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Quality Account 2017

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Welcome from our CEOOn behalf of Bass Coast Health, I am proud to present the 2016/17 Quality Account. All public hospitals are required by the Department of Health and Human Services (DHHS) to produce a Quality Account each year. The Account presents a clear and transparent report against DHHS’s quality and safety indicators.

Quality and Safety are a priority for Bass Coast Health. At a local level we have implemented many changes to ensure Quality and Safety is first and foremost in what we do.

Safer Care Victoria was established on 1 January 2017 as part of the Victorian Government’s response to Targeting Zero, the review of hospital safety and quality assurance in Victoria.

Safer Care Victoria is the peak state authority for leading quality and safety improvement in healthcare. Its role is to oversee and support our health services to provide safe, high-quality care to patients.

One of Safer Care Victoria’s aims is to provide patients, clinicians and hospitals with tools and resources to improve quality and safety in the health system. We have been pleased to work with and host Safer Care Victoria at Bass Coast Health and this Quality Account aims to provide a brief overview of some of our achievements. .

Bass Coast Health has taken the opportunity over the past year to review and improve how we deliver safe, high-quality care to the members of our community.

We hope that this Quality Account gives you a better understanding of some of our successes over the past year, and an insight into the important work we are continuing.

It is with great pleasure that I share the following achievements for 2016/17 as we have improved and strengthened the services we deliver to you:

• Successful organisation-wide accreditation under the National Safety & Quality Healthcare Standards (in March 2017) by the Australian Council on Healthcare Standards

• Successful re-accreditation under the Human Services Standards (in March 2017) by the Australian Council on Healthcare Standards

• Successful re-accreditation under the Commonwealth Home Care Common Standards in June 2017

• Full compliance for our aged care facilities Kirrak House (in April 2017) and Griffiths Point Lodge (in May 2017) under the Aged Care Standards

• Successful re-accreditation of our Emergency Department against the Australasian College for Emergency Medicine Quality Standards

• Successful re-accreditation of our junior medical staff training program against the Postgraduate Medical Council of Victoria’s Standards

• Completion of an external Clinical Governance Review (in October 2016) and successful implementation of the resulting recommendations

• Development of the Strategic Plan 2016 – 2020 including review and refresh of the Mission, Vision and, in particular, Values, as part of the development of the new Strategic Plan

• Endorsement by the Board of the South Gippsland Clinical Services Plan in collaboration with South Gippsland Hospital, Gippsland Southern Health Service and DHHS

• Expansion of our community and sub-acute services

• Refurbishment of our operating suite, including the upgrade and installation of new air handling units

• Commencement of construction of the Phillip Island Health Hub at Cowes

• Relocation of the medical and specialist consulting areas to the front of the hospital to improve access for the community

• Development of the Gippsland Cancer Connections webpage

• Participation in the Healthy Together Achievement program

• Establishment of cardiology referral partnerships with Peninsula Health to ensure the timely transfer of our cardiac patients to receive care from specialist cardiac services

• An annual increase of 6% in our Emergency Department (ED) presentations, with improvements in their timely treatment. Continued achievement of state-wide benchmarks, including off-stretcher times for patients attending our ED via an ambulance

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• Establishment of a fast track area in our ED

• Introduction of a volunteer program to support patients and their families in our ED

• Improved partnerships with mental health providers, Victoria Police and Ambulance Victoria to establish the Mental Health and Police Response (MaPHa) initiative

• Development of a Maternity Capability Framework to support professional development and mandatory competency levels for our maternity staff, and provide safe and consistent care

• Implementation of our Child Safe Action Plan

• Partnering with Bass Coast Shire, Gippsland Primary Health Network and other local health services to establish optimal Home and Community Care (HACC) program transition and a National Disability and Insurance Scheme (NDIS) Implementation Strategy

• An increased number of graduate nurses

• Development of new food safety programs for each Bass Coast Health site.

These are just a few of the achievements we have celebrated in the past year, with every success driving us to continue to improve our health service to deliver the best possible care we can offer.

None of these achievements would have been possible without the hard work and dedication of Bass Coast Health’s extraordinary staff, who show their commitment to both the organisation and the community we serve every day.

Finally, I would like to make special mention of the amazing team of volunteers Bass Coast Health is incredibly fortunate to have. Both Bass Coast Health and the Bass Coast community are indebted to them for the donation of their personal time that makes a difference in so many ways.

Jan Child Chief Executive Officer

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Executive Director of Medical Services reportAs Bass Coast Health’s Executive Director of Medical Services, my responsibility is to ensure that the delivery of health care provided to our patients by our medical staff follows the hospital values of: WE CARE – Wellbeing, Equity, Compassion, Accountability, Respect and Excellence.

Since I joined Bass Coast Health in July 2016, a focus on quality and safety has seen major clinical governance reforms that have swept the organisation. I have been closely involved with the executive team in implementing actions that have seen recommendations from the Clinical Governance Review enacted.

We have developed a competency framework for our senior medical staff, GPs, staff specialists and visiting specialists, to be sure that the doctors we appoint have the appropriate qualifications to perform their medical duties and that their scope of clinical practice is clearly defined. We ensure they maintain their skills, knowledge and experience by continuing to make sure they receive professional development and that they complete specific courses and mandatory training. These include topics chosen by Bass Coast Health, such as hand hygiene and aseptic technique. Moreover, the quality of their work is audited and any adverse events are investigated and recommendations are provided to ensure we learn from these events and modify our policies and practices.

My complimentary role is as medical surveyor with the Australian Council of Healthcare Standards (ACHS), so I have the privilege of being part of survey teams that visit other hospitals in Australia to measure them against the ACHS accreditation standards and determine whether the hospital has quality programs in place to satisfy the ten National Safety and Quality in Health Service Standards (NSQHSS). Bass Coast Health is very proud to have received this accreditation in March 2017. I am an ardent supporter of the concept that these standards should be part of what we do every day in providing safe, high-quality health care to our patients and clients, and not just at the time of accreditation. I am pleased to say that at Bass Coast Health accreditation requirements are now part of our day to day work.

My other role that benefits Bass Coast Health is as a surveyor with the Postgraduate Medical Council of Victoria (PMCV) which accredits training positions for junior doctors.

A team of PMCV surveyors conducted an accreditation visit at Bass Coast Health in May 2017, and we received a glowing report with full accreditation of the junior doctor posts and their senior medical staff supervisors. The Bass Coast Health senior medical staff play an important part as role models for the junior doctors.

Bass Coast Health is now embarking on an exciting journey to upgrade to sub-regional status and better integrate with, and extend our quality patient care standards, to the other hospitals in the South Gippsland region. I very much look forward to being part of the Bass Coast Health executive team on that journey.

Associate Professor Bruce Waxman Executive Director Medical Services

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Statewide Plans and Statutory Requirements

Aboriginal healthThe Improving Care for Aboriginal Patients Program (ICAP) was developed to improve access to mainstream health services in Victoria for Aboriginal and Torres Strait Islander people. Results from the Gippsland Cultural Competency Framework audit conducted in 2016 and the Aboriginal Care in Acute Services Continuous Quality Improvement Tool, have formed the basis of an organisation-wide Cultural Competency Action Plan.

Bass Coast Health has implemented many strategies throughout this reporting period to improve experience and help Aboriginal and Torres Strait island people link with local and regional health services including;

• development of a Diversity Framework to support inclusive practice more broadly across the health service

• continued implementation of the Gippsland Aboriginal Health Cultural Competence Framework

• increased linkages and engagement with the local Aboriginal community and more consultation with regional Aboriginal stakeholders to improve the resources it provides to Aboriginal and Torres Strait Islander people.

• staff participation in Cultural Awareness training, with many participating in local events.

• continued promotion to staff and the general public of the Black Pages, a directory of indigenous services and supports available in Gippsland designed to be a valuable resource to assist people to navigate the health system

• significant national dates have been promoted to staff with a Welcome to Country, flag raising and smoking ceremony held during National Reconciliation Week in May 2017.

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Statewide Plans and Statutory Requirements (continued)

Our Lesbian, Bisexual, Gay, Transgender, Intersex and Queer communityThe Bass Coast Health ‘Looking Out’ guide was launched to provide staff with guidance about how to provide inclusive practice for the Lesbian, Bisexual, Gay, Transgender, Intersex and Queer (LGBTIQ) community.

To strengthen this knowledge, several staff attended ‘LGBTIQ Inclusive’ training. The ‘Looking Out’ guide was also promoted and shared with neighbouring health services. Bass Coast Health participated in a LGBTIQ Equality Roadshow with other key stakeholders to promote the inclusiveness of its services.

An exciting outcome of this was the formation of the South Coast LGBTIQ Inclusion Advisory Group, which includes local government and representatives from other health services. Bass Coast Health also participated in a consultant survey which identified possible strategies to embed inclusive LGTBIQ practice into its services in the future.

Child Safe StandardsThe Child Safe Standards improve the way organisations prevent and respond to child abuse. During the past year, Bass Coast Health developed and implemented an action plan to be compliant with these Standards.

A ‘Child Safe Policy’ was created and Bass Coast Health’s ‘Code of Conduct’ was amended to incorporate child safety requirements. A statement of Bass Coast Health’s commitment was developed and publicly placed on the website.

Child-specific policies were reviewed to align with the Standards and current legislation. Appropriate staff were Identified as Child Safe Champions to provide ongoing support for staff when required. Additionally, an education campaign was implemented to ensure all staff and volunteers are aware of their obligations to report concerns of harm or abuse.

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Consumer, Carer and Community Participation

Community Advisory CommitteeThe Bass Coast Health Community Advisory Committee ensures that consumer views are considered in the decision making processes for the health service at all levels. The committee works with the Board throughout the year to provide input into strategic decisions for service planning, consumer participation and the safe, high-quality care that Bass Coast Health provides.

This year Bass Coast Health welcomed three new members to the Community Advisory Committee – Neil Beddoe, Greg Mead and Faye Tuchtan, who join Caroline Talbot (Chair), Bruce Proctor, Kate McLaughlin, Hilary Kerrison, Terry Shannon and Joyce Ball.

Bass Coast Health farewelled Anwyn Martin, Griselda Thompson and Jack Dunn, who collectively provided an outstanding 11 years of voluntary service on the committee. The Board and staff of Bass Coast Health would like to wish the retiring members well in their future endeavours and express their gratitude for the role and influence the Community Advisory Committee have had in driving consumer participation at Bass Coast Health.

Partnering with ConsumersConsumer, carer and community participation is a meaningful process encouraging individuals to contribute to decision-making about their own health care and treatment, and broader health policy, planning and service delivery.

Health outcomes and experiences are improved if people are given an opportunity to be actively involved in their health care decisions. Health services are improved when consumers are involved in improvement opportunities and higher level strategic decision-making and governance.

Bass Coast Health is committed to partnering with consumers in all aspects of care planning, delivery and evaluation. Many successful initiatives have been completed in partnership with consumers including:

• the Board Open Access meeting attended by consumers, stakeholders and the broader community

• consumer input into the development of the Clinical Services Plan, including collaboration between the Board, the Community Advisory Committee and other community members

• strengthened partnerships, broadening knowledge, skills and collaborative networking opportunities with the appointment of three new Community Advisory Committee members

• community Advisory Committee member attendance at Health Issues Centre - The Survey Says Keep Asking Forum.

• development of the Phillip Island Community Advisory Group, to ensure that services delivered from the Phillip Island Health Hub, currently under construction, will be appropriate and meet the needs of the Phillip Island population

• review of assessment tools used to identify risks to the patient, carer and family during admission

• development of the ‘Making Your Stay Safer’ booklet, designed in plain English and provided to all patients on arrival

• installation of larger and more useful whiteboards beside each patient bed improving communication between clinicians and patient, family and carers

• launch of the Recognise, Engage, Act, Call, Help is on its way (R.E.A.C.H) initiative which helps consumers, family members and carers raise concerns they may have about the condition of the person receiving care

• development of the Cancer Connections webpage, accessible via the Bass Coast Health website, providing greater access to information for people living with cancer

• participation in the first Victorian Health Experience Survey by our community-based clients, increasing opportunities for Bass Coast Health to benchmark consumer experience and improve how care is provided.

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Your experience whilst in our careYour experience matters. Bass Coast Health is committed to delivering person centred care to improve health, wellbeing, care experience and health outcomes with our community.

Bass Coast Health seeks feedback about your experiences and constantly looks for ways to improve them.

The Victorian Healthcare Experience Survey (VHES) collects feedback from a range of users of Victorian public health services. Each month consumers are randomly selected and invited to participate in the survey. The survey asks consumers to answer a number of questions about their experience and the care they received from the health service. These results are provided to the health service to examine and identify ways in which it can improve.

In December 2016, a downward trend was seen in positive responses from people who were asked if they were as involved in their care and treatment as they wanted to be.

In response to this:

• staff awareness has been raised about the importance and benefits of partnering with consumers in care

• consumer information has been reviewed in collaboration with consumers

• documents and forms have been reviewed to support involvement of patients and families

• clinical handover is held at the bedside and involves the patient

• patients and families are actively involved in discharge planning.

As a result of this focus on partnering with consumers, patient experience scores improved. This focus continues in recognition of the need to engage with, and involve, patients and families in care and treatment.

Consumer, Carer and Community Participation (continued)

100%

98%

96%

94%

92%

90%Jul-Sep 2016 Oct-Dec 2016 Jan-Mar 2017 Apr-Jun 2017

Patients who reported a positive overall patient experience against a target of 95%

76%

74%

72%

70%

68%

66%September 2016 December 2016 March 2017 June 2017

Patients who were as involved as they wanted to be in decisions about their care and treatment

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Disability Action PlanIn line with the Victorian State Disability Plan 2017–2020, Bass Coast Health designs services that are complementary, holistic and integrated so absolutely everyone can access services.

The Health Literacy Plan has been a key focus for Bass Coast Health to ensure patients and clients have access to information that is easily understood. This is crucial to support people to make informed decisions and ensure they are able to access the right services at the right time,

in the right place, independently or with the supports they need.

One exciting initiative started this year was the Scope Communication Access project. The aim of this project is to become a Communication

Accessible Organisation. In Victoria 1 in 500 people need communication aids and strategies for successful communication.

A visual assessment of main reception and waiting areas, bathroom facilities and walkways has helped Bass Coast Health to develop an action plan towards becoming a communication accessible organisation. If successful, Bass Coast Health will be awarded with a certificate and will be able to display a symbol to let people know services are communication-accessible and able to respond to people’s communication needs.

A further initiative has been the strengthening of systems for reporting, investigating and responding to suspected or known abuse. Key relevant policies and procedures have been reviewed to maximise appropriate response and to encourage partnering in care. Processes have also been enhanced that promote a positive complaints culture and support equitable access and inclusiveness.

Interpreter servicesInterpreter services are offered to anyone who is identified as needing the service or who requests it.

According to the 2016 Census data the Bass Coast Shire population predominately speaks only English at home and 0.6% either speak another language, speak English not well or do not speak English at all. These percentages represent a slight increase in numbers since 2011.

For 2016/17 there were no occasions where interpreter services were required by patients or clients at Bass Coast Health. To ensure interpreter services are appropriate and in consideration of the 2016 Census data a review of Bass Coast Health’s Interpreter Options Policy has been initiated. Following this review staff education will be provided to ensure those who require an interpreter are identified and access is provided.

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Accreditation statusTo ensure it provides a recognised level of safe, high-quality care, Bass Coast Health is evaluated against certain national and state-based Standards. This process involves either a review or self-assessment of its performance against standards that are set by an external independent body. Each set of standards focuses on safety, quality, consumer participation, the health outcomes of our patients/clients and areas that could potentially pose a high safety risk to patients. This provides a consistent standard for the level of care that patients/clients should expect from Bass Coast Health.

Bass Coast Health is fully compliant and accredited under:

• National Safety & Quality Health Service Standards

• Human Service Standards

• Home Care Common Standards

• Residential Aged Care Standards

• Australasian College of Emergency Medicine Quality Standards

• Postgraduate Medical Council of Victoria Standards

• National Family Day Care Standards.

Quality & Safety

How we seek feedback and respond to complaints Receiving feedback from consumers about what we do well and also how we could do better enables Bass Coast Health to make meaningful changes based on their experience and in support of our Vision – Excellence in Care.

Consumers are invited to provide feedback using feedback forms, the Bass Coast Health website, email, by phone or in person. Information about ways to give feedback is provided on admission to the hospital or when starting with any of our programs. It is also available on the Bass Coast Health website – www.basscoasthealth.org.au

Consumer feedback is shared with staff. Compliments are displayed and celebrated. Where areas for improvement are identified, action plans are developed within teams and improvement initiatives completed.

Most of the time we get it right, but it is important that we understand when we don’t. Complaints are managed promptly with all staff encouraged to immediately address issues raised. Consumers are engaged throughout the complaints process to ensure concerns are heard and they remain informed on how their complaint has been addressed.

Surveys within the hospital and in community services identified that a significant number of consumers did not

know how to make a complaint. A number of improvement initiatives were completed in response to this including:

• staff education sessions highlighting the importance of advising consumers about how they can make a complaint or provide feedback

• updating of resources such as Bass Coast Health’s Community Client Information Booklet to better describe ways to provide feedback or make a complaint

• review and update of information on the Bass Coast Health website regarding feedback and complaints

• enhanced focus on benefits of feedback through improved sharing of consumer feedback and outcomes of complaints with staff.

Bass Coast Health participates in the state-wide Victorian Health Experience Survey (VHES) which allows us to review and reflect on a wide range of consumer experiences. VHES provides targeted feedback in Adult Inpatients, Emergency Department and Maternity services. In addition, in 2016 a survey was introduced for Community Health services. The survey covers a range of topics including wait time, environment including cleanliness, communication, privacy dignity, care and treatment, health information and discharge planning.

During a review against the National Standards in early

2017, it was identified that while Bass Coast Health has a strong

consumer participation framework it could be improved further by

embedding it across all programs and services. Work has

begun on educating staff in all areas on the principles of consumer participation and how they could further involve consumers, family and carers in

developing and improving service delivery within their areas.

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“Incredibly professional midwives and always

placing patient care as the number one priority”

“ED staff took extra time in the early hours to explain and reassure me, thank you”

“All staff treated mum with love, respect and kindness,

with all her needs met. I will be forever grateful”

RESPONSE TO COMPLAINTS AND FEEDBACK – A CASE STUDYWhat Happened?A consumer told Bass Coast Health about their unfavourable experience on presenting to the Emergency Department, where they were diagnosed with a fracture to the wrist. A plaster cast was applied and they were advised that an urgent referral would be made prior to their discharge home.

The appointment with the orthopaedic specialist didn’t occur for twelve days after discharge, which caused the consumer significant stress and inconvenience. In addition to this, the consumer was worried about whether their plaster cast had been applied correctly.

Staff were concerned when they heard about this experience and immediately initiated an investigation.

What did we do about it?A review of referral processes began to examine why it took twelve days for the appointment to be made. It was discovered during the review that urgent referrals made to one particular health service were not actually reaching the right people. Bass Coast Health collaborated with this health service to make improvements to this referral process, and as a result, orthopaedic referrals are now received promptly so that patients are able to be triaged in a more timely and appropriate manner. Contact details for the health service were updated and an internal referral flowchart was developed to assist Bass Coast Health staff to make and follow up referrals. In addition to this, a roster of local specialists is now distributed to all departments to ensure that Bass Coast Health consumers are advised about local treatment options.

Whilst this experience was disappointing, it provided an opportunity to improve referral pathways and consumer access to local specialist services. Staff at Bass Coast Health apologised to the consumer and expressed their gratitude to them for sharing their experience. They also let the consumer know that the issue they raised had led to system improvements that would benefit future consumers.

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Quality & Safety (continued)

People Matter Survey - Patient Safety CultureEach year, health services are asked to survey their staff about workplace culture, education and training and overall staff satisfaction. In particular there is a focus on patient safety culture.

The results of the 2017 People Matter Survey showed that an average of 84% of Bass Coast Health staff had a positive response to the questions that measure patient safety culture against a target of 80%. This is higher than the rate achieved in the 2016 People Matter Survey report.

There is a very strong link between patient safety and workplace culture. To address responses received from the People Matter Survey Bass Coast Health:

• developed a People Matter Action Plan

• established a People Matter Working Group to progress actions and monitor outcomes.

The People Matter Action Plan addressed key areas such as:

• workforce culture

• internal communication

• health, wellbeing and support

• education, training and support

• workplace design and environment

• staff safety.

CASE STUDYA SAFETY-CENTRED ORGANISATION A significant focus of 2016 was on ensuring there was a robust Clinical Governance Framework across Bass Coast Health. Clinical Governance describes the systems, processes, leadership and culture that are at the core of providing safe, effective, accountable and person centred healthcare.

An external review was commissioned to examine existing systems and processes and provide recommendations on areas for improvement. The review identified a number of opportunities for improvement including:

• enhanced policy framework to guide all aspects of care

• development of capability frameworks for all services to ensure only patients who could be safely treated at Wonthaggi Hospital were admitted

• identifying key training to be completed by all staff to support safe care

• identifying specific training to be completed by clinical staff

• improved sharing of information between health care professionals

• enhanced reporting and investigation of clinical incidents to prevent them happening again

• enhanced measuring and reporting of performance against standard targets.

These recommendations were shaped into a comprehensive Action Plan. All actions were addressed and outcomes reported regularly to the Board of Directors and senior staff. A high level of engagement by staff across all services ensured that actions were completed and improved processes and systems adopted as the new way to do things.

The 2017 People Matter Survey showed a pleasing 16% increase in positive responses to the question “Management is driving us to be a safety-centred organisation” supporting this focus on patient safety and Clinical Governance.

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Improving staff safety Everyone has the right to feel safe at work and Bass Coast Health takes this very seriously. A particular focus is on occupational violence through supporting staff in prevention and appropriate response to episodes of occupational violence and aggression.

Bass Coast Health has developed an overarching policy and program for the prevention of occupational violence. This includes specialist training for staff and the establishment of an Aggression Management Team, to ensure a safer working environment.

‘Managing Occupational Violence and Aggression’ training and ‘Responding to Code Grey’ training both underwent major reviews this year ensuring a contemporary model appropriate to different staff roles. This training is now scheduled on a monthly basis with tailored training also provided to teams and work groups as needed. Since the launch of the new program, 322 staff have attended this training.

The Bass Coast Health ‘Prevention of Bullying and Harassment Policy’ has been finalised, along with the ‘Code of Conduct’ which defines acceptable workplace behaviours. These are discussed as part of Bass Coast Health’s Corporate Orientation for all new staff. In addition, online Prevention of Bullying and Harassment training is a mandatory training module for all staff and is required to be completed upon commencement of employment and every two years thereafter.

A major review of Bass Coast Health’s Emergency Procedures Manual, evacuation maps and emergency codes was undertaken this year. This included training 145 Emergency Area Wardens. Seven mock fire and evacuation exercises were held across the health service, with more planned to occur regularly in the future.

All of these initiatives have improved safety for staff by providing improvements to formalised safety systems and frameworks and by up-skilling staff through training and education.

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Adverse events Bass Coast Health is committed to safe, high-quality care. Sometimes, however, things do go wrong. An adverse event is an incident that results in unintended harm to a person receiving care. Unfortunately some incidents can have serious outcomes for the patient.

Robust clinical governance that supports safe, high-quality care assists in minimising the likelihood of adverse events. Bass Coast Health’s clinical governance framework includes comprehensive policies & procedures, quality and safety committees, proactive management of incidents and a focus on continually improving care.

All serious adverse events are reviewed by a team of senior clinicians with broad clinical expertise to identify any issues regarding the quality of care, safety or effectiveness of the health service. Improvement strategies aimed at reducing harm to those who use Bass Coast Health’s services are identified from these reviews.

A number of improvements have resulted from case reviews of falls that resulted in harm during 2016/17, including:

• introduction of a ‘post fall huddle’, which includes the patient and provides an immediate response to a fall

• therapists undertaking outdoor walking assessments with patients prior to home visits

• review and enhancement of key assessment and care planning documents to better identify falls risks and support the documenting of falls prevention and harm minimisation strategies

• review of allied health referral processes to ensure timely referrals and assessments by relevant disciplines.

In line with Bass Coast Health’s Values, staff demonstrate excellence and accountability in all aspects of care and are supported to strive towards the provision of safe, high-quality care with the strong message ”the standard you walk past is the standard you accept.”

Quality & Safety (continued)

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5

4

3

2

1

0

Contaminated Instruments

Developed Pressure Injury

Surgical Site Infection

Clinical Handover

FallsWith Harm

Number of adverse events 2016/17

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Preventing and controlling healthcare-associated infections Bass Coast Health is committed to minimising hospital acquired infections through the use of contemporary, best practice infection prevention and control measures.

A key measure of effective infection prevention is to monitor the rate of hospital acquired cases of Staphylococcus Aureus Bacterium (SAB) infections. Bass Coast Health reported no hospital-acquired SAB cases during 2016 (target: 0.02 cases per 10,000 bed days).

A key part of minimising hospital-acquired infections is the need for all clinical staff to complete aseptic technique

competencies. This involves staff completing online training followed by a practical assessment to demonstrate use of best practice infection control measures. 93% of nursing staff have successfully completed these competencies.

To ensure staff and patients are not exposed to infections during procedures involving sharps (eg needles or scalpels), Bass Coast Health introduced safety devices to assist with its sharps safety program. These devices were introduced in February 2017 and since then there have been no sharps- related incidents compared to 9 in 2016.

Healthcare worker immunisation (influenza)A successful 2016 influenza campaign saw 81% of staff immunised against the state target of 75%. This focus on staff immunisation will continue to protect patients, residents and staff.

Staff Influenza immunisation compliance

Reporting period Target Performance

18/04/16 – 19/08/16 75% 81%

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Number of prescriptions filled by our pharmacists

2015/16 3,356

2016/17 3,294

How do we perform against our targets?

Therapeutic Guidelines give recommendations for the treatment of community acquired pneumonia (CAP) in general populations. Bass Coast Heath prescribes according to these guidelines and measures how well it does this.

Audit results show an upward trend for prescribing antibiotics in line with the guidelines for patients with community acquired pneumonia and met the target of 90% for Jan – Mar 2017

To achieve these favourable results, initiatives included:

• medication prescriber feedback and education

• antibiotic Awareness in the Medication Safety Bulletin

• pharmacy review and immediate feedback to prescribers

• participation in Antibiotic Awareness Week activities

100%

90%

80%

70%

60%

50%

40%

30%

20%

10%

0Jul-Sep Oct-Dec Jan-Mar

Percentage of patients with community acquired pneumonia that are prescribed antibiotics in line with guidelines

Wonthaggi Hospital

Target

Medication safetyMedicines are the most common treatment used in health care and although they contribute to significant improvements in health, they can also be associated with harm.

Because medicines are so commonly used, they are associated with higher rates of errors and adverse events. Up to 50% of these are potentially avoidable. These errors and medication-related adverse events can include allergic reactions, interactions, drug prescribing errors, administration errors and dispensing errors - with an impact ranging from minor consequences to being life threatening.

Bass Coast Health has safety systems in place to minimise medication errors and to safeguard medication prescribing, administration and dispensing practices

What’s New?Bass Coast Health is monitoring the

number of patients who are reviewed by a clinical pharmacist within 24 hours of

admission to ensure safe and appropriate prescribing and use of medicines.

How do we monitor medication safety?

Bass Coast Health monitors a range of medication safety aspects against Key Performance Indicators and regularly reports these to its Board and Quality and Safety Committees.

Monitoring of processes for known high-risk medications, in comparison to our past performance, supports Bass Coast Health to maintain a continuous quality improvement culture.

Some of the performance indicators monitored relate to antibiotic prescribing for community-acquired pneumonia; documenting and matching (reconciling) current medications on admission; and providing a current, comprehensive and accurate medication list on discharge.

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Audits show that a discharge summary containing a comprehensive medication list was completed for the majority of patients on discharge.

This ensures important medication information, including medication changes, is communicated to the patient, family and carers and to the patient’s GP and their community pharmacy.

To further improve patient safety, a review of the method and process of generating and communicating these medication lists on discharge is planned, to further optimise accessibility of this information for the patient and members of the health care team.

Audits show the majority of current medications were documented and reconciled at the time of admission. This process is undertaken by medical staff as part of the admission process and by pharmacists when reviewing patients.

Bass Coast Health pharmacist will continue to monitor performance against a target of 90%

Percentage of patients whose current medications are reconciled on admission

(Medication reconciliation is matching prescribed hospital medication with usual medication)

Percentage of patients provided with a comprehensive medication list on discharge

100%

95%

90%

85%

80%

75%

100%

95%

90%

85%

80%

75%

Jul-Sep Oct-Dec Jan-Mar Apr-Jun

Jul-Sep Oct-Dec Jan-Mar Apr-Jun

Wonthaggi Hospital

Target

Wonthaggi Hospital

Target

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Leaving Hospital

Making your stay with us safer

Adapted from New Zealand Quality and Safety Commission - BCH V1, Dec 2016

Family Escalation of Care We know that you know yourself or your

loved one best. Let us know if you notice a worrying change. Tell the nurse your concerns

If your concern is not responded to, or you or your loved one is getting worse, act. Ask to speak to the nurse in charge and request a ‘clinical review’. This should occur within 30 minutes. If you are still concerned call an advanced nurse to request an

emergency response by calling 5671 3384.

Partnering in Care Partnering in care is meaningfully involvement in decision making about care and treatment, and the wellbeing of the patient/family/carers. We recognise you and your family/carer as members of your healthcare team.

Please, feel free to ask any questions, at anytime.

Before you leave, make sure: you have all the information you need to be safe at home

your medicines have been explained to you, particularly if they’ve changed you know who to contact if you have any questions or concerns you know when your next appointment is.

DOC-ORG-066

Quality & Safety (continued)

Preventing harm from fallsFalls are a significant cause of harm to older people. This risk is particularly increased when there is sensory decline, reduced lower limb strength, cognitive impairment or if a person suffers from other medical conditions. Another contributing factor can be a change in the person’s environment, such as a stay in hospital. Falls are one of the largest causes of harm in care. Preventing falls and minimising their harmful effects is critical.

The 2016/17 data indicates an increase in falls with major and minor harm in comparison to 2015/16. This can be attributed to increased education on reporting harm from falls correctly within the incident management system. Correct reporting ensures that all falls (including near-misses) are investigated and followed up. All falls with major

harm undergo a formal Case Review including all members of the team and the patient themselves. By conducting these reviews, staff are able to explore the contributing factors and identify opportunities for improvement.

To help reduce the risk of falling, all patients are assessed on admission to measure their risk of having a fall. Depending on the level of risk, individualised strategies are developed in partnership with patients and families to reduce the likelihood of a fall and harm from a fall.

Point of Care audits are regularly conducted at a patient’s bedside to monitor if a person’s risk has been assessed. Audits for 2016/17 indicated an average of 99% compliance against a target of 95% for Falls Risk Screening completion on admission.

Of the 91 patients audited at their bedside, an average of 99% had received a Mobility/Falls Risk Screen at the time of their admission in 2016/17.

This year, in consultation with consumers, a booklet was adapted from the Health Quality & Safety Commission in New Zealand. The booklet is written in easy English and advises patients, families and carers on ‘9 simple steps to keep yourself safe during your hospital stay’. Feedback received from consumers about this booklet is that it is

informative and encourages patients, family and carers to contribute to their own safety. The booklet contains information on patient identification, preventing such things as blood clots, pressure injuries, falls and infections, and information about medicines, escalation of care, leaving the hospital and partnering in care.

Hospital and community falls incidents

80

70

60

50

40

30

20

10

0 Near miss Minor Major

2016-17

2017-18

19

Preventing pressure injuriesPressure injuries are areas of damage to the skin and underlying tissue caused by constant pressure or friction. This type of skin damage can develop quickly in anyone with reduced mobility, such as older people or those confined to a bed or chair. Pressure injuries can be difficult to treat and can lead to serious complications.

At times patients are admitted to hospital with an existing pressure injury, and occasionally pressure injuries develop whilst people are in care. An initial Risk Screen helps to identify the level of risk a person has of developing a pressure injury. Once this level of risk is known, strategies can be put in place to minimise the risk. Preventative strategies include patient and carer education, thorough

daily skin assessments, regular position changes, a healthy diet, good hygiene and skin care. Equipment such as specialised mattresses or cushions and gel pads can also be used to assist with relieving pressure on various parts of the body.

If a pressure injury is present or develops in care, accurate assessment and documentation is an essential part of determining appropriate management. To better monitor the progress of wounds, Bass Coast Health implemented a Regional Wound Chart which provides a consistent approach to the management and monitoring of wounds.

In last year’s Quality Account Bass Coast Health reported a strong focus on identifying and improving reporting and monitoring processes for pressure injuries. This focus has continued throughout 2016/17 and proven very successful, with the frequency and accuracy of reporting increasing. Knowing how many patients come to hospital with a pressure injury and identifying when one develops whilst in care means improvements can be made to a patient’s care.

To support safe, high-quality care, a review of risk assessment tools was initiated to ensure that the best assessment methods and care strategies were put in place in a timely way.

Point of Care audits are regularly conducted at a patient’s bedside to monitor if a person’s risk has been assessed. 2016/17 audits indicated that an average of 99% compliance was achieved against a target of 95% for pressure injury risk screening.

30

25

20

15

10

5

02015/16 2016/17

Pressure injuries - hospital and community

Admitted with pressure injuryDeveloped in care

20

Blood and blood productsBass Coast Health has continued to employ a high degree of scrutiny to ensure that it is consistently looking at ways to minimise wastage of its blood and blood products. Regular audits of its systems and processes dealing with blood and blood products provide valuable insight into how improvements and efficiencies can be achieved, along with the avoidance of wastage. All blood wastage episodes are reviewed by Bass Coast Health’s Blood Transfusion Committee, with recommendations made when improvements are identified.

The usage of any blood or blood products requires consent. Bass Coast Health’s robust clinical guidelines are referenced to national guidelines, which ensures Bass Coast Health continues to attain full compliance against the 100% target for obtaining consent.

Hand hygieneHand Hygiene competency is mandatory for all Bass Coast Health staff to complete on an annual basis. Simple measures such as knowing the appropriate times to complete hand hygiene play a crucial role in patients avoiding hospital acquired infections. There are now 23 trained staff auditors working across the organisation to collect data on a monthly basis. This allows regular feedback to be provided back to staff and visitors regarding compliance.

The National Hand Hygiene Initiative (NHHI) requires staff hand hygiene audits to be conducted and reported in March, June and October every year. With such a large pool of auditors now collecting surveillance, Bass Coast Health has been able to increase its national data submission for the 2016/17 period from 300 moments of hand hygiene collected to 1134.

Quality & Safety (continued)

Red blood cell wastageThreshold 2015/16 2016/17

2.4% 0.3% 0.3%

Documented valid consentTarget 2015/16 2016/17

100% 100% 100%

95%

90%

85%

80%

75% October 2016 March 2017 June 2017

National hand hygiene compliance

Wonthaggi Hospital

Target

21

Maternity servicesThe 2016/17 reporting period for Maternity Services is based on figures from the Victorian Perinatal Performance Indicator 2014/15 Report.

Bass Coast Health did not meet the expected state-wide public hospital targets in the following two indicators out of ten overall indicators.

Significance of the results

Having a caesarean section can prolong recovery from the birth, increase the small risk of serious morbidity after the birth and increase the risk of major complications in subsequent pregnancies. Therefore, reducing the number of avoidable caesarean sections minimises these problems. One of the ways to achieve this is by encouraging women who have had a prior caesarean section to safely attempt a subsequent vaginal birth after caesarean (VBAC) and by supporting them to achieve this.

What we are doing to improve them

The safety of its birthing mothers and their babies is of paramount importance at Bass Coast Health, and sound clinical judgment is used to determine the safest and most appropriate options for each birthing mother.

Bass Coast Health introduced a regular meeting to discuss individual cases which includes midwives, doctors and an obstetrics consultant to develop the safest plan for each mother and baby.

Significance of the results

Women who smoke while pregnant have an increased risk of ectopic pregnancy, miscarriage, experiencing pre-term labour and are more likely to give birth to a low-birthweight baby compared with nonsmokers.

What we are doing to improve them

Effective interventions are multi-faceted and based on individual needs and circumstances.

Providing education is a key strategy towards reducing smoking. Bass Coast Health midwives discuss and note health and pregnancy-related issues around smoking and smoking cessation behaviours at each antenatal visit. Where smoking is identified, harm-minimisation is encouraged and a referral to the QUIT program is offered to families who smoke.

Rate of women smoking during pregnancy after 20 weeks gestationReporting period Result

State wide average (public hospitals) 12.6%

Bass Coast Health 17.2%

Vaginal births after primary caesarean sectionReporting period Result

State wide average (public hospitals) 27.4%

Bass Coast Health 23.8%

22

Residential Aged Care ServicesResidential Aged Care services report their performance against the five public sector Residential Aged Care.

Quality Indicators: This data is reported to DHHS on a quarterly basis. The figures below indicate average results across four quarters over the 2016/17 financial year.

Quality & Safety (continued)

What we are doing to improve

All residents have their risk of falling reviewed regularly. Care plans are then developed, including strategies to reduce their risk of having a fall. All falls are reviewed and followed up to ensure appropriate strategies introduced as needed. Review by physiotherapists is provided if required.

Kirrak Residential Aged Care Facility

Griffiths Point Lodge

Similar Sized Facility

25

20

15

10

5

0

30

25

20

15

10

5

0Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4

Falls Kirrak Residential Aged Care Facility Griffiths Point Lodge

23

What we are doing to improve

The weight of residents is monitored regularly and strategies for providing appropriate nutrition for them is put in place as needed. Residents are provided with a wide range of menu choices. If needed, residents are referred to the dietician for assessment and advice. This may include a change to portion sizes or frequency of meals, as well as nutritional supplements.

3.53.02.52.01.51.00.5

0

1.2

1.0

0.8

0.6

0.4

0.2

0

76543210

1.2

1.0

0.8

0.6

0.4

0.2

0

12

10

8

6

4

2

0

141210

86420

2.5

2.0

1.5

1.0

0.5

0

25

20

15

10

5

0

Q1 Q2 Q3 Q4

Q1 Q2 Q3 Q4

Q1 Q2 Q3 Q4

Q1 Q2 Q3 Q4

Q1 Q2 Q3 Q4

Q1 Q2 Q3 Q4

Q1 Q2 Q3 Q4

Q1 Q2 Q3 Q4

Pressure Injuries Kirrak Residential Aged Care Facility Griffiths Point Lodge

Restraints Kirrak Residential Aged Care Facility Griffiths Point Lodge

Weight Loss Kirrak Residential Aged Care Facility Griffiths Point Lodge

Medications Kirrak Residential Aged Care Facility Griffiths Point Lodge

24

Escalation of careSometimes, friends or family may notice a change in the condition of their loved one whilst in Bass Coast Health’s care. Patients, carers and families can often recognise signs of deterioration before they are clinically evident. It’s important that people are confident about who they can speak to about this change. This is referred to as ‘escalation of care’. To improve its escalation of care process, Bass Coast Health introduced the REACH model this year. REACH stands for the steps in the process of escalation - Recognise, Engage, Act, Call, Help is on its way.

Evidence indicates that patients themselves or families can act as effective initiators of escalation.

Developed by the NSW Clinical Excellence Commission, the REACH model is a graded approach to patient/carer/family-activated escalation. It encourages patients, carers and

family members to initially engage with their nurse if they are concerned that ‘something is not right’. If they continue to be worried they can escalate their concerns by requesting a clinical review, which should occur within 30 minutes. If patient, carers or family members are still concerned and all other avenues of the issue being addressed have been exhausted, an independent review or rapid/emergency response can be activated by the patient/carer or family member.

REACH casts the safety net wider and provides assurance that help is on its way and has proved effective at Bass Coast Health. In fact, since its introduction, all concerns have been resolved in the early stages of the REACH process and have not required a patient, carer or family member to ask for a rapid/emergency response.

Quality & Safety (continued)

25

Leaving hospitalEach year, health services are asked to survey their patients about their experience during their time with the health service.

This survey is called the Victorian Healthcare Experience Survey (VHES). Some of the questions in the survey relate

to the patient’s experience with being discharged from hospital.

The Department of Health and Human Services set the target for the average score of people reporting a positive experience as 75%.

To strengthen this further, staff have been working on improving communication with patients and carers in planning patient discharges. The Emergency Department is also collaborating with staff in the Health Independence Programs and Allied Health departments to ensure a more holistic discharge is achieved.

Medical staff are ensuring that all patients discharged home from the Emergency Department have a letter for their GP explaining the patient’s presentation to the Emergency Department and any follow up care required.

Victorian Health Experience Survey Results - discharge care

Reporting period Target Achieved

July 2016 – September 2016 75% 82%

October 2016 – December 2016 75% 89%

January 2017 – March 2017 75% 82%

April 2017 – June2017 75% 87%

Continuity of Care

26

End of life careSafe and high-quality end of life care should be aligned with the values, needs and wishes of the individual and their family or carers. It should be provided by appropriately qualified and skilled teams with a focus on coordination of care.

In 2016/17 an evidence based model for Bass Coast Health’s Palliative Care Service was implemented. This model aligns with national and state-based guidelines regarding best practice palliative care, addressing in particular the first Priority of Victoria’s End of Life and Palliative Care Framework - Person Centred Services. The model included the development of a new Palliative Care Policy Framework,

staff education and training and the introduction of protocols, tools and resources to guide care. These have a particular focus on quality palliative care assessments that enable clients and carers to have input into their own care planning. The new decision-support tools prompt staff to enhance their professional understanding and engagement, and this supports improved palliative care outcomes for clients and carers. Feedback from consumers and staff suggests that this enhanced model improves patient experience, increases patient and staff satisfaction and supports a positive partnership between patient and family and health professionals.

Advance Care PlanningBass Coast Health recognises that supporting a person to plan for future health is a key aspect of safe, high-quality care. Advance Care Planning is about discussing life goals, values and choices with your family or carer and your healthcare professionals. Writing these down can help guide health decision-making in the future if you cannot make or communicate your own decisions.

All patients admitted to Bass Coast Health are asked if they have an Advance Care Plan. If they have an existing plan, this is made known to staff and kept in the medical file. If they do not have a plan, patients are offered further information or the opportunity to discuss Advance Care Planning either during their hospital stay or afterwards.

Bass Coast Health is working in collaboration with other services such as Gippsland Primary Health Network and Ambulance Victoria to raise awareness of Advance Care Planning among health professionals and the community. In addition, Bass Coast Health has provided targeted community education to increase understanding of the

benefits of Advance Care Planning and how to go about it. A key initiative to support this community awareness was the launch of the Advance Care Planning page on the Bass Coast Health website which provides information, resources and useful links for consumers.

Often patients present to the Emergency Department extremely unwell and unable to make decisions for themselves. When our healthcare team identifies that the person has an Advanced Care Plan it provides clear direction and guidance regarding the sorts of treatment and care the person wants. This direction allows for a care plan to be put in place, in partnership with family or carers that respects the values and wishes of the person. On a number of occasions, an Advance Care Plan has ensured patients receiving care at Bass Coast Health have not had to undergo treatment or interventions which they would find unacceptable.

50%

40%

30%

20%

10%

0July-Sep Oct-Dec Jan-Mar Apr-Jun

% of Patients over 75 admitted with Advanced Care Plan

State target

BCH actual

Continuity of Care (continued)

27

Loch

GrantvilleCorinella

Bass

AndersonArchies Creek

Wonthaggi

Cape Paterson

San Remo

Newhaven

Ventnor

Cowes

Rhyll

Inverloch

Dalyston

Kongwak2.

3. 12.

5.

4.

1.7.

9.

8. 11.

6.

10.

Melbourne

Main Site

1. Wonthaggi Hospital 235 Graham Street, Wonthaggi Vic. 3995 Phone: 03 5671 3333

Satellite Sites

2. San Remo 1 Back Beach Road, San Remo Vic. 3925 Phone: 03 5671 9200

3. Cowes 14 Warley Avenue, Cowes Vic. 3922 Phone: 03 5951 2100

Outreach Sites

4. Grantville Grantville Transaction Centre Cnr. Bass Highway & Pier Road, Grantville Vic. 3984 Phone: 03 5671 3333

5. Corinella Corinella & District Community Centre 48 Smythe Street, Corinella Vic. 3984 Phone: 03 5671 3333

6. Inverloch 14 Reilly Street, Inverloch Vic. 3996 Phone: 03 5671 3333

Residential Aged Care Facilities

7. Kirrak House Baillieu Street, Wonthaggi Vic. 3995 Phone: 03 5671 3250

8. Griffiths Point Lodge Davis Point Road, San Remo Vic. 392 Phone: 03 5678 5311

Maternal & Child Health Sites

9. Wonthaggi Miners Dispensary 169 Graham Street, Wonthaggi, Vic. 3995 Phone: 03 5671 3136

10. Inverloch 16 A’Beckett Street, Inverloch Vic. 3996 Phone: 03 5671 3136

11. San Remo San Remo Kindergarten 23 Back Beach Road, San Remo Vic. 3925 Phone: 03 5951 2302

12. Cowes Phillip Island Early Learning Centre 161 Settlement Road, Cowes Vic. 3922 Phone: 03 5952 2938

Our MissionDelivering person centred care to improve health, wellbeing, care experience and health outcomes with our community.

Our VisionExcellence in care

Our ValuesWellbeing

Equity

Compassion

Accountability

Respect

Excellence

Quality Account feedback Bass Coast Health develops its Quality Account in partnership with its Community Advisory Committee to ensure that community feedback is incorporated into its design.

Bass Coast Health is very eager to hear your feedback about this year’s Quality Account. You can leave your feedback by phoning the Bass Coast Health Quality Department on 03 5671 3365 or by completing a short survey on Bass Coast Health’s website - www.basscoasthealth.org.au.