QUALITY ACCOUNT

2016 − 2017

www.kyhealth.org.au

OUR PURPOSE

OUR VALUES

EMPATHY

We actively listen to understand your

feelings.

We show empathy by acknowledging others’

emotions.

Individuals are included in decisions about their

care and have their needs acknowledged.

We provide choices and support individual

wishes.

Our actions demonstrate our

compassion for others.

WELLBEING

Safety is at the forefront of everything we do.

People feel safe in our care.

We foster a person centred approach through flexible,

individualised care.

We support the physical, emotional,

social and psychological health of all.

COMMUNITY

People experience a welcoming, friendly

approach.

We embody the cohesiveness and spirit of

our communities.

Everyone feels connected and has a sense of

belonging.

Our teamwork is built on cooperation,

collaboration and communication.

HEALTHY COMMUNITY. LOCAL CARE.

Highlights Establishing Cancer Day Unit

Reviewed Complaint

Management Policy and Procedures

Introduce ViCTOR (Victorian Endorsed Track and Trigger tools) for pediatric patients and UCC presentations

Commenced Consumer Practice

Partners Project

Improved Internal Referral Processes

Continued review of Clinical Pathways

Introduced use of Whiteboards at patient bedsides

Review of Discharge Planning processes

Antimicrobial Formulary List and Prescribing Guideline revised

Participation in Residential Care

‘Better Resident Care” Project

CONTENTS

2 Chief Executive Statement

3 Consumer, Carer and Community Participation

4 Community and Consumer Experience

5 Cultural Responsiveness and Diversity

6 Closing the Gap

7 Family Violence

8 Cancer Services

9 Breastfeeding Café

10 Quality and Safety

10 Clinical Governance

10 Monitoring and Investigation

11 Accreditation

12 Consumer and Staff Experiences

12 Discharge

13 Happy or Not?

14 Complaints

15 Compliments

16 Staff Experience and Patient Safety

17 Continuity of Care

17 Perioperative Services

19 Infection Prevention and Control

20 Staff Health: Vaccination Program

21 Food Safety Program

21 Cleaning and Environment

22 Blood Matters

23 Medication Safety

24 Falls Prevention and management and

24 Pressure Injury Management and Prevention

25 Aged Care Services

26 Aged Care Quality Services

28 Planned Activity Group

29 Transitional Care Program

30 Primary and Community Health

32 District Nursing

33 Campaspe Early Childhood Intervention Service

34 Advance Care Planning

26 Volunteers

36 Education

36 Students 36 Graduate Nurse Program

On behalf of Kyabram District Health Service, I am pleased to present to you the Quality Account for 2016-2017

The Quality Account is an important way for our health service to report on the quality of the care and services provided and to demonstrate to you the improvements in the services we deliver to our local community.

The quality of the services is measured by looking at indicators of clinical safety, care effectiveness and the community’s experience of the care provided.

In keeping with our Purpose to achieve a healthy community through the provision of local care, KDHS continues to evaluate and improve our models of care to ensure our services remain consumer focused and are integrated and better coordinated both internally and with our external partners.

Through the Board Clinical Governance framework, KDHS has established four pillars for governing, monitoring and improving quality & safety of the care we provide.

KDHS has continuously maintained quality accreditation under the National Standards Program which applies predominately to our acute care health service, the Aged Care Standards Agency which applies to Sheridan, our residential aged care facility and through home care standards for our home based and aged person support programs.

KDHS has also achieved accreditation as a provide under the national Disability Insurance Scheme (NDIS) Over the past 12 month reporting period, KDHS has continued to minimise a number of its key identified clinical risks resulting in reductions in the level of risks aligned to pressure ulcer prevention;

hospital acquired infection related incidents and timely response to escalation in care. The KDHS Board has identified three current high clinical risk priorities for close monitoring. These priorities are minimising incidents related to surgical procedures; the prevention of falls resulting in injury in the aged care residents and ageing inpatient community and providing effective clinical governance oversight in medication management.

We look forward to reporting on our progress in minimizing and hopefully, eliminating these risks in the coming years

Throughout the reporting period, KDHS consistently reported a patient satisfaction rating of 98% and above. Our staff rating for patient safety is 83% (state average is 72%) and 92% of KDHS staff recommend a friend or relative to be treated as a patient at KDHS. (State average is 72%)

We hope you enjoy reading about what has happened at your local health service in the past 12 months with the assurance that the KDHS Board, Managers, Staff and contracted providers continue to strive towards improving quality and safety outcomes for our community. Peter Abraham Chief Executive

CHIEF EXECUTIVE STATEMENT

KDHS Board of Directors, Management and staff are continuing to build strong partnerships

with our community and the people who may use, or at some stage, need to use our Health

Service. We aim to involve people in their own health care wherever possible and we

encourage and support consumer and community participation in care and treatment

decisions for individual consumers as well as the development, review and improvement of

KDHS services

Consumer involvement in Committees, forums and workshops assists to improve policy and

care, treatment and wellbeing and also assists with the development or review of our

brochures and information.

Consumers participating in the health service governance structures and committees offer a

consumer perspective by providing advice to the Board on issues such as access to services,

redesign and improvement strategies, quality of care, strategic planning, consumer advocacy

and processes for further developing consumer participation and engagement.

The Consumer Participation Plan 2015-2017 has been reviewed and approved in consultation

with the Community & Cultural Governance Committee and consumers. Completion of the

Plan met 100% timelines and is scheduled for further development and actions.

Review processes and progress is a performance indicator of the Committee and a report is

provided bi-annually. Actions and improvements from the Plan include:

Commencement of training for consumer engagement and partnerships

Partners in Practice funding submission and commencement

Consumer Literacy Group review of all new and revised brochures prior to distribution

Diversity Plan reviewed and submitted to DHHS

Policy review including Interpreter and Language Services

CONSUMER, CARER AND COMMUNITY PARTICIPATION

Community and Consumer Experience

Improving the Healthcare Experience

In November 2016, KDHS was announced as one of

four successful recipients of first round funding from the

Health Issues Centre Practice Partners Program.

At KDHS we know that ‘everyone has a healthcare

experience’, and this project encourages patients,

resident’s, carer’s and community members to share

their healthcare journey, experience and ideas with

our staff through ‘CARE’ (conversation and reflective

practice) discussions.

Led by the Quality, Experience and Safety Unit, KDHS

are using these conversations to further develop empathy

in all that we do and to support all staff to see themselves

as caregivers. This occurs through the presentation of

healthcare stories at meetings and as part of staff

education.

Using the healthcare stories, KDHS is working with staff

and a small consumer representative working group to

understand care experiences in relation to patient-

centred care principles. This allows the health service

to deliver improvements in care that meet patient needs,

and ultimately lead to improved safety, quality

care and experience for everyone.”

If you would like to meet with a KDHS

representative to share your story in a

confidential manner, arrange a ‘CARE’

conversation with a small group of friends,

or would like further information, please

email the Experience and Innovative

Practice Coordinator on :

experience@kyhealth.org.au

or phone 5857 0300

Key Highlights

15 face-to-face individual

CARE discussions

Monthly meetings of an

“Improving Healthcare

Experience” Working Party

Training of 3 consumers in

“Co-production for Health

Consumers”

Active recruitment of patients

willing to have CARE

discussions

Use of patient CARE

discussion at Clinical

Governance Meetings

Use of experience stories and

data to inform planning and

implementation of services

improvements

Bi-monthly “You said, we did”

posters published to inform

the community of

improvements

Cultural Responsiveness and Diversity

The Community and Cultural Governance Committee and the Aboriginal Health

Governance Committee are involved in assisting us to provide responsive and

accessible services that meet the needs of diverse communities including Aboriginal

and Torres Strait Islander people and the LGBTI community. This also includes

provision of quality, professional language services if required.

The Committee also supports improvements in communicating with culturally and

linguistically diverse groups, ensuring access to all, advocating on the behalf of clients,

ensuring staff knowledge and skills, and provision of culturally appropriate meal choices.

We aim to deliver services that are relevant and accessible for all ensuring

diverse and cultural needs are not a barrier to service provision.

KDHS has continued to deliver improvement objectives in the Cultural Responsiveness

and Disability Plan with significant outcomes including:

Review of Interpreter and Language Services

Access to information in languages appropriate to current patients, residents and

clients as well as for the vision impaired.

Completion of a gap analysis against the Rainbow Tick Standards and an approved

action plan for implementation.

During the 2016-2017 period, the Victorian Hospital Experience Survey (VHES) indicated

that only 4% of responses were from patients from non-English speaking backgrounds

and none of the respondents had requested interpreter services. 3% of patients needed

help understanding English however family and other support was available in all

instances.

Closing the Gap

Improving Care for Aboriginal Patients (ICAP)

KDHS continues to be committed to ensuring appropriate health services are delivered in

accordance with the Aboriginal community’s cultural needs

In May 2017, KDHS employed an Aboriginal Health Liaison Officer (AHLO) to work with

communities and build sustainable relationships while improving access and services with

the engagement and support of the Aboriginal Health Governance Committee. The AHLO

has also focused on enhancing existing relationships with Aboriginal Community

Controlled Health Organisations(ACCHO) and arranging attendance by Rumbulara

representatives to the Health service.

During 2016-2017 we have also:

Investigated and arranged appropriate training and education opportunities for staff

Ensured cultural resources and information is available to help staff better understand

aboriginal culture and respond appropriately

Strengthened the commitment to accurately identifying all Aboriginal and Torres Strait

Islander patients on admission and when accessing services – this ensures we are

able to provide care appropriate to their cultural needs

Continued to develop positive relationships between KDHS and the local Aboriginal

community

Reviewed and revised the current Aboriginal Health Plan

Continued to work with the University of Melbourne in the Inclusive rural health care

at KDHS project including positive outcome of staff focus groups and workshops

Foundation student’s collage based on the book: “How the Murray River was Made” by Irene Thomas

Family Violence

Prevention, early identification and responding to family violence is a priority action for

KDHS with a number of initiatives both at organisational and community levels

occurring during the last 12 months.

In November 2016, KDHS committed to spreading the White Ribbon message

promoting ‘the positive role men can play to stop violence against women and be part

of this social change’, and participated in a Campaspe Shire awareness campaign.

We recognise domestic violence inflicts physical injury, psychological trauma and

emotional suffering and its impacts can last a lifetime. It can happen to anyone at any

time and knows no socio-economic or cultural boundaries. KDHS is an important

contact point for people who may have experienced family violence, presenting an

opportunity for early identification and referral for those who may be at risk.

Our staff have participated in further education to raise awareness, strengthen their

understanding of, and ability to identify and respond to family violence. KDHS staff

are engaged in the Campaspe Family Violence Action Group and have formed

pathways of support to specialist Family Violence services

Strengthening the Health Service Response to Family Violence

Cancer Services

KDHS commenced delivery of Cancer

Services in July 2016 in partnership with

Goulburn Valley Health to meet the needs

of people with cancer living in Kyabram and

local areas.

Our focus for Cancer Services has been on

providing “Care Close to Home” and this

has resulted in the establishment of the:

Medical Oncology Clinic

Day Oncology Unit

Allied Health and Supportive Care

services

Physical Activity in Cancer Care

Program

The Medical Oncology clinic, staffed by

senior Medical Oncologists, provides a

regular visiting service to Kyabram for

patients who have been recently diagnosed

with cancer, are undergoing chemotherapy

treatment, or having regular specialist

review.

Our four chair Oncology Day Unit was

purpose built to provide chemotherapy and

supportive treatments to patients in a

comfortable and supportive environment.

Extensive planning and development of the

service saw the engagement of consumers

in providing valuable feedback into the

Oncology Day Unit to ensure the

environment, services and resources met

the needs of patients, carers and family

members. The treatment area looks out

onto a restful outdoor area following a

complete ‘garden blitz’ thanks to the

Echuca and Shepparton Bunnings team

and now includes a range of beautiful

plantings, garden furniture and a tranquil

water feature.

Chemotherapy is delivered in a safe

environment via ‘state of the art’ Smart

Infusion Pumps with Oncology Medication

Guardrails, and is supported with the

expertise of the Medical Oncologists and

Oncology Pharmacist. Our dedicated

nursing staff have undergone extensive

training and clinical placement in the

delivery of chemotherapy and have a

strong focus on providing person-centred

and supportive care to all patients.

We recognize that the benefits of exercise

is beneficial for people during cancer

treatment to help manage some of the

common side effects of treatment, speed

up return to usual activities and improve

quality of life. Our trial Physical Activity in

Cancer Care Program has been

established to address this need and an

Accredited Exercise Physiologist is now

offering professional exercise advice to

support people having cancer treatment to

be as physically active as their abilities and

conditions allow.

Cancer Services cont’d

The service is provided at Kyabram District

Health Service, Echuca Regional Health

and Rochester and Elmore District Health

Service. The 6-month trial project, funded

by Loddon Mallee Integrated Cancer

Services, is to develop a service that meets

patient needs and is accessible through a

GP-led chronic disease management plan.

The Exercise Physiologist works closely

with the oncology teams and allied health

staff at the health services to ensure the

exercise plans are safe and tailored to the

individual.

The Medical Oncology Clinic, Oncology

Day Unit and Physical Activity in Cancer

Care Program are valuable community

services which complement the existing

extensive allied health and community

nursing, advance care planning and

palliative care services available at KDHS

to people living with cancer in Kyabram and

surrounding communities.

Breastfeeding Cafe

The Breastfeeding Café continues into

its third year. The group meets on a

monthly basis and welcomes all new

parents to come and seek friendship

from other new parents, listen to guest

speakers and gain support from

midwives and a Maternal and Child

Health Nurse.

The Cafe is advertised via the KDHS

Facebook site as well as in the local

newspaper and all new parents are

encouraged to participate through our

pregnancy care service.

…Thank you to Nursing staff for the care and kindness shown to my husband and the extra time taken to make sure he was comfortable…

Family Member, Oncology Unit

QUALITY AND SAFETY

Clinical Governance

Clinical Governance is a shared responsibility at Kyabram District Health Service. It

provides a framework ensuring we consistently provide safe, high quality care and is

fundamental in ensuring improvements in patient safety.

The KDHS Clinical Governance Framework outlines the organisation’s structures,

processes, staff responsibilities and reporting. Measurement and reporting of

performance is reported to a number of committees and process and outcome measures

are monitored internally or benchmarked with external organisations. The Clinical

Governance Committee meets quarterly and members include consumers, Board

members and staff.

Monitoring and Investigation

KDHS supports a reporting culture in which staff are encouraged to report incidents, inclusive of errors, hazards or near misses. This consistent approach ensures a detailed analysis and review of any serious incidents or adverse events and identifies if there are trends or special cause variations.

Where an adverse event has occurred or where there was an indication that there may

have been the likelihood of such an occurrence, a screening tool is used to guide

investigation processes and enables us to learn from experiences, errors or near misses

and be accountable for the effect they may have on those involved. Communication is

open and honest with all relevant parties under the principles of Open Disclosure

Review includes the Directors of both Medical and Clinical Services, nursing staff and

Medical Officers with reports to the Clinical Quality and Safety Committee and Clinical

Governance Committee

Effectiveness

Consumers of health care should be able to expect that the treatment they will receive will produce measurable benefit. Effectiveness relates to the extent to which the treatment, intervention or service achieves the desired outcome

Appropriateness

Interventions are performed that will produce the desired outcome – appropriateness is about using evidence to do the right thing to the right patient, at the right time, avoiding over and under utilization

Acceptability

Opportunities must be provided for health consumers to participate in health service planning, delivery, monitoring and evaluation at all levels – should enhance the acceptability of services

Safety

Harm arising from care including the environment in which it is carried out, must be avoided and risk minimised in care delivery processes

Accreditation

Accreditation standards provide a nationally consistent statement of the level of care

patients, resident, clients and all members of the community should be able to expect

from health service organisations.

Surveys are conducted by independent bodies and are a rigorous process to assess the

quality of care and services. In May 2017, surveyors from the Australian Council of

Healthcare Standards (ACHS) conducted a successful survey across all Acute and

Primary Health Services with a further 3 year accreditation attained. This result was a

recognition of the commitment of staff in continuing to provide high standards of quality

care and service.

Accreditation

Framework

Applies to: Outcomes

National Safety and Quality Healthcare Standards

Organisation-wide KDHS was successfully accredited in May 2017 for a 3 year period.

Commonwealth Aged Care Accreditation

Sheridan Aged Care Successfully accredited in August 2015

Community Common Care Standards

Community Home Care

Program

District Nursing Social Support Program (formerly Planned Activity)

Successfully accredited - July 2020

Surveyors also noted in the final report that: “The organisation is

commended for the work that they are doing in building and

establishing a culture of safety through; education; training and

support; the provision, review and response to timely and

accurate data; dedication to the involvement of consumers

throughout all aspects of the patient journey; as well as the

passionate leadership within Infection Control and Blood Safety,

in particular” – Final Report June 2017

CONSUMER AND STAFF EXPERIENCES

Surveys are a valuable source of information to assist in improving our performance.

Every 3 months, the Department of Health and Human Services sends a survey to

randomly selected patients and participation is voluntary and anonymous.

This survey, the Victorian Hospital Experience Survey (VHES) looks at many areas

including our nurses, medical practitioners, care, treatment, discharge, communication

and non-clinical services.

For 2016-2017, 97% of patients, both medical and surgical, who responded to the VHES survey rated their overall hospital experience as either 'very good' or 'good'. This was an excellent response and above the overall State rate of 91%. For both the January – March and April – June 2017 periods, KDHS achieved 100%

Discharge

During 2016 – 2017, all clinical departments have maintained a strong focus on discharge planning

and continuing care and treatment in the home environment where the need has been identified.

Review of discharge is continuing and incorporates medication information, discharge summaries,

planning for continuing services and processes to obtain feedback and support for patients once

they had returned home.

Discharge surveys have been revised and phone calls from staff following discharge enable

patients to discuss any concerns and ensure they have any further information they may need.

The overall discharge satisfaction

rate for the 2016-2017 period is

98% in comparison to the overall

State average of 84%.

Survey results again identified some areas for improvement including discharge

processes and there is a continuing focus on improving the discharge process,

information provided and discharge planning.

The Victorian Hospital Experience Survey for Community Health Services was also

introduced in 2016 however there were not enough responses for an result to be

provided, This survey will again be held commencing October 2017 with a focus by staff

on working with clients to provide feedback

Happy or Not?

To further strengthen our quality Feedback mechanisms, KDHS have introduced “Happy

or Not” feedback collection units.

These units are used to target a specific question over a designated time period and

are available in four locations across the organisation. While the answers do not provide

comprehensive feedback information, they allow measurement of satisfaction and are

used to support areas that are a focus at any given time.

They have also been instrumental in assisting the measurement of our empathy value

and providing improvement data following the introduction of the “Hello, my name is…”

campaign.

2 examples of the improvement results following improvement measures are:

Do you know the name of the person

caring for you today?

Improved from 67% in July to 88% in

December following introduction of the

“Hello, my name is…” campaign

Have your needs been met today? Measuring consumer reaction to KDHS

values – 92%, an improvement of 4% from

88% in 2016

Complaints KDHS recognises that compliments,

suggestions and complaints are a

valuable source of feedback and form an

integral part of our continuous quality

improvement systems. Handling

complaints and acknowledging

compliments involves all staff.

Information on the process for providing feedback is available with the feedback boxes but is

also provided in all patient, resident and consumer information brochures. Each time a

complaint is received, it is communicated to the appropriate Manager who conducts a

thorough review. The outcome of the investigation, including an explanation of any

contributing factors and lessons learned, is communicated back to the consumer.

Details are used anonymously to

improve practice and reports are

provided to the Clinical Governance

Committee.

During 2016 -2017, the number of

complaints has increased by 14% to 49

from 42 in 2015-2016. 47% related to

care and interaction with staff, a

decrease of 8%) while administrative processes and facilities made up the remainder and

included concerns with access, signage, equipment and communication

Patients, residents, clients and their families are also able to lodge complaints with the Health

Complaints Commissioner if they are not satisfied with outcomes of investigations by KDHS.

The Aged Care Complaints Commissioner also investigates complaints related to Residential

Aged Care and Community Home Support programs. There have been no complaints lodged

externally during 2016-2017

During 2017, a visual report on complaint and suggestion outcomes was also developed and

is displayed throughout the Health Service and on the KDHS website.

“You Said, We Did…” provides information on complaints and suggestions and the outcomes

to ensure all members of our community are aware of the actions taken

and the importance to KDHS of feedback received

…”This hospital is the best ever. Kids

should be given lollies at appointments – I

really want to come here again”…

5 year old Joseph

…Lodged a complaint about treatment

and attitude towards daughter by a

service at KDHS – more than happy with

the way it was managed and the ongoing

communication…

John G

2013-2014 2014-2015- 2015-2016 2016-2017

Total 43 32 42 49

0

10

20

30

40

50

60

Total Complaints

Compliments

Compliments are also important as recognition of the care and services we provide.

They are acknowledged and shared with the staff

involved.

Recording of formal compliments commenced

In 2015 and in 2016-2017, 41 written

compliments have been received as well as many

thank you cards and informal notes of appreciation.

This does not include the numerous cards and

thank you’s provided directly to staff.

Compliments recorded were also for clinical care,

the Advanced Care Planning program and the

facilities provided.

KDHS continuously explores ways to encourage

consumers, families, carers and staff to provide

feedback on care and services whether that is a compliment, complaint or suggestion.

… Compassionate, caring

and thoughtful staff…

Adele P (MSW)

Our Facebook page provides information to the

community and our “Likes” continue to

increase. The KDHS website also has a new

look. www.kyhealth.org.au

Please also follow us on our new Instagram page _kyhealth

…Excellent care from all

Nursing staff and Doctors

O.F. Day Surgery…

Lois B

Staff Experience and Patient Safety

People Matter

Staff at KDHS are asked annually to participate in an external survey - “People Matter” -

distributed by the Victorian Public Sector Commission. Information is gathered across a

broad range of people management issues such as employee commitment and job

satisfaction. Another focus area is staff feedback on patient safety and in 2017, 47% of

staff participated with above average results on all questions when compared with similar

health services.

97% of staff responding to the survey believe the organisation provides high quality

services and that the organisation is driving towards a “safety-centred organisation” with

87% job satisfaction. 91% believe KDHS treats employees with dignity and respect while

92% stated they would recommend KDHS to relatives and friends

KDHS continues to focus on embedding our Values of Empathy, Wellbeing and

Community with a continuing focus on further embedding the values within every

department.

Following a Board commitment in 2015, “Crucial Conversations”, a two-day education

course, has continued to provide staff with the necessary skills for fostering open dialogue

with almost 200 staff completing the training.

…Fantastic, friendly staff – highly

recommend to anyone…

CONTINUITY OF CARE

Perioperative Services

Kyabram Health secured the services of 2

new surgeons in 2017.

Dr Senthil Rengasamy provides another

option for our community as an

orthopaedic specialist and Dr Muthukumar

Subramaniyan provides Ear, Nose and

Throat specialist

services to our

community.

Both surgeons consult in Kyabram and

provide surgical services at KDHS on a

monthly basis.

Our ability to provide endoscopic surgery

has been enhanced with the purchase of a

new colonoscope, as well as a carbon

dioxide gas unit that ensures a better

postoperative period for clients as they

recover from a colonoscopy. To further

complement our endoscopic services, a

processor that allows for digital imagery

has also been purchased in 2017.

KDHS continue to utilise the services of a

theatre consultant to review and provide

guidance for our perioperative services

Minor Procedure Treatment

Rooms

Until 2016 minor procedures were being

conducted in the Day Procedure Unit by

Doctors and were identified as a less than

optimal patient experience while also

impacting on Theatre availability and

available funds.

As a result of review, minor

procedures were relocated

to an ambulatory care

setting in the Health &

Wellbeing Wing and provided an improved

care and treatment experience in a safe

and appropriate setting for non-admitted

treatment services.

The service commenced in 2016 and

following implementation, surveys were

sent out to clients and all doctors

participating in the provision of services

through the clinic. There was 100%

satisfaction from both clients and GP's with

some feedback and suggestions for

improvement.

As a result, lighting has been improved

and additional sources found for the

provision of specialized equipment.

Satisfaction with the changes is reflected

in continuing increased usage.

Renal Dialysis

The Renal Dialysis (RDU) at KDHS currently operates Monday to Saturday and continues to

facilitate treatments for 12 local patients from the Kyabram district and wider community with

7 permanent, experienced staff members. The Unit is also to provide treatments for visiting or

holidaying patients from around Australia and overseas and demand increases for this service

over the Christmas and Easter periods.

Kyabram RDU remains a satellite unit of St Vincent’s Melbourne and continues to benefit from

their ongoing support, including a visiting Renal Nurse Practitioner.

A satisfaction survey of clients in 2017 noted an overall increase in satisfaction of 7% from

89% in 2015 to 96% in 2017.

Further information was provided in relation to a response relating to knowledge of

complaints systems.

Infection Prevention and Control

Infection Prevention and Control – Our priority

Infection prevention & control is the responsibility of management and all health care

workers within our health service.

An infection is an illness caused by “germs” such bacteria and viruses. By following a few

simple measures such as hand hygiene and vaccinating staff against influenza, we can

reduce the risk of spreading germs to patients, resident’s staff and visitors.

KDHS participates in the National Hand Hygiene (HH) Initiative. To facilitate hand hygiene

compliance, hand basins and alcohol hand rub are located throughout the organisation.

Signage also promotes HH to staff, patients and visitors. In 2016, HH stands were placed

at the entrance to the hospital, urgent care and at the café. This encourages outpatients

and visitors to be aware and practice hand hygiene.

Health care workers compliance to the 5 moments of HH is audited regularly. The

organisation consistently achieves the performance target of 80% compliance and in June

2017, this figure has increased to 85%.

The April – June 2017 VHES results indicated 94% of patients noted hand-wash gels

were available for patients and visitors to use

and that they had observed staff using hand

hygiene products.

5 Moment sof Hand Hygiene:

Before touching a patient

Before a procedure

After a procedure or body fluid exposure

After touching a patient

After touching a patient’s surroundings

Staff Health: Vaccination Program

Staff health is another essential component of infection control and prevention. It

incorporates immunisation and the management of occupational exposure.

KDHS offers all health care workers free influenza vaccination. Even healthy people can

catch and spread the flu bug and vaccination is the most effective protection against

influenza.

Strategies have been introduced to increase the immunisation rate including

immunisation hours, providing a mobile service to departments and use of promotional

literature. As a result, 230 (76%) of 301 health care workers were vaccinated against

influenza in 2017. This is an increase of 22 staff with a vaccination rate of 76%.

50

60

70

80

90

2014 2015 2016 2017

Sta

ff r

ate

- %

Immunisation Rates

Food Safety Program

External third party audits are

conducted each year and

determine compliance with both

the Victorian Food Act 1984 and

FSANZ (Food Standards Code)

2009.

Following a comprehensive review of

the Food Safety Plan, KDHS has again been compliant against the standards and is

reviewing the Plan to ensure it continues to meet legislative and safety requirements.

Cleaning and Environment

Cleaning standards and auditing requirements for healthcare facilities are governed by

the Cleaning Standards for Victorian Public health facilities 2011. Environmental cleaning

schedules are in place and audits undertaken regularly. Until June 30th 2017, external

cleaning audit results have been forwarded to DHHS.

Internal audits are also regularly conducted and are reported to the Infection Prevention

and Control Committee for

discussion. During 2016-2017,

cleaning audits continued to meet

very high standards exceeding

mandatory compliance rates on all

occasions for all Moderate to Very

High Risk areas.

Survey results from the Victorian Hospital Experience survey also support audit results

with 96% of patients finding the hospital “very clean” – this is an improvement of 10%

from the previous year and is 21% the State average

Moderate

High

Very High

Moderate High Very High

Mandatory 85% 85% 90%

KDHS 90% 93% 98%

Average % Compliance

…Staff are to congratulated for achieving

such a high cleaning standards…

ACHS Surveyors, Mary 2017

Moderate

High

Very High

Moderate High Very High

Mandatory 85% 85% 90%

KDHS 90% 93% 98%

Average % Compliance

Blood Matters

With a qualified Transfusion Nurse on site, there continues to be significant improvements

in the management of blood and blood products.

The Transfusion Nurse works with staff, reviewing all aspects of blood product transfusion

and any associated issues or concerns. Audits of practice, systems and documentation

occur monthly and results are reported to all staff and management.

A project that commenced in 2013 focusing on Orthopaedics has continued to be

successful in the reduction of unnecessary transfusions and compliance with the National

Blood Authority Patient Blood management guidelines. As a result, combined rates for hip

and knee replacements transfusions has reduced from 80% in 2012 to 6% (one-two

patients per year) as the result of diligent blood testing prior to surgery and changing of

practices .

This project is again being evaluated to focus on length of patient stay and discharge

planning.

One of the major focuses for blood and blood product management is on clear and

complete documentation to ensure clinicians are able to document the best possible

transfusion history and make informed decisions and has seen the introduction of not only

a blood pathway, but also an Immunoglobulin pathway and a Ferinject pathway.

Following scheduled audit processes and some minor changes to the document,

significant improvement has been achieved with compliance increasing to 100% from

82% in the 2015-2016 period

The areas of improvement include:

Consent – an increase from 84% to over 90% with only 1 consent not signed due to

emergency circumstances.

A new patient education booklet for patient information has been simplified to ensure

patient understanding of procedures

Development of a Massive Transfusion policy and kit. This resulted from a mock

scenario held during Blood Transfusion Month with 24 nurses and 3 Doctors involved

and attending. Pathology staff also attended.

The introduction and promotion of Ferinject to improve treatment for patients who are

found with lower than normal Iron levels. This has reduced a patient’s admission time

for iron treatment from 6-8 hrs to only 30 minutes. It has also seen a substantial

increase in the diagnosis and treatment of patients with iron deficiency anaemia

(IDA). In 2014, 9 patients presented for Iron therapy increasing to 99 in a 6 month

period in 2017.

All clinical staff participates in the Blood Safe e-learning program with ongoing support

and resourcing by the Transfusion Nurse who also conducts short education sessions for

staff. 86% of staff in the Acute, Theatre, Porters, District Nursing and Dialysis areas have

currently completed the training package.

Medication Safety

At KDHS medication safety depends on providing the right medication to the right patient

in the right dose and at the right time and there are continuing efforts to ensure

medication safety for all patients and residents.

Medication Month is held annually in March with promotion of safety and staff education

supported by visual displays, resources and a staff awareness campaign. There is also a

focus on improving incident reporting for medications to ensure all “near miss” incidents

are captured. These incidents are those were a prescribing, dispensing or documentation

error may lead to an incident if not identified prior to administration.

An annual medication administration competency program is available for all Registered

Nurses and medication-endorsed Enrolled Nurses and KDHS participates in the National

Medication Chart audit program and bi-annual completion of the National Medication

Safety review.

With the opening of the Oncology Day Unit, a Pharmacy Chemotherapy Action Plan was

developed, implemented and monitored to ensure safe practice with 84% of required

actions now completed and the remainder being addressed. A risk assessment was also

completed Minor Procedures Treatment Clinic to ensure safe medication storage and

access and has resulted in secure storage and access.

There is a continuing focus on medication management and administration resulting in a

decrease in incidents over the year of 7% from 175 to 163. 55% of these incidents (91)

are rated as “Near Miss” where the possibility of an incident was identified before

administration of medication. It is also important to note that many of the total number of

incidents and “near miss” reports, (46%) directly relate to documentation, security,

storage, and prescribing. Of the total number of incidents reported, none have had an

adverse outcome or resulted in patient harm.

Patients are also provided with information at discharge about changes to their

medications including those to continue, which medicines may have stopped being used

and any new medication that has been started.

Acute MSW Sheridan

2014-2015 48 16

2015-2016 95 81

2016-2017 99 64

0

20

40

60

80

100

120

Medication Incidents

Falls Prevention and Management

The Falls Committee has been active in ensuring all patients, residents, clients and staff

have access to current and comprehensive information and resources.

Strategies and guidelines are in place for falls prevention and management throughout

KDHS and includes assessment and screening on admission to the hospital, residential

aged care and community care.

The number of falls has decreased by 12% for the period with 2 fractures reported as a

result of falls in Aged Care.

Policies and procedures have been reviewed and equipment has been purchased to

assist falls prevention including sensor mats, mobility aids and improved nurse call

systems.

Pressure Injury Management and Prevention

Acute MSW Aged Care

0

50

100

150

200

By Clinical Area

2014-2015 2015-2016 2016-2017

Pressure injuries most commonly occur when patients are elderly or are confined to bed

and susceptible areas of their body are subject to constant pressure.

A four-point classification scale on the depth of the injury is used to determine the

severity and treatment options from stage 1 through to stage 4.

Screening and management of at risk patients ensures prevention strategies are in place

and include consultations with wound specialists, pressure relieving mattresses and heel

protectors. Patients, carers and family are also involved in developing appropriate

strategies for management and information is provided both during their stay and on

discharge.

There were 22 pressure injuries reported in the Acute area, an increase of 10 from the

previous year. Of the 22, 12 were admitted with existing pressure injuries either from

another health care facility or from their home and 4 of these patients had multiple

pressure injuries present. Of total admissions, this is 0.1% of 100 occupied bed days for

admitted inpatients.

Aged Care Services

Sheridan Aged Care

Sheridan has developed a framework for

moving the residential service to a more

consumer driven model of care delivery

incorporating partnerships in care - one that

emphasizes the resident’s experience. The

key concept is “how do we make each day

special for the individual”. This program is

called, “Continuing my life’s journey – my

way”.

Workshops for staff, residents and relatives

have commenced and it is anticipated that

a service specific model will be developed

and ready for trial by January 2018.

Sheridan hopes that the model will

incorporate a level of flexibility so that all

resident cohorts now and into the future will

be supported to meet their goals.

Sheridan recently undertook a very

successful celebration of Aged Care Week

within the public health sector. This week

involved the following activities:

Nomination for PSRAC Aged Care

Volunteer Award – local photographer

Kylie Biltris nominated for her work with

Sheridan residents

Staff & Volunteer Feature Wall displayed

in the Sheridan foyer which has been

well read

Appreciation Notes (KDHS all

departments, residents, families,

community) – 120+ received

Staff and volunteer nominations for

Recognition Awards which were

announced at a special afternoon

tea and presented by the KDHS

Director of Clinical Services

Facebook page – Posting every day

throughout the celebratory week,

photos of resident and staff

engagement.

Resident activities including creation

of an Acrostic Poem in appreciation

of Staff & Volunteers which was

presented at the afternoon

celebration.

Sheridan has embraced social media

particularly the last 12 months providing

an opportunity for residents to retain their

community involvement. It’s noted with

delight that when residents are featured,

hits to those uploads well exceed normal

traffic with many family members sharing

the photos with their loved ones. This has

now evolved into a regular resident

activity where the facebook posts are

displayed on the large screen TV to

enable residents to view posts and all

comments made by family and friends.

Sheridan will commence a Carers group,

from September 2017 to enable

supporting partnerships in care service

delivery and allow opportunities for debrief

and education that supports the carer role.

The program will be run on a monthly

basis and carers will have access to carer

respite during the program

Aged Care Quality Indicators

Pressure Injuries

Pressure injuries occur when an area of skin has been damaged due to unrelieved

pressure. It usually occurs over the bony areas especially heels, buttocks and toes. There

has been a decrease of 19% in pressure injuries overall for the period with only Stage 1

and 2 reported.

Falls and Fractures

A comprehensive falls assessment is conducted by nursing staff and takes into

consideration the resident history, medical conditions, medications and mobility to

determine the risk of falls. For the 2016-2017 period, there has been a decrease of 24%

and fractures remain at 2 with ongoing reviews to identify areas for further improvement.

We strive to minimise these events and injuries while respecting the individuality of the

residents and risks that may present. Interventions have been implemented for improved

management of falls including increased use of sensor mats to alert staff.

Use of Physical Restraint

The use of physical restraint and type of restraint is similar and is above the rate of other

facilities across the state as there are a number of residents who have requested

interventions for their safety at various times. Even though this is implemented at the

residents request, such use meets the Department definition of restraint and therefore

must be reported and included in data. We continue to minimise use as much as possible

while respecting the choices made by residents and family who may request that

restraints are used for resident safety.

Multiple Medication Use

Sheridan residents who have more than nine medications prescribed remains comparable

to the previous period however at times, is above both the average and the State rate.

Medication is reviewed by the doctor and only prescribed as required dependent on each

individual resident. The number of residents who are prescribed more than 9 medications

has decreased in the latter part of the period.

Unplanned Weight Loss

Resident weights are monitored from admission and then monthly to ensure any concern

for resident weight loss is investigated, referred to the dietician and that adequate and

appropriate nutrition and hydration is provided. A personalised care plan is developed and

residents have a choice of meals. Sheridan continues to monitor and review weight loss

for all residents and this has resulted in consistent improvement in weight loss and

management for the year. There are systems in place to provide high quality food options

and a review of meals and delivery is occurring.

Our Journey to Sheridan, June 2017

Dad was admitted to Sheridan in June 2017 after a 3 month stay in Acute Services at

Kyabram District Health. Previous to this, Mum had looked after Dad at home with

visits from district nurses and St John of God.

The day of the move was very distressing for all of us but the staff at Sheridan were

friendly and welcoming; we had a couple of hiccups in the first couple of weeks but

after having a meeting with the Aged Care Manager, we got the concerns sorted out

very quickly.

There was never-ending paper work but staff were very knowledgeable and

helpful and navigated us through this process.

98 % of the staff have been amazing, they are very friendly and have been very

respectful and professional. Dad and Mum have a few favourites that go above and

beyond for them both and they bring a smile to Dad when they are in his room.

Dad was only in Sheridan a couple of weeks when he had his 89th birthday. The

staff were amazing, from posters wishing him a happy birthday to a beautiful nurse

baking Dad a cake. This helped us all settle in so much quicker.

The facility is bright and clean and welcoming and it is a credit to everyone involved.

The nursing staff at Sheridan have been awesome. They smile and speak

whenever we are visiting and they are giving dad and mum awesome care and

some laughs along the way. Dad knows about road trips and feet massages, car

shows and families. He enjoys the banter that happens in his room.

Dad is yet to become involved in Sheridan activities. The lifestyle coordinator has

tried but hopefully one day soon this will happen.

The cleaning staff are doing a great job and dad enjoys their conversation while

they are busy cleaning.

The catering staff do a great job and are also very friendly; again we have a few

favourites!!!

So to sum up our very anxious transition to Sheridan – it’s been an amazing journey,

meeting so many wonderful people along the way.

Thank you

Joy, Don and Glad

Planned Activity Group

The purpose of a Planned Activity Group

(PAG) is to contribute to both the physical

and emotional wellbeing of participants and

improve their ability to live at home as

independently as possible

A range of enjoyable and meaningful

activities are provided to enhance the

participant’s wellbeing and maintain their

skills. They are also able to enjoy social

interaction with others and participate in the

community outings and activities. For

people with carers, Planned Activity Groups

also support the care relationship.

The activities provided in PAG are

designed with this in mind. We currently run

three programs across Kyabram and

Stanhope combined with twice weekly bus

outings. Client satisfaction with the

program, the information provided and the

activities and choices remains at 100% with

83% of the respondents stating they are

“very satisfied”

Kyabram PAG has also enjoyed merging

with Stanhope participants for some new

events in 2017. One in particular was

‘Andrea Ruie DVD on the Big Screen’ and

a number of interesting screenings of David

Attenborough’s engaging Life DVD’s.

Campaspe Shire Library also provide a

range of activities on a monthly basis with

the most recent being the introduction of

technology utilising the iPad with a program

called OSMO.

OSMO is an interactive game of

recognition of words, pictures and shapes

and has the capacity to recognise the

participant’s skill level and automatically

adjust the game to match. This allows a

range of participants to use OSMO at the

same time and be supported at their own

cognitive level.

In the past year, the clients have also

enjoyed:

A cultural experience during NAIDOC

week

The monthly BBQ.

monthly men’s ‘Ky Club’ luncheon outing

while the ladies indulge in High Tea.

Art and painting each month with local

artist Murray Ross

Concerts including “ Fred Astaire “ in

concert and “Frankie J Holden and

Michelle Pettigrove” both at Riverlinks

during 2016-2017

Regular bus trips for lunch and

sightseeing to Echuca, Rushworth,

Tatura, Nathalia, Numurkah

The PAG Team are continuing to review

programs in consultation with clients to

ensure we meet their needs and provide a

program that is client focused.

Transition Care Programme (TCP)

Transition care provides short-term care

that seeks to optimise the functioning and

independence of older people after a

hospital stay. The care is goal-oriented,

time-limited and therapy-focused. It

provides older people with a package of

services that includes low intensity

therapy such as physiotherapy and

occupational therapy as well as social

work, nursing support or personal care to

maintain and improve physical and/or

cognitive functioning.

It seeks to enable older people to return

home after a hospital stay rather than

enter residential care prematurely.

…Program couldn’t be better.

And I would not be here if it

wasn’t for the care, thank you all

so much….

…The Transition Care Program

was a vital step in ensuring

continued supported

independence at home….

TCP Breakfast Group

Primary and Community Health

Diabetes Management and Education

The Diabetes Service at Kyabram District Health Service has successfully met the high standards of

the National Association of Diabetes Centres

(NADC) to be recognised as an NADC accredited

Diabetes Centre. We participated in a rigorous

accreditation process demonstrating our commitment

to diabetes care, quality improvement and improving

health outcomes through displaying reflective

practice, evidence based care and best practice

clinical care. This process has seen a collaboration

with an Endocrinology specialist Dr Esther Briganti

which provided the opportunity to expand services

offered for Type 1 diabetes clients within Kyabram

and surrounding areas.

We were commended on a proactive and reactive service to meet goals of high level patient-

centred care, empowering clients with pre-diabetes care, multidisciplinary integrated care and

strong collaboration.

We offer diabetes services to clients with Type 1, type 2 and gestational diabetes. Our service

includes group education programs. In February 2017 a Continuous Glucose Monitoring clinic

has been added to the services at Kyabram, which is enabling us to meet the needs of more

clients and improving health outcomes. This service is through GP or Endocrinologist referral. It

entails a small sensor being inserted into the abdomen, a small transmitter being attached to

the sensor and up to 288 interstitial glucose reading being uploaded to a receiver. This receiver

is then uploaded at the end of the 7 day period, which gives valuable data and graphs for

guiding adjustment/modification to diabetes management. The Diabetes Care Centre at

Kyabram District Health Service is now assisting other health services within the LGA and

Hume region to initiate the same process assisting in the development of service excellence in

relation to Diabetes care within rural Victoria.

Client comments:

"Very happy with the staff, they were amazing"

"It was helpful receiving the information from the

download so I could review it to see where improvement

be made. The continuous glucose monitor definitely

would help in the management of diabetes. Thank you"

Mind & Body Gentle Yoga – Tai Chi

Many studies have been written on the holistic health benefits of Yoga and Tai Chi. With this in

mind, Community Health Nurses from Stanhope and Tongala Health, outreach sites of

Kyabram District Health Service worked in partnership and designed co existing programs of

Yoga and Tai Chi for registered Community & Allied Health clients. These clients were referred

from previous disciplines e.g. Physiotherapy, Cardiac Rehabilitation and the Strength and

Balance Programs.

The pilot program of Gentle Mind & Body Yoga and Tai Chi was provided to complement

existing programs by offering clients the opportunity to participate in an exercise program which

provided both physical and mental health wellbeing.

These gentle forms of exercise and stress management both bring mind and body together.

Yoga – “Union” – a harmony between the physical, mental, emotional and spiritual aspects

of life, is built on the tree main elements of exercise, breathing and meditation. A gentle

form of exercise and stress management.

Tai Chi – the generation of life energy - integrates gentle flowing movements with deep

breathing which gently revitalizes the body and relaxes the mind, promoting and

maintaining relaxation and strength with minimum use of muscle.

The benefits of both exercises are that they incorporate low-impact, slow-motion movements

and incorporate a relaxation therapy.

The pilot programs were evaluated with pre and post surveys which gave positive results.

Participants charted and graded their readiness to change and achievements on individual care

plans which, when reviewed, showed individual health goals were reached.

The success of the Yoga and Tai Chi pilot programs has opened the way for future

implementation and integration into

Community and Allied Health Services.

…My calmness & awareness of my body &

health has carried over from my classes, so

they have had ongoing benefits to me…

District Nursing

The KDHS District Nursing Service provides individualized in-home services for clients within the

Kyabram, Girgarre and Merrigum areas. Staff aim to improve the health status and maximize the

independence of their clients and carers.

Services include palliative care, hygiene care,

medication management, wound management,

and breast cancer care. Staff work closely with a

client’s general practitioner and other health

providers to ensure a combined approach to

achieving quality care and outcomes. Self-referrals

are accepted as well as referrals from hospitals, and general practitioners.

During 2016-2017, there have been improvements implemented in management systems,

equipment and storage and the provision of mobile communication equipment including:

Developed a clinical waste management policy for the community setting

Reviewed Medication Administration policy

Developed and implemented a policy for Cytotoxic Waste and Spills Management and Disposal

Introduced mobile tablets and phones for immediate offsite contact and access to data

Developed and implemented an observation toolbox for staff on home visits to ensure all client

clinical needs are able to be met safely and promptly by staff

New secure document storage and key safe systems installed

Primary and Allied Health Speech Pathology

A survey in clients in 2017 highlighted 86% client satisfaction with care and services – this was

a slight decrease of 7% from 2016 with further actions taken to ensure provision of information

on complaints handling and advocacy

During 2015-2016, Primary & Allied Health Speech Pathologists have worked extensively with

parents, kindergarten teachers and children to introduce a screening program for early

intervention for children prior to them commencing school.

The success of this program was dependent on Allied Health, parents and educators working

closely together to implement an innovative model for early intervention services. The program

has continued with developmental screening in early years education to assist in increasing

early identification and provision of therapeutic input for those at-risk. At this time, 36% of the

children screened have been recommended for referral to Speech Pathology Services.

Teachers and parents have participated in consultation throughout the process and further

focus groups are scheduled for feedback on the program, structure, content and evaluation for

further improvement. Teachers have also engaged with Speech Pathologists in education to

provide them with skills to identify concerns and feel more confident and equipped to

recommend referral pathways to families.

…I am very grateful to the Service

and the friendship of “the girls”.

Services are excellent…

Campaspe Early Childhood Intervention Service (CECIS)

The Campaspe Early Childhood Intervention Service

(CECIS ) is a program that provides support and assistance

to children and their families with a disability or developmental

delay from birth to schoolage. This service works with the child

and their family to provide the support, skills and knowledge to

meet the changing needs of their child’s development and to

optimise the child’s development.

During the past 12 months (CECIS) has undergone many changes in preparation of the

transitioning into National Disability Insurance Service (NDIS). All of our current families in our

service as well as the families that left our service last year, will all transition

across to the NDIS. The current ECIS staff have spent the past 12 months ensuring that we

have a sound understanding of this new model service delivery so that we can assist our

families through a smooth transition to ensure the best possible outcomes for our families.

To ensure that we can provide the highest quality service here at KDHS for our families under

the NDIS scheme, we will be extending our service, which is currently birth to school age, to a

accommodate the important transition into school environment and we will be now providing a

service from birth to 18 years of age.

In preparation for this change of service delivery, the current have reviewed many current

process’s to ensure that we are delivering an efficient and effective service. This includes the

introduction of a new process to allow for electronic documentation, service planning and

delivery, recording of statistical data as well as all recording all relevant information for the

client. The added benefit is that it will be available on to mobile devices so that the clinicians

will be able to use this program wherever the service delivery occurs.

In June this year, our annual satisfaction survey was completed with 100% satisfaction in all

areas Some of the comments provided to the team were as follows:

The team has been very good. They are helpful and very accommodating, they are easy to

get along with and are excellent with [my child].

The key Worker helped with accommodating our needs as a family and what best suited.

I am very grateful that they have the option off seeing me in my home town as I don’t

currently have car to drive to Kyabram

Another exciting aspect that the CECIS team has been working on in the last 12 months

is the development of various group sessions to offer to our families in the future.

Due to high demand one of the groups, “Skills for School” has begun running during term

3 this year and has been very well received by our families with high numbers attending

every week.

Advance Care Planning

The provision of a free Community Advanced Care Planning (ACP) service is promoted

to the community through education and information sessions with 100% of ACP’s

managed through the Health Service.

A comprehensive review of the ACP program has been completed against the DHHS

ACP key priorities (Advance care planning: have the conversation – a strategy for

Victorian health services 2014 -2018) with 100% compliance against expected outcomes

in the third year of a four year requirement.

Advance Care Planning Policy is comprehensive and current for all clinical areas. 100%

of ACPs are documented in the healthcare record with scheduled monitoring, auditing

and reporting mechanisms in place to identify any required improvement

A complete and comprehensive Information Pack is in place to assist patient and family in

decision making processes. In 2016, at the suggestion of a family member, any person

wishing to make an appointment and discussion Advance Care Planning is provided with

a letter of what to think about, what will be discussed and the steps of the process prior to

their first appointment. Inpatients are provided with information to enable them to make

informed decisions and appointments are made on request to meet with the ACP

Coordinator following discharge or during their admission

In September 2016, ACP became part of the Primary Health team as it fits well within our

community care model. A survey of a randomly selected group of clients was completed

in March 2017 with 18 of 20 responses. Results identified that 100% of clients are very

satisfied with the process.

2012 2013 2014 2015 2016 2017 YTD

No. of ACP's 0 41 151 262 327 405

0

50

100

150

200

250

300

350

400

450

No. of ACP's

Volunteers

Volunteers are Vital!

At Kyabram District Health

Service we value the

contribution volunteers

make across all sections of

our organisation.

Working in a wide range of

areas including Sheridan

Aged Care, Social Support

Group (SSG), Acute,

Primary Health and Support

Services, volunteers bring a

wealth of knowledge, skills and

abilities that are greatly

appreciated by staff and consumers.

Our dedicated group of 43 volunteers are a vital part of the KDHS team and we are

grateful for their ongoing support.

In the last financial year our volunteers have contributed in excess of 4,845 hours of

volunteering across our organisation - this does not include the contribution of the Ladies

Auxillary, Heart Group and members of our Consumer Partnerships.

KDHS volunteers played a vital role in the development of a Youtube Campapse Region

Volunteering Story which was launched in June and is available on our website at

https://www.youtube.com/watch?v=IBSPM55Bz-E

They have also enjoyed a movie night at the Plaza Theatre to celebrate National

Volunteer Week and have participated in the two wellness days which showcase the

services available through Primary Health and included yoga and exercise classes.

This year we have farewelled one of our long time Sheridan volunteers, Val Sartori who

has retired after 30 years. We also acknowledge Shirley Carmody, Jeanette Mc Gregor

and Helen Hearn who celebrate 10 years of volunteering at PAG / Social Support Group

Education and Training

Education continues to be delivered to over staff at KDHS by internal and external

facilitators with a range of topics provided against the National Quality and Safety

Standards , Aged Care Standards, legislation and best practice. External education

provided has included Advanced Life Support Safe Medication Management, Assessment

of the Older Person, Care of the Deteriorating Patient, ECG Interpretation and Mental

Health Education.

Many staff have also completed education externally specific to their individual role.

A comprehensive review was completed during the year on training and education units

for all staff and changes were introduced in May 2017. With continued staff diligence,

clinical competency, currency and relevance to practice has been maintained. There has

been a slight increase in staff competency attainment, with an improvement of 11%

completion as at 30th June 2017

Students

KDHS has provided support for approximately 100 students from a range of disciplines

including nursing, physiotherapy, occupational therapy and speech pathology in the last

financial year. Strong relationships also continue with a number of Universities and

Registered Training Organisations including La Trobe University and GOTAFE with new

partnerships created with other Training Providers

KDHS also supports Work Experience placements in conjunction with local schools for

Year 10 – 12 students. Areas of placement include Nursing and Allied Health. Affiliated

schools are St Augustine’s College, Moama Anglican Grammar, Rochester Secondary

College and Kyabram P12 College

Graduate Nurse Program

In 2017, KDHS welcomed 3 Graduate Nurses Who work on a rotational basis across the

organisation spending time in Acute and Aged Care with the ability to gain experience in

both Theatre and the District Nursing Service. There is also a Graduate Physiotherapist

and Exercise Physiologist on the staff who work directly with their Department Managers

and staff.

www.kyhealth.org.au

35 Birdwood AvenueStanhope VIC 3623

Phone: (03) 5857 0451 Email: comhealth@kyhealth.org.au

37 Mangan StreetTongala VIC 3621

Phone: (03) 5857 0245Email: chtongala@kyhealth.org.au

Fenaughty StreetKyabram VIC 3620

Phone: (03) 5857 0200Email: info@kyhealth.org.au