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Kerang District Health Quality of Care Report 2012 - 2013
Cover i mage
RN 1 Jeecinta Lightbody seen here with long term patient ,Joyce MacLean in the Chemotherapy Unit..
Edition 2012 - 2013
2
Contents
Welcome 3
Maintaining and enhancing standards 4
Improving care 8
Listening to our consumers 11
Doing it with us, not for us 12
Caring in our community 13
3
Welcome We are pleased to present our 2012 -13 Quality of Care Report
Quality and safety underpins every service and
program that Kerang District Health provides to our
community. Both the Board of Management and
Executive Directors are responsible for ensuring that
we have robust systems and processes that support
safe and good quality care to achieve optimal
outcomes for our patients. Each and every member of
staff should be committed to improving the way we
work for the benefit of our consumers, their families
and carers.
The Quality of Care Report is Kerang District
Health’s report to the community on our quality and
safety systems, processes and outcomes. This
information is presented using text, tables, statistics,
stories and consumer comments to illustrate how we
monitor quality and safety. It identifies how we
improve the health care we provide to our
community, and how we consult with consumers to
meet their needs.
Once you have read this report, please do not hesitate
to let us know how we can improve our service and meet the needs of our consumers. By listening to you,
we will further make this health service one that
belongs to the community. We hope that you enjoy reading this Quality of Care Report.
Robert Jarman
Chief Executive Officer
Distribution of our Quality of Care Report
Kerang District Health Quality of Care Report is
distributed at our Annual General Meeting, and will
be available on our website:
www.kerangdistricthealth.org.au. It will also be
widely distributed in Kerang through a letter box
drop, and to the outlying districts through the mail
delivery system. Copies are also available at the
hospital and medical clinics.
We welcome your feedback on the Quality of Care
Report or your suggestions for new areas to be
included in next year’s report. Please fill out the
enclosed feedback form and send it back to us.
Last year fifteen consumers provided feedback on the
report with the overall opinion summarised in the
words of one consumer, “a thorough, comprehensive,
detailed report on the care and running of our
hospital.”
In this report you will find information on the Victorian
Patient Satisfaction Monitor, a Department of Health
survey that reports on patient satisfaction and Kerang
District Health’s own feedback initiative that gathers
comments from consumers across the health service.
We encourage you to contact us if you are thinking
about volunteering at Kerang District Health, or about
getting involved as a consumer.
Victorian Patient Satisfaction Monitor Indices Results for Wave 23,
July 20 to Dec 2012 Index (20-100 scale)
KDH
Wave 23 score
KDH
Wave 22 score
Category D (like
sized hospitals)
Wave 23 average
Overall Care (OCI) 85.9 87.1 86.0
Access and Admission (AAI) 84.8 89.5 84.5
General Patient Information (GPII) 89.7 89.7 89.1
Treatment and Related Information (TRII) 86.1 87.1 85.7
Complaints Management (CMI) 87.6 88.4 87.1
Physical Environment (PEI) 83.4 84.9 84.8
Discharge and Follow-up (DFI) 84.6 85.5 83.9
Consumer Participation Indicator (CPI)
86.9 88.6 86.6
4
Maintaining and
enhancing standards Health Service Accreditation
As an independent organisation and the main accrediting
body for health services in Australia, the Australian Council
on Healthcare Standards (ACHS), assesses health services
against a set of comprehensive standards
In October last year Kerang District Health took part in a
Periodic Review Assessment by ACHS to assure our
community that we are performing well and are able to
provide safe, high quality care. We performed well in this
accreditation survey, gaining an MA (marked
achievement rating (above average) for all standards. As
part of the survey, ACHS made recommendations on
areas where further improvement could be achieved,
and in October 2013 a self-assessment on our progress
towards meeting the recommendations was submitted to
ACHS.
Residential Aged Care Accreditation
All residential aged care facilities across Australia, such as
Glenarm, must be accredited in order to receive
Australian Government funding. The Aged Care Standards
and Accreditation Agency (ACSAA) is the independent
body that manages this process.
Quality & Safety in Residential Aged Care
Each quarter, Kerang District Health reports to the
Department of Health on five key aspects of the clinical care
provided to our residents in Glenarm. These are called
Quality Indicators in Public Sector Residential Aged Care
Services. This process enables us to identify possible
improvements to be actioned, and to measure and report
on our efforts for improvement. The areas we report on
include: pressure ulcers, falls and falls with fractures,
restraint, nine or more medications, and unplanned weight
loss.
Right Kerang District Health Public Sector Residential Aged
Care Quality Indicators 2012 – 2013. (state averages in
brackets)
INDICATOR Per 1,000 bed days.
GLENARM Aged care facility
1.
Pressure ulcers – Stage 1 Pressure ulcers – Stage 2
Pressure ulcers – Stage 3
Pressure ulcers – Stage 4
1.17% (0.60%) 0.49% (0.62%)
0.19% (0.11%)
0.00% (0.60%)
2.
Prevalence of falls Prevalence of falls with fractures
7.69% (7.35%)
0.19% (0.12%)
3.
Incidence of physical
restraint
3.79% (1.10%)
4.
Incidence of resident prescribed nine or more
medicines
5.84% (4.17%)
5.
Unplanned weight loss
0.78% (0.82%)
.
Above : Ruby enjoys knitting as one of the activities in
Glenarm Nursing Home
5
Maintaining and
enhancing standards National Safety & Quality Health Standards
The Australian Commission on Safety and Quality in
Healthcare has developed 10 National Health Standards for safety and quality in the Acute setting. These standards were implemented on 1 January 2013. They are evidence-based improvement strategies to address the gaps between current and best practice that the Department of Health has identified as
affecting a large number of patients.
The primary aims of the National Health Standards are: to protect the public from harm and to improve the quality of health service provision.
Each criterion has a series of items and actions that are required in order to meet the Standard.
Kerang District Health has conducted a gap analysis
against each of the criterion in the standards to identify
areas that require work to improve clinical practice.
Each action within a Standard is designated as either Core or a Developmental Action.
There are a total of 256 actions – 209 core actions and 47 developmental actions. Core, are critical for safety and quality, and Developmental, are aspirational targets.
To pass accreditation an organisation must pass all the core actions.
At Kerang District Health accreditation will be carried out by ACHS – Australian Council on
Healthcare Standards and follows the same process of: Self-Assessment Periodic Review, Self-Assessment and Organisation Wide Survey.
Kerang District Health Organisation Wide Survey date is 02 - 04 Sept 2014.
1 Governance for Safety and Quality in Health Service Organisations - the quality framework required for health service organisations to implement safe working systems
2 Partnering with Consumers - to create a consumer-centred health system by including consumers in the development and design of quality health care. 3 Preventing and Controlling Healthcare Associated Infections - to prevent infection of patients and to manage infections effectively when they occur . 4 Medication Safety - to ensure clinicians safely prescribe, dispense and administer appropriate medicines to informed patients.
5 Patient Identification and Procedure Matching - to identify patients and correctly match their identity with the correct treatment. 6 Clinical Handover - the effective clinical communication whenever accountability and responsibility for a patient’s care is transferred. 7 Blood and Blood Products - the safe, effective and appropriate management of blood and blood products. 8 Preventing and Managing Pressure Injuries – to prevent patients developing pressure injuries and implementing best practice management when pressure injuries occur. 9 Recognising and Responding to Clinical Deterioration in Acute Health Care - to respond quickly and effectively to patients when their clinical condition deteriorates. 10 Preventing Falls and Harm from Falls - to reduce the incidence of patient falls and implement best practice management when falls do occur.
6
Maintaining and
enhancing standards Safety and Quality framework at KDH
The framework at Kerang District Health is based on the
Victorian Government Clinical Governance Policy Framework
which is built on the four domains of quality and safety –
Consumer Participation, Clinical Effectiveness and
Appropriateness, Effective Workforce, and Risk
Management.
The Management Quality Risk Committee oversees clinical
governance of the health service and monitors quality and
safety. Two Board of Management members, the Chief
Executive Officer, Corporate Services Director, Director of
Nursing, Quality Coordinator, Nurse Unit Managers and
Department Heads attend the meeting. Departmental
Operational Quality meetings are held each month, to
facilitate the transfer of information and discussion of
audit results. Staff are encouraged to suggest how
improvements can be made to both clinical and non-
clinical processes.
An organisational Continuous Improvement Plan is linked
to the KDH Strategic Plan 2012 - 2015. Departmental
plans have also been developed and are linked to the KDH
Strategic plan. The Accreditation Action Plan /Status
report includes recommendations from the previous ACHS
Periodic Review, and gaps identified against all of the
actions required to meet the National Safety and Quality
Standards.
Consumer participation
We are required by the new National Safety and Quality
Standards to develop a Consumer Participation Strategy
that aims to build strong partnerships with our community,
to enable them to have greater input into health care. This
occurs when consumers are meaningfully involved in
decision-making about their care and treatment, or when
providing input about service delivery, health policy or
planning.
Currently we have many initiatives that gather data on
patient experience, but the new standard requires for
consumers to be more involved in being part of finding the
solutions to aspects identified for improvement.
During 2013 Kerang District Health will be seeking
consumers to be members of the Consumer Participation
Committee and they will be offered training in how to fulfil
this role.
Clinical effectiveness
Clinical effectiveness is crucial for providing appropriate
and timely care, and to ensure that patients are
informed and involved in decisions about their care.
One strategy we use for measuring clinical effectiveness
is to compare patient outcomes with those of other
hospitals. We take part in the ACHS Clinical Indicator
benchmarking program where our results are compared
to other like sized hospitals for a number of clinical
areas.
Regular clinical audits are undertaken to identify
issues that need improvement. Any aspect identified
for improvement has an action entered onto the
departmental quality plan, and reaudits occur to
ensure that the change in practice is being adhered to
until it becomes embedded as routine practice.
Effective workforce
We check the qualifications, registration, work history
and references of medical, nursing and allied health
applicants before they start work at Kerang District
Health, We also check their scope of practice according to
their qualifications and experience. This is to ensure that
all clinical staff have the right skills and qualifications to
provide safe health care. Annual checks are also conducted
on registrations for all clinicians.
We invest in ongoing education and professional
development through our Personal Development Days,
online resources and online ELearning courses. All staff
undertake mandatory training each year to remain
competent.
7
Maintaining and
enhancing standards Risk management
Risk management is the process of identifying what,
where, when, why and how something could happen
that may adversely affect patients or systems.
We use the Victorian Health Incident Management System
(VHIMS), a state-wide electronic system for reporting and
managing incidents, adverse events and near misses.
Each incident is investigated by the Nurse Unit Manager
or Department Head to improve practice and to prevent
similar events happening again.
The Incident Review Panel reviews all incidents each
month. It brings together the key staff involved in the
investigations and the implementation of recommended
actions. Informed discussion occurs with journal entries
made into VHIMs to update the record. Trends are
identified and implemented strategies are reviewed for
effectiveness.
KDH Top Risks at 30 June 2013
Risk Risk Score
1 Medical Emergencies (Ref: 2) High -12
2 Foetal Emergencies (Ref: 3) High -12
3 Management of acute Psychotic
episodes (Re: f5)
High -12
4 Obstetric Emergencies (Ref: 4) Medium - 9
5
Maintenance of Accreditation Status with Aged Care Standards
Accreditation Agency (Ref: 9)
Medium - 9
6 Risk of Litigation (Ref: 16) Medium - 9
7 Possibility of injury in use of
Wheelchair lifter on Bus (Ref: 61)
Medium - 9
Facts and figures
In 2012 – 2013 Kerang District Health had a
total of 1,811 separations - 918 overnight
separations, and 893 same day separations.
There was a total of 4,124 bed days - 3,231
overnight bed days and 893 same day bed days.
The total overnight daily average of patients was
11.53 patients, with the average length of stay
3.49 days.
There were 311 minor surgical procedures and
107 major surgical procedures conducted during
the year.
There were 50 births for the year, with a total of
171 new born days recorded.
There were 2,830 outpatient attendances.
Glenarm had a total of 10,273 bed days.
District nurses recorded 8,661 visits.
Day Centre program recorded 2,700 contacts.
Mobile Day Activity program recorded 836 contacts.
The Exercise program recorded 3,106 attendances.
There were 1,565 Men’s Shed attendances.
There were 30 staff incidents and 36 staff hazards
recorded on VHIMS, with 26 days lost to workers
compensation.
There were 1,230.58 sick days taken, and 229.76
carer’s leave days taken.
There were 12,028.42 annual leave hours taken, and
108,617 annual leave hours accrued; 2,070 long
service leave hours taken, and 226,361 long service
leave hours accrued across the health service.
8
Improving care Medication safety
The Management Quality Risk committee oversees
medication management at Kerang District Health. Staff are encouraged to report any errors involving
medications, including near misses, as this enables us to develop new initiatives to ensure that the
prescribing, dispensing and administering of
medications is made safer for our patients.
Information about the medications patients are
currently using is an important part of the admission
process; as is providing written information to patients
about their medications upon discharge from hospital.
Some of our doctors are now providing a printed sheet
outlining the medication dose, time to be taken, the
purpose of the medication and possible side effects to
their patients upon discharge, and the feedback from
our local survey supports this initiative.
Client feedback
We have recently introduced a pharmacy review of the
patient’s medications upon discharge, as another
means of ensuring that the patient is fully informed
about the medications that they are to take, and to
reconcile any new medications with medications on file
at the local pharmacy. This also allows the patient or
their carer to ask any questions and have them
answered by the pharmacist.
We have widen the scope of the audits conducted on medications to cover PRN medications, outpatients card
medications, legibility of orders, and the standard compliance medication audit.
In response to a recommendation from the Accreditation Periodic Review the Director of Medical
Services wrote to all our doctors regarding results of medication and medical documentation audits, to urge
greater compliance with GP’s signing and ceasing medications, and also noting the time of
history/examination of patients in the progress notes.
In addition an audit tool was developed to review the
overall degree of legibility of the doctors’ handwriting
covering the following criteria: 1 = notes can be read by a nurse new to the
organization or a non-nurse. 2 = writing can be read by staff familiar with the script.
3= writing creates concern and requires follow up
with a staff member who is familiar with the script. In the first audit, 10 histories were reviewed with an
overall compliance rate achieved of 82%.
Notes are now being typed which alleviates issues with
legibility, and student Doctors are now writing progress notes and having them co-signed by the GP.
In order to address the non-signing of medications all
medication charts are collected at the end of each shift and checked for compliance to legal requirements, and
this has improved compliance in this area.
High alert medications including drugs of addiction have been identified and include medicines with a low
therapeutic index; and medicines that present a high
risk when administered by the wrong route or when other system errors occur.
To improve this Kerang District Health follows the PINCH acronym:
P - Potassium
I - Insulin N - Narcotics
C - Chemotherapy H - Heparin
We have listed the medicines and developed risk
mitigation strategies to prevent errors from occurring.
Medications were given to me on a Medications were given to me on a Medications were given to me on a Medications were given to me on a printed sheet explaining what time to printed sheet explaining what time to printed sheet explaining what time to printed sheet explaining what time to take them and what they were for take them and what they were for take them and what they were for take them and what they were for ---- this this this this is an excellent idea.is an excellent idea.is an excellent idea.is an excellent idea.
In 2012 In 2012 In 2012 In 2012 –––– 2013 there were2013 there were2013 there were2013 there were::::
48 medication errors for Glenarm ; 48 medication errors for Glenarm ; 48 medication errors for Glenarm ; 48 medication errors for Glenarm ;
82. for Acute ward, an82. for Acute ward, an82. for Acute ward, an82. for Acute ward, and d d d
1 for District Nursing recorded on 1 for District Nursing recorded on 1 for District Nursing recorded on 1 for District Nursing recorded on VHIMs,VHIMs,VHIMs,VHIMs,(Victorian Incident (Victorian Incident (Victorian Incident (Victorian Incident Management System) Management System) Management System) Management System) as well as the as well as the as well as the as well as the errors identified by the visiting errors identified by the visiting errors identified by the visiting errors identified by the visiting pharmacistpharmacistpharmacistpharmacist,,,, who who who who conducts weekly conducts weekly conducts weekly conducts weekly audits audits audits audits on on on on files of patients who are on 9 files of patients who are on 9 files of patients who are on 9 files of patients who are on 9 or more medications. or more medications. or more medications. or more medications.
9
Improving careFalls prevention
Falls occur in all age groups; however the risk of falls
and harm from falls varies between individuals due to
factors such as eye sight, balance, muscle strength,
bone density and medication use. Falls remain a
significant issue in the safety of patients in Australian
hospitals, and although the risks are well documented
impaired mobility is also a major falls risk and is not
age defined.
In 2012 Kerang District Health developed an organisational wide policy on the Prevention of Falls and Fall Related Injuries with Falls Prevention made a
quality project across the health service focusing on a review of falls risk screening in Acute, District Nursing
and Day Centre. Work has been conducted on ensuring appropriate tools are in use with the orange sticker
used to flag prevention strategies in patients identified
as a high risk of falls.
Education of staff on changed strategies and audits on patient files for compliance to risk assessment and care
planning are conducted.
In 2013 the falls project continues and has a focus on
care planning and prevention strategies in line with best practice. Staff are using an escalation criteria for
patients who are in the high falls risk category, and when rated on the higher scale, staff are documenting
hourly checks, offering fluids, toilet break, and change
in position for patients.
Also simple strategies such as reducing clutter in patient rooms, ensuring that the bed is in a low
position, that the light is left on in the bathroom, and
that the patient’s glasses or waking aid are within reach are put in place – every little bit helps.
Falls risk status has been included on the Nursing Care
Plan with prevention actions to be noted.
Pressure injuries The chances of acquiring a pressure injury are increased when people are ill and admitted to hospital.
Pressure injuries can result in a longer stay and
prevention is a priority at Kerang District Health.
Pressure injuries are defined as any lesion caused by unrelieved pressure resulting in damage of the skin and
underlying tissue – they cause pain, distress and debility for patients and residents.
Risk minimization strategies are put in place such as the use of electronic air mattresses, and a soft mattress
in theatre. Surgical patients whose procedure is to last more than three hours are given gel pads to relieve
pressure areas.
In May 2013 a Pressure Injury and Prevention
Management Manual was adopted and is to be implemented with training for staff to be arranged.
Audits of current patients to assess Pressure Area/Skin Integrity occur to check if patients have been assessed using the Braden Scale Assessment Tool.
The audit conducted in January 2013 showed overall
compliance was 86% with the following noted: 6 clients were checked with 5 noted to have skin
issues. 3/5 had issues noted on the history /examination.
3/5 had the braden scale assessment conducted.
4/6 had evidence in the care plan of wound management strategies with 2/6 n/a.
5/6 had evidence that the care plan was being followed 3/6 had evidence of reassessment if the health status
had changed e.g fall or decline in condition with 3/6 n/a.
In 2012 In 2012 In 2012 In 2012 –––– 2013 2013 2013 2013 Glenarm haGlenarm haGlenarm haGlenarm had d d d 79797979 falls reported onto falls reported onto falls reported onto falls reported onto VHIMsVHIMsVHIMsVHIMs,,,, and and and and Acute ward recorded Acute ward recorded Acute ward recorded Acute ward recorded 29292929 falls on VHIMs.falls on VHIMs.falls on VHIMs.falls on VHIMs. (Victorian Health Incident Management (Victorian Health Incident Management (Victorian Health Incident Management (Victorian Health Incident Management System)System)System)System)
The The The The above overall compliance result of above overall compliance result of above overall compliance result of above overall compliance result of 86% showed an increase of 30.6% in 86% showed an increase of 30.6% in 86% showed an increase of 30.6% in 86% showed an increase of 30.6% in compliance to the previous audit results compliance to the previous audit results compliance to the previous audit results compliance to the previous audit results of 55.5%.of 55.5%.of 55.5%.of 55.5%.
In 2012 In 2012 In 2012 In 2012 –––– 2013 Glenarm 2013 Glenarm 2013 Glenarm 2013 Glenarm recordedrecordedrecordedrecorded 40 40 40 40 pressure area/skin integrity injuriespressure area/skin integrity injuriespressure area/skin integrity injuriespressure area/skin integrity injuries reported onto VHIMs and Acute ward reported onto VHIMs and Acute ward reported onto VHIMs and Acute ward reported onto VHIMs and Acute ward recorded recorded recorded recorded 10101010 pressure arepressure arepressure arepressure area injuriesa injuriesa injuriesa injuries on on on on VHIMs.VHIMs.VHIMs.VHIMs.
10
Improving carePreventing infections Monitoring the rates of infections in our patients and
finding ways to reduce those rates is an important part of keeping our patients safe during their hospital stay.
Kerang District Health is part of the state wide program to monitor patients for infections following surgery.
Last year our results were above the state average and in line with regional rates.
We monitor any blood stream infections caused by staphylococcus aureus (golden staph) as part of the
national program
Kerang District Health participates in the National Hand
Hygiene strategy with audits conducted twice yearly. Our latest results achieved an overall compliance rate
of 87% which is well above the Department of Health’s benchmark of 70%
All staff and visitors are encouraged to use the alcohol
hand gel. Wave 23 of the Victorian Patient Satisfaction
Survey results indicated that 81.8% of Acute patients indicated they observed hospital staff cleaning their hands between patients all of the time. A clean hospital is not just a pleasant place to recover
from illness or injury, but cleanliness plays a vital role in reducing the risk of patients developing an infection
during their stay. Our external cleaning audits for 2012 and 2013 showed that we successfully met the
Department of Health cleaning standards in all risk categories with overall compliance rate for the audit
conducted in October 2012 of 99%.
In order to prevent the spread of influenza the
Department of Health supplies Fluvax to Kerang District Health staff and aged care residents.
The graph below shows the number of staff who received fluvax
Blood safety
Blood safety
Informed consent for a blood component transfusion
means the Doctor and patient (or carers) discuss the risks, benefits and alternatives to having a transfusion.
As a result of the discussion the patient or carer will: • understand what medical action is
recommended and why.
• be aware of the risks and benefits associated
with the transfusion.
• appreciate the risks of receiving and possible
consequences of not receiving the recommended therapy.
• be given the opportunity to ask questions.
• give consent for the transfusion.
• receive two brochures Blood – who needs it? and A Blood Transfusion.
We participate in the Blood Matters clinical audit
program run by the Australian Red Cross Blood Service. We also carry out our own audits to ensure we comply
with best practice and that we are compliant with informed consent.
The audit in March of all transfusions for January
and February 2013, showed overall compliance of
95.7% with the following noted:
7/7 had a signed consent form.
7/7 signed consent by Doctor.
6/7 had the pathway completed as required.
5/7 had the cross match form signed by 2 people.
7/7 were transfused when the HB was less than
100g/l
7/7 had signs and symptoms of the need for a
transfusion, or ongoing bleeding noted.
7/7 had blood administered in < 30 minutes from
the time it left Pathology.
....
Our policies on blood and blood Our policies on blood and blood Our policies on blood and blood Our policies on blood and blood transfusions have been reviewed to transfusions have been reviewed to transfusions have been reviewed to transfusions have been reviewed to ensure that they meet legislative ensure that they meet legislative ensure that they meet legislative ensure that they meet legislative rerererequirements and follow best practice quirements and follow best practice quirements and follow best practice quirements and follow best practice guidelines.guidelines.guidelines.guidelines.
An analysis of the results indicated An analysis of the results indicated An analysis of the results indicated An analysis of the results indicated that 1 normal saline was not double that 1 normal saline was not double that 1 normal saline was not double that 1 normal saline was not double signedsignedsignedsigned,,,, and on one occasion only 1 and on one occasion only 1 and on one occasion only 1 and on one occasion only 1 nurse signed nurse signed nurse signed nurse signed the cross match form.the cross match form.the cross match form.the cross match form.
11
Listening to our consumers The Victorian Patient Satisfaction Monitor (VPSM) is
a survey that monitors and reports on patient
satisfaction with public hospital services throughout
Victoria. This information is reported to the
Department of Health. For Kerang District Health, it
enables us to compare our patients’ satisfaction
with similar hospitals and the State.
The most recent report, for VPSM Wave 23, is for the
period July 2012 to December 2012. There were 128
consumers who completed the surveys for Kerang
District Health during this period. The Overall Care
Index (OCI) identifies patient satisfaction with the care
provided by a health service, and achieved a rating of
86%. VPSM reports the OCI to the Department of
Health.
In July an Action Plan was devised to improve areas
identified for improvement:
• Weekend discharge plans to improve.
• Information for discharge especially written
medication information and discussion around this with the patient to occur.
• Planning discharge at all levels with ward staff
using the Nursing Admission Tool to improve. • Explanation to patients about waiting and service
times if delays expected to occur.
• Doctors to prepare before blood transfusions and
iron transfusions, documents including cross match or scripts, consent and orders in order to
prevent delays
• Post op patients now to get 1.5 - 2 rounds of
sandwiches.
•
Sample verbatim responses July to Dec 2012
Local surveys
To complement the VPSM feedback, Kerang District
Health conducts a phone survey to 10 random patients
each month and seeks feedback on admission, care
provided, including consumer input into the planning of the care, cleanliness of the room and bathroom, meals ,
discharge planning and services provided.
On two occasions during the year we have also sought on the spot comments from consumers across the health service, using a feedback card in inpatient areas and in District Nursing.
Our Midwifery surveys collect feedback on antenatal care, care during delivery, breastfeeding, comfort of the room, cleanliness of the bathroom, satisfaction with the meals offered, and domiciliary mid care. Overall ratings were excellent with the following comments received from some of our patients:
Helping us to improve
Complaints and compliments help us understand how
best to improve our services. The complaints we
receive can relate to communication, the
environment, food services, and timeliness of care –
and any other aspects of care raised by patients,
carers or families.
All comment, complaint and suggestion forms are forwarded to the Chief Executive Officer. Each form is registered with a brief summary outlining the nature of the complaint, what the investigation found and what the outcome was, provided to the monthly Management Quality Risk meeting.
In 2012 – 2013 the complaints were reviewed to identify any trends, and it was identified that the complaints against staff tended to be about the manner and language used in communicating with the patient or carer, rather than about the care. In 2012 – 2013 there were 30 complaints received by the health service. These were investigated and action taken as required.
Being able to relax knowing that I was Being able to relax knowing that I was Being able to relax knowing that I was Being able to relax knowing that I was in the best place for min the best place for min the best place for min the best place for my wellbeing and y wellbeing and y wellbeing and y wellbeing and care.care.care.care.
Friendliness of the staff and their Friendliness of the staff and their Friendliness of the staff and their Friendliness of the staff and their commitment to providing appropriate commitment to providing appropriate commitment to providing appropriate commitment to providing appropriate care.care.care.care.
I am an outpatient receiving I am an outpatient receiving I am an outpatient receiving I am an outpatient receiving chemotherapy and I cannot fault the chemotherapy and I cannot fault the chemotherapy and I cannot fault the chemotherapy and I cannot fault the staff I have contact with on staff I have contact with on staff I have contact with on staff I have contact with on each weekeach weekeach weekeach week
We were very happy with all the care We were very happy with all the care We were very happy with all the care We were very happy with all the care provided fromprovided fromprovided fromprovided from the knowledgeable and the knowledgeable and the knowledgeable and the knowledgeable and supportive midwives.supportive midwives.supportive midwives.supportive midwives.
All midwifery staff were friendly All midwifery staff were friendly All midwifery staff were friendly All midwifery staff were friendly and full of information guiding a and full of information guiding a and full of information guiding a and full of information guiding a new mother through a new experiencenew mother through a new experiencenew mother through a new experiencenew mother through a new experience....
12
Doing it with us, not for us The DOH policy “Doing it with us not for us” (2010 –2013) is a key way of measuring our success
1.The governing body is committed to consumer, carer and community
participation appropriate to its diverse
communities. Target indicator = 75%
Kerang District Health has appointed an Aboriginal Liaison Officer in 2013.
A Cultural Responsiveness Plan exists and we are required to report our progress on cultural responsiveness to the Department of Health against six requirements. VPSM – Wave 23 overall care index score of 86%
VPSM – Wave 23 How well cultural /religious needs were met = a score of 4.14 out of a possible score of 5.0
2.Consumers, and where appropriate,
carers are involved in informed decision–making about their treatment,
care and wellbeing at all stages and with appropriate support.
Target indicator VPSM = 75%
Maternity Services = 90%
Wave 23 Victorian Patient Satisfaction Monitor results for Consumer
Participation Index were 86.9% and KDH received a mean score of 4.26 compared to the state wide mean of 4.02. for “the way staff involved you in
decisions”. Wave 23 VPSM results for General Patient Information KDH received a score
of 89.7.
Annual Maternity Satisfaction Survey indicated 100% for care in labour ward
and post birth care and involvement. In 2012 a number of staff received training on patient centered care.
3.Consumers, and where appropriate, carers are provided with evidence-
based, accessible information to support
key decision making along the continuum of care.
Target indicator - = 85%
Wave 23 Victorian Patient Satisfaction Monitor results for “treatment and related information” Kerang District Health received an overall score of 86.0
on par with category D hospitals average score of 86.0
We use the telephone translation services for people requiring an
interpreter.
4.Consumers, carers and community members are active participants in the
planning, improvement, and evaluation of services and programs on an ongoing basis. The target indicator = 75% for
public hospitals covering the 6 specified
areas.
Boards of Management members are involved in Strategic Planning.
Community members are involved in the development of the some service
programs.
Board of Management members are members of the Management
Quality/Risk Committee – they receive audit reports, adverse events data,
key performance indicators on falls, pressure ulcers, aggression incidents
medication safety, complaints and triage urgency cat 1 – 5.waiting times,
All Board of Management members receive the minutes of the Management
Quality/Risk meeting, KPIs and accreditation reports.
Members on the Community Participation Register are involved in the
development and review of written consumer information.
Members on the Community Participation Register are involved in the development and review of the annual Quality of Care Report.
5.The organization actively contributes
to building the capacity of consumers,
carers and community members to
participate fully and effectively. The
target = 75% for public hospitals.
Early in 2013 the Quality Coordinator and a Board of Management member
attended a training day at the Health Issues Centre Melbourne and returned to Kerang District Health and conducted training for senior staff on consumer
participation.
13
Caring in our community Julie’s story
Norm and Julie Foster moved from Melbourne to
Kerang in September 2012 to enjoy a “tree change”
for their retirement. Not feeling well Julie attended
Fitzroy Street Clinic and saw Dr Harry Vanrensburg
who ordered tests and regrettably, in December 2012
diagnosed that Julie was suffering from Mesothelioma.
After various invasive procedures Julie commenced
chemotherapy treatment at Kerang District Health in
March 2013, where she completed six sessions of
chemotherapy over eighteen weeks, with the sessions
taking five hours each time. Half way through the
treatment regime Julie had a scan and received a ray
of hope, as the results showed that the tumour had
shrunk. At the end of the six sessions Julie says that
she is feeling “pretty good”, and added that she had
put herself on a high antioxidant diet.
Julie was asked how she had come into contact with
exposure to asbestos, and revealed that she had been
exposed as a nine year old girl when she played in the
backyard alongside discarded building materials, while
her father renovated their family home.
Again, as a nineteen year old bride, she assisted her
husband by sweeping up and cleaning the site as he
renovated their bathroom and kitchen. Both buildings
sadly contained asbestos sheeting and as she aptly
states:
” in those days we unaware of the dangers”.
Norm and Julie have been amazed at the quality of
care received at Kerang District Health, and also at
Swan Hill District Health and Bendigo Health Care,
where the care received and the transfer of
information has been exceptional. Julie says that
“everyone right down to the tea lady has a smile and a
greeting at all three facilities.”
A palliative care nurse visits once a month and Julie
welcomes her visit. She admits that she has been dealt
a death sentence, but you only have to speak with this
lady for a short time, to realise that she has an
inspirational, positive attitude and spirit. In her own
words she is “striving to live longer than her initial
prognosis.” which she has achieved twice over, and
continues to amaze her family and the clinicians
involved in her care.
Lauren’s story
After attending antenatal care Lauren Edwards presented to Kerang District Health for an elective
caesarean section in April 2013.
On admission she was warmly welcomed and shown to her room, where a nurse verified her paperwork.
Lauren was second on the surgery list, but she said it
felt like she waited for an eternity, before going to theatre and being prepared for her caesarean section.
Finally at 2.20 her baby daughter was born weighing
3146.85gms. Lauren and John named their daughter
Arlie.
There is always a small risk of developing an infection post operatively, and unfortunately Lauren developed
a post-operative infection which was treated with antibiotics over a five day period. Lauren recovered
well and was happy with the care she received from
nursing and medical staff, and especially the care of her baby daughter.
“ Everyone was outstanding, particularly the way the nurses cared for my daughter when I was unwell. All
staff, even down to the girls delivering the meals were always pleasant and courteous”.
In September 2010 Kerang District Health changed
to a Shared Care Model of Care for maternity
services, which is a team approach between the
Midwifery team and GP Obstetrician in the care of
the woman having an uncomplicated pregnancy.
Responsibility is shared for a woman’s care,
including communication, a shared Maternity record,
and Management of results and abnormal findings.
The focus is on education, preparation, involvement
and active birth, providing an opportunity for women
and their families to participate fully in pregnancy and
birth.
Our staff are committed to providing an integrated
service of the highest quality.
14
Caring in our community Men’s Shed setback
In December 2012 the Kerang District Health Men’s
Shed building was damaged by fire which forced its
closure for over five months. The fire destroyed
benches, equipment, electrical wiring, the main roller
door, and a vital beam in the workshop. It took time
for the insurance claim to be processed and to get
repair work authorised, but by April 2013 construction
work within the Burgoyne Street facility was in full
swing. Work to replace the roller door, roof panels and
electrical wiring that was damaged in the blaze was
almost completed. Members had commenced building
work benches to replace ones that were destroyed,
and were looking forward to moving back into the
workshop after five months of waiting. “All the
tradesmen involved in the project were fantastic” said
Harry Sambrooks coordinator of the program.
Despite not having a work space members remained
active by converting a portable classroom from Kerang
South Primary School into a meeting and tea break
room, where they discussed ideas on how to fix the
workshop, or share a joke. The fact that the members
could still come together was important.
Today the Men’s Shed is fully operational with the
existing members enthusiastic about the repaired
workshop, and new members continuing to join the
group.
The Men’s Shed program operates each Tuesday,
Wednesday and Thursday with anyone interested in
further information encouraged to contact Harry on
5452 1198.
Below: Carl Peterson and Rex Bradley are enjoying being back
with their tools in the repaired Men’s Shed.
15
Caring in our community Tony’s success
Anthony (Tony) Morosoli is a 72 year old gentleman
who suffered a heart attack in 1998; he had stents
inserted in 1999, and suffered a stroke in 2001.
In March 2012 he underwent a triple bypass operation
and commenced at the Kerang District Health
Rehabilitation Exercise Program mid-year after an
initial physio assessment. Tony commenced with a
limited program of
8 repeats of most
exercises using
low weights, and
taking lots of rest
periods between
exercises. His
balance was not
good, so he
required
assistance and
encouragement
from the program
workers.
As the weeks
passed Tony was
able to repeat the
exercises more
often and have
fewer rest
periods. Weights
were slowly
increased and
after three
months the
program became
more achievable
for Tony and his
confidence and
general health
improved. He is now able to do things that could not
do before, such as gardening and walking his dog Max
over the Railway footbridge.
The program has now been tailored to maintain Tony’s
strength and fitness, which has resulted in him
enjoying a better quality and happier lifestyle with his
wife. He attends sessions on Tuesday and Thursday
and along with improving his health, he enjoys the
social aspect of the program and has met many new
people.
Tony’s physio update shows a significant improvement
to his strength, balance and general stamina.
For further information on the exercise programs are
contact Karyl on 5450 9203. the programs are held n
each Tuesday and Thursday. Consumers can be
referred by their General
Practitioner or they may
self-refer. All participants
are required to have an
initial physio assessment
to determine the type of
program required.
Day Centre activities
are held on Monday
Wednesday and Friday
and cater for elderly
members of the
community who enjoy
activities, musical
entertainment, and the
company of others.
Participants can be
picked up at their home
and returned in the
afternoon by the Kerang
District Health Day
Centre bus.
The Mobile Planned
Activity Program is held
on Tuesday and
Thursday. On Tuesday
Kerry our bus driver
collects participants who
travel to Quambatook
for activities with local
residents and share a meal at the Quambatook hall.
On Thursday Kerry operates a service for clients who
require assistance with shopping, and medical
appointments. Again, clients share lunch together and
are collected from their home and returned in the
afternoon. This service is particularly focused on
country clients who may no longer wish to drive.
Above: Tony Morosoli busy at the Exercise Program