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TRANSCRIPT
Your Health Service HealthCOLAC AREA
Quality of Care Report 2013/2014
More than just a Hospital!
Emergency Health Services
Ambulance Dial 000
Urgent Care (Doctors attending the Urgent Care are private practitioners and fees will apply).
(03) 5232 5100
Medical Clinics
Corangamite Clinic (03) 5231 5866
Otway Medical Clinic (03) 5231 5300
Dr D Borsos (03) 5231 6664
Birregurra Community Health Centre - Dr. R. Sarkis (03) 5236 2000
Other Useful Numbers
Lifeline 131 114
Poisons Information 131 126
Mental Health Service 1300 763 254
Drug and Alcohol Service 1800 888 236
Child Protection Service 131 278
Sexual Assault Crisis Centre 1800 075 599
Colac Pharmacy (03) 5232 2399
Chemmart Pharmacy (03) 5231 4022
Purely Dental Clinic (03) 5232 2600
Your Helpful Numbers HealthCOLAC AREA
LONGROADAPPEAL
THE
BRINGING CANCER
TREATMENTSTO COLAC
DONATE NOW
www.cahfoundation.org.au
HELP US SHORTEN THE ROAD
THE LONG ROAD APPEAL
Quality of Care Repor t 2013/2014
The National Safety and Quality Health Service (NSQHS) Standards have been developed to drive the implementation of safety and quality systems and improve the quality of health care in Australia
Your Health Service HealthCOLAC AREA
It is with pleasure that the Board and the Team of Colac Area Health present the Quality of Care Report to our community for the 2013/2014 financial year.
You are encouraged to give your comment on the report to guide report improvements for 2014/2015.
Feedback form is available on the back page and on the Colac Area Health website.
Geoff Iles CHIef exeCUtIve OffICeR
Quality of Care Repor t 2013/2014
1. Clinical Governance. Governance for Safety and Quality in Health Service Organisations
6. Clinical Handover.
2. Partnering with Consumers. 7. Blood and Blood Products.
3 Preventing and Controlling Healthcare Associated Infections.
8. Preventing and Managing Pressure Injuries.
4. Medication Safety.9. Recognising and Responding to Clinical Deterioration in Acute Health Care.
5. Patient Identification and Procedure Matching.
10. Preventing Falls and Harm from Falls.
A better way to care
Over the last 12 months we have been working with our staff and the Community Advisory Committee to involve consumers in our
health service to ensure better health outcomes.
this has included the following initiatives:
Bedside audits
Development of Acute Discharge survey
Adoption of Consumer Participation Plan for the organisation
Acknowledgement of Country Policy for staff
Review of Interpreter Services Guidelines to ensure easy access for clients
A new brochure process to accommodate consumer feedback
Consumer involvement in staff committees and Project Control Groups
Development of plan to involve consumers in staff training
education for staff about involving consumers in their care including video resources, case studies and role plays
Review of HACC Plan which includes plans for supporting Cultural Diversity
Cultural Diversity training for staff and consumers
Staff representative on Closing the Gap Committee (Barwon)
two Wathaurong Aboriginal family Support staff working from Colac Area Health one day a week
Consumer approved logo
Consumer Participation
Quality of Care Repor t 2013/2014
ConsumerRepresentative
Approved
How can I be involved?We encourage you to be involved in choices about your healthcare whether you are a patient or a carer.
We encourage you to have your say in relation to care plans, ways we can improve our service to make your stay easier for you. We also value your feedback and encourage you to take an active role in your health service through the Community Advisory Committee or volunteering for our programs.
You can visit the “Our Community” section of our website or contact our Consumer Participation Coordinator on 5232 5158 to find out how you can be involved.
Quality of Care Repor t 2013/2014
20,578 people live in
the Colac Otway Shire
3.2% of our
population speak
a language other
than English
at home
0.94% of our
population are
Aboriginal or
Torres Strait
Islander
7.9% of our population were born overseas
Life Expectancy in Colac Otway
Shire isMale - 78.3
Female - 81.7
DID YOU KNOW?
Consumer Participation
JANUARY 2015MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY SATURDAY SUNDAY
1 2 3 4
5 6 7 8 9 10 11
12 13 14 15 16 17 18
19 20 21 22 23 24 25
26 27 28 29 30 31
Notes:
Quality of Care Repor t 2013/2014
The number
of consumers treated in Urgent Care?7,962
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Promoting independence, autonomy, confidence
and self-worth, respite for carers and mental stimulation.
The Adult Day Activity Program has introduced a Strength and Balance component into our Program,
in conjunction with our Rehabilitation service.
It is designed for clients who have completed their rehabilitation program and are wanting social interaction and continuation of gentle exercise.
the success of the program has seen an increase of days the Strength and Balance Program is being offered and an increase in clients wanting to participate.
We are running our regular Program from tuesday to friday. Approximately 70 people have accessed our Program in the last 12 months.
the Birregurra Adult Day Activity Program started in february 2014. Which is part of the Birregurra Community Health Centre. We run the program on the same philosophy as the Adult Day Activity Program in Colac.
The Adult Day Activity Program
Quality of Care Repor t 2013/2014
FebRUARY 2015MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY SATURDAY SUNDAY
1
2 3 4 5 6 7 8
9 10 11 12 13 14 15
16 17 18 19 20 21 22
23 24 25 26 27 28
Notes:
Quality of Care Repor t 2013/2014
1,805 adult dental treatments in 2013/2014
The objective of the Kinder Wide Smiles (KWS) program is to improve access to dental services for children identified
as having caries and to improve dental awareness and knowledge of parents and or guardians.
‘Smiles4Miles’ is a Dental Health Services victoria (DHSv) initiative which works in partnership with Community Dental Health Clinics to improve the oral health of pre-school aged children in victoria. the key health promotion messages encouraged with the ‘Smiles4Miles’ program focus on drink well, eat well and clean well.
to complement ‘Smiles4Miles’, the Kinder Wide Smiles program was developed at Barwon Health and implemented here at Colac Area Health.
ObjectivesProvide dental assessments to children who may otherwise not attend clinics
Remineralise initial carious lesions in the kindergarten settings rather than refer to dental clinics
Provide oral health promotion information through child and parent activities
Achieve cost benefits by examining and treating children in non-clinical settings
Improve access to dental services for those children identified as having caries
Kinder Wide Smiles Program
Quality of Care Repor t 2013/2014
Dental caries is
tooth decay
Triage Compliance 2013/2014the percentage of patients presenting for emergency care triaged as category 1, 2 or 3 that are offered access to care within 24 hours/7 days/14 days of triage.
Survey results from parents, pre and post-intervention and from Kindergarten managers were analysed to improve processes for the continuation of the program.
In 2013, 2,371 children participated in the program. Positive responses from parents and guardians indicate and confirm the effectiveness of the program.
Kinder Wide Smiles Program
Triage Compliance
Actual Target Variance
Category 1 85.7 % 85.0 % 0.7 %
Category 2 88.0 % 80.0 % 8.0 %
Category 3 91.8 % 75.0 % 16.8 %
Quality of Care Repor t 2013/2014
MARCH 2015MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY SATURDAY SUNDAY
30 31 1
2 3 4 5 6 7 8
9 10 11 12 13 14 15
16 17 18 19 20 21 22
23 24 25 26 27 28 29
Notes:
Quality of Care Repor t 2013/2014
In 2013/2014
1,994 children
received dental
treatments
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Our Community Palliative Care service is based on a shared care model, which includes two specialist Palliative Care Nurses, supported by our Home Nursing team, Palliative Care volunteers, Local GP’s, Allied Health team, a Clinical Nurse Coordinator and a Palliative Care Registrar from Barwon Health.
this provides our clients access to specialist services to ensure a better quality of life with symptom management and support, to enable them to die in their place of choice.
this year, Community Palliative Care delivered almost 500 hours of service to families in the Colac Otway catchment.
this could include services for symptom management such as pain relief or constipation, emotional support for the client and their carer, and most importantly, resources and support to remain at home for as long as possible.
Community Palliative Care
Quality of Care Repor t 2013/2014
Palliative Care Weekthe focus for Palliative Care Week this year was “Let’s work together, Palliative Care, everyone’s business”.
Our Palliative Care Nurses participated in this week-long event by reaching out to the community to provide education and information forums. this was very well received, with many community members attending on the night.
Community Palliative Care
Quality of Care Repor t 2013/2014
We participate in the victorian Patient Satisfaction Survey to ascertain the public’s level of satisfaction with the Palliative Care service that they have received. In previous years, the response has been very positive with a high level of satisfaction.
APRIL 2015MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY SATURDAY SUNDAY
1 2 3 4 5
6 7 8 9 10 11 12
13 14 15 16 17 18 19
20 21 22 23 24 25 26
27 28 29 30
Notes:
Quality of Care Repor t 2013/2014
In 2013/2014 5,825 consumers were treated as acute inpatients
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Hand Hygienethe Australian Commission on Safety and Quality in Healthcare recognises the “5 moments for hand hygiene” developed by the World Health Organisation (WHO 2009) and adopted by Hand Hygiene Australia. Hand hygiene helps protect patients against acquiring infectious agents from the hands of healthcare workers.
We regularly audit hand hygiene activities of health care workers and submit three reports to Hand Hygiene Australia each year. We have a 70% compliance rate which compares favourably with national figures. Hand hygiene is promoted throughout the organisation and hand hygiene products are readily available. Staff are encouraged to attend practical hand hygiene sessions and encourage visitors to use hand hygiene.
VICNISS Reports and ACHS Infection Control Clinical Indicator SuiteWe participate in the victorian Surgical Site Infection Hospital Acquired Infection Surveillance (vICNISS) program. the primary aim of vICNISS is to lower the number of infections acquired in victorian hospitals. Infection rates and occupational exposure rates are reported to vICNISS on a monthly basis. Hospital acquired infection rates are closely monitored and continue to be within the acceptable range.
Staff Health Infection prevention for healthcare workers is an important part of our infection control and prevention program. this includes promoting immunisations.
the influenza immunisation program protects staff from influenza and contributes to the protection of the wider Colac community. In 2013/2014, 64% of staff received the influenza vaccination.
During the year we promoted flu vaccinations on the local radio station MixxfM encouraging members of the community to take the opportunity to receive the influenza vaccination provided by their doctors.
Infection Control
Quality of Care Repor t 2013/2014
Antibiotic Stewardshipthe Antibiotic Stewardship Program aims to change antibiotic prescribing to reduce overuse, reserve the last line agents and promote the use of agents less likely to select resistant bacteria.
Our activities are informed by guidelines and demonstrated incidence of antibiotic resistance.
therapeutic guidelines are widely available. Internal and external audits of antibiotic prescribing are performed. the results of audits are discussed at the Infection Control and Prevention Meetings.
Infection Control
Medication Safety
Quality of Care Repor t 2013/2014
Become a resistance fighter! Resistant bacteria are a serious enemy.
What can you do to help?Do not expect your doctor to prescribe antibiotics for everything that ails you
If you do have a bacterial infection take the full course, don’t keep a few for next time
Give your body a chance to get better without medication. Rest and fluids often help your natural healing process to occur
Do not stock pile antibiotics
Remember antibiotics will not kill viruses such as colds and flu
MAY 2015MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY SATURDAY SUNDAY
1 2 3
4 5 6 7 8 9 10
11 12 13 14 15 16 17
18 19 20 21 22 23 24
25 26 27 28 29 30 31
Notes:
Quality of Care Repor t 2013/2014
How many
people had
surgery in
2013/2014?
3,055 2,886 - elective
169 - urgent
Environmental Servicesenvironmental Services are an integral part of our organisation.
the standard of cleaning we provide is very high, well above the Acceptable Quality Level (AQL) required in the “Cleaning Standards for victorian Health facilities 2011”. Monthly cleaning audits are conducted internally by a Qualified victorian Cleaning Standards Auditor (QvCSA). We have two QvCSA auditors on site.
to ensure the hospital meets the requirements of the Department of Health an annual audit is carried out by an external Auditor, from Infection Prevention Australia (IPA). Our last audit was 16 July 2014.
the cleaning audit conducted was based on the “Cleaning Standards for victorian Health facilities 2011”.
the standards act as a guide for developing service specifications, be easily interpreted to meet our obligations.
the standards:
Reflect the outcomes required of a cleaning service
Do not measure process but remain focused on the need to have a clean and safe environment
focus on the needs of the patient/client
emphasise services are a vital component in the development and maintenance of a health care services quality system
Require a demonstration and commitment to continuous quality improvement
Cleaning Audits
Quality of Care Repor t 2013/2014
Cleaning AuditsData is reported to the Department of Health in March, August and November. the results of the annual audit demonstrates the quality of service we provide.
Cleaning Audits
Quality of Care Repor t 2013/2014
AREA2012/2013
SCORE2013/2014
SCORE
Very High Risk – AQL 90% Operating Suite and CSSD
98% 99%
High Risk – AQL 85% Sterile supply areas, Urgent Care, Pharmacy, Wards etc.
93% 94%
Moderate Risk – AQL 85% Laboratories, Mortuary, Medical Imaging, Waiting Rooms, Administration
100% 92%
Overall Facility Score – AQL 85% 95% 94%
JUNe 2015MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY SATURDAY SUNDAY
1 2 3 4 5 6 7
8 9 10 11 12 13 14
15 16 17 18 19 20 21
22 23 24 25 26 27 28
29 30
Notes:
Quality of Care Repor t 2013/2014
In 2013/2014 our kitchen produced 182,500 meals
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Grand OpeningOn 22 August 2013 we unveiled our new $1.9 million student accommodation building which can house 14 student doctors, nurses or allied health professionals.
“The aim of the building is to ensure that the new students find their way to Colac and other rural areas to ensure that
medical workforce shortages are being addressed and that specialist training can be provided in a rural setting.”
We named the building in honour of pioneering Colac Doctor Arthur edward Brown. Dr Brown was a ground breaker with his approach to community medicine.
Student Accommodation
Quality of Care Repor t 2013/2014
JULY 2015MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY SATURDAY SUNDAY
1 2 3 4 5
6 7 8 9 10 11 12
13 14 15 16 17 18 19
20 21 22 23 24 25 26
27 28 29 30 31
Notes:
Quality of Care Repor t 2013/2014
How many were babies born at CAH?
169
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Birregurra CommunityHealth Centre
Quality of Care Repor t 2013/2014
Who are we and what do we do?the Birregurra Community Health Centre provides multidisciplinary services, support groups and activities to the Birregurra community and immediate surrounding areas. Our primary goal is to provide responsive services and activities in order to support positive health and wellbeing outcomes and a vibrant and engaged community.
the Birregurra Community Health Centre Advisory Committee provides community guidance, direction, feedback, support and advocacy for the Centre, staff, and community. the Birregurra Community Health Centre Auxiliary provides invaluable financial support to the Centre.
the Birregurra General Practice operates from the Centre, along with a number of visiting and sessional services which include; Community Health Nursing, Maternal and Child Health, Breast Care Nurse, Diabetes Resource Nurse, Podiatry and Nail Clinics.
Ongoing programs and activities:
We have fantastic community facilities available for hire, and we encourage community groups of all shapes and sizes to facilitate activities, meetings, and groups from the Centre. We have a subsidised rate for room hire for not-for-profit community groups. the Centre also has a gym with low membership rates and afterhours access.
MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY9:30-2:30 pm
Adult Day Activity Program
9:00-10:30 am Yoga
1:30-3:00 pm tai Chi
7:00-9:00 pm Craft group
7:30-9:00 pm Bridge
9:00-10:00 am exercise class
(Blue Water fitness)
1:00-3:00 pm french class
7:00-9:00 pm Life Drawing
every 4th tuesday: 11:30-3:00 pm
Greet eat Meet group
9:00-10:00 am Walking Group
6:30-8:00 pm Yoga
10:00 am Community
shopping bus to Colac
10:00-12:30 pm Skills Connection
(external)
10:00-12 noon Birre Mum’s Group
10:30-12 noon Craft Group
12 noon Lunch on fridays
3:00-4:30 pm exercise class
(Blue Water fitness)
What has been achieved in 2013/2014?there are new weekly programs and activities, including the Adult Day Activity Program, Birregurra Mother’s Group, and community french classes.
We have established a Youth events Committee that will be the key to developing exciting events and programs for young people in Birregurra.
Our weekly lunch program had its one year anniversary, and is still going strong, with up to 30 members of the community attending each week for wholesome meals prepared by our wonderful volunteer cooks and helpers.
the Birregurra community welcomed a new Coordinator in february, who brings a rich background in community development and service design and delivery.
What does the future hold?Over the next 12 months, we will focus on the Centre’s service development, which will include exploring opportunities to expand the services available to you. Our service and community development plans will be guided by our commitment to social connection, health promotion, health and wellbeing services.
Birregurra CommunityHealth Centre
Quality of Care Repor t 2013/2014
AUGUST 2015MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY SATURDAY SUNDAY
31 1 2
3 4 5 6 7 8 9
10 11 12 13 14 15 16
17 18 19 20 21 22 23
24 25 26 27 28 29 30
Notes:
Quality of Care Repor t 2013/2014
88 volunteers
supported us
in 2013/2014
Our bedside clinical handover boards are in place in the Acute Ward and will commence as part of the handover-of-care at 1:00 pm. these boards, and the new handover process which accompanies them, promotes patient involvement in care discussions and care planning from admission to discharge.
Clinical Handover
Quality of Care Repor t 2013/2014
traditionally our handover session has been held in a closed room with information flowing from nurse to nurse without the immediate input of the patient or carer. the new process requires handover to take place at the bedside engaging patients fully with their care and progress. Obviously sensitive information is handled privately. Research shows patient involvement improves patient outcomes and bedside handover reduces errors.
While the ‘boards’ can be seen at the end of each bed are the most obvious sign of the change, the reduction in communication errors and the increase in patient satisfaction are our primary goal in implementing this change. An audit in six months will inform us if we have met our primary goal.
Quality of Care Repor t 2013/2014
Quality and Safety
Quality of Care Repor t 2013/2014
Clinical Governance is the system by which health services are responsible and accountable for providing quality and safe care. Providing and enhancing a great consumer experience is the central focus of all that we do at Colac Area Health.
We recognises the six key dimensions of Quality identified by the victorian Quality Council:
Safety effectiveness
Appropriateness Acceptability
Access efficiency
In addition, our Quality Improvement framework aligns with the Clinical Governance Domains of Quality and Safety contained within the Colac Area Health Clinical Governance framework:
Consumer Participation Clinical effectiveness
effective Workforce Risk Management
A range of processes are in place to support the dimensions of Quality and Safety to monitor and continually improve patient care:
Committees that monitor our performance
Incident and complaint management
Accessible policies, guidelines and procedures to provide safe care
Collecting data with set internal and external benchmarking to monitor improvements
It’s a Board objective to have Colac Area Health quality of services well measured.
Providing the great experience every time for every consumer
SePTeMbeR 2015MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY SATURDAY SUNDAY
1 2 3 4 5 6
7 8 9 10 11 12 13
14 15 16 17 18 19 20
21 22 23 24 25 26 27
28 29 30
Notes:
Quality of Care Repor t 2013/2014
How many Service types do Community Services provide?52
term 3 eNDs
Quality of Care Repor t 2013/2014
Access to Allied Psychological Services (AtAPS) Children’s counselling service is funded by Barwon Medicare Local. this service is for children 0-12 years who have, or are at risk of, developing a mental, childhood behavioural or emotional disorder.
Referrals are required from a GP or paediatrician. Arrangements with GP’s and paediatricians have provided free access to the service.
We have one AtAPS clinician 2 days per week. this service has been well utilised over the past 12 months with over 40 referrals made in 2013/2014 with 30 children and their families receiving a clinical service which can include social skills development, school liaison, parenting and family based therapy, building attachments and relaxation training.
the program has strong links with the Barwon Medicare Local providers. Undertaking supervision in Geelong and participating in team meetings with other Barwon AtAPS clinicians provides the best possible service to the Colac community.
Allied Psychological Services (ATAPS)
Consumer Story9 year old Stacey (** not real name and details have been de-identified) was referred to AtAPS because of anxiety and refusing to go to school. following an assessment the family was able to think about Stacey’s school refusal in the context of recent grief and loss of a close family member. We discovered Stacey was feeling scared mum might not be home after school.
Allied Psychological Services (ATAPS)
Quality of Care Repor t 2013/2014
We worked on building her attachment with mum and feeling safe and secure at home to be able to begin to build independence attending school. Liaison with the school support services built their capacity to assist Stacey feeling part of the school team and having stronger connections to the school environment and her peer group.
Stacey was attending school 80% of the time when she finished counselling. Stacey, her family and the school were feeling more positive and optimistic about her ability to continue her education and her anxiety has decreased to a manageable level.
OCTObeR 2015MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY SATURDAY SUNDAY
1 2 3 4
5 6 7 8 9 10 11
12 13 14 15 16 17 18
19 20 21 22 23 24 25
26 27 28 29 30 31
Notes:
Quality of Care Repor t 2013/2014
How many
consumers
use Community
Services?
13,000
term 4 starts
On OfferA free tax Help service run by volunteers has been set up and is supported by the Australian tax Office. Contact Neighbourhood House for further details (03) 5232 5210.
every friday night a free community dinner provides meals and social support to local families. this program is supported by our cafeteria and other local businesses and is manned by volunteers. Approximately 30 to 35 people attend including about 10 children.
the Neighbourhood House is home to three playgroups including a Home Schooling group that uses the community garden in their learning program.
every thursday there is a craft and social group made up of local people and Iranian asylum seeker families who come together to share food and skills. trinity College recently donated five sewing machines to the house to assist in this program and they are well used.
every six weeks a community lunch is held in partnership with Pathways and St Laurence with attendances around 50 people.
A well used community garden supported by many different people are growing and tending plots there.
Computers are available which allows families to keep in touch.
Laminating, printing, computer, internet access and form filling services are available and provide a workplace for six volunteers to acquire skills and increase social connections.
Neighbourhood House
Quality of Care Repor t 2013/2014
this year, we have hosted celebrations and forums for:
Blokes Day Out Refugee Week
volunteer Week Neighbourhood House Week
Parkinsons victoria Asylum Seeker Resource Centre
Deakin University’s ‘You the Man ‘
.....with more events planned next year.
Colac Neighbourhood House is currently home
to 46 diverse groups who meet regularly here.
Quality of Care Repor t 2013/2014
Neighbourhood House
NOVeMbeR 2015MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY SATURDAY SUNDAY
30 1
2 3 4 5 6 7 8
9 10 11 12 13 14 15
16 17 18 19 20 21 22
23 24 25 26 27 28 29
Notes:
Quality of Care Repor t 2013/2014
How many people did Corangamarah care for?
138
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Corangamarah Residential Aged Care
Quality of Care Repor t 2013/2014
Corangamarah consistently performs well against the State-wide High Care indicators. Resident medications are reviewed by a pharmacist on a regular basis with feedback provided to the residents GP for ongoing management.
Corangamarah – Residential Aged Care
Corangamarah consistently performs well against the State-wide High Care average. Resident medications are reviewed by a pharmacist on a regular basis with feedback provided to the residents GP for ongoing management.
At Corangamarah our Falls numbers are consistently below the State-wide High Care average. We pride ourselves on ensuring all residents have a risk assessment on entry to provide them with strategies to minimise the risk of falls during their stay. We also encourage residents to opt in to our hourly resident rounding program where nursing staff provide additional supervision and ensure fundamental care needs are being met on a more regular basis.
Corangmarah consistently performs well against the State Wide benchmark for Stage 4 pressure ulcers - where full thickness tissue loss has occurred. This is primarily due to the vigilance of our wound care nurses who conduct regular skin inspections on all of our residents to prevent the occurrence of pressure ulcers.
0.01.02.03.04.05.0
Q112/13
Q212/13
Q312/13
Q412/13
Q113/14
Q213/14
Q313/14
Q413/14
Medication Management
Incidence of Nine or More Medications Benchmark
012345678
Q112/13
Q212/13
Q312/13
Q412/13
Q113/14
Q213/14
Q313/14
Q413/14
Falls Management
Prevalence of Falls per (1000 bed days) Benchmark
0.00
0.02
0.04
0.06
0.08
Q112/13
Q212/13
Q312/13
Q412/13
Q113/14
Q213/14
Q313/14
Q413/14
Stage 4 Pressure Injury
Stage 4 Pressure Injury Benchmark
Corangamarah – Residential Aged Care
Corangamarah consistently performs well against the State-wide High Care average. Resident medications are reviewed by a pharmacist on a regular basis with feedback provided to the residents GP for ongoing management.
At Corangamarah our Falls numbers are consistently below the State-wide High Care average. We pride ourselves on ensuring all residents have a risk assessment on entry to provide them with strategies to minimise the risk of falls during their stay. We also encourage residents to opt in to our hourly resident rounding program where nursing staff provide additional supervision and ensure fundamental care needs are being met on a more regular basis.
Corangmarah consistently performs well against the State Wide benchmark for Stage 4 pressure ulcers - where full thickness tissue loss has occurred. This is primarily due to the vigilance of our wound care nurses who conduct regular skin inspections on all of our residents to prevent the occurrence of pressure ulcers.
0.01.02.03.04.05.0
Q112/13
Q212/13
Q312/13
Q412/13
Q113/14
Q213/14
Q313/14
Q413/14
Medication Management
Incidence of Nine or More Medications Benchmark
012345678
Q112/13
Q212/13
Q312/13
Q412/13
Q113/14
Q213/14
Q313/14
Q413/14
Falls Management
Prevalence of Falls per (1000 bed days) Benchmark
0.00
0.02
0.04
0.06
0.08
Q112/13
Q212/13
Q312/13
Q412/13
Q113/14
Q213/14
Q313/14
Q413/14
Stage 4 Pressure Injury
Stage 4 Pressure Injury Benchmark
At Corangamarah our number of falls are consistently below the State-wide High Care average. We pride ourselves on ensuring all residents have a risk assessment on entry to provide them with strategies to minimise the risk of falls during their stay. We also encourage residents to ‘opt’ in to our hourly resident rounding program. Our staff provide supervision and ensure fundamental care needs are being met on a more regular basis.
DeCeMbeR 2015MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY SATURDAY SUNDAY
1 2 3 4 5 6
7 8 9 10 11 12 13
14 15 16 17 18 19 20
21 22 23 24 25 26 27
28 29 30 31
Notes:
Quality of Care Repor t 2013/2014
There were 2,770 medical admissions in 2013/2014
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term 4 eNDs
EQuIPNationalthe introduction of National Standards are about patient safety, quality of care and partnering with our consumers in all aspects of their care.
In September 2013, we underwent a periodic review by the Australian Council on Healthcare Standards (ACHS) against 3 of the 10 National Standards with the addition of an extra 5 evaluation and Quality Improvement Program (eQuIP) standards. Our accreditation status is continued, having met all core actions. An organisational wide survey will be undertaken in September 2015.
Community Care Common Care StandardsA quality review against the Community Care Common Standards was conducted by ACHS at the same time of the eQuIPNational review in September 2013. the review is for HACC funded services provided by Colac Area Health. All standards were met, with positive comments from the surveyors.
Residential Aged Carethe Aged Care Quality Agency conducted an unannounced visit to Corangamarah in March 2014. All four standards were met with positive comments provided by surveyors with regards to excellent care provided to residents by our staff. Corangamarah are also progressing towards re-accreditation in September 2015.
Accreditation
Quality of Care Repor t 2013/2014
Providing the great experience every time for every consumer
Last survey3 Standards
18 outcomesall met
Department of Human ServicesAs an organisation funded through the Department of Human Services (DHS) for direct client service delivery, our family and Community Programs is independently reviewed and accredited every three years. Our accreditation determines our authority to deliver Child first and family Services.
the next independent review is in October 2014 and a self assessment for the independent review body has been prepared.
Feedback At Colac Area Health we encourage and value consumer feedback as the information provides us with an insight in the experience of our consumers and is used to evaluate and improve the services we provide.
Our aim is to make providing feedback as easy as possible and is available to our community via website, feedback forms, telephone and face to face discussions. feedback boxes are located throughout our health service.
Colac Area Health continues to record an increase in compliments, with a slight increase in complaints from previous year.
Complaints July 2013 – June 2014Colac Area Health would like to have your concerns dealt with in a timely manner by early acknowledgement and closure. At times it is difficult to keep these timeframes, but we do aim to keep you updated. We recognise that delays in resolving complaints can be frustrating for all concerned.
Accreditation
Quality of Care Repor t 2013/2014
Acknowledge within 2 days 84%
Resolved within 30 days 76%
What is a pressure injury? A pressure injury is an area of skin that has been damaged because of:
Unrelieved pressure
friction or shear for example poorly fitting shoes
Presence of constant moisture
they commonly occur on the heels, toes or buttocks
How do pressure injuries occur?Our blood delivers oxygen and nutrients to our cells. When there is unrelieved pressure to an area the tissue will be compressed causing blood flow to be interrupted. Cells can be damaged and die.
this is called Pressure Injury.
Corangamarah consistently performs well against the State-wide benchmark for Stage 4 pressure injuries - where full thickness tissue loss has occurred. this is primarily due to the vigilance of our wound care nurses who conduct regular skin inspections on all of our residents to prevent the occurrence of pressure injuries.
Pressure Injuries
Quality of Care Repor t 2013/2014
Corangamarah – Residential Aged Care
Corangamarah consistently performs well against the State-wide High Care average. Resident medications are reviewed by a pharmacist on a regular basis with feedback provided to the residents GP for ongoing management.
At Corangamarah our Falls numbers are consistently below the State-wide High Care average. We pride ourselves on ensuring all residents have a risk assessment on entry to provide them with strategies to minimise the risk of falls during their stay. We also encourage residents to opt in to our hourly resident rounding program where nursing staff provide additional supervision and ensure fundamental care needs are being met on a more regular basis.
Corangmarah consistently performs well against the State Wide benchmark for Stage 4 pressure ulcers - where full thickness tissue loss has occurred. This is primarily due to the vigilance of our wound care nurses who conduct regular skin inspections on all of our residents to prevent the occurrence of pressure ulcers.
0.01.02.03.04.05.0
Q112/13
Q212/13
Q312/13
Q412/13
Q113/14
Q213/14
Q313/14
Q413/14
Medication Management
Incidence of Nine or More Medications Benchmark
012345678
Q112/13
Q212/13
Q312/13
Q412/13
Q113/14
Q213/14
Q313/14
Q413/14
Falls Management
Prevalence of Falls per (1000 bed days) Benchmark
0.00
0.02
0.04
0.06
0.08
Q112/13
Q212/13
Q312/13
Q412/13
Q113/14
Q213/14
Q313/14
Q413/14
Stage 4 Pressure Injury
Stage 4 Pressure Injury Benchmark
How to prevent a pressure injury?
DoCheck your skin regularly
Change your bed or chair position regularly which will relieve pressure on bony areas
Apply moisturiser twice daily
Use mild, pH neutral, non-irritant skin cleansers and body products
Protect skin exposed to friction
Check your skin regularly and seek help if you have any sore, blistered or red skin
eat a nutritious diet
Use pillows and foam wedges to protect bony prominences
Avoid heel or sacral contact with hard surfaces
Don’tDo not massage or rub the skin over bony areas (eg hip bones)
Do not sit in a chair for long periods of time - change position regularly
Do not use foam rings, donuts or fluid filled bags
Do not leave the skin in contact with moisture for long periods of time
Pressure Injuries
Quality of Care Repor t 2013/2014
We’d like to hear from youthe Quality of Care Report is an important annual report outlining how we continually improve ways in which we deliver services to you our community.
Your opinion is important to us. It helps us plan our future direction. You all have a significant role in the shaping our health service.
Our visionColac Area Health aims to be a recognised leader in the development and provision of responsive, integrated health care.
Our missionto promote the health and wellbeing of the Colac and district community through the provision of quality acute, aged, residential and community services that are accessible, affordable, flexible and integrated.
Quality of Care ReportIn the development of this report we invite the community to provide feedback and comment.
this year the report aims to:-
Help the reader become more informed of our services and programs
Incorporate last year’s feedback which was been reviewed by the Board and executive team and reflected in this year’s report
Please turn over and complete the feedback form as the comments and information you provide will
assist to produce our next Quality of Care Report
We want your feedback
Quality of Care Repor t 2013/2014
This report has made me more aware of:
I would like to see more of:
I would like to see less of:
Contenteasy to read
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What features did you like the most?
Report layouteasy to follow
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Report FormatPlease rank (1 = preferred, 4 = least-preferred) the following format options according to your preference:
Calendar
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CONTACT DETAILSGeneral enquiries (03) 5232 5100
thank you for taking time to complete this form.
We do value your feedback.
Please detach the form and return in-person to one of our receptions or post to:
Chief Executive, Colac Area Health 2-28 Connor Street, COLAC VIC 3250
If you would like us to contact you in regard to any item in this report,or you are interested in supporting your Health Service, please complete your details and return to us.
Name: Phone Number:
Address: Email:
Tear me out, Send me back with your feedback
Quality of Care Repor t 2013/2014
ACUTEInpatient Services
Medical/Surgical WardMaternityHaemodialysis
Perioperative ServicesSurgeryCentral Sterilizing Service Dept (CSSD)Pre-admission Clinic
Urgent Care Visiting Consulting Clinics
OrthopaedicGynaecologyOpthalmology
RESIDENTIAL AgED CARE
Corangamarah - High CareAged Care facilityRespite Care
COMMUNITY SERvICESCommunity Nursing
Post Acute CareBirregurra Community Health CentreCancer Link NurseContinence SupportDiabetes educationHome NursingAdvanced Care PlanningHospital in the HomeHospital Admission Risk ProgramMcGrath Breast Care NursePalliative CareWound Management
Allied HealthAdult Day Activity CentrePublic Dental ClinicCommunity Rehabilitation ServiceHealth PromotionRestorative CareSmoking Clinic
Allied Health Clinical ServicesNutritionOccupational therapyPhysiotherapyPodiatrySocial WorkSpeech Pathology
Family and Community Programs
Adolescent Community HealthAlcohol and Other Drug ServiceBarwon South West Children’s Resource ProgramBarwon South West Homelessness ServiceColac Neighbourhood HouseCommunity Women’s HealthChild fIRSt Intakefamily Supportfamily violence/ Women’s Counsellingfinancial and General Counsellingtransitional HousingYouth Health HubYouth and Children’s Counselling
CO-LOCATED SERvICEStime for YouthJigsaw - Adolescent Mental Health
vISITINg SERvICES
Barwon Community Legal ServiceBarwon Centre Against Sexual AssaultDrink Driver education Programfamily PlanningGambling and financial CounsellingOncology Review ClinicPathways Rehabilitation and Support ServicesProsthesis and Orthoticsvictims of CrimeWatharong Aboriginal Health
DIAgNOSTIC SERvICESPathologyRadiology/Medical Imaging
MEDICAL SUppORT SERvICES
Governance for Quality and SafetyMedical RecordsPharmacy
CORpORATE SUppORT SERvICES
Administrative ServicesPathways Child and Adolescent MentalHealth Serviceengineering Servicesenvironmental Servicesexecutive Servicesfood ServicesWorkforce training and Development
Your Health Service HealthCOLAC AREA
Quality of Care Repor t 2013/2014
Back cover designed by Montanna Bagdonas
ConsumerRepresentative
Approved
Quality of Care Repor t 2013/2014