quality of care report for 2011-2012. - south west alliance of rural
TRANSCRIPT
QOC - food saftey [ ]1
QOC our community
What is Credentialing?
Moyne HealthyKids Project
Floyd - a man of his word
BEIMS - enhancing care
Moyne Health Services
quality of care Report 11/12
Introducing Moyne Health Services
3 MessagefromtheChiefExecutiveOfficer
4 WelcometotheQualityofCareReport
4 OurVision,MissionandValues
5 OurHighlightsandDisappointments
5 StrategicQualityGoals
6 Victoria’sOldestCountryHospital
OurLongevity-163YearsofServicetoThePortFairyCommunity
Our Governance
8 BoardofManagement
10 GovernanceinHealthcare
11 CredentialingforHealthProfessionals
11 CredentialingofClinicalStaffatMoyneHealthServices
11 DefiningtheScopeofClinicalPractice
Our People
12 Executive
13 KeepingourStaffKnowledgeandSkillsUptoDate
14 MaintenanceStafftraining
15 2011StaffServiceAwards
Involving Our Community
16 Wheredothepeoplewecaredforcomefrom?
17 MoyneShireCommunityProfile
17 DuringaTypicalWeek
17 CulturalDiversity
Ensuring Quality and Safety
20 Accreditation-ExternalReviewofQualityandSafeCare
21 MeasuringQualityandSafety-VictorianPatientSatisfactionMonitor
22 ResidentSatisfaction
23 PeopleMatterSurvey
24 EnsuringQualityandSafetythroughRiskManagement
25 SafeMedicationManagementAcrossMHS
25 MedicationManagement
26 SafetyInitiativesinResidentAgedcareMedicationManagement
27 PreventionandMinimisingFalls
27 ProgresswithFallsManagementinAgedcare
28 EnhancingPressureAreaPrevention
29 BloodManagement-thegiftoflife
30 PreventingandControllingHealthRelatedInfections
30 HandHygiene
31 InfectionSurveillanceandReporting
31 AntimicrobialStewardshipProgram
31 VaccinationProgram
32 EnvironmentalServicesCleaningProgram
33 FoodSafety-MealsonWheels(MOW)
34 ResidentialAgedCareIndicators
34 WoundManagement@MHS
35 YourSay-Comments,Suggestions,Feedback,Complaints,Compliments
36 LimitedAdverseOccurrenceScreening(LAOS)Program
36 BuildingEngineeringInformationManagementSystem(BEIMS)-enhancingsafecare
Continuity of Care
37 ServiceAccessCoordination
37 PuttingthePersonattheCentre
38 PromotingParticipation
40 Bed-sideHandover-aninitiativeinpartneringwithconsumers
41 MoyneHealthyKidsProject
41 AdvancesinClinicalPractice-KeepingusUptoDate
41 BedsideTroponinProject
42 SHEDProject
42 LifeStories
Floyd-amanofhisword!
Val’sStory
[ ] QOC - contents2
Contents
Message from the Chief Executive Officer
Iamdelightedtopresentthisyear’sQualityofCare(QOC)Reporttoourcommunity.TheQOCReportprovidesacomprehensiveandinformativecoverageofallaspectsofourhealthcareservices.Iamsureyouwillfindthetestimonials,illustrativematerialandthesubjectmatterinteresting.
IencourageyoutoreadtheQOCReportinconjunctionwiththe2012AnnualReport.ThiswillprovideyouwithanexcellentoverviewoftheperformanceofMoyneHealthServices.
CongratulationstotheQOCReportteamwhohaveworkedtirelesslyinpreparingthismaterial.TheTableofContentsandthecolourfulpresentationofthetopicsprovidethereaderwithaneasyguidetotopicsofinterestacrossarangeofmaterial.Thisyear,weareparticularlypleasedthatwereceivedthehighestscoreforGroupDandEHospitalsinthe2011VictorianPatientSatisfactionMonitor(VPSM)p[35].ThisfactalonedemonstratesthatourlocalcommunityandhospitalvisitorsholdMoyneHealthServicesinhighregard.
WewillcontinuetovalueyourfeedbackandIencourageyoutocontactMoyneHealthServicesshouldyouhaveanysuggestionsonhowwecanimproveourservices.
David Lee
Chief Executive Officer
Key Definitions
ACHSAustralianCouncilonHealthcareStandards.
ACSAAAgedCareStandardsandAccreditationAgency.
ACSQHC AustralianCommissiononSafetyandQualityinHealthCare.
BACeS BoardAssuranceonCompliancee-System.
BEIMS BuildingandEngineeringInformation ManagementSystem
BOMBoardofManagement.
CACPsCommunityAgedCarePackages.
CALD CulturalandLinguisticDiversity.
CEOChiefExecutiveOfficer.
DoH DepartmentofHealth.
DONDirectorofNursing.
DVADepartmentofVeteransAffairs.
EACHExtendedAgedCareintheHome.
ED EmergencyDepartment.
EEOEqualEmploymentOpportunity.
FOI FreedomofInformation.
HACC HomeandCommunityCare.
HRHumanResources.
ICT Information,CommunicationandTechnology.
KPIKeyPerformanceIndicator.
KRAKeyResultArea.
MHSMoyneHealthServices.
OH&S OccupationalHealthandSafety.
OPDOutpatientsDepartment.
QOC QualityofCareReport.
QPSQualityPerformanceSystem.
RNRegisteredNurse.
Separation Theprocessbywhichanepisodeofcareforanadmittedpatientceases.
SWARHSouthWestAllianceofRuralHospitalsisanITallianceofhospitalsandmultipurposeagencies.
VHAVictorianHealthcareAssociation.
VMIAVictorianManagedInsuranceAuthority.
VMOVisitingMedicalOfficer.
VPSMVictorianPatientSatisfactionMonitor.
WEISWeightedEquivalentInlierSeparations.AformulaappliedtotheresourceweighttodeterminetheWEISforrecoveryoffunding.
QOC - welcome [ ]3
[ ] QOC - welcome4
Welcome to our Quality of Care Report
ThisQualityofCareReportisouropportunitytosharewithyouhowweprovideaccessible,safe,highqualityhealthcare.IthasbeenpreparedinaccordancewithDepartmentofHealthguidelinestoprovideourcommunity-theconsumer,carer,patientandresidentofMoyneHealthServiceswithinformationaboutwhatwedo.Wehavechosentofocusonathemeof“Longevity”forthisyear’sreport.
AtMoyneHealthwetakequalityandsafetyseriously.OurStrategicPlan2012-2015placessafeandeffectivecareattheforefrontofallofouractivity.WehaveanumberofcommitteesresponsibleforourClinicalGovernancethatguidethisprocess.Thedataandotherinformationthecommitteesexaminerelatingtoqualityandsafecare,informsthecontentofthisReport.Weaimtoprovideyouwitha“lookinside”ourorganisationtoshowhowweensurethateverypersonreceivesthebestcareandservicespossible.
Adiversegroupofstaffhaveformedaworkingparty,andwithinputfromothershaveworkedtogethertogathertheinformationandwritethisyear’sQualityofCareReport.TheproductionofthereporthasbeenoverseenbyourGovernance,QualityandRiskCommittee.
Theplanningofthisreportinvolvedanumberofinformalmeetingstodiscusswhattoincludeandhowtopresenttheinformation.Toassistuswiththefinaldecisionwe:
• ReviewedtheguidelinesfromtheVictorianDepartmentofHealth,toensureweaddressedallthemandatoryareas.
• LookedatourpreviousQualityofCareReports.
• ReviewedQualityofCareReportsfromotherhealthservices.
• DiscussedwithmembersoftheCommunity‘whatshouldbeincluded’and‘How’?
Thereportincludesseveralsections.ThefirstsectionsdescribeMoyneHealthServices,ourgovernanceandourstaff.Thisisfollowedbysomedetailsofourhistorytakingintoaccountournominatedtheme“longevity”,detailsofourcommunityandwherethoseusingourservicescamefrom.Latersectionsdetailperformanceinformationandstatisticsincludingkeyareassuchasincidents,falls,medicationerrors.Howwemanagetheseareasandstrivetoprovidethebestpossiblequalityandsafecare.Wehavealsoincludedsomestoriesaboutpersonalexperiencesofsomeserviceusers.
CopiesofourQualityofCareReportwillbedistributedwiththeOrganisation’sAnnualReport.CopieswillalsobeavailableatlocalhealthclinicsandpubliclocationssuchastheVisitorInformationCentre.AcopywillbeavailableontheMoyneHealthServiceswebsite:www.moynehealth.vic.gov.au
Wewouldliketohearwhatyouthinkofourreport.Youcandothisbycompletingthefeedbackcardincludedinthereportandpostingittous,byputtingyourthoughtsintothefeedbacksectiononthewebsite(seeabove)orbycontactingmedirectlyon:(03)55680100.
Wethankallofthoseinvolvedintheproductionofthereport.Wethankyouforreadingthereportandhopethatyoufinditinterestingandinformativeandenjoyreadingit.
Belinda Westlake
Information, Quality & Risk Manager.
Our Vision, Mission and Values
Vision
OurVisioniswhatwewishtoseeinthefuture-Ourcommunitywillhaveaccesstoon-going,highestqualitycare.
Mission
OurMissionisourreasonforbeingandhelpsusimplementourVision-Toprovideanexcellent,sustainable,holistichealthcareservice.
Values
Weoperatethroughourcorevalues.
Wevalue:
• Competence,professionalismandintegrity
• Respectfortheindividual
• Activecommunityinvolvementandconsultation
• Accountability
• Equityinaccesstocare,impartiality
• Innovationandconstantlearning
• Kindness
QOC
5
Our highlights
CompletedtheMoyneHealthServicesMasterPlanforthecapitalredevelopmentofthesite.
AchievedthehighestVictorianPatientSatisfactionMonitor(VPSM)resultsinthestateforGroupDandEhospitalsp21.
Obtaineda$117,756HomeandCommunityCare(HACC)GranttoassistinestablishinghealthservicesattheKoroitsite.
PurchasedandimplementedtheBuildingandEngineeringInformationManagementSystem(BEIMS)resultinginasubstantialimprovementtomonitoringmaintenancerequestsandresponsetimes.
and disappointments
Receivedapoorhandhygieneresultof57%inourrecenthandhygieneauditp31.
Decommissionedthestaticrainwatertanksduetoincreasingcompliancecostsandinfrastructurechallenges.
QOC - welcome [ ]
Strategic Quality GoalsQuality of Care and Risk ManagementWe consistently provide high quality and safe care services to our consumers and our community (VHRP 1,2,5).
•Achieveandexceedaccreditationofourhealthcareservices.
•Monitor,reportandcontinuouslyimprovequalityandsafetyinourhealthcareservicestothecommunity.•Continuouslyexplorethefuturedirectionofeachofourhealthcareservices.•Providehealthcareservicesthatareresponsivetotheneedsofourlocalcommunity.•Collaborateanddeveloppartnershipswithotherhealthcareagenciesindevelopingourhealthcareservices.QOC
[ ] QOC - welcome6
Our Longevity - 163 years of service to Port Fairy CommunityMoyneHealthService(MHS)hasdevelopedfroman1849four-roomcottageat40JamesStreet,Belfast(PortFairy)toamulti-milliondollarhealthservice.
PortFairyHospital,Victoria’soldestcountryhospital,hasanimpressivehistoryofservicetothecommunity.
ThePortFairyHospitalhasenjoyedanalmostuniquelevelofcommunitysupport.Traditionally,manylocalfamilieshavegenerouslysupportedourhospital.
History ofOur Growth
1855
Thecentralportionofthepresentstructurewasbuiltwithaspecialgrantof£1000thatwasmatchedbythecommunity.
1875
Additionsweremadetothebuildingatacostof£1145/6/6andsupportedbyapublicappeal.Theseadditionsincludedthetwolargemulti-purposeroomsatthefrontoftheHospital.
1887
FatherMauriceStackbequeathed£1000thatwasusedtobuildtheStackFeverWard.TheFeverWardwasclosedin1939,however,aslateas1991itwasstillbeingutilisedtoaccommodatemaleresidents.
TheFeverWardwasthenaBoardRoomduringthe1950s.TheStackFeverWardwasinastateofdisrepairandwasdemolishedduring1992.Thesitewasthenusedtobuildanewdementiacentrein1998.
1891
Theupstairsportionofthe1855buildingwasconvertedtonursesquarters.Todaythispartofthebuildingisusedasaboardroom.
1934
LordandLadyHuntingfield,accompaniedbyMr.C.L.McVilly,SecretarytotheCharitiesBoard,openednewadditionstotheHospital.Theadditionsincludedasun-roomandaone-bedandatwo-bedroomontheNorthside,andanoperatingtheatre,birthroom,nursery,atwo-bedroomandtwoone-bedroomsontheSouthside.Thetotalcostwas£7,500.
1959
TheGovernorofVictoria,SirDallasBrookes,officiallyopenedanewmaternitywingoftheHospitalonthe4thFebruary.TodaythiswingformspartofthenewBelfastHouseNursingHome,establishedinMay1996.
1965
SirRohanDelacombe,GovernorofVictoria,openedtheNursesHomeadjacenttotheHospitalbuildingsonthe7thApril.ThisbuildingisnowthePrimaryCareBuilding.
1976
ThePrimeMinisterofAustralia,TheRightHonourableMalcolmFraser,M.P,opened,onthe22ndApril,anewoutpatientandcasualtydepartment,togetherwiththenewhospitalwardblocknowhousingtheAcuteServices.
1988
Atwenty-five-bedresidentialhostelcalledMoyneyanaHousewasopenedbytheGovernorGeneralofAustralia,SirNinianStephen,inJune.
1996
TheMinisterforHealthandAgedCare,TheHonourableRobKnowlesM.L.C.,openedBelfastHouse,a30-bedresidentialagedcarefacility,onthe19thMay.Thisbuildingwasconstructedatacostof$2million.
1998
MoyneHealthServicesestablishedPortFairyMedicalClinicnexttotheDaycareCentre,inpartnershipwithSackvilleClinicmedicalpractitioners,atacostof$325,000.
A$1.9millionredevelopmentofMoyneyanaHostelincludedthefollowing:
• 10-placedementiaunit
• dining/activitiesarea(TheWoodrupRoom)
2000
ThePortFairyHospital,BelfastHouseandMoyneyanaHouseandassociatedservicesbecameMoyneHealthServices.
2001
Thefollowingcapitalprojectsincluded:
• frontofthehospitalwasreturnedtoaheritagefacade,acoveredlinkwasputinplacetointegratetheservicesandtheacutewingadministrationareaswererenovated.
Victoria’s oldest country hospital
7
2004
MoyneHealthServicesundertookminorcapitalworkstorepairdamagetotheDayCentrebuildingandincreaseofficeandconsultingspace.Thebuildingwasre-launchedasthePrimaryCareBuilding.
2005
Constructionona17-bedextensiontoMoyneyanaHouse.Thenewwingprovidedanadditionalfiverespitebedsand12permanentresidentialplaces.
2006
SirNinianStephenopenedtheMoyneyanaHouseExtensionon28thApril.
2010
MoyneHealthServicesconducteditslastoperatingtheatrelistonthe24thSeptemberandextendedthePortFairyMedicalClinictoaccommodateadditionalGeneralPractitioners.MoyneHealthServicespurchased101RegentStreet.
2011
MoyneHealthServiceswasendorsedbytheDepartmentofHealthastheCommitteeofManagementoftheKoroitHealthServiceslandandbuildings.MoyneHealthServicesacquired98BankStreet,PortFairytofacilitatethefutureexpansionofthesite.
Present
TodayMoyneHealthServicesincorporatesthePortFairyHospital,MoyneyanaHouse(AgedCareHostel),BelfastHouse(AgedCareNursingHome),PrimaryCareServices,CommunityHealthServicesandHomeBasedServices.Itcontinuestobeanessentialandintegralpartofthecommunity.
QOC - welcome [ ]
QOC
[ ] QOC - governance8
Geoff YoulPresident
Geoff is President of the
Yambuk Recreational Reserve
Committee, Trustee Port Fairy
Public Cemetery Trust and
Vice President South West
District Rifle Association.
Geoff is a primary producer
based in Yambuk.
Terms of appointment
01.01.00-30.06.13
Board Committees
• Executive(Chair)
• AuditandRisk
• ExecutiveRemuneration
andGovernance
• MurraytoMoyne
(Amajorfundraisingevent)
Ralph LeuttonSeniorVicePresident
MSc(UQ)
Ralph is a self-employed
lobbyist, facilitator and trainer.
He sits on a number of
National Boards representing
vocational education and
training. President Port Fairy
Men’s Shed.
Ralph has vast experience in
management, research and
teaching.
Terms of appointment
01.07.10-30.6.13
Board Committees
• ExecutiveCommittee
• Environment(Chair)
• StrategicWorkingGroup
Charlie BlackwoodJuniorVicePresident
BachelorofVeterinaryScience
(SydneyUniversity),MACVSc,
BBsc.
Charlie is a Partner in the
Warrnambool Veterinary Clinic
located in Port Fairy. President
of Port Fairy Consolidated
School Council.
Terms of appointment
25.11.04-30.06.14
Board Committees
• Executive
• Audit&RiskCommittee
(Chair)
Susan Kewley
AdvancedDiplomaofBusiness
(HumanResources)
Susan is employed by
Moyne Shire as the Human
Resources Coordinator and
has experience in public sector
Governance, Strategic Planning
and Policy Development.
Member of the Moyne Shire
Arts & Culture Committee and
member of the Port Fairy
Book Club.
Terms of appointment
01.11.05-20.03.12
Board Committees
• ExecutiveRemuneration
&GovernanceCommittee
(Chair)
• Marketingand
Communications
Peter O’Keeffe
Peter is the Director of
Global Power Design. Peter’s
interests include Folk Festival-
Construction Crew (30 years),
Red Cross-Disaster Relief Plan
(Water purification) and golf.
Terms of appointment
01.11.95-30.06.12
Board Committees
• Executive
• OccupationalHealthand
Safety(Chair)
• StrategicWorkingGroup
(Chair)
mhs board of management
QOCQOC - governance [ ]9
Kerrie Robertson
DipAppliedSocialSciences-
WelfareStudies,AssocDip
FamilyTherapy
Kerrie is a Social Worker and
Family Counsellor in private
practice.
Terms of appointment
24.10.02-30.06.14
Board Committees
• OccupationalHealthand
Safety
• Governance,Qualityand
Risk(Chair)
Eda Ritchie AM
AMusA,GradDipBusiness
Board member of Port
Fairy Spring Music Festival,
Melbourne University
Publishing, Ian Potter Museum
of Art, Hillview Quarries Pty
Ltd. Trustee of the RE Ross
Trust and Council Member
University of Melbourne.
Chair Victorian College of Arts
Foundation.
Terms of appointment
27.11.03-30.06.12
Board Committees
• Marketingand
Communications(Chair)
David Ryan
BA,LLB
David is a Solicitor. In addition to
his own legal practice, he works
for the Department of Human
Services as a Support Officer.
David is a committee member
of the local Multicultural
Development Unit.
Terms of appointment
01.11.95-30.06.13
Board Committees
• Governance,Quality
andRisk
• MurraytoMoyne
Richard Walter AM
BComm,MTRP(Melb),
MRP(Penn)
Richard is Independent Chair
of the Moyne Shire Audit
Committee.
Terms of appointment
01.07.08-30.06.14
Board Committees
• AuditandRisk
• ExecutiveRemuneration
andGovernance
[ ] QOC - governance10
Governance in Healthcare
Goodgovernanceisvitaltoimprovingsafetyandqualityofhealthcareservices.
GovernancereferstothesetofrelationshipsandresponsibilitiesestablishedbyaHealthServicebetweenitsexecutive,workforceandstakeholders(includingconsumers).Governanceincorporatesthesetofprocesses,customs,policydirectives,lawsandconventionsaffectingthewayanorganisationisdirected,administeredorcontrolled.Itdetermineshowhealthservicesaredeliveredandhasadirectimpactonthesafetyandqualityofcare.
WhilemosthealthcareinAustraliaisassociatedwithgoodclinicaloutcomes,patientsdonotalwaysreceiveallthecarethatisrecommendedtothemandpreventableadverseeventscontinuetooccur.
Inrecentyears,Australianhealthserviceshaveincreasedtheirawarenessof,andinvestmentin,safetyandquality.Healthserviceshavedevelopedandimplementedpolicy,educationalmaterialsandprocessesforimprovement.Thesechangeshaveimprovedthesafetyandqualityofhealthcareforpatientsbutmorestillneedstobedonetoensureallpatientsareprotectedfromharmandreceivethehighestpossiblestandardofcare.
Projectionsfortotalhealthcarespendingindicatethatfinancialpressureonthehealthcaresystemwillcontinuetoincreaseinthefuture.
ACSQHC 2011
AtMoyneHealthServices(MHS)wearecontinuallystrivingforwaysofimprovingthequalityofcareweprovidetoourconsumers.ThisisreflectedinourMissionStatement:
“Toprovideanexcellent,sustainable,holistichealthcareservice”.
TheBoardofManagementembracetheconceptofQualityImprovementandacknowledgetheirresponsibilityundertheHealthServicesAct1988forensuringanappropriatestructure,systemsandprocessesareestablishedtosupporttheorganisationinprovidingqualityandsafecare.
TheBoardhasendorsedtheMHSQuality,RiskandGovernancepolicyasameansofensuringthesafetyandqualityofthecareweprovide.
Thedeliveryofhighqualityandsafecareisparamounttogoodgovernance.ArangeofmeasuresareinplacetoassistMHSinachievinghighqualityandsafetyincareandarebasedontheQualityFramework.
providing quality, safe care -
health service governance
QOC - governance [ ]11
Theobjectivebeingtomaintainaninformative,comprehensive,organisation-wideprogramthatdeliverstherightcaretoeverypatient,residentorclient,achievesthebestpossibleoutcomesoneveryoccasionandfocusesonthedomainsofqualityandsafety.
Credentialing for Health Professionals
Credentialingbyhealthserviceorganisationsisaprocessusedtoverifythequalificationsandexperienceprimarilyofmedicalpractitionerstodeterminetheirabilitytoprovidesafe,highqualityhealthcareserviceswithinaspecifichealthcaresetting.
Credentialinghasthepotentialtoimprovesafetyforpatientsbyensuringclinicianspracticewithintheboundsoftheirtrainingandcompetency,andwithinthecapacityoftheserviceinwhichtheyareworking.
Credentialingispartofawiderorganisationalqualityandrisk-managementsystemdesignedprimarilytoprotectpatients.
ThetermCredentialingisusedbyspecialistnursingassociationsandgroupsinadifferentwaytoaddressthelackofagreementaboutnursingspecialtycategories.
ACSQHC 2011
Credentialing of Clinical Staff at Moyne Health Services
Itisimportantthatallmedical,nursingandalliedhealthstaffhavetherightqualificationstopractice.MoyneHealthServicesensuresthattheacademicqualifications,skillsandprofessionalregistrationofallclinicalstaffiscurrentandappropriate.Thisallowsustobeconfidentoftheemploymentofqualifiedandcompetentmedical,nursingandalliedhealthstaff.
• Clinicalstaff,includingmedical,nursingandalliedhealthstaffmustprovideevidenceofregistration,qualificationsandongoingprofessionaldevelopmenthours
• Doctorsandalliedhealthstaffareappointedascontractworkers
• Doctorsareappointedforaperiodof3yearsandsubsequentre-appointmentsarefor3years
• TheBoardofManagementareresponsiblefortheappointmentandcredentialingofdoctors.
Duringthe2011-2012yearwehad1newMedicalStaffmembergothroughthecredentialingprocess.
MHShasaConsultantMedicalDirectorwhoprovidesongoingsupporttoensurerobustsystemsremaininplace.
Thereisaprocessofestablishingthequalificationsandensuringthatthepeoplewhoareemployedandworkinthehealthservicehavetheappropriatetrainingandcurrentprofessionalregistrationtopractice.Thisprocessisundertakenatcommencementofemployment(initialapplication)andannuallywhentheregistrationisdueforrenewal.ForNursingstaffthisoccursinApril-Mayeachyear.RegistrationwiththeAustralianHealthPractitioner’sRegulationAgency(AHPRA)isrequired.AHPRAwasformedbyanActofParliamentandisboundbytheHealthPractitionerRegulationNationalLaw(2009)TheNationalLawisinforceineachStateandTerritory.
Defining the scope of clinical practice
AlsoknownasPrivileging,followsonfromCredentialingandinvolvesdelineatingthescopeofanindividualmedicalpractitioner’sclinicalpracticewithinaparticularorganisation.
Department of Health, Victoria, Australia 2011
“To provide an excellent, sustainable, holistic health care service”
[ ] QOC - people12
Sandra Winnen
Food Services Manager
• AppointedNovember,2005.
• Responsibleforthesupervisionofcateringservices,mealsonwheels,foodsafetyplanandliaisonwiththeAuxiliaries.
• CoordinatescateringsupportforoutsideeventssuchasMurraytoMoyneandthePortFairyFolkFestival.
David Lee
BNurs(QUT),MComm(UQ)PGDipCSP,MAICD
Chief Executive Officer
• AppointedJuly,2007.
• ResponsiblefortheoveralloperationofMoyneHealthServices.
• Extensiveexperienceinthearmedforces,nursingandhealthmanagement.
• MemberofSWARHExecutiveCommittee,DepartmentofHealthQualityReferenceCommitteeandCharteredSecretariesNationalPublicSectorGovernanceCommittee.
Dr Bruce Warton RFD
MB,BS,Hons(Monash),BHA(UNSW),FRCSEd,FRCOG,FRANZCOG,FRACMA,AFACHSM,CHE,DTM&H(JCU),GradDipHealthandMedicalLaw(Melb).
Director of Medical Services
• AppointedJanuary,2011.
• Responsibleforassistingwiththedevelopmentofrobustcredentialingandprivilegesandmedicalappointmentsprocesses.
• BrucehasextensiveexperienceasaDirectorofMedicalServicesandinthearmedforces.
• FormerlyDirectorofMedicalServicesatWesternDistrictHealthServiceandGoulburnValleyHealth.
Leigh Parker
BBus(Acc),AFCHSE
Finance and Human Resources Manager
• AppointedMay,2008.
• Responsibleforthemanagementoffinance,informationtechnology,humanresourcesandoccupationalhealthandsafety.
• FormerlyDeputyCEOofTerangandMortlakeHealthService.
• MemberoftheSWARHFinanceCommitteeandtheFMISOracleWorkingGroup.
Fran Kinnersly
R.N.MRCNA
Director of Nursing
• AppointedFebruary,2005.
• Responsibleforthemanagementofclinicalcareservices.
• MemberoftheRoyalCollegeofNursingandanactivememberoftheVictorianSmallRuralHealthServicesDirectorofNursingExecutiveCommittee.
• Franhasextensiveexperienceinacuteandsurgicalnursingandmanagement.
• DeputyChairBarwonSouthWestNursingExecutiveGroup.
• CommitteeMemberofVictorianHealthcareQualityAssociationandPublicSectorResidentialAgedCareExecutiveLeadershipGroup.
mhs executive management
QOCQOC - people [ ]13
Belinda Westlake
BAppSC(HIM).MAE(Melb),FAAQHC
Health Information, Quality and Risk Manager
• AppointedOctober,2002.
• Responsibleforthemanagementofhealthinformation,qualityandriskprograms.
• BelindaholdsthepositionofChairoftheBarwonSouthWestQualityAdvisoryCommittee.
• PresidentoftheVictorianHealthcareQualityAssociation.
• MemberVictorianQualityCouncilPatientTransferGroup.
Glynis Dean
RNCertificateofPeri-operativeServices
Aged Care Services Manager
• AppointedMay,2011.
• Responsibleforthemanagementofresidentialandcommunityagedcareservices.
• Extensiveexperienceincriticalcarenursingandprojectmanagement.
Pauline McGee
RNRM
Primary and Community Care Manager
• AppointedMarch,2008.
• Responsibleforthecoordi-nationofthecommunityhealthcareservices.
• Paulinehasabackgroundinthecommunityhealthcaresectorincludingyouth,women’shealthandcommunityhealtheducation.
• MemberoftheSouthWestPrimaryCarePartnershipExecutiveCommitteeandmemberofRegionalAllianceofmentalHealthPromotion.
Tim Drew
Maintenance Services Manager
• AppointedJune,2011.
• Responsibleforthesupervisionandcoordinationofmaintenanceservices.
• Timisaqualifiedcarpenterandregisteredbuilderwithtwelveyears’experienceintheconstructionindustry.
[ ] QOC - people14
Maintenance Staff TrainingThroughouttheyear,theMaintenancedepartmenthascompletedvarioustrainingprogramsinanattempttoeducatestaffinbestpracticeandkeepskillsuptodateandrelevant.Thedepartmentismadeupoftradesmanandskilledhandymen.Thesecourseschallengestaffandmakethemawareofthepreciousenvironmentweworkin.
“a great deal of training has been given to staff”
AllmaintenancestaffhaveundertakenmandatorytrainingandattendedInfectionControlstudyseminars.Inadditiontothis,agreatdealoftraininghasbeengiventostaff,toensurethesmoothimplementationoftheBuildingandEngineeringInformationManagementSystem(BEIMS).
OneofthemajorimprovementswithintheDepartmentistheknowledgewehavegainedthroughattendingvariousoccupationalhealthandsafetycourses.Thesecoursesinclude:WorkingatHeights,WorkinginConfinedSpaces,HealthandSafetyRepresentativeandElectricalTestandTag.Inaddition,onestaffmemberhasbecomelicencedinhotwaterThermostaticMixingValveservicing.
Allofthetraininghasbeenembracedbystaffandprovidesthemwithsufficientknowledgetoperformmaintenancetasksinasafe,non-threateningmannertoresidents,patients,visitorsandstaff.
QOC - people [ ]15
2011 Staff Service AwardsThisyear’sstaffappreciationawardswereheldon14thOctober2011.Eachrecipientreceivedanindividualinvitationtotheawardsnight.PresidentoftheBoardofManagementofMHSGeoffYoulpresentedthestaffwiththeirawards.Thereweresevenstaff,frombothclinicalandsupportservices,whowererecognisedformorethan15yearsofservice.MHStakesprideinacknowledgingandrewardingit’sstaff,fortheloyaltyandpositiveoutlooktheybringtogethertomakeupthefaceofMHS.
BRONZE MEDALLIONS
LynLeddin 5YearsService
JohnKinnersly 5YearsService
PaulaLee 5YearsService
RobbieLee 5YearsService
JudithChaplin 5YearsService
RosemaryRees 5YearsService
TrudiBaxter 5YearsService
LillianSerong 5YearsService
MelindaPulham 5YearsService
FionaHellier 5YearsService
RebeccaKeane 5YearsService
LucyTaylor 5YearsService
ChristinePatterson 5YearsService
SandraSproal 5YearsService
SILVER MEDALLIONS
AnnVickery 10YearsService
DonnaKelly 10YearsService
JanetDrake 10YearsService
GiroPevitt 10YearsService
DonnaTodd 10YearsService
RachaelCoffey 10YearsService
MichelleArnold 10YearsService
CherylNeate 10YearsService
LaureenBeks 15YearsService
AngelaBrian 15YearsService
RobynHarrison 15YearsService
ShelleyCoffey 15YearsService
GOLD MEDALLIONS and a gift were awarded to
JennyRyan 20YearsService
SusanLane 20YearsService
FrancesKinnersly 25YearsService
[ ] QOC - community16
Where do the people we cared
for come from?MoyneHealthServicesislocatedinthecoastaltownofPortFairywithinMoyneShire,intheSouthWestofVictoria.PortFairyisnamedafteracuttercalled“Fairy”.ItwaspreviouslyknownasBelfast.Settlementoftheareadatesfromthe1830s,aidedbytheearlierconstructionofawhalingstation.
TheMoyneShirewascreatedin1994andcoversanareaofapproximately5,500squarekilometreswithapopulationofaround16,900.
TheareaservedbyMoyneHealthServicesconsistsofthetownsofPortFairy,Yambuk,Koroitandthesurroundingdistricts.Thisareahasapopulationofapproximately5000.
TheMoyneareaishometoawiderangeofservicesandindustry,includinghealthandcommunityservices,dairy,freshfishindustry,pharmaceuticals,manufacturedfoods,seafoodprocessing,quarrying(roadmaterialsandcutbluestone),transportandeducationcentres.PortFairyalsohasabusytouristindustrythatincludesweekend,summerholidaysandspecialeventssuchasthePortFairyFolkFestival.Attimesthisseesustreatingvisitorsfromawiderangeoflocations.
TheAdmissionsgraphshowsthepostcodesofpatientsadmittedtoouracuteservicesduringthefinancialyear2011-2012.
ItisalsointerestingtolookatwherethepeoplewhopresenttoourUrgentCareareacomefrom.Thepictureisalittledifferent.TheEmergencyAttendancesgraphshowsthetownorhomestateofthosewhopresentedtoUrgentCarebetweenJuly2011andJune2012.
TheEmergencyAttendancesgraphreflectstheholidaydestinationcharacteristicofPortFairywithanincreasedpercentageofpresentationsfrompeopleresidingoutsidethetownshipofPortFairy.ItwasinterestingtonotetheincreasedpercentagefromWarrnambool-aneighbouringRegionalcentrewithafullyfundedEmergencyDepartmentatthePublicHospital.
Port Fairy
Warrnambool
Macarthur
Yambuk
Killarney
Koroit
Broadwater
Hamilton
Other Victorian
Interstate
Port Fairy
Warrnambool
Macarthur
Yambuk
Killarney
Koroit
Broadwater
Hamilton
Other Victorian
Interstate
Overseas
Admissions
Emergency Attendances
QOC - community [ ]17
Moyne Shire Community Profile
The2011censusshowed15,955peoplelivingintheMoyneShire.Ofthese100(0.7%)werefromNonEnglishspeakingbackgroundsand143(0.9%)speakalanguageotherthanEnglishathome.Thetop4overseasbirthplacesrankedfromhighesttolowestwere:UnitedKingdom,NewZealand,NetherlandsandGermany-theNetherlandsbeingthedominantnon-Englishspeakingcountryofbirth.
TheIndigenouspopulationoftheShireis190(1.2%).
Peopleovertheageof65makeup16%ofthepopulation.
Source: Australian Bureau of Statistics, 2011 Census Quickstats
Cultural Diversity at Moyne Health
AsaruralproviderofhealthcareMoyneHealthServicesaimstomeetthechallengeofrespondingtoadiverserangeofissuesforserviceuserssuchastheirgeographicisolation,accesstosupportservices,and
lownumbersofCALDconsumers.CulturalresponsivenessisabouthavingaskilledworkforceabletorespondeffectivelytotheneedsofavarietyofconsumersinAustraliansociety.Itisrecognisedthatculturallydiverseconsumersinsmallercommunitiesmayhavehigherneedsduetoisolation.
Cultural Responsiveness FrameworkTheCulturalResponsivenessFrameworkaimstoconsolidatetheachievementsofculturaldiversityactionplansandtoimproveandextendculturalresponsivenessperformance.ItiscloselyalignedwithMHSStrategicPlanningprocessesandalsospecificallyalignedtothedomainsoftheVictorian Clinical Governance Policy Framework,2009.Itisbasedonfourkeydomainsofqualityandsafety:organisationaleffectiveness;riskmanagement;consumerparticipation;andeffectiveworkforce.Therearesixstandardsforculturallyresponsivepractice.
Domain: Organisational effectiveness
Standard 1: ‘A whole-of-organisation approach to cultural responsiveness is demonstrated
• AgencyandAustralianBureauofStatisticsdataisreviewedtoensureservicesareplannedtomeettheneedsofCALDconsumers
During a Typical Week,Moyne Health Services …• Providesover$230,000ofhealthandwell-beingservicestoourCommunity• Treats44EmergencyPatients• Discharges9patientsbacktotheirhome• Providesapproximately40patienttreatmentdaysinhospitalbeds(5-6patientseachday)• ProvidesResidentialAgedCareto520residents(75residentsperday)• Provides96DistrictNursingServicesvisits• Provides207CommunitybasedAgedCareclientvisits
[ ] QOC - community18
• Partnershipswithmulticulturalandethno-specificcommunityorganisationsaredevelopedandco-optedmembersprovideactiveparticipationinPlannedreviewandservicedevelopmentatMHS.
• TheInterpreterpolicyenablespeoplewithalowlevelofEnglishproficiency,orwhouseAuslanastheirfirstlanguage,accesstoprofessionalinterpretingandtranslatingserviceswhenmakingsignificantlifedecisions,orwhereessentialinformationisbeingcommunicated.
• InterpretersymbolsaredistributedtoserviceareasthroughoutMHSfordisplayinentrancesandwaitingareas.
Standard 2: Leadership for cultural responsiveness is demonstrated by the health service
• Trainingopportunitiesareprovidedtostaff
• Allstaffhaveaccesstotheculturaldiversitypoliciesandassociateddocumentationthroughtheonlinepolicysystem.
Domain: Risk management
Standard 3: Accredited interpreters are provided to patients who require one
• Overthepast12monthsinterpreterserviceswereaccessedforanItalianspeakingmaleinpatient.
• 98.9%ofpeopleinPortFairyspeakonlyEnglish.
Domain: Consumer participation
Standard 4: Inclusive practice in care planning is demonstrated, including but not limited to: dietary; spiritual; family; attitudinal and other cultural practices
• Organisationalpolicyandproceduressupportconsumerchoicefortheprovisionofappropriatemeals.
• VPSMreportsindicatedexcellentresultsinthisareap21.
Standard 5: CALD consumer, carer and community members are involved in the planning, improvement and review of programs and services on an ongoing basis
• TheCommunityDiversityCommitteeperformancewasreviewedtomonitorrelevanceandeffectiveness.
• AgaptoberesolvedatthemomentistoincreasemembershipandattendancetoCommunityDiversityCommitteemeetings.
Domain: Effective workforce
Standard 6: Staff at all levels are provided with professional development opportunities to enhance their cultural responsiveness
• StaffhaveattendedCulturalawarenesstrainingoverthelast12monthsOrganisationalpracticesandpoliciessupportculturalresponsiveness.
QOC - community [ ]19
Cultural Responsiveness In Action
Emergency Department
Overthepast12monthsMHSEmergencyDepartmentprovidedtreatmentto2312individuals.Thepie-chartbelowshowsthebreakdownofcountryofbirthforthesepeopleandshowsthecleardominanceofAustralianorigins.
Primary and Community Care Services
PrimaryandCommunityCareServicesincludeAlliedHealthandAmbulatoryServices.Overthepast12months(1July2011-30June2012)CommunityHealthServicesatMoyneHealthServiceswereaccessedby1208recipients.
Recipientsoftheseserviceswerefromfollowingcountries:Australia,England,NewZealand,Scotland,Wales,GermanyNetherlands,India,NorthernIreland,PhilippinesandSingapore.Interpreterserviceswerenotaccessedtodelivertheseservices.
IndividualsaccessingPlannedActivityGroupswereeitherAustralianorEnglishborn.CulturalCelebrationsheldbyPlannedActivityGroupsoverthepast12monthsincluded:
• StPatricksDay
• ShroveTuesday
• IndianLunchduringCulturalCelebrationweek
• AFLGrandFinalCelebrationie:FootyTippingresultsandpresentation
• HighTeafortheQueen’sDiamondJubilee
• “ArmchairridetoChina”-PhotosandstoriesandmemorabiliafromatriptoChina
• ChristmasBreakup,BigCookedBreakfastforclients,staffandvolunteers
• Buffetsupper,reminiscenceforsinglepeoplewithnosignificantothers
Improving care for Aboriginal and Torres Strait Islander Patients
2011ABSCensusDataindicatesthattotalpopulationandhousinginformationconfirmedthat3,094peoplepermanentlyresidedwithinPortFairy.
Ofthese,17residentsidentifiedthemselvesasbeingAboriginalorTorresStraitIslanders.TosupportAboriginalandTorresStraitislanderhealthoutcomes,MHSiscontinuingtoimproveserviceaccessforthisgroup.WorkingcollaborativelywithregionalAboriginalLiaisonOfficersand“ClosetheGapProject”CoordinatorsisfundamentaltoassiststafftoidentifyandaddressgapsandbarriersinreferralpathwaysforAboriginalandTorresStraitIslanderpeopleinourregion.Thesepartnershipssupportstafftodeveloptheskillsrequiredtoundertakeculturallyappropriateassessmentstosupportdeliveryofculturallyappropriate,timelyandcoordinatedservicestoAboriginalandTorresStraitIslanderfamilies.
Australia
England
New Zealand
Netherlands
USA & Canada
Ireland
Singapore
Other
What we know about our community
Country of Birth
Non-Indigenous (3094)
Indigenous (17)
[ ] QOC - quality & safety20
Accreditation - External review of quality, safe care
Accreditationisasystemtopromoteandsupportsafepatientcareandcontinuousqualityimprovementofhealthservicesthroughaprocessofregularassessmentandreview.Byitselfaccreditationdoesnotensurethesafetyandqualityofhealthcareprovidedtopatients.However,accreditationiseffectiveaspartofanimprovementsystembecauseitcanverifythatactionsarebeingtaken,thatsystemdataandinformationarebeingusedtoinformtheanalysisofissuesandprogramsolutions,andthatsafetyandqualityimprovementisbeingachieved.
ACSQHC 2011
Externalaccreditationprogramsprovidetheopportunityforustohaveanindependentreviewofhowwellweprovidequality,safecare.Itisanopportunitytomeasuresafetyandqualityofcareandservicesthroughtheeyesofexternalexperts.
AtMHSweparticipateinanumberofaccreditationprogramstocoverthewiderangeofservicesthatweoffer.Thereareseveralexternalbodiesdeliveringaccreditationprocessesdesignedtoassessthecareweprovideandensurethatitissafeandeffectivewhenmeasuredagainstnationallysetstandards.
Theaccreditationprogramsinvolvetrained,externalassessorsvisitingourHealthServicetomeasurethestandardsofcareandserviceprovided.Thestandardsassessedspanacrossclinicalareasincludingacute,agedcareandprimaryandcommunitycareandnon-clinicalareassuchasmaintenance,foodservices,cleaning,financeandadministration.
TheAustralianCouncilonHealthcareStandards(ACHS)istheaccreditingbodyresponsibleforaccessingMHSasawhole.ACHSsurveyorslookatservicesacrossthewholeorganisationincluding:AcuteCare,ResidentialAgedCareandPrimaryCare.TheyusetheEvaluationandQualityImprovementProgram(EQuIP)standardsandcriteria.WealsoparticipateintheAgedCareAccreditationProgram.
TheAccreditationprocessesforHealthServicesacrossAustraliaisabouttoundergosignificantchange.TheAustralianCommissionforSafetyandQualityinHealthCaredevelopednewaccreditationstandards-“theStandards”followingextensivepublicandstakeholderconsultation.TheStandardsareacriticalcomponentoftheAustralianHealthServicesSafetyandQualityAccreditationSchemeendorsedbytheAustralianHealthMinistersinNovember2010.
TheStandardsprovideanationallyconsistentanduniformsetofmeasuresofsafetyandqualityforapplicationacrossawidevarietyofhealthcareservices.Theyproposeevidence-basedimprovementstrategiestodealwithgapsbetweencurrentandbestpracticeoutcomesthataffectalargenumberofpatients.TheStandardsaredesignedtoassisthealthserviceorganisationstodeliversafeandhighqualitycare.
TheBoardofManagementofMoyneHealthServiceshavemadethedecisiontoproceedwiththeAustralianCouncilonHealthcareStandards(ACHS)forhospitalaccreditationsurveysandhaveelectedtoparticipateinthe“EQuIPNational”program.ThiswillseeMHSparticipatinginaPeriodicReviewsurveyinJune2013usingtheEQuIPNationalstandards.
ThepastyearhasbeenrelativelyquietinrelationtoAccreditationvisits.Thedetailedresultsandscheduledreviewsareoutlinedinthetableabove.
TYPE OF ACCREDITATION OUTCOME
AustralianCouncilonHealthcareStandards
OrganisationWideSurveyApril2011
ExcellentResultswithongoingaccreditationachieved
Periodic Review June 2013
HomeandCommunityCare(HACC) NofurthercontactsinceoursuccessfulreviewoftheDistrictNursingServiceswasconductedinconjunctionwiththePeriodicreviewinApril2009.
Likely review with Periodic Review June 2013
CACPsandEACHReview SuccessfulreviewlookingatCACPsandEACHstandardswasachievedinNovember2011
AgedCareAccreditation-
BelfastHouse
MoyneyanaHouse
Accreditationsuccessfullymaintained-nounannouncedvisitsinthepast12months
AgedCareSiteAuditscheduledfor18thand19thSeptember2012
QOC - quality & safety [ ]21
The Victorian Patient Satisfaction Monitor - Measuring Quality and Safety
TheVictorianPatientSatisfactionMonitor(VPSM)hasbeendevelopedbytheDepartmentofHealthtoassisthospitalstoimproveservicesandpatientsatisfaction.Itisasurveythataskspatientsabouthowtheyfeltabouttheirhospitalvisit.ResultsfromtheVPSMsurveyareusedbyhospitalstoidentifywaysthattheycanimprove.AstandardisedquestionnaireissenttoallMoyneHealthServicespatientsiftheyhaveagreedtoparticipate.TheinformationisthencompiledbyUltrafeedback,thecompanycontractedbytheDepartmentofHealthtocollect,analyseandreportthedata.
TheinformationthatwereceivebackfromVPSMresponsesisusefultoassistwithmonitoringthequalityofthecareandservicesthatweprovide.Thereportsreceivedprovidedetailsthatallowustoprioritiseareasforfurtherworkandalsotoacknowledgetheareasthatwearedoingwellandtopassthisinformationontostaff.Thegraphshowsthe
overallinformationthatwereceive.ThesearethemostrecentresultsthathavebeenreceivedfromUltrafeedbackandtheDepartmentofHealth.Thesummaryreportstates:
“Patients were very satisfied with most aspects of their stay at Moyne Health Services. The Hospital is typically performing above D Category average. Specifically, Moyne Health Services scored statistically significantly higher than the Category D average in the most recent survey for the Overall Care, General Patient Information, Treatment and Related Information, Complaints Management and Discharge and Follow-up Indices and the Consumer Participation Indicator”.
“…the majority of patients reported that they were helped a great deal by their
stay in hospital and felt that the length of time spent in hospital was about right.”
Whenwecomparetheseresultswithprevioussurveys,themostsignificantvariationisadramaticimprovementintheDischargeandFollow-upindicatorwherethesatisfactionratingraisedfromarateof86to89increasingthegapbetweenthelevelofsatisfactionatMHSandthatatothersimilarsizedfacilitiesandallfacilitiesaroundVictoria.
Thequestionnairehasthreequestionsthatareconsideredtomeasurethepatient’s“overallhospitalexperience”.Theseare:
• Thinkingaboutallaspectsofyourhospitalstay,howsatisfiedwereyou?
70
75
80
85
90
95
Moyne Health Similar Hospitals - average Average - ALL Victorian Hospitals
Access andAdmission
ComplaintsManagement Discharge &Follow-up
ConsumerParticipation
Overall CareGeneral Pt Info Treatment Info
Physical Enviro MoyneHealth
SimilarHospitals-Average Average-ALLVICHospitals
22
• Howmuchdoyouthinkyouwereactuallyhelpedbyyourstayinthehospital?
• Wasthelengthoftimeyouspentinhospital…?(toolong,tooshort,aboutright)
ThetablebelowshowsthecurrentandpreviouswavemeanscoresforoverallsatisfactionforMHS,aswellasthecurrentwavemeanscoresforoverallsatisfactionforsamecategoryhospitalsandforthestate-widesample.
Thecategoryorstate-widescoreiscolouredorangeandshaded,whichindicatesthatthecorrespondingscoreforMHSis(statistically)significantlyhigher.
Resultswereverygoodandweresupportedbythefollowingcomments:
“Friendly, approachable staff, excellent on call doctor. Wasn’t in my home town (arrived via ambulance) but still had excellent care, follow up phone call from doctor with blood test results.”
“My family and I were so pleased to see that there are still hospitals like this around. This is the way hospitals should be like!”
AtMHSwefindtheVPSMprovidesuswithveryusefulinformationandagreatdealofdetailabouthowourpatientsfeelaboutthecareandservicesthatweprovide.Wewillcontinuetousetheseresultstoidentifyourweakerareasandtoprogressivelyimproveacrossallareas.
0
20
40
60
80
100
MEAN SATISFACTION
MHS WAVE 21 MEAN 4.83
MHS WAVE 20 MEAN 4.63
CATEgORY D WAVE 21 MEAN 4.73
CATEgORY D WAVE 20 MEAN 4.52
Thinking about all aspects of your hospital stay, how satisfied were you?(where1=Verydissatisfiedand5=Verysatisfied)
QOC[ ] QOC - quality & safety
Satisfaction with Residential
Aged Care Services
ThelevelofsatisfactionwithourResidentialAgedCareServicesisconstantlybeingmonitored.BothAgedCareHomes-BelfastHouseandMoyneyanaHouseholdregularResidentmeetingstoensurethatthelinesofcommunicationarekeptopen.Thesemeetingsprovideanopportunitytotalkaboutwhat’shappeninginthehomesandtodiscussanyconcernsthatresidentsmayhave.ItisalsoquitecommonforhealthservicestafftoattendthemeetingstoprovideanupdateaboutspecificissuesforexampletheFoodServicesManagermightattendtotalkaboutmenuupdates.
BothHomesalsoparticipateinanannualsatisfactionsurveywhichtakesacomprehensivelookathowhappyresidentsarewithallaspectsofthe
careandservicesprovided.Thegraphbelowshowstheresultsfortherangeofquestionsanswered.Theresultswerepleasingwiththeoverallsatisfactionratingachievingascoreabove90%satisfied.
Theresultsthatwereceiveareusedinplanningandeffortsaretakentoimproveinourweakerareas.Wealsocompareourresultswiththeresultsachievedatsimilarorganisations.ThisisdonethroughourmembershipwithQualityPerformanceSystems(QPS)andwereceivereportsbackthatshowhowweareperformingcomparedtootherplaces.ThegraphbelowisforMoyneyanaHouseandshowsthatourresultscorrespondwiththoseofothersimilarfacilities.BelfastHouseachievedsimilarresults.
10.OverallV
iews
oftheHom
e
9.MaintainingC
omm
unityC
ontact
8.ResidentServices-Environm
ental
7.ResidentServices-Food
6.ResidentServices-Medical,
TherapyandPersonal
5.TheHom
e’sCom
fortandSurroundings
4.YourAccom
modation
andLivingArea
3.InvolvementandSocial
Environment
2.Activities&
PassingTim
e
1.ServicesReceivedfrom
CareStaff
Moyneyana: 87.33 Minimum Mean Maximum
100
80
60
40
20
0
Resident Satisfaction - Section Results - Total % ScoreBelfast House 2011 - Results (Average Percentage Score)
Resident Satisfaction Index
QOC - quality & safety [ ]23
About the People Matter Survey
ThePeopleMatterSurveyisaclimateandopinionsurveythatcollectsdataonemployeeperceptionsofthevaluesandprinciplesappliedintheirworkplace.TheSurveyalsogathersinformationonabroadrangeofpeoplemanagementissuessuchasemployeecommitmentandjobsatisfaction.
ForVictorianpublicsectororganisations,thevaluesandprinciplesappliedwithintheorganisationmustreflectthepublicsectorvaluesandemploymentprinciplesoutlinedinthePublic Administration Act 2004 (PAA).ThesevaluesestablishthenatureoftherelationshipbetweenGovernment,thecommunityandworkcolleaguesandextendtoeverythingwedo.
SomeMoyneHealthServices(MHS)staffparticipatedinthisyear’ssurveyalthoughweonlymanagedalow19%responseratemakingitdifficulttodrawvalidconclusions.FromtheinformationgatheredMHSperformedstronglyinsomeareasandtherewereareasforimprovementidentified.
Our disappointments, where we scored in the lowest quartile of the result, were in the following areas:
• Values
• Responsiveness
• Integrity
• EqualEmploymentOpportunity
• Genderisnotabarrier(indicated that it was)
• Intentiontoleave
• JobSatisfaction
• Fairpay
• Jobsecurity
• Overalljobsatisfaction
Our pleasing results where we achieved scores in the highest quartile were in the following areas:
• AwarenessofOrganisationalPoliciesandProcesses
• YourExperiences
• JobSatisfaction
• RegularFeedback/recognition
• Abilitytoworkonowninitiative
• PatientSafety
• Workplacewellbeingandcommitment
• Principles
• Merit,FairandReasonableTreatment
• Values
• Impartiality
• Leadership
Therewasawiderangeofresultsandthereappeartobesomeinconsistencies.TheseresultswillbelookedatinconjunctionwithEmployeesatisfactiondatatodeterminewhatareasneedfurtherwork.
QOC
Staffsocialisingaftermuchhardwork,ataPost-accreditationcelebration
24
Ensuring Quality and Safety through Risk Management
MoyneHealthServices(MHS)recognisesthattherearerisksinherentacrossallareasofbusinessanditisourorganisation’spolicytoachieve‘bestpractice’inidentifyingandcontrollingalltheriskstowhichitmaybeexposed.
Riskisthechanceofsomethinghappeningthatwillhaveanimpactonourobjectives.TheMHSRiskManagementPolicydefinesRiskManagementas“coordinated activities to direct and control an organisation with regard to risk”.Wemanageorganisationalriskstominimiseanynegativeimpactontheachievementofourobjectivesandtomaximiseourabilitytorealisepotentialopportunities.
AlllevelsofstaffatMHShaveresponsibilitiesassociatedwiththemanagementofrisk.Thisprocessspecifiestheriskresponsibilitiesofdifferentgroupsandindividualsthroughouttheorganisation.TheBoardofManagementandExecutiverelyonhavingaccesstodetailedandcurrentriskinformationtoassistthemtomakemoreinformeddecisionsregardingstrategicdirectionandoperationalobjectives.
AtMHSRiskManagementisintegratedintoexistingbusinessprocessessuchasplanning,qualitymanagementandinternalaudits.Theobjectivesofariskmanagementframeworkareto:
• Provideasystematicapproachtotheearlyidentificationandmanagementofrisksallowingustomeetpublicinterestobligationsandbusinessobjectives;
• ProvideconsistentriskassessmentcriteriatakingintoaccountMHS’sriskappetite;
• Makeavailableaccurateandconciseriskinformationthatinformsdecisionmakingandbusinessdirection;
• Adoptrisktreatmentstrategiesandcontrolsthatarecosteffectiveandefficientinreducingrisktoanacceptablelevel;and
• Monitorandreviewrisklevelstoensurethatriskexposureremainswithinanacceptablelevel.
Benefits
Riskmanagementprocessesareinplacetosupportustomeetourvaluesanddeliveronourobjectives.Applicationofaconsistentandcomprehensiveriskmanagementprocesswill:
• Increasethelikelihoodofusachievingourstrategicandbusinessobjectives;
• Encourageahighstandardofaccountabilityatalllevelsoftheorganisation;
• Supportmoreeffectivedecisionmakingthroughbetterunderstandingofriskexposures;
• Createanenvironmentthatenablesustodelivertimelyservicesandmeetperformanceobjectivesinanefficientandcosteffectivemanner;
Safeguardourassets-human,propertyandreputation;and
• Meetcomplianceandgovernancerequirements.
ThelastyearhasseensomesignificantachievementsinRiskManagement.Theseinclude:
• EnhancingreportingandaccountabilityprocessesthroughtheAuditandRiskCommitteetotheBoardofManagement
• ImproveddocumentationfortheongoingmonitoringandreviewofRisksontheRiskRegister
• Achievingahighlevelofcomplianceinourannualself-assessmentoftheRiskManagementProgram
• Achievinga“VeryGood”(Highest)ratinginourVMIASiteRiskSurvey(SRS).
[ ] QOC - quality & safety
NEEDS IMPROVEMENT ADEQUATE gOOD VERY gOOD
Recommendationsmadewithrespecttocontrollingortreatinghighorextremerisks,orasignificantnumberoflowormediumlevelrisksand/oranumberofoutstandingtreatmentrecommendations
Thesitedemonstratesriskmanagementsystemswithasignificant,ornumberof,risksrequiringtreatmentoradditionalcontrols
Thesitedemonstrateseffectiveriskmanagementwithmostriskappropriatelycontrolledwithaminorrecommendationshavingbeenmade
Thesitedemonstrateseffectiveriskmanagementwithrisksappropriatelycontrolledandfewornorecommendationshavebeenmade
Summary of ObservationsPortFairyHospitalhasachievedanoverallSRSratingofverygood.
MoyneHealthServicesPortFairyHospitalFINALSRS.doc©VMIA2012
25
Safe Medication Management across MHS
AtMoyneHealthServicesweaimtoprovideconsistentsafemedicationmanagementacrossallareasofthehealthservice.Medicationmanagementhasbeenwidelyreportedasanarearesponsibleforahighnumberoferrorsandadverseeventsduringhealthserviceadmission.1.6percentofhospitaladmissionsarereportedtobeassociatedwiththeoccurrenceofanadversemedicinesevent,andmedicinesareconsideredtobethecausalagentof10percentofalladverseeventsexperiencedinHospitals.
Medicationadministrationisamultidisciplinaryprocess,beginningwhenthemedicalpractitionerdecidestoprescribemedication,continuingwiththewritingofthemedicationchartandthedispensingofthemedicationfromthepharmacy,andendingwiththepreparationandadministrationofthemedicationtothepatient.Errorsmayoccuratanystageintheprocess.
MostmedicationadministrationrelatederrorsatMHSare:
• Signatureomissions(28%ofallreportedmedicationincidents)-themedicationwasgivenbutnotsignedfor,or
• Omitteddose-medicationmissedornotadministeredattheduetime.
Therewerealsosomeincidentsreportedinvolving
• Medicationgivenatthewrongtime
• Wrongdosegiven(oftenfollowingachangeindose)and
• Documentationcalculationerror-incorrecttotalling(miscount)ofthedangerousdrugregister(remainingstock)andtranscribingerrorsfromonepagetothenext
ThePieChartbelowdemonstratestheareasthatmostoftheincidentsoccur.Itshouldbenotedthatsignatureomissions-wherethedrugwasgivencorrectlybutthedocumentationwasnotcompleted,isthemostcommonerrorinBelfastHouse.
WealsoreceivefeedbackfromhospitalpatientsaboutthecarearoundmedicationsthroughtheVictorianPatientSatisfactionMonitor(VPSM)-asurveysentouttopeopleaftertheyaredischargedhome.Therearetwoparticularquestionsrelatingtomedicationmanagement:“Explanationofpurposeofmedicines”and“Explanationofside-effectsofmedicines”thatareillustratedinthegraphbelow.
Medication Management
Policyandproceduresareimplementedacrossourservicestosupportanddirectsafedeliveryofmedicationstoourpatientsresidentsandserviceusers.Toensurethepoliciesandproceduresarereflectiveofcurrentandsafepractices,referencesfromsuchsitesastheAustralianCommissiononSafetyandQualityinHealthCare,BestPracticeModeldevelopedbytheAustralianPharmaceuticalAdvisoryCouncilandtheNursingandMidwiferyBoardofAustraliaareusedwhenreviewingandrevisingthecontentanddirectivescontainedwithinthepolicies.
Staffareprovidedwithtrainingeachyear.WehaveengagedtheservicesofRuthGreentoprovide“inhouse”professionaldevelopmentdaystodeliverevidencebasedfactsandchallengeourstafftoimprovetheirknowledgeandpracticeintheadministrationofmedications.Staffcompleteanannualon-linemedicationcompetencytorefreshtheirknowledge.TheSOLLEsystemallowsustoenrolourstaffintoonlinecompetenciesandallowsthemanagerstomonitortheprogressofstafftowardsthecompletionoftheircompulsorycourses.Therearealsoothercoursesofinterestavailable.StaffalsohaveaccesstoAgedCareChannelrecordedprogramsthatcoverpharmacologyandadministrationofmedicationsforallstafffromRNstoPCAs.Staffhaveaccesstocurrentdrugreferences/textse.g.TherapeuticGuidelines,AustralianMedicationHandbook,tonameacouple.Theseareavailablebothashardcopybooksandonline.Newlyqualifiedstaffhavesupervisedmedication“rounds”untiltheyhavebeenassessedascompetentbyourClinicalNurseEducator,tomanagedmedicationadministrationwithoutdirectsupervision.
Intheeventofanincidentoccurring,wehaveanonlinereportingsysteminplace,‘Riskman’.Staffeitherself-reportorwhenfoundtheincidentisreported.TheUnitManagerisalertedbyemailthatanincidentrequiresinvestigation.Theinvestigationprocessorreviewoftheincident,ispartofourcontinuousimprovementprocesswherethepersoninvolvedmayexplainthecircumstancesthatwereinvolvedandthatledtothe
Acute
Belfast House
Moyneyana House
Other areas
0
1
2
3
4
5
Latest Survey Previous Survey Similar Hospitals Average forVictoria
QOC - quality & safety [ ]
PurposesofMedicines SideEffectsofMedicines
TheresultsshowthatMoyneHealthServicesisconsistentlyperformingbetterthansimilarfacilitiesandbetterthantheaverageforVictorianHospitalintheopinionofthepatientswhocompletedthesurveys.
Location of Incidents
incidentoccurring.Thefocusoftheinvestigationistopreventtheincidentbeingrepeatedagain.Theresultoftheinvestigationprocessallowsustotightenourprocessesifagapisrecognised.Dependingontheoutcomesoftheinvestigation,areviewofthemedicationmanagementpoliciesandproceduresorstaffcounsellingandeducationmaybetheendresult.
Safety Initiatives in Age Care Medication Management
InResidentialAgeCareaRegisteredNurseisresponsibleforthemedicationmanagementportfolio.ThisensurescontinuityforstaffandprovidesaresourcepersonforstudentnursesandGraduateNursestoutilise.
InconjunctionwithourlocalPharmacist,fromMcLean’sPharmacy,whoperformsrandomMedicationChartaudits,theAgeCareNurseUnitManager(NUM)meetswiththePharmacisttoconductCollaborativeResidentialMedicationReviews.ThesearereviewsonrandomlyselectedResident’smedications.Medicationsthathavebeenprescribed
arereviewed,thecombinationsofmedicationsandanysideeffects,recommendationsarethenmade.TheprocessconsiderstheResident’scompleteportfolioofprescribedmedications.Thefindingsarethenpassedontotheirdoctorforreviewandcommentasrequired.
Medicationchartsareauditednightlyforsignatureomissions,residentinformationdetailsandprescribingdocumentation.TheseauditshaveassistedustoreduceourreportedMedicationincidentnumbers.
TheintroductionofMedicationexpiryauditsallowsus,eachmonthtocheckthatallmedicationsthatareopened(Eye-drops,Medicines,Creamsetc.)arelabelledwitha‘date’openedsticker,sothatstaffcanidentifyexpiredstockanddiscard.ThisensuresthatResidentsarenotreceivingexpiredmedications.
TheintroductionoftheResidentindividualmedicationordercharthassuccessfullyaidedinthepreventionofoverorderingofResident’smedications.Italsoensuresthatthereisacontinuoussupplyofmedicationsrequired.
Policyandprocedurespertainingtomedicationmanagementareregularlyreviewed.Theseandaccompanyingprotocolsareinplaceandareconsistentwithlegislativerequirements,nationaljurisdictionalandprofessionalguidelines.Wecontinuetoprovideeducationalopportunitiesforcaregiverstoupgradetheirmedicationqualificationsandthereisasysteminplacetoverifythattheclinicalworkforcehavemedicationcredentialsappropriatetotheirscopeofpractice.
[ ] QOC - quality & safety26
Prevention and Minimising of FallsFalls are a common public health problem, becoming increasingly more frequent with increasing age. Although falls can occur at all ages, they become particularly problematic for older people or those from high falls risk populations when compounded by an acute health problem requiring hospitalisation, or for those requiring admission to residential care settings.
Victorian Quality Council, 2004.
PhysiotherapistshaveanimportantroleinminimisingtheoccurrenceoffallsatMHSbyidentifyingfactorsthatmaycontributetoafallandimplementingstrategiestopreventfalls.Strategiesmayincludeprescribingexercisestoimprovemusclestrengthandbalancereactions,prescribingagaitaid(walkingstickorwheeliewalker)tocompensateforanybalancedeficit,oralteringthehomeenvironmenttoremoveanyhazards.Manyfallsarealsobehaviourrelated,soitisimportantforindividualstobeawareoftheircapabilitiesandlimitations.
Fallsareaparticularchallengeinresidentialagedcarefacilitieswhereagerelatedriskfactorsareinevitable.AtMoyneHealthServices,thephysiotherapistvisitsallresidentsinMoyneyanaHouseandBelfastHouseshortlyaftertheiradmissiontoassesstheirbalanceandmobility.Acareplanisthenputinplaceoutlininghowmuchassistancetheseresidentsrequirewiththeirmobilitytasks.Residentsareencouragedtodoasmuchastheycanforthemselvesinordertomaximisetheirphysicalabilities,butstaffareavailabletoassistincaseswheresafetywouldotherwisebecompromised.Eachresidentisreviewedatleasteverysixmonthswherethisassessmentprocessisrepeatedsothattheplancanbeupdatedifanychangeisdetected.Thiscareplanalsoincludesanexerciseprogramthattheresidentmayperformtoimprovetheirbalancecapability.
InMoyneyanaHouse,alowerlimbstrengthandbalanceexerciseclassisconductedonaweeklybasis.Thistargetseachmusclegroupinthelowerlimbsandalsoaimstochallengetheresidents’
balance.Residentsarealsoencouragedtowalkforexercise,andhaverecentlybeenmotivatedbya‘WalkaroundVictoria’programwheretheircumulativedistancewasplottedonamap.Thisthemewasthentiedintotheirweekly‘FriendshipGroup’whereresidentsdiscussedthetownsandotherdestinationsthattheyhadtheoreticallyreachedalongtheway.
Forresidentsinthecommunity,anoutpatientphysiotherapyserviceisavailabletothoseeligibleforHACC(homeandcommunitycare)funding.Thisincludespeoplewhoareelderly,frail,haveadisabilityorcareforsomebodywithadisability.Thisservicealsoinvolvesanassessmenttoidentifyfactorsthatmayincreasetheriskofafallandstrategiestoaddressthesefactors.Ifappropriate,areferralmaybemadeforindividualstoattendthecommunitygymwheretheycanhaveaccesstoequipmenttohelpimprovetheirlimbstrengthandbalanceinagroupenvironment.
Progress with Falls Management in Residential Aged Care
Ourfallsmanagementprogramisfocussedonminimisingthenumbersoffallsandalsotheinjuriesthatresultfromfalls.Therearemanystrategiesinplacetoassistustoachievethisandwehavebeenabletomaintainalowlevelofinjuriesresultingfromfallsthemostcommonbeingskintears,orsmallcutsthatmayrequireabandaid.WecompareourperformanceinthisareawithotheragedcarefacilitiesacrossAustralia.Ourresultshaveconsistentlyshownthatwehavelessfallsthanaverageandlessinjuriesthanaverage.Wehavemaintainedtheseresultsforanumberofyears.
Thegraphbelowshowsourfallsincidentsforthepastthreeyears.Wemust
rememberthatfallsincludefoundsittingonthefloorandanymovementdownwardandsoattimeswillinclude“falsepositives”sosomeoccurrencesthatwerenotactuallyafall.
Someofthesefallsarerecordedwhenresidents“rolloutofbed”.Toassistinreducingtheseverityoftheseincidentsfloorlinebedsareprovidedforhighfallsriskresidents.TherecentacquisitionofthreenewfloorlinebedsinBelfastHousehasincreasedthenumberofatriskresidentsusingthesebedsandreducedthelikelihoodofharmfromafall.
Wecontinuetoreviewcareplansandconductfallsriskassessmentstoensureallappropriatepreventativemeasuresareinplace.WealsoworkwithourPhysiotoeducatestaffandresidentsregardingfallsmanagement.Residents’mobilityispromotedthroughvariousprogramssuchastheMoyneyanaMovers,walkinggroupandtheWalkaroundVictoria
“Falls are a common public health problem, becoming increasingly more frequent with increasing age”
QOC - quality & safety [ ]27
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[ ] QOC - quality & safety28
Enhancing Pressure Area Prevention
Pressureulcersarealargelypreventableadverseoutcomeofahealthcareadmission.ResearchindicatesthatPressureinjuriesarethefifthmostcostly,commonlyoccurring,preventablecondition.TheimportanceofpressureinjurypreventionandeffectivemanagementofpressureinjurieswhentheydooccurhaspromptedtheinclusionofStandard8:PreventingandManagingPressureInjuries,inthenewNationalSafetyandQualityHealthserviceStandards.
Bothstaffandpatientshavearoletoplayinpressureulcerprevention.Patientsareincreasinglyencouragedtobemoreinvolvedintheirowncare.Developingpatientawarenessoftherisksofpressureinjuriesanddevelopingcareplansinpartnershipwiththem,canimprovecompliancewiththecareplanandminimisepressureinjuries.
Apressureinjuryisasore,anareaofskinthathasbeendamagedduetounrelievedandprolongedpressure.TheterminologyvariesfromPressureUlcertoPressureInjury,PressureInjuryisinlinewithnationalandinternationalmovestorecognisethatulcersareonlyoneformofapressureinjury.Pressureinjuriesare
usuallyfoundonbonypartsofthebody,butcanoccuralmostanywherethatpressurehasbeenappliedforaperiodoftime.
TheVictorianQualityCouncildeveloped‘Move,Move,Move’and‘PreventingPressureUlcers-aninformationbookletforpatients’toimproveconsumerunderstandingofpressureulcerpreventionandmanagement.ThisinformationisprovidedintheadmissionpackgiventoeverypatientandresidentadmittedtoMoyneHealthServices.
MoyneHealthparticipatesinthePressureUlcerBasicsonlinetraining,conductedbytheVictorianQualityCouncil.StaffcompletetheonlinepressureulcertrainingpackagesthroughourSOLLEeducationprogram.
OnadmissiontoMHS,allpatientsandresidentsarethoroughlyassessedtodeterminetheirriskofdevelopingapressureulcerduringtheirhospitalstay.Wherethereisahigherrisk,morepreventativemeasurescanbetakenbythenursingstafftoimproveoutcomesandreducepressureulcers.
Nursingstaffusearangeofspecialequipmenttohelpreducethepressureulcerrisksuchas:airordynamichighdensitymattresses,pressurerelievingcushionsandheelwedges.Patients
andresidentsareencouragedtokeepasactiveastheirconditionallows,andareencouragedtohaveregularpositionchangesduringtheirstay.
MoyneHealthServices-BelfastHouserecordedonepressureulcer(December2011)inthelast12months.Nursinginitiativestotreatthisincludeduseofairmattressandregularpositionchangesinbedoftheresident.TherearecontinualeffortsincludinglookingatequipmentandinnovationstoalleviatepressureareastoourResidents.
AsamemberofQualityPerformanceSystemsbenchmarkingprogram,wecompareourperformanceinPressureUlcermanagementwithothersimilarfacilitiesacrossAustralia.Weareproudtohaveonceagainachievedexcellentresultsacrossallfacilitiesandhavemaintainedthisresultforseveralyears.
Preventing Pressure Ulcers
Whatcanyoudo?
MOVE, MOVE, MOVE
Thebestthingyoucandoisrelievethepressurebykeepingactive,andchangingyourpositionfrequently,whetheryouarelyinginbedorsittinginachair.Ifyouareunabletomoveyourself,thestaffwillhelptochangeyourpositionregularly.Specialequipmentsuchasairmattresses,cushionsandbootiesmaybeusedtoreducethepressureinparticularplaces.
LOOK AFTER YOUR SKIN
Keepyourskinandbeddingdry.Letstaffknowifyourclothesorbeddingaredamp.Tellstaffifyouhaveanytendernessorsorenessoverabonyareaorifyounoticeanyreddened,blisteredorbrokenskin.Avoidmassagingyourskinoverbonypartsofthebody.Useamildsoapandmoisturizedryskin.
EAT A BALANCED DIET
Wanttoknowmore?
Askyournurseorhealthcareprofessional.
Department of Human Services, Victoria Victorian Quality Council
QOC - quality & safety [ ]29
Blood Management - the gift of lifePatientbloodmanagementencompassessafepracticefortheuseofbloodforapatient.Itisindividualisedcare,whichhasthepatientsafetyatthecentre,withcarefulattentiontocorrectdetailandprocedures,theaimbeingbettertreatmentoutcomes.
TheBloodMattersProgramisaVictorianStateGovernmentprogramforimprovingthequalityandsafetyofhospitaltransfusioncaretopatients.Qualitymanagementintheclinicaluseofbloodcomponentsinvolvesadministeringtherightquantityoftherightcomponentintherightwayattherighttimetotherightpatient,withadequatedocumentationofbothprocessandoutcomes.MoyneHealthServiceactivelyparticipatesintheBloodMattersProgramandmonitorscompliancewithprocesseswhenmanagingbloodproducts.Thisensureswehaveanddemonstratethesystemsinplacetopreventerrorsinbloodmanagement.InadditionMoyneHealthServicesparticipatesinmonitoringperformancewhenmanagingbloodbyreportingresultsasauditedviatheACHSClinicalIndicatorsprogram.
AllRegisteredNurses,priortoparticipatinginanypartofthebloodtransfusionprocessmustsuccessfullycompletethenationaleducationprogram‘BloodSafee-learning’developedbyclinicalexpertsintheareaoftransfusion.
MoyneHealthServicesprovided68bloodtransfusionsepisodesina12monthperiod(July2011-June2012).In2011-2012MoyneHealthServiceshashadanincreaseof59%moretransfusionepisodeswherebloodhasbeentransfusedtopatientsatMHSincomparisontothe2yearsprevious.
MHSdatacollectionandmonitoringofthetransfusionprocessusedconsistentclinicalindicatorsforaccreditationpurposesatStateandNationallevels.Someoftheclinicalindicatorsmonitoredinclude:
• Clinicalandlaboratoryindicationsfortransfusion
• Appropriatepatientidentificationpriorandduringtransfusion
• Pre-transfusiontesting;observationandidentitychecksandposttransfusionobservation
• Bloodwastage(unitsunabletobetransfused)
• Reportingofadverseevents
Auditresultswhenmeasuredagainstthe“Better,Safer,Transfusions”criteriaareillustratedbelow:
2011-2012resultsasdemonstratedinthegraph:
• PatientConsentsigned:100%
• BloodWastage:nounitsofbloodwerewastedorreturnedtobloodbank(100%usagecompliance-improvementarea)
• Clinicalandlaboratoryindicationsfortransfusion:metcriteria97%oftransfusionepisodes(x2didnothaveapre-transfusionrecordedhaemoglobinlevel)
• Nursingdocumentationpre-transfusion:100%compliance
• Correctprocessmaintainedforpatientidentification:100%compliance
• Nursingdocumentationduringtransfusion:100%compliance
• Nursingdocumentationposttransfusion(completed):98%compliance(improvementarea94%to98%)
OftheRegisteredNursesthatparticipatedinthebloodtransfusionmanagementprogram,100%haveattendedthemandatoryonlinebloodtraining(BloodSafeeLearning)requiredpriortomanaginganypartofthebloodtransfusionprocess.BloodSafeeLearningAustraliaisAustralia’smostrecognisedonlinecourserelatingtoclinicaltransfusionpracticeincludingbloodspecimencollection,transportation,useandpatientbloodmanagementandaimstoimproveclinicaltransfusionpracticeandpatientbloodmanagement.
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Correct indications
[ ] QOC - quality & safety30
Preventing and Controlling Health care related Infections.
TheinfectioncontrolprogramatMHSisdevotedtomaintainingthesafetyofallpatients,residents,healthcareprofessionalsandthesurroundingcommunitybyprotectingthemagainstinfectiousdiseases.Toassistindeliveringasuccessfulprogram,itisvitalthattheprocessofidentifying,preventingandimplementingcontrolmeasuresisutilisedandmaintainedinordertoreducetheriskofinfectiontransmission.
hand hygieneHandhygienecompliancecontinuestobeoffocusatMHS.ItiswellresearchedandrecognisedbytheWorldHealthOrganisationgloballythathandhygieneplaysasignificantroleinpreventingthetransmissionofinfection.Itisasimplemeasurethatwhenperformedcorrectlycanreducetheriskofinfectionandillness.MHSHandHygieneauditoutcomesareallreportedtotheDepartmentofHealthwiththeexpectationthattheAcceptableQualityLevels(AQL)willbemet,whichis
currently65%withanexpectedincreaseto70%inthenearfuture.ForthesereasonsMHShasbeendevotedtoimprovingstaffhandhygienecompliancerates.Overthepast12monthsstaffhavecontinuallybeeninformedoftheexpectationforcorrectperformanceinrelationtohandhygiene.ThishasbeenimplementedandgovernedbyreviewingMHSHandHygienepolicy,monitoringforcomplianceofthe5momentsofhandhygieneandcompliancetoadheretoMHShandhygienepolicyinrelationtojewellery;byinternalandexternalaudits.Staffawarenessandeducationhasbeenthemainkeytocontinuallystrivingtoimprovecorrect
handhygienecompliance.HandhygieneeducationandpromotionwillcontinuetobeaprioritytoensuresafeoutcomestoallstaffandclientsatMHS.
ThepoorhandhygieneresultisreflectedinthemostrecentVictorianPatientSatisfactionmonitorresultwhichasks“how often did you observe hospital staff cleaning their hands between attending patients?”Resultsweredownfrom61%to51%ofthetime.Thisdeclinehasbeenaddressedthroughextratrainingwithdetailedexplanationsforstaff,directivesfromseniormanagementandtheintroductionofdisciplinaryprocessesfornon-compliance.
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QOC - quality & safety [ ]31
Infection Surveillance & Reporting
Infectionratesurveillanceandreportinginrelationtohospitalandcommunityacquiredinfectionsassistsinimplementingprocessestominimisetheriskofinfectiontransmission.AtMHSacuteandoutpatientwardpresentationsarerequiredtobereviewedandreportedtotheVicNISScoordinatingcentre.InfectiontypesmonitoredandreportedincludeClostridiumdifficile,MRSAinfections,VancomycinResistantEnterococcusinfectionsandBloodstreaminfections.Influenzavaccineuptakebystaffmembers,occupationexposuresandhandhygienecomplianceoutcomesarealsoreportedtotheDepartmentofHealthviaVicniss.ThisprocessenablesMHStheabilitytomonitorforpotentialriskfactorsortrendsandassistinplanningandevaluatinginterventionstopreventtransmissionofinfection.
MHSrecognisesthatagedcareresidentsarevulnerabletoinfectionsduetolivinginalargecommunallivingenvironment,whichiscateredtobyalargeflowofhealthcareprofessionals,visitors&families.Atpresent,surveillanceandmonitoringofagedcareinfectionratesisnotarequirement,howeveratMHSpotentialorsuspectinfectionsarereportedviathe‘Riskman’system.ThisyearthisprocesshasenabledMHSinfectioncontrolprogramtoidentifyareaswhereinterventionsandeducationwererequired.Areasincludedincreasededucationandawarenessof
therelativelynew‘gastroenteritisbug’,Clostridiumdifficile.Educationinrelationtobladdermanagementandcathetercarewasdeliveredtostaff.Aneducationalopportunitywasalsoprovidedforresidentsandtheirfamiliestoattend.
Antimicrobial Stewardship Program
MHSInfectioncontrolprogramissupportingtheAntimicrobialStewardshipProgram.ThisprogramisaimedatassessingcurrentantibioticusageinAustraliaincludingtheappropriatenessandeffectivenessforassistinginthereductionofHealthcareAssociatedInfections(HAI)andlimitingtheincreaseofmulti-resistantorganisms.Thisinitiativewasimplementeddueto“recognition that as antimicrobial resistance increases and development of new antimicrobial agents’ declines, it is critical that antimicrobials are used wisely and judiciously”.ThisprocessrequiresreportingtoTheAustralianCommissiononSafetyandQualityinHealthCare(ACSQHC)forreviewofcurrentusageandprescribingwithinourhealthcarefacilities.MHSinfectioncontrolisaimedatprotectingtheirclientsfromunnecessaryillnessesanddevotedtoassistinreducingHealthcareAssociatedInfections(HAI)andlimitingtheincreaseintheprevalenceofmulti-resistantorganisms.
Vaccination ProgramMHShasexpandeditsstaffvaccinationprogramtoassistinreducingtheriskofpreventableillnessessuchasPertussis(whoopingcough).OverrecenttimesithasbeenevidentthroughoutAustraliatherehasbeenanincreaseinpresentationsforwhoopingcoughplacingnewbornsatrisk.PertussishasalsobeenpresentwithintheMoyneregiondisplayingtheneedtopromotevaccinationuptake.ThisyearMHShasincludedthepertussisvaccinealongwiththeInfluenzaandHepatitisBvaccinefreetoallstaffmembers.
WiththecurrentinfluenzaseasonuponusMHScontinuestoofferinfluenzavaccinationforprotectiontoourstaff,residentsandpatients.Thisyeartherehasbeenanoticeableincreaseintheuptakeofthevaccinebystaffandvolunteers.Upuntilthe30thJune2012,andwithstaffcontinuingtoaccessthevaccine,therehavebeen115influenzavaccinesadministeredtostaff&volunteers,6Pertussisvaccines&3coursesofHepatitisBadministeredsincelateMarch.Agedcareresidentshavemaintained“herd”immunitywithinthefacility’swith85%ofresidentschoosingtohavetheinfluenzavaccinethisyear.InfluenzacontinuestobeveryprevalentwithinourcommunityandongoingpromotionfortheuptakeoftheinfluenzavaccinewillcontinueandbesupportedbyMHS.
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MHS Aged Care Influenza Vaccine Uptake 2012
[ ] QOC - quality & safety32
Environmental Services Cleaning Outcomes ThisyearMHSEnvironmentalServicehavesuccessfullyimplemented‘microfiber’cleaningacrossthewholefacilitywhilstmaintaininghighcleaningstandards.Lastyearstaffundertookaninitialcleaningtrialwithintheacuteward.Thistrialwasimplementedinonedepartmenttodeterminetheeffectivenessofthe‘microfiber’productsandthefeasibilityofintroducingthisnewproductMHSwide.DuringthistimeregularswabbingofsurfaceswasperformedtoensurethecleaningprocesseswereeffectiveandthesafetyofMHSclientswasbeingmaintained.
Environmentalservicesstaffhavedemonstratedthewillingnessanddedicationtoimproveandmaintainsaferpracticeswithintheirdepartment.Theyhavesuccessfullyprovidedstaff,residents
andpatientswithanimprovedcleaningpracticethatwillcontinuetoprovidegoodcleaningoutcomesacrossthewholefacility.Thissystemhasproventobe;userfriendly,environmentallysafer,andmoretimeefficient.Theintroductionof‘microfibre’cleaningatMHShasprovidedacleanandsaferenvironmentforstaff,patients,residentsandvisitors.
Toensureeffectivecleaningstandardsaremaintainedenvironmentalserviceshasalsoincludedworkingmatrixes.MatrixeshavebeenimplementedtoensureamorefluentworkflowcanbemaintainedandcleaningjobsareconsistentlyperformedasrecommendedbythecleaningstandardsofVictoria.TheintroductionofthematrixeshasprovidedstaffwithasenseofownershipinregardtotheirworkpracticeoutcomesatMHS.
Infectioncontrolauditsareperformedonaregularbasistoidentifytheneed
forimprovement.Thisyeartheseauditshaveledtotheimplementationofnursescleaningschedules,upgradingofclinicalwastebinsandstorage,improvingcurrentpractices,maintainingcompliance,andimplementingandpurchasingequipmentsuchasmoreeffectivealginatebagsandsafetyneedledevices.
MHSisawareandstronglyappreciatesthatinfectioncontrolmeasures,basedonbestpractice,currentstandardsandguidelineswillprovidethebestprotectionforpatients,residentsandhealthcarepersonnel.MHSwillcontinuetostrivetowardspromotingsafety,qualityandavaluedhealthcareservicetoitscommunity.
QOC
Acceptablequalitylevel(AQL)forVeryHighRisk90%,AQLforallotherareas85%,Overallhospitalscore(OHS)is90%
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VHR=VeryHighRisk,HR=HighRisk,MR=ModerateRisk,LR =LowRisk
QOC - quality & safety [ ]33
Food Safety - Meals on Wheels (MOW)Afoodsafetyprogramisadocumentedsystemformanagingparameterslinkedtofoodsafety.MoyneHealthServicesprogramssystematicallyidentifythefoodsafetyhazardsthatarereasonablylikelytooccurinfoodhandlingoperations.Eachhazardidentifiedcanbecontrolledandwherenecessaryacorrectiveactionisputinplaceandregularreviewprovidedoftheprogramtoensureitisappropriate.FoodSafetyisakeyaspectoftheFoodServicesprovidedbyMoyneHealthServices.
Eatingwellisimportanttoassistpeopletostayhealthyandindependent.MoyneHealthServicesMealsonWheelsprogramdelivershealthymealstotheclient’shometonotonlyensuretheirnutritionalrequirementsarebeingmet,buttoprovideregularsocialcontactandafriendlychecktoseealliswell.Thisassistspeopletocontinuetoliveintheirownhomes,wheremostarehappiest.Ouraimistoimprovequalityoflifebyhelpingpeoplemaintaintheirsafetyandindependenceathomeandinthecommunity.
MealsonWheelsprovidemealstosuitaclient’spersonalrequirementsandcanaccommodatespecialdietaryneedsandtastepreferences.
StandardMealsonWheelsconsistofsoup,mainmeal,dessertandjuiceandmaybedeliveredhot,coldorfrozen.MoyneHealthServicesofferasevendayserviceoffreshlycookedmealsandvolunteerstodelivermealstoclients’homes.MealsonWheelsdeliveredmealsarepreparedaccordingtonutritionalguidelinesthatrequirethemealstoprovideonethirdofnutritionalneedsfortheday.
QOC
“Eating well is important to assist people to stay healthy and independent”
[ ] QOC - quality & safety34
DistrictNurseKatieHowellloadingthecarfortheday.
Residential Aged Care Indicators In2003theGeronticNursingClinicalSchoolofLaTrobeUniversitydevelopedasetofqualityofcareperformanceindicatorsfortheDepartmentofHumanServicesforuseinResidentialAgedCarefacilities.Theindicatorswereintendedtoassistinmonitoringandimprovingthequalityofcarebeingprovided.
MoyneHealthServiceshasreportedtheirresultsinrelationtotheindicatorssincetheinceptionoftheprogram.Theinformationthatiscollectedincludes:
Indicator 1: PrevalenceofPressureUlcers
Indicator 2:PrevalenceofFallsandFall-relatedfractures
Indicator 3:IncidenceofPhysicalRestraint
Indicator 4:IncidenceofResidentsPrescribed9ormoreMedicines
Indicator 5: IncidenceofUnplannedWeightLoss
Theseindicatorsarecollected,reportedandthenthefeedbackandcomparisondatareceivedfromtheDepartmentisreviewed.BothBelfastHouseandMoyneyanaHouseconsistentlyachieveexcellentresultsfortheindicators.Therehavebeenafewexceptionaloccasionswhenourratesarehigherthanexpectedbutthiscanbeexplainedbyisolatedsituations.Theoverallinformationindicatesthatweareperformingatahighlevelandachievingsomeofthebestresultsbeingreported.
WeusethisinformationinconjunctionwiththeinformationthatwegetfromQualityPerformanceSystems(QPS)toprovideapictureofhowweareperformingincomparisontoourpeersandtoidentifyopportunitiesforimprovement.
Wound Management @ MHS
AllNursingstaffatMHShavetheopportunitytoaccessawiderangeofeducationalandprofessionaldevelopmentsessionswithregardswoundcareandmanagementofthehealingprocess.TheeventshavebeencoordinatedbyourregionalWoundCareConsultantLeslieStewart.Acombinationoffacetofacestudydaysandtheuseof“webex”softwaretoprovidethesesessionshasincreasedtheaccesswithintheworkenvironmentforstaff.Thishasallowedustomakethemostoftheopportunitiestogaintheinformation.
Thequalityofthepresentershasbeenexceptional,withseveralsessionsbeingprovidedbySandyDeanawell-knownguruofthewoundcareassociation.Topicsincluded:Assessment, measurements, debriding, dressings and compression strategiestobeabletomanageawidevarietyofacuteandchronicwounds.
TheDistrictNursingstaffareabletomanageawiderangeofwounds,withintheperson’shome,ratherthanhospitalisation.TheuseofVistrak - (which traces wound, calculates viable & non-viable tissue, takes circumference measurements) dopla (circulation) recordings and sequential photos of the wound progress are some of the techniques that are utilised.Liaisingwithotherhealthprofessionalsaspartoftheteammanagementapproachtowoundhealing,theprocesswillpossiblyincludereferralstodietitian,podiatrist,diabeticeducators,GP’s,OT’sandphysiotherapist.“HealthCareGuides”producedbyConnectedWoundCare(aDHSsupportedinitiative)havebeenproducedtoeducateandprovidesupporttotheclienttobepartofthepartnershipinthehealingofchronicwounds.
QOC - quality & safety [ ]35
Your Say - Comments, Suggestions, Feedback, Complaints, Compliments
Commentsandcomplaintsfromconsumersprovideuniqueinformationabouttheirneedsandthequalityofcareandservicesthattheyreceive.Thereareanumberofwaystomakeasuggestion,shareanideaormakeacomplaintregardingthecareandservicesthathavebeenreceivedatMoyneHealthServices.
“Comments,Suggestions,FeedbackForms”and“ComplaintsForms”,areavailablethroughoutthefacility.TheycanbefoundintheAcuteHospitalattheNurse’sStation,attheFrontReceptionandintheStaffDiningRoom,CommunityHealth,inBelfastHouseandinMoyneyanaHouse.
Staffarehappytodiscussanyconcernsorlistentoideasforimprovement.Inmostcasestheywillrecorddetailsononeoftheaboveformsandensureitispassedtotheappropriatemanager.Consumersandtheircarersareencouragedtodiscussanyconcernsaboutclinicalcarewiththeirtreatingdoctor.
InVictoriaindividualshavearightofaccesstotheirhealthinformationandtomakecomplaintsabouthealthserviceproviders.TheOfficeoftheHealthServicesCommissioner(HSC)isanindependentstatutoryauthorityestablishedtoreceiveandresolvecomplaintsabouthealthservices.TheHSCalsohandlescomplaintsaboutdisclosureofhealthinformationandaccesstohealthinformation.
The2012annualreviewofourcomplaintsmanagementprocesseswasdoneusinganewtoolthatwasdevelopedbyNSWHealth.Itwasverycomprehensiveandidentifiedafewareasthatwecoulddevelopfurther.Weachievedaverygoodscoreof80%compliant.Themajorareaforfurtherdevelopmentisinthetrainingoffrontlinestaff.WehaverecentlygainedaccesstoausefulDVDfromtheAgedCareChannelthatwillmeetourneedsinthisarea.StaffwillbeencouragedtowatchtheDVDtoimprovetheirunderstandingofthemanagementofcomplaints.
OurresultsintheVictorianPatientSatisfactionMonitor,asurveyofAcutepatientsshowongoingsteadyimprovement.Thegraphbelowshowsourperformanceoverthelast5yearsinthe“ComplaintsManagementIndex”.ItshowsconsistenthighlevelperformancethatisratedaboveothersimilarorganisationsandsignificantlyabovetheaverageforallVictorianHospitals.
“Staff are happy to discuss any concerns”
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Limited Adverse Occurrence Screening (LAOS) Program
What is LAOS?LAOSpromotesthedetection,monitoring,preventionandearlymanagementofadverseeventsinVictoria’ssmallruralhospitals.InsmallruralhospitalsGPsworkingasVisitingMedicalOfficers(VMOs)admitpatients,provideacuteservices,andparticipateinafter-hourscare.LAOSprovidessmallruralhospitalsandVMOswiththeresourcestoparticipateinconfidentialpeerreview,whichpromotesdiscussionofadverseeventsandoffersrecommendationsforimprovedclinicalcare.
MoyneHealthServices(MHS)hasparticipatedintheOtwayDivisionofGeneralPracticeLAOSprogramforthepastnineyears.TheLAOSprogramprovidesanimportantaspectofourclinicalandmorespecifically,medicalqualityprogram.RecommendationsreceivedthroughLAOSarediscussedatourVisitingMedicalOfficers(VMOs)meetingwheredoctors,nursingstaffandmanagementcanconsidereachrecommendationandmakedecisionsabouttherelevancetoMoyneHealthServices.TheyarealsoconsideredatourClinicalGovernancemeetings.
EffectivefromJuly1,2009theLAOSselectioncriterionforselectionofrecordshasincluded:
1. Patientdeath
2. Unplannedreturntotheatrewithinsevendays
3. Unplannedreadmissionwithin35daysofdischarge
4. Transfertoanotherhealthservice
5. Patientlengthsofstaygreaterthan35days,and
6. Anyrecordwhichhasbeenrecommendedbyadoctororotherhealthprofessionalforreview.
Asaresultofthe“EvaluationofLAOS2012”theLAOSProgramaswehaveknownitwillnolongercontinuebeyondDecember2012.ItisanticipatedthatthepeerreviewprocessprovidedthroughtheprogramwillbeincorporatedintoMHS’sClinicalGovernanceProgram.
36
MaintenanceManagerTimDrewintroducesBEIMStostaff.
[ ] QOC - quality & safety
BEIMS - enhancing safe care:
TheBuildingandEngineeringInformationManagementSystem(BEIMS)waslaunchedliveinMarchofthisyear.BEIMSisanelectronicandautomatedsystemformaintenancerequisitions,contractandcontractormanagementandpreventativemaintenance.
PreviouslyMHSusedapaperbasedsystemformaintenancerequisitions,servicecontractsandpreventativemaintenance.Thesesystemswerebasedonaseriesoftriplicaterequisitionslips,handwrittennotesandcalendarentries.Thesepaperbasedsystemswereinefficient,labouriousandcreatedthepotentialforitemstobemissedoroverlookedduetohumanerror.
TheintroductionofBEIMShasimprovedthefollowingatMHS:
• linesofcommunicationbetweenmaintenancerequestorsandthemaintenancedepartment
• OH&Soutcomesthroughadocumentedandauditablepapertrail
• contractmanagement
• contractormanagement
• staffsatisfaction
• thenumberofhoursspentonunplannedwork
• reportingonmaintenancecostsandperformances
• compliancewithaccreditationstandardsandstatutoryobligations
BEIMShashadapositiveinfluenceonsomanypartsoftheorganisationandwillcontinuetodosoasfurtherBEIMSmodulesareintroduced.TheaboveimprovementsarecertainlyenhancingsafecareatMHS.
QOC - care [ ]37
Service AccessServiceaccessisanintegratedsystemsupportedbysystematicprocessesandconsistentpracticewhichcansignificantlycontributetopositiveconsumer,organisationalandwiderservicesystemimpacts.Serviceaccess/intakeisaboutmakingitsimplerandeasierforpeopleandtheircarerstoaccessservices.
Olderpeople,peoplewithadisability,carersorpeoplewithconcernedfamilyorfriendscanphonetheCommunityCareCoordinator(CCC)andreceiveone-to-oneadviceaboutappropriateagedcare,alliedhealthandcommunitybasedservices.Theymayalsomeetface-to-faceifpreferred.
Thiscreatesopportunitiestoinfluencetheservicesystemasawholebypartneringwiththeconsumertoenhanceservicecoordinationandintegrationwiththegoalofimprovingconsumeroutcomes.
ServiceCoordinationplacesconsumersatthecentreofservicedeliverytoensurethattheyhaveaccesstotheservicestheyneed,opportunitiesforearlyinterventionandhealthpromotion,andimprovedhealthandcareoutcomes.
TheCCC,canassistreferraltoservices,suchas:
• districtnursing
• podiatry
• homesafetyreview
• organisedgroupswithsocialsupportactivities
• physiotherapy
• occupationaltherapy
• AgedCareAssessmentServices(ACAS)
Putting the Person at the Centre
AtMoyneHealthServicesweareworkingtowardsenhancingthepersoncentredapproachtoprovidingcare.
Patientorconsumercentredcareishealthcarethatisrespectfulof,andresponsiveto,thepreferences,needsandvaluesofpatientsandconsumers.Differentdefinitionsandterminologyhavebeenusedtodescribetheconceptsinthisareabutkeyprinciplesofpatientcentredapproachesinclude:
• treatingpatients,consumers,carersandfamilieswithdignityandrespect
• encouragingandsupportingparticipationindecisionmakingbypatients,consumers,carersandfamilies
• communicatingandsharinginformationwithpatients,consumers,carersandfamilies
• fosteringcollaborationwithpatients,consumers,carers,familiesandhealthprofessionalsinprogramandpolicydevelopment,andinhealthservicedesign,deliveryandevaluation.
Patient-centred care is ‘an approach to the planning, delivery, and evaluation of healthcare that is grounded in mutually beneficial partnerships among healthcare providers, patients and families’.
Institute for patient and family centred care.
Thereisincreasingevidencesupportingthisapproachtoachieveimprovementsinthecareexperienceforcarerecipients.Someoftheimprovementsidentifiedinclude:decreasesinmortality,reductioninratesofhospitalacquiredinfection,reducednumbersofsurgicalcomplications,improvementsinpatientfunctionalstatusandhigherqualityclinicalcare.
WearefocusingonmanyoftheseareasthroughouttheHealthServiceandmonitorourperformancethroughtheQualityProgram.TheVictorianPatientSatisfactionMonitor(VPSM)assessessatisfactionwiththeseaspectsforourHospitalinpatients.Ourmostrecentresultsindicatethatweareperformingquitewellinthisarea.Thegraphbelowillustratesourachievementswhencomparedwithourpreviousresults,theaverageforsimilarsizedhospitalandtheaverageforallhospitals.
Policy Context
ServiceSystem:
AgencySystems
ConsumerCare
SocialSupport
GP’s
HPopportunities
CH
Acute
Sub-Acute
Rehabilitation
4.3
4.4
4.5
4.6
4.7
4.8
Current Results Previous survey
Moyne Similar Hospitals All Hospitals
Access to Services
[ ] QOC - care38
Promoting ParticipationMoyneHealthServicesencouragestheparticipationofCommunitymembersandConsumersindecisionmakingabouthealthpolicyandplanning,careandtreatment,andthewellbeingofourcommunity.WefollowtheguidelinesestablishedbytheDepartmentofHealthintheir“Doingitwithusnotforus”,StrategicDirection2010-13.ThisistheVictorianGovernment’spolicyandhasthefollowingaim:
Forconsumers,carersandcommunitymemberstoparticipatewiththeirhealthservicesandtheDepartmentofHealthinimprovinghealthpolicyandplanning,careandtreatment,andthewellbeingofallVictorians.
Advantagestoincreasedparticipationinclude:
• Anaidtoimprovehealthoutcomesandthequalityofhealthcare
• Animportantdemocraticright
• Amechanismtoensureaccountability.
How Moyne Health Services meets the standards:
Standard 1:
Theorganisationdemonstratesacommitmenttoconsumer,carerandcommunityparticipationappropriatetoitsdiversecommunities.
• TheConsumerConsultationandParticipationPolicyhasbeenadoptedbytheBoardofManagementandisavailabletoallstaffthroughthePromptonlinepolicysystem
• TheCommunityHealthandWell-beingGroupincludesrepresentationfromkeyareasoftheCommunityandCommunityGroups.
• TheVictorianPatientSatisfactionMonitor(VPSM)resultsspecificallyrelatingtotheConsumerParticipationIndexprovideuswithusefuldataaboutourperformanceintheHospitalarea.Thesatisfactioninthisareahasbeenconsistentlyhighandabovethesatisfactionreportedforsimilarhealthservices.TheVPSMsurveyasksthreekeyquestionsaboutparticipation:
•Theopportunitytoaskquestions(1)
•Thewaystaffinvolvedyouindecisions(2)
•Arestaffwillingtolistentohealthcareproblems(3)
See results in the graph below
Standard 2
Consumers,and,whereappropriate,carersareinvolvedininformeddecision-makingabouttheirtreatment,careandwellbeingatallstagesandwithappropriatesupport.
WeperformedverywellintheVPSMConsumerParticipationIndicatorasindicatedbythegraphbelow.
WeassesstheinvolvementofagedcareresidentsintheirannualsatisfactionsurveythroughtheQualityPerformanceSystem(QPS).TherearetwoquestionsthatspecificallyaddressResidentinvolvementinthecareprovided.Weachievedveryhighscoresforboth(shownintheorangetables):
Standard 3
Consumers,and,whereappropriate,carersareprovidedwithevidence-based,accessibleinformationtosupportkeydecision-makingalongthecontinuumofcare.
• TheVPSMprovidesuswithusefulinformationinthe“writteninformationrating”.Thisisanareathatwehaveconsistentlyreviewedinrecentyears.ThegraphbelowdemonstratesourperformanceinthisareathelastVPSMsurveyperiod.Itispleasingtoseethatwhencomparedtootherhospitalswerateverywell.
WealsocollectthisinformationfromouragedcareresidentsthroughtheQPSsatisfactionsurvey.Theyratehowwellwekeeptheminformedaboutthingsthatmayaffectthem.Themostrecentsurveywasrated:
3.6
3.8
4
4.2
4.4
4.6
1 2 3
Opportunities to have a say in things that may affect you
4.40/5 88.00%
How well are you informed of the things that may affect you
4.31/5 86.25%
Consumer Participation Rating - Specific Questions
Being kept informed about things that may affect you
4.31/5 86.25%
Moyne VIC Average D Hospital Average
3.6
3.7
3.8
3.9
4
4.1
4.2
4.3
4.4
Written Info aboutCondition
Moyne
VIC Average
D Hospital Average
QOC - care [ ]39
Standard 4
Consumers,carersandcommunitymembersareactiveparticipantsintheplanning,improvement,andevaluationofservicesandprogramsonanongoingbasis.
ACommunityConsultationprojecttogatherinformationforserviceplanninghasbeencompletedandtheinformationusedinplanning.
ThereisaServicePlanningCommitteewithrepresentationfromstaff,doctorsandcommunityrepresentatives.
Suggestions,complaints,feedbackprocessesarewellestablishedandaplainlanguageflierhasbeendevelopedtoassistthecommunity,staff,patients,residentsandtheirfamiliestounderstandtheprocess.
OurAuditandRiskCommitteehasseveralCommunityRepresentativeswhoareactive,productivecommitteemembers.
Standard 5
Theorganisationactivelycontributestobuildingthecapacityofconsumers,carersandcommunitymemberstoparticipatefullyandeffectively.
Weareprogressivelyworkingondevelopingthisarea.Wehaveinplace:
• Communitymembershiponsomeoperationalandstrategiccommittees
• Processestoensureparticipationincareacrosstheorganisation
• Processestoencouragesuggestionsandfeedback.
“Doing it with us not for us”
[ ] QOC - care40
Bed-side handover - an initiative in partnering with consumers.
Thereisplentyofevidencesupportingthenotionthateffectiveclinicalhandovercanreducecommunicationerrorsbetweenhealthprofessionalsandimprovethesafetyofpatientcaredelivery.CommunicationproblemshavebeendemonstratedtobeamajorcontributingfactorinhospitalsentineloradverseeventsthathavebeenreportedtotheVictorianDepartmentofHealth.Theriskofadverseeventsoccurringactuallyincreaseseachtimeapatientisdischargedortransferredbetweenunits,medicalofficersandcareteams.
Consumercentredcareinvolvestheactiveparticipationofpatients,consumersandcarersintheplanning,deliveryandevaluationofcare.Theeffectivenessofhandovercommunicationmaybeenhancedbytheparticipationofpatients,carersandfamilymembers.MHSAcuteServicescommencedtriallinghandoveratthepatientbedsideattheafternoonshiftchangeoverasofJune2012,theaimbeingtoreducepotentialmisunderstandingsandcommunicationerrorswhenattendingtotheclinicalhandoverofpatientinformation
Thepatient/consumerisintroducedtotheincomingteamandparticipatesinthehandoveratthepatientbedside.Thisincomingteamreviewsthemedicationchartsandadministrationrequirementsformedications,andincludesthepatientinreviewingtheirownmedicationmanagement.Thepatientandcarerareincludedindiscussionandencouragedtoparticipateinmanagingfortheirplanofcareduringtheadmission,andindiscussionsandplanningforexpecteddischargefromhospital.Thepatientisabletoparticipateactivelyinthecareprogression,expectationsandpreparationforexpecteddischargefromhospital.
Recentfeedbackhassupportedthetrialofclinicalhandoveratthepatientbedside.Patientsreporttheyfeelmoreincludedintheplanningandactioningoftheircareandhaveclearerexpectationsforwhentheyarepreparingfordischarge.Thisreducesthepotentialfordependencyuponthesystem,resultsin
reductioninthelengthofhospitalstayandlikelihoodoffrequentreadmissionbyensuringclearcommunicationandgoalsettingbetweenthepatientandtheircaregivers,carers,alliedhealthandmedicalprofessionals.
Moyne healthy Kids Project SouthWestHealthyKids(SWHK)Moyneisacommunitybased,healthdevelopmentinitiativepromotingphysicalactivityandhealthyeatinginchildrenandtheirfamilies.Itisacollaborativepartnershipoflocalgovernment,communityandhealthagenciesincluding:MoyneHealthServices,TerangandMortlakeHealthServices,MoyneShireCouncil,SouthWestHealthcare-MacarthurCommunityHealthandSouthWestSport.
MoyneHealthServicesCommunityHealthisprimarilyinvolvedwiththecommunitiesofPortFairyandKoroit.
Our concerns
Weareconcernedaboutthecurrentupwardtrendinoverweightandobesity,particularlyinchildren.Thenumbersofourchildreneatinganutritiousdietarelow.Levelsofphysicalactivityaredropping,whilsttimespentusingelectronicmediasuchastelevision,theinternetandcomputergamesareincreasing.Studiesfirmlyestablishthelinkbetweenpoornutritionandeatinghabits,combinedwithadeclineinahealthylifestyle,andresultingoverweightandobesity.InAustraliamorethantwothirdsofmenandmorethanhalfthewomenareoverweightorobeseandstudieshaveprojecteda50%increase
inobesityandasustainedprevalenceofoverweightfortheAustralianpopulation.“Tomorrow’soverweightandobeseadultsaretoday’schildren”.
“Healthyeatingandexerciseincreaseenergy,moodandconcentration.Theseallenhancelearningcapacityandphysicaldevelopment.”Feedbackaboutobesityandtheimportanceofnutritionandphysicalactivitytochildren’sdevelopmentandlearning:
• Morethanthreequarters(78.4%)ofstakeholdersinterviewedreportedthattheyhadaroletoplayinaddressingchildhoodobesity.
• Thirtysevenpercent(37%)ofstakeholdersinterviewedthinkthecommunityhasanissuewithobesityandbeingoverweight,while12%didnotthinkitanissueinthecommunity.Afurther34%ofresponseswereeitherunclearordidnotdirectlyanswerthequestion.
About lunchbox contents
Onaverage12.4%oflunchboxesacrossall‘communitiesofinterest’didnotcontainamainmeal(Definedasasandwich/wrap,left-overorfastfood-proteinorspreadwithbiscuitsalsocountedasamainmeal).InMoyne10.6%oflunchboxesweremissingmainmeals.
Other key findings from the lunchbox audit include:
• Fewlunchboxes(average5.1%)acrossallcommunitiesofinterestcontainedatleastoneserveofvegetables.
• Onaverage28%oflunchboxesacrossallcommunitiesofinterestdidnotcontainfruit.
• Onaverage72%oflunchboxescontainedoneormoreservesoffruit.
QOC - care [ ]41
• Anaverageof60.8%ofalllunchboxescontainedatleastoneserveofbiscuits
• Anaverageof21.9%containedtwoormoreservesofbiscuits.Unfortunately this category does not distinguish between sweet biscuits and dry biscuits, or between home-made and commercial biscuits.
• Anaverageof26%ofalllunchboxescontainedatleastoneserveofcakeorslice (Unable to distinguish between home-made and commercially made cakes/slices or serving size)
• Anaverageof15.6%containedatleastonemueslibar.
• Justoverhalf(50.4%)ofalllunchboxescontainedpackagedsnackswithanaverageof21%oflunchboxesacrossall‘communitiesofinterest’containingtwoormorepackagedsnacks.
• Nineteenpercent(19%)oflunchboxescontainedconfectionary.
• Eightpercent(8.1%)oflunchboxescontainedsweeteneddrinks.
Advances in Clinical Practice - Keeping us Up to Date
The Point of Care (POCT) Troponin ProjectBACKGROUND:Troponin is a complex of three proteins found in blood integral to muscular contraction in skeletal and cardiac muscle.
• TheVictorianCardiacClinicalNetwork(VCCN)commencedinFebruary2009andaimstoimprovequality,access,equity,costeffectivenessandsustainabilityofcardiacservicesinVictoriathrough:
• Facilitatingacoordinatedapproach,basedonevidencebasedguidelinesforthecareandmanagementofbothadultsandchildrenwithcardiacconditions.
• Workingacrossorganisationalboundariestodevelopeffectivehealthsystemresponsestoenhancecardiacserviceprovisionandimprovecardiachealthoutcomesacrossthestate.
In2010theVCCNorganisedacardiacservicessurveytobeconductedacrossallservicesinregional/ruralVictoria.Someoftheconsistentrecommendationsfromthesurveyswere:
• Thataframeworkforthemanagementofacutecoronarysyndromeinruralstate-widehealthservicesbedevelopedwhichtakesintoaccountthelimitedaccesstosupportservicessuchasradiologyandpathology.
• Accesstoacardiologist(couldbephoneonly)bemadeaccessibletoallruralhealthservices24/7.
• Thedevelopmentofaconsistentpolicyforpointofcaretestingdevelopedforallruralhealthservicesandthatthispolicyincludesacompetencytool.
Aspartofarangeofactivitiesfor2011-12theVCCNdecidedtoundertakeapilotofpoint-of-caretroponin(POCT)assaystoassistinthetriageofpatientspresentingwithchestpainintheEmergencyDepartment/UrgentCareServicecentresinsmallruralhealthservices.ItwasdecidedtoundertakethispilotinthesevenhealthservicesintheSouthWestRegion.
PURPOSE Theoverallaimistointroduceanacutecoronarysyndromepathway,toSouthWestVictoria,andevaluateitsimpactbyimprovingaccesstoevidence-basedacuteandfollow-upcardiaccare,throughtheprovisionofthefollowingresourcesandimplementationstrategies.
OBJECTIVES• Introduceapilotprojectonbedside
POCTbloodtestingforcardiactroponinincentresthatcannototherwiseensureaturnaroundtimefortroponinassaysof<60minutes(24/7)tosupporttimelyriskstratificationanddecision-makingregardlessofgeographiclocation.
• ImprovedaccessibilitytospecialistcardiologyadviceregardingECGinterpretation,otherdiagnostictestinterpretation,triageandtreatmentdecisions.Thisservicewouldaimtoprovidepromptadvice24hours/7daysaweekutilisinganescalatingpagingservice,withanaverage
responsetimeof<10minutes.
• Provisionofcomprehensivecardiaccontinuingmedicaleducationforthemedicalandnursingworkforceservicingtheseareas.
• Adherencetocardiacclinicalguidelines.
• DevelopagreedClinicalPathwaysforChestPain/AcuteCoronarySyndrome.
TheprojectinvolvedPointofCareTroponin(POCT)testinginsevenhealthservicesintheBarwonSouthWesternRegionofVictoriaforpatientspresentingwithasuspectedacutecoronarysyndrome.Sevenhospitalsiteswereidentifiedforinclusion:Warrnambool,Portland,Timboon,Camperdown,PortFairy,Heywood,andTerang.
Dr.TimBaker,DirectorofSWHCWarrnamboolEmergencyDepartment,wastheoverallleadclinician.TechnicalsupportwasprovidedbyRosyTirimacco,iCCnet(IntegratedCardiovascularClinicalNetworkCHSA)SouthAustralia.MargaretBullwastheCardiacClinicalFacilitatorfortheproject.Herroleinvolvedmedicalandnursingstaffeducation,supportandfeedbackthroughouttheprojecttimeframeoftenmonthsandco-ordinatingasteeringcommitteetodelivertheprojectoutcomes.RocheprovidedtrainersforPOCTmachine12thDecember2011andMHSwentlive19thDecemberwiththeiCCnetproviding24hoursupport.
OUTCOME• ReviewoftheASSESSMENT&
MANAGEMENTclinicalpathwayforCHESTPAINMANAGEMENT@MHS
• OngoingPOCTbloodtestingusingtheRoachcobash232machine,withtechnicalsupportandqualitymonitoringby,iCCnetSouthAustralia.
• Ongoingaccesstoadvicelinetoon-callcardiologistinGeelong(BarwonHealth).
• Reliable,qualitativetestsformyocardialdamagemarkerstoassistclinicianstorapidlyriskstratifypatientsandensureearliermanagementmeasuresintotheroutinecareofthesepatients.
• ImprovedaccuracyandspeedwithwhichchestpainpatientspresentingtoMHSarediagnosedandtreated.
[ ] QOC - care42
ShED - Small Hospital Emergency Department, Project
TheSmallHospitalEmergencyDepartmentproject(SHED)wasaregionalprogramruncollaborativelybetweenDeakinUniversityandanumberofsmallruralhealthserviceswithemergencydepartmentsthatarenotfundedbytheDepartmentofHealth.Theprojectwasestablishedtogatherinformationaboutthenumbersandtypesofattendancesattheseemergencydepartmentsanddetailsabouttheoutcomeoftheattendance-howmanypeoplewereadmittedortransferredorhowmanyreceivedtreatmentandwenthome?
TheSHEDprojectgatheredasubstantialamountofveryinterestinginformation.IthasnotyetbeenfinalisedbutMHShasseensomepositiveoutcomesfromourparticipation.TheprojecthasencouragedandallowedforsomesignificantchangesinthewayinformationaboutEmergencyDepartmentattendancesisgatheredandmaintained.Wenowhavegooddataaboutthepeoplewhoattendandthisinformationisusedforfutureplanning.Thequalityoftheclinicalinformationhasalsobeenimprovedandprovidesahigherqualityofdocumentationforongoingpatientcare.
Insummarythisprojectprovidedtheimpetustomovetoelectronicrecordsintheemergencyareaandhasledtosignificantimprovementintheinformationthatisavailable.Wecannoweasilyprovidestatisticalinformationandveryquicklyaccessinformationneededforpatientcare.
Life Stories
Floyd - a man of his word!
“Floydisamanofhisword”statedEffieGriffen.FloydwasborninBankSt,PortFairy,grewupinYambukinalargefamilyofthreebrothersandasister.HisfatherwasNormanWattsandmotherIdaHumphryswhocamefromStHelens.HeattendedschoolatConsolidatedSchoolinPortFairy.Whenheleftschoolhestayedonthefarmtowork.FloydMarried
LynnGraysonin1970andtheyhavefourchildren,Tim,Justin,LisaandNaomi.
AneighbourofFloyd’squoted“IhavebeenaneighbourofFloyd’sandLyn’sforoverfortyyearsandgottoknowFloydverywellandasweallknowFloydhadavegiepatchatYambukorshouldhavesaidpaddocksofvegies,egpeas,carrots,beans,potatoes,pumpkins,younameitFloydgrewitandIforgotthesaladonions,”“Floydwasahardworkingpersonandwouldhaveagoatanythingespeciallyworkingwithsteel”.
FloydisstillamemberoftheYambukFireBrigadeandhasjustreceivedhis50yearsofservicemedal.FloydwasalsoamemberoftheBoardofManagementhereatMHS.HewasontheBoardfromAugust1972untilNovember2003.Hehasseenawealthofchangestothehospitalanditssurroundings.Floydislookingforwardtoallthefuturechangesinthenext15yearsatMoyneHealthServices.HesometimeswisheshewasstillontheBoardwhenhecanseewherechangesneedtobemade.
FloydmovedintoBelfastHousein2005afterhehadastroke.Heisnow66andtakingaveryactivepartinBelfastHouse.
Floydsharehistimebetweenbeingthejokeking,growingalltypesofvegetablesinthegarden,attendingallresidentsmeetings,bowls,runsthehoionaWednesdaymorningandattendspubluncheseachfortnight.FloydgrewtomatoplantsfortheresidentsofMoyneyanaHouseoneyear.NancySmyrksaid“TheywerekeptverybusydowninMoyneyanamakinggreentomatopickleswithallthetomatoesthatyear”.Floydstilllovesajokeandachatandlikestokeephiseyeonallthechangesaroundhim.Floydsaid“IfyouareunabletoliveathomeBelfastHouseisthebestplacetobe”.
QOC - care [ ]43
Val’s StoryUponenteringtheCollegestreetentranceatMoyneyanaHouse,youmayfindthe‘urge’toindulgeinabitofretailtherapy.Thereismuchhereto‘tempt’thehappyshopperandresident.ValHardingismorethanhappytoassistwithyourpurchases.
ValistheRetailManageroftheFriendsofMoyneyanaHouse‘Craft’table.
ValcametoMoyneyanaHousefouryearsagofromGeelongandhashadalonghistoryofCharityandVolunteerinvolvement.Val’smothervolunteeredregularlybeforeandafterretirementandVal’sdaughtercurrentlyworksforacharityoutletinGeelong.Togethertheyarenowabletoshareacommongoaltowardshelpingothers.
ValhasstrongtiesinPortFairywithhersister,SylviaAllenandextendedfamilylivingherealso.
SincecomingtoMoyneyana,Valhasinvolvedherselfinboththe‘home’andthesurroundingPortFairycommunity.
SheisalongtermmemberoftheThursdayCraftGroupheldatFayLemke’shomeandthroughthisassociation;theMoyneyanaHouseCrafttablewas‘born’…………nowaveryprofitablelittlefundraiserforthe‘FriendsofMoyneyanaHouse’.
Valisinvolvedinthestockingofitemsonthetable;generalupkeep;takingorders;collectingmoneyaswellasmakingcraftsforthetableherself…….....…averybusyladyindeed.
Whennot‘keepingshop’,Valcanbefoundbusywithchoresaroundthe‘home’………collectingandfoldingofthelinenserviettesforthediningroom;stockingthefruitbowlsonthetables;generalhousekeepingwiththe‘resident/family’kitchenette;givingexpertattentiontotheindoorplantswithhervery‘greenthumbs’;attendingtotheneedsofthebudgieshereinthehomeandassistingresidentsandvolunteerswiththeMondayafternoonBingo.Valisvery‘techsavvy’andutilisesthecomputertoemail,playgames,accessonlineshoppingsitesaswellaskeepinguptodatewithalltheGeelongnewsthroughdailyaccessoftheGeelongObserveronline.
ValisveryhumbleinregardstohersuccessesinlifehereinPortFairyandstatesthat,“Havingthecrafttableaswellasmyotherjobsaroundthe‘home’givesmeagreatsenseofpurpose……toalwaysknowwhatIwillbedoingwhenIwakeupeachday”.
ShetalksaboutthegreatpersonalpleasurethatshereceivesthroughhelpingothersandthatherinvolvementwithboththecommunityinMoyneyanaandthroughoutPortFairy,hasledtomanynewmeaningfulfriendshipsaswellasastrongsenseofbelonging.
Wethinksheisjust………wonderful.
LeisureandLifestyleStaffRobbie&OrielbelievethatresidentslikeValdemonstratehowaperson,livinginresidentialcarecanstillleadafullandactivelife,withopportunitiesfordecisionmaking,maintainpersonalidentityandindependence,achievement,communityinvolvement,helpingothersandsuccess.
MOYNEYANA HOUSE31 College Street,
Port Fairy Vic 3284
PORT FAIRY HOSPITAL30 - 36 Villiers Street,Port Fairy Vic 3284
BELFAST HOUSE 97 Regent Street,
Port Fairy Vic 3284
SPRINg PARK 33 Mill Street,
Koroit Vic 3282
PhotograPhy Francis & Francis © 2012
QOCMOYNE HEALTH SERVICES
P.O. Box 93 Port Fairy VIC 3280Phone: (03) 5568 0100
www.moynehealth.vic.gov.au