re Invited!

I would like to extend an invitation to APHA members and all those involved in the private health sector to attend the 29th APHA National Congress in Melbourne from 11 to 13 October 2009.

The past year has presented significant challenges for all sectors of the economy with the Global Financial Crisis resulting in a shift in consumer sentiment and uncertain times ahead.

Of course, challenges also give rise to opportunities. This is particularly the case in the health sector as the Government reaches the business end of its health reform process, and the difficult economic circumstances mean that all public funding is under increased scrutiny, including a desire to achieve maximum efficiency for each "health dollar" spent.

Against this background, our Congress theme for 2009 will be Maximising the Opportunities. We will be analysing and discussing developments in health policy, technology, financing, infrastructure and safety and quality to ensure that

private hospitals are positioned to take advantage of the opportunities presented by the changing environment.

More details on program sessions and speakers are available on the Congress website www.apha.consec.com.au. Make sure you join us in Melbourne to ensure you can maximise the opportunities presented by these challenging times.

Michael Roff

Chief Executive Officer Australian Private Hospitals Association

Save tHat date : 11 – 13 October 2009, Grand Hyatt Melbourne WebSite Live : Visit www.apha.consec.com.au for information on the Congress program and speakers.

SPonSorSHiP & trade exHibition oPPortunitieS : Consec - Conference Management T: (02) 6251 0675 • E: [email protected]

regiSter onLine : Easy registration is now available online at www.apha.consec.com.au.


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Australia’s Top Nurses Named in HESTA Awards

A midwife whose goal is for every Aboriginal and Torres Strait Islander child to begin life at the starting line, and not behind it, was named Australian Nurse of the Year at the HESTA nursing awards.

Lyn Olsen from the Bunurong Health Service in Dandenong, Victoria, took out the top award for her work with the Koori Maternity Services Program. “We had 17 babies born through the service last financial year. My aim is to keep these children healthy through their antenatal care so they begin life at the starting line and not behind it,” Lyn said.

“I believe a nurse’s job is to care. Other professions have to keep their distance but people let nurses, especially midwives, into their personal space and that’s such a privilege.”

Dandenong and District Aborigines Cooperative manager Andrew Gardiner described Lyn as “a great human being who is a professional asset to our community in working towards closing the 17-year life expectancy gap and raising the health status of our community”.

The Australian Graduate Nurse of the Year Award went to Hobart’s Stav McDevitt for being a holistic carer who believes in knowing the patient - not the illness. A career in nursing was a long-held dream for the Royal Hobart Hospital recruit, who won $5000 for travel and further education.

“I was a lab technician for many, many years and I always wanted to retrain as a nurse,” Stav said.

“I was always more interested in people than specimens but there were mortgages and children and it took a long time for me to get

to a point where it was possible. Now I just love nursing so much and I want to keep doing it until I’m in my sixties or seventies – as long as I can.”

The Innovation in Nursing Award went to Jamie Rutherford, Nurse Unit Manager at Melbourne

Health’s North West Dialysis Service. Jamie was recognized for his work improving quality of life for patients receiving kidney transplants from donors with incompatible blood types. He won $10,000 to progress and enhance his innovative work.

HESTA is one of Australia’s largest superannuation funds, drawing members from the health and community services sector. The $25,000 total prize pool was funded by Members Equity Bank.

HESTA CEO Anne-Marie Corboy said the winners were selected from a field of more than 400 nominees and the breadth of talent was astounding.

“These amazing winners remind us of the incredible compassion, inventiveness and courage to be found in the nursing profession. These nurses were nominated by colleagues, patients and patients’ families. They are a credit to their profession and HESTA is proud to recognise their fantastic achievements,” Ms Corboy said.

Paul Fitzmaurice to Represent APHA on Prostheses and Devices Committee

Paul Fitzmaurice has been appointed by Health Minister Nicola Roxon to represent APHA on the Prostheses and Devices Committee. Paul is currently Executive Manager, Corporate and Commercial Operations for Ramsay Health Care. This role includes group procurement across Ramsay’s 63 Australian hospitals, including the negotiating the supply of prostheses and medical devices.

Paul has almost 20 years experience in finance, administration and executive management in both the public and private sectors.

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Australian Business Volunteers Look for Midwives to Assist in Indonesia

Midwives trained in Indonesia are not trained in, or experienced at, best practice standards of hygiene, patient care and gentle birth. Australian Business Volunteers (ABV) is currently searching for Australian midwives to assist an Indonesian NGO with capacity building for local midwives and other medical staff in order to establish a high standard and improve the level of hygiene, quality of patient care and gentle birth protocols. The lower standards are particularly acute in Aceh, where most of the local midwives and birth attendants were killed in the 2004 tsunami.

Yayasan Bumi Sehat (Healthy Mother Earth Foundation) (YBS), is an NGO that was founded in 1995. YBS provide Maternal and child health and general family health. It has been operating a Safe Motherhood/ Infant Survival Clinic and Education project in Bali (for 14 years), and Aceh (for four), assisting people in Indonesia with culturally appropriate maternal-infant health, as well as paediatric and general health and education services, including a Youth Centre in Bali to teach English and basic computer skills to unemployed youth, and a

permaculture training project in Aceh.

The Aceh facility runs on solar power, with wind generated backup, and staff are fed from large, organic gardens and a fruit orchard. YBS is a registered Indonesian charity with advisory and executive boards comprised of local, national and non-national professionals (some of whom are also staff.) YBS achieves a high standard of maternal and child health through culturally sensitive prenatal and post partum care, with birthing centres in both Nyuh Kuning, Bali, and Samatiga, Aceh.

The goal of the volunteer will be to establish best practices and improve the standard of hygiene and patient care, adherence to gentle birth protocols, and more efficient record keeping for midwives and medical staff. They will be asked to mentor staff in best practices standards that should be exercised in patient care and hygiene, and gentle birth protocols and ensure these are followed. They will also work to improve the record keeping of the clinic.

They may also establish workshops to train midwives and birth attendants in best practices standards of patient care, hygiene and gentle birth protocols and train junior midwives, other midwives and birth attendants through workshops on topics such as haemorrhage prevention and control, prenatal nutrition, hygiene in the birth setting, breastfeeding support and start-up.

In Aceh, they will use compassionate non-verbal trauma counselling skills with local midwives and patients to encourage and guide Midwives and dukun bayi (traditional birth attendants) traumatized by the 2004 tsunami to return to practicing their profession and empower them in their roles as leaders that could be setting examples of best practices care.

Prospective applicants will need to be a certified midwife with good midwifery skills, a commitment to team work, coaching and mentoring others and an awareness and sensitivity of cross-cultural settings. Further information on this and other volunteering positions can be found on the ABV website: www.abv.org.au.

about aHPa

The australian Private Hospitals association (APHA) is the peak national body representing the interests of the private hospital sector and has a diverse membership that includes both private hospitals and industry partners.

APHA members are part of the largest and most influential Private Hospital Industry Association in Australia. APHA continues to be the untied voice of the private hospital sector influencing public policy, engaging industry powerbrokers, and facilitating an environment for members to further their objectives.

Members elevate their organization profile through affiliation with a trusted and respected industry body and benefit in number ways, including:

Access to a Network of Information•

Elevated Organization Profile•

Leadership & Direction•

Engagement with peers, issues and trends at the Annual National Congress•

Access to a powerful community of over 300 private hospitals and industry partners•

Recognition of success at the Annual APHA/Baxter Awards for Quality & Excellence•

Education and development•

Participation or advertising in Private Hospital Magazine•

discounts & deals for aPHa Members

Angela Hook Member Services Manager


Enquire about Private Hospital Membership or Industry Partner Membership today! Contact APHA Member Services Manager, Angela Hook, on 02 6273 9000

or email [email protected] for more information.

new Financial Year, new Website! APHA Member Hospitals will soon be searchable on a new website that is currently under construction. The new website will present information to members and the public by way of a great new design and

layout and include fantastic new features, including a new “Find a Hospital” function which will allow visitors to search by name, region or specialty. Stay tuned to www.apha.org.au.

Contact Angela Hook, APHA Member Services Manager, for details: 02 6273 9000

Safety and QualityAPHA Members & benefits63


The Carbon Pollution Reduction Scheme: A Health Sector Perspective

On 15 December 2008, the Federal Government released the White Paper for Australia’s Carbon Pollution Reduction Scheme (Scheme). When the Scheme commences on 1 July 2011, around 1000 Australian companies will be required to purchase and surrender carbon pollution permits equivalent to their greenhouse gas emissions each year. Some of the larger hospitals and medical facilities, which emit 25 kilotonnes or more of carbon dioxide equivalent (CO2-e) will be caught by the Scheme and may be required to purchase permits. For other health care providers, the Scheme is relevant as the Scheme may increase the cost of procuring certain services.

Each carbon pollution permit will allow the emission of one tonne of CO2-e of greenhouse gases accounted for under the Kyoto Protocol (namely, carbon dioxide, methane, nitrous oxide, sulphur hexafluoride, hydrofluorocarbons and perfluorocarbons). Permits are likely to sell for around $23 each at the commencement of the Scheme, with the Scheme imposing a transitional price cap of $40 per permit.

Medical facilities covered by the Scheme Hospitals, and other medical facilities, that emit 25 kilotonnes or more of CO2-e each year will be caught by the Scheme. The Scheme will adopt the ‘operational control’ test, as used under the National Greenhouse and Energy Reporting Act 2007 (Cth) (NGER Act), so that liable entities under the Scheme

will be those entities that have operational control of a facility that directly produces 25 kilotonnes or more of CO2-e each year. The Scheme only covers scope 1 emissions, that is, direct emissions by facilities into the atmosphere. This includes, for example, emissions produced by on-site generators. Entities will not be required to surrender permits for indirect (scope 2) emissions resulting from the facility’s energy consumption. (The entities that generate the electricity will be the entities required to surrender those permits).

‘Operational control’ and Scheme exceptions A liable entity (being a controlling corporation1 or another member of the corporation’s group) has operational control over a facility if it has the authority to introduce and implement operating policies, health and safety policies, or environmental policies for that facility. There are exceptions under the Scheme to the ‘operational control’ rule. With the approval of the Scheme regulator, entities with ‘financial control’ over a covered facility may take on Scheme liability where all of the following criteria are met: • Both the transferee and transferor agree to the transfer of liability under the

Scheme

• A single entity takes on Scheme obligations for a given facility

• The entity taking on obligations under the Scheme agrees to accept responsibility for emissions reporting for that facility

legal matters... with Alison Choy Flannigan

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• The entity that is taking on obligations can demonstrate its capacity to obtain information to satisfy its reporting requirements under the NGER Act

• The Scheme regulator is satisfied that the entity taking on Scheme obligations has the capacity to meet the liability

• The entity taking on the liability is incorporated in Australia, and

• The entity taking on Scheme obligations agrees to do so for a minimum of four years.

The exception carved out by the Scheme is in response to submissions received on the Green Paper by stakeholders who were concerned that the operational control approach places liability on an entity that does not derive financial benefit from a facility. It follows that with the approval of the Scheme regulator, a liable entity will have the ability to transfer Scheme obligations to a subsidiary within its group provided that the criteria listed above are met. Where an entity takes on liabilities for a medical facility under the Scheme, that entity will also be required to take on reporting obligations for that facility under the NGER Act.

Monitoring and reporting obligations Under the NGER Act, both scope 1 and scope 2 emissions count toward the facility threshold. In contrast, only scope 1 emissions are counted under the Scheme. This means large users of electricity, such as hospitals, may not be caught by the scheme even though they are required to report under the NGER Act. Liable entities under the Scheme will be required to monitor and report their emissions in accordance with the same emissions estimation methodologies used under the NGER Act. The aim is to provide continuity for liable entities and ease the cost of compliance with the Scheme. Like the NGER framework, liable entities can choose which estimation methodology they will use in order to balance the costs of using higher methods against the benefits of improved emissions estimates.

The NGER Act requires the submission of emissions reports by 31 October each year following the end of the compliance period on 30 June. A single report submitted via the Online System for Comprehensive Activity Reporting (OSCAR) will satisfy an entity’s obligations under both the NGER Act and the Scheme. These reporting requirements will add to the administrative burden for hospitals in NSW that are already required to submit Energy Savings Action Plans to the NSW Department of Energy, Utilities and Sustainability.

Timetable for Scheme commencement

February 2009 - Exposure draft of legislation to implement Scheme released for public comment

May 2009 - Scheme legislation introduced to Federal Parliament

Mid 2011 - Subject to Parliamentary approval, proposed commencement date of Scheme

This article was written with my colleague, Charmian Barton, Partner of DLA Phillips Fox, a specialist in environment and climate change law.

For more information, please contact: Alison Choy Flannigan, Partner Health, Biosciences and Pharmaceuticals DLA Phillips Fox Tel +61 2 9286 8629 [email protected]

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1 A controlling corporation is a constitutional corporation that does not have a holding company in Australia.

legal matters...66


on the ground...68

….with Geoff Adams What is your current position and how long have you been there?

My current positions are National Environment Manager for Ramsay Health Care since 2008, and Property and Infrastructure Advisor for Greenslopes Private Hospital since 2005. Prior to that I was in several roles, Property Services Manager, Services Engineer, Biomedical Engineer, with Ramsay Health Care since 1995 and at Greenslopes since 1990. Prior to that, I was a Biomedical Engineer with the Tasmanian Department of Health Services.

How did you come to be the Environmental Manager for Ramsay Health Care?

Throughout the organisation there is considerable interest and desire to minimise our adverse environmental impacts. Most hospitals are active with Environmental and Resource Efficiency teams, but it was recognised as desirable to facilitate this activity nationally. Ramsay Health Care draws on expertise from its Hospitals for its national committees, and it is always seen as desirable to draw on our most directly affected, most interested and greatest relevant expertise in choosing nominees. I am both affected and interested, but additionally I am one of few professional engineers in the organisation, so almost uniquely placed to participate in the team and take on the Environment Manager Role to coordinate the activity.

What is Ramsay’s commitment to environmental initiatives and how do you guide that commitment?

Ramsay Health Care recognises its responsibilities in all areas of Corporate Social Responsibility and, as protection and enhancement of the environment is a social issue, we accept our responsibility to do everything we can to both decrease our adverse impact on the environment, and to enhance the safety, appeal, and economics of our collective future. We accept that as an organisation we can have a greater impact and therefore have greater responsibility than the individual. As a Health Care Organisation, we particularly promote Health and Safety and recognise the impact that environmental harm has and will have on the health and safety of the community.

Secondly we fully accept our legal and moral

obligations.

Thirdly, our shareholders, directors, staff, clients

and other stakeholders individually desire

an optimum environment for themselves

and their children. The stakeholders drive

the organisation, so their commitment is the

organisation’s commitment. Our shareholders

also want to achieve environmental outcomes

at lowest cost, so we need to ensure initiatives

are responsibly managed. Many environmental

initiatives actually generate greater savings

than their whole of life cost, so become

financial priorities as well.

We see the need to turn the commitment

to environmental issues into initiatives to

achieve best outcomes, and it is my role to

coordinate, innovate, share, assess, prioritise,

guide and report the initiatives to achieve best

environmental outcome at the earliest time

and lowest cost.

What are some of the initiatives you have been involved with directly?

I have had the opportunity to study and optimise the operation of the chillers at

Greenslopes Private Hospital. Because the

system is complex with a diversity of resources,

there were lots of options, and it has been

possible to conceive, implement and test

algorithms to control the system for best

overall efficiency across the range of operating

conditions. We have implemented those

algorithms in software to automate always

running the system near optimum efficiency.

I have been given the opportunity to visit many

of our other sites, to learn of their initiatives

and facilitate sharing of innovations. Because

of the diverse background of our sites, there is

much diversity in infrastructure as well, giving

both wider challenges as well as a diversity of

solutions. Part of my role is to match up best

solutions for each problem. An example of

this process is sterilisers. Several of our sites

have implemented measures to save water

used as part of the steriliser process, in several

ways. From these sites, the alternatives have

been offered to other sites. Most recently, St

George Private Hospital is installing new and

retrofitting old chillers to recover both water

and energy for reuse, using ideas that are an

extension of these earlier initiatives.

Geoff Adams, National Environment Manager for Ramsay Health Care



v

We are collecting detailed data from all our sites, to comply with legislation, compare and contrast our sites and identify areas of problems and successes, and raise awareness of resource efficiency.

We are experimenting with new lighting technology as it develops, to advise hospitals on suitability for the various applications and compliance with standards. We have made a decision to remove refrigerators from all patient rooms other than maternity wards.

How have environmental initiatives at Ramsay benefited the company? Can you show long-term cost savings?

Most of the initiatives to date have been so good that they could have been justified on cost saving alone, some with payback periods as short as 3 months. Even when unprofitable, some projects have been carried through simply on their environmental benefit, or as an encouragement on staff involvement. In any case we seek to internally or externally publicise our successes to benefit the reputation of the company. We do try to integrate environmental benefit into new infrastructure projects primarily intended to expand our business, accepting added cost if it shows environmental benefit immediately or positions us better for future higher costs or tighter targets. We investigate opportunities to integrate new project infrastructure with that existing elsewhere on site to improve efficiency overall, or taking the opportunity to replace older less efficient equipment earlier than otherwise justified. Apart from the direct environmental and financial benefits, improving infrastructure has substantial safety and risk benefits as well.

What conflicts do hospitals face especially with the proposed changes to Australia’s policy on climate change?

Our prime function is delivery of health care, and we will do nothing that impacts adversely on that primary role. For example, in office areas we can allow temperatures to range more widely in a ‘dead band” before exerting energy to limit the conditions. Up to a point this can actually make people more comfortable, but can be taken further to the point they “don’t mind too much”. However keeping patients comfortable and safe, and particularly keeping sterile areas within tight tolerances on temperature, humidity and air exchanges, means that we cannot do the same in major parts of our facilities. We can only achieve efficiencies there with better engineering, rather than by relaxing effectiveness.

Conflicts of intention have arisen with the focus of legislation too purely on site specific energy efficiency. In the past there has also been effort on peak power reduction as well, for example the creation of rate difference between peak and off peak consumption. Peak power impacts on distribution systems, which then also impacts on efficiency, but the impact is offsite where it “doesn’t count”. For example systems like the ice storage at Greenslopes Hospital are good for the company in that they save cost, good for the supplier and environment in that they make the distribution system cheaper and more efficient, saving energy overall, but in the current analysis consuming more energy on-site and therefore counting against us. It is difficult to fully eliminate inconsistencies between method and intention in a system as complex as energy distribution.

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